Comparison of two delayed strategies for renal replacement therapy initiation for severe acute kidney injury (AKIKI 2): a multicentre, open-label, randomised, controlled trial

High bicarbonate replacement fluid and time to pH normalization during continuous veno-venous hemofiltration with regional citrate anticoagulation: a retrospective single-center cohort study

Background

In critically ill patients, acid-base disorders are common before start of continuous renal replacement therapy. The aim of this study was to determine the influence of a high bicarbonate replacement fluid (30 mmol/L, Phoxilium®) on underlying acid-base disturbances.

Methods

This single-center retrospective study included patients treated with continuous veno-venous hemofiltration (CVVH) at a medical ICU from January 2018 to May 2019. All patients received CVVH with regional citrate anticoagulation (RCA) and a high bicarbonate RF (Phoxilium®). Patients were categorized based on their initial pH. Acid-base parameters were closely monitored over 72 h at pre-specified intervals.

Results

The study included 64 patients with a median age of 68 years. At the start of CVVH, 56.3% (n = 36) had acidemia, 12.5% (n = 8) had alkalemia and 32.3% (n = 20) had a normal pH. The median pH of patients with acidemia [0 h: 7.28 (interquartile range 7.23-7.33)] was corrected quickly to the normal range within 8 h [7.36 (interquartile range 7.29-7.4)]. The median pH of patients with alkalemia took longer (48 h) to reach normal values and patients with a normal pH showed a further pH increase within the normal range over the 72 h. All patients showed an increasing bicarbonate and base excess from 24 to 72 h.

Conclusions

The RF in CVVH with RCA appears to be one of several factors influencing acid-base balance. Patients with different pre-existing acid-base disorders showed distinct correction kinetics. Prospective studies are needed to determine the clinical relevance of these findings and to optimize RF composition for better patient outcomes.

Dialysis Dependence in Standard versus Accelerated Initiation of KRT in AKI: A Post Hoc Analysis

Key Points

Background

The Standard versus Accelerated Initiation of Renal Replacement Therapy in AKI Trial showed that among critically ill patients with AKI, an accelerated KRT initiation strategy resulted in more KRT dependence at 90 days, as compared with a standard strategy. However, it is unclear whether this difference exists among participants who likely would have been treated with KRT in usual practice.

Methods

Secondary analysis of the Standard versus Accelerated Initiation of Renal Replacement Therapy in AKI randomized controlled trial, analyzing participants who received more than the median number of days of KRT, which served as a proxy for high probability of requiring KRT under usual practice. Two sensitivity analyses redefined the cohort as (1) those with ≥24 hours of oliguria who received KRT and (2) those who received any KRT. Using the same statistical approach as the original trial, we calculated unadjusted relative risks with 95% confidence intervals (CIs) for the exposure of randomized KRT initiation strategy (accelerated versus standard) on the outcome of KRT dependence at 90 days among survivors.

Results

Among the 1184 participants who received ≥6 days of KRT (670 and 514 in the accelerated and standard arms, respectively), baseline characteristics remained balanced between treatment arms. The relative risk of KRT dependence at 90 days was attenuated and nonsignificant: 1.21 (95% CI, 0.84 to 1.78), compared with 1.74 (95% CI, 1.24 to 2.43) in the overall trial. The results were similar in sensitivity analyses.

Conclusions

Among patients who likely would have been treated with KRT in usual practice, there was no significant difference in 90-day KRT dependence among survivors between those randomized to the accelerated and standard KRT initiation strategies. These results suggest that the harm of long-term KRT dependence may be largely due to KRT initiation (versus never initiation) rather than earlier initiation.

Clinical Trial registry name and registration number:

NCT02568722.

Clinical effects of combination therapy with continuous renal replacement therapy and continuous intravenous sodium infusion therapy

INTRODUCTION

This single-center retrospective study investigated the clinical effects of combination therapy involving continuous renal replacement therapy (CRRT) and continuous intravenous sodium infusion therapy (cIVNa) in critically ill patients with prerenal acute kidney injury (AKI) who were expected to experience insufficient plasma refilling.

METHOD

The clinical data of 92 patients were analyzed. Clinical data from the control (CRRT, n = 49) and intervention (CRRT + cIVNa, n = 43) groups were compared statistically.

RESULTS

Combination therapy increased blood pressure and urine volume, while reducing hypotension events, indicating hemodynamic stabilization. Furthermore, it significantly improved the 90-day survival rate (61.9% vs. 38.8%, p < 0.05), 60-day and 90-day survival rates without RRT (59.5% vs. 28.6%, p < 0.01; 54.8% vs. 26.5%, p < 0.01, respectively), survival discharge rate from intensive care unit, CRRT withdrawal rate, and renal replacement therapy withdrawal rate.

CONCLUSION

Combination therapy with continuous renal replacement therapy and continuous intravenous sodium infusion therapy may be a useful treatment option for critically ill patients with prerenal acute kidney injury who require continuous renal replacement therapy.

Timing of kidney replacement therapy in critically ill patients: A call to shift the paradigm in the era of artificial intelligence

Acute kidney injury (AKI) is a common condition in intensive care units (ICUs) and is associated with high mortality rates, particularly when kidney replacement therapy (KRT) becomes necessary. The optimal timing for initiating KRT remains a subject of ongoing debate. Emerging tools and methodologies, such as machine learning and advanced sub-phenotyping, offer promising insights into refining AKI management. Moving beyond the traditional "early" versus "delayed" paradigm and the heavy reliance on serum creatinine measurements, there is an opportunity to develop treatment strategies tailored to the unique pathophysiological and medical context of each patient. Such individualized approaches could potentially improve outcomes and transform AKI management into ICUs. However, KRT is not without risks. Hemodynamic instability poses a significant challenge, complicating the management of critically ill patients. The selection of a KRT modality-whether intermittent hemodialysis, continuous renal replacement therapy, or peritoneal dialysis-introduces additional complexities. Each modality has distinct advantages and limitations, requiring a careful, patient-specific approach to ensure optimal care. This decision-making process is further influenced by the availability of specialized equipment and trained personnel, resources that may be limited in some settings. Notably, current evidence does not demonstrate a clear survival or recovery benefit from the early initiation of dialysis. This narrative review explores the ongoing debates surrounding KRT timing and methodology, highlighting the importance of adopting patient-centric, individualized strategies to navigate the evolving landscape of AKI management.

Complementary role of transcriptomic endotyping and protein-based biomarkers for risk stratification in sepsis-associated acute kidney injury

BACKGROUND

Sepsis-associated acute kidney injury (SA-AKI) is a prevalent and severe complication in critically ill patients. However, diagnostic and therapeutic advancements have been hindered by the biological heterogeneity underlying the disease. Both transcriptomic endotyping and biomarker profiling have been proposed individually to identify molecular subtypes of sepsis and may enhance risk stratification. This study aimed to evaluate the utility of combining transcriptomic endotyping with protein-based biomarkers for improving risk stratification in SA-AKI.

METHODS

This secondary analysis of the PredARRT-Sep-Trial included 167 critically ill patients who met Sepsis-3 criteria. Patients were stratified into three transcriptomic endotypes-inflammopathic (IE), adaptive (AE), and coagulopathic (CE)-using a validated whole-blood gene expression classifier. Eight protein-based biomarkers encompassing kidney function, vascular integrity, and immune response were measured. Predictive performance for the primary endpoint kidney replacement therapy or death was assessed using receiver operating characteristic curve analysis and logistic regression models.

RESULTS

Stratification into transcriptomic endotypes assigned 33% of patients to IE, 42% to AE, and 24% to CE. Patients classified as IE exhibited the highest disease severity and were most likely to meet the primary endpoint (30%), compared to AE and CE (17% and 10%, respectively). Kidney function biomarkers showed stepwise increases with AKI severity across all endotypes, whereas non-functional biomarkers (neutrophil gelatinase-associated lipocalin [NGAL], soluble urokinase plasminogen activator receptor [suPAR], and bioactive adrenomedullin [bio-ADM]) exhibited endotype-specific differences independent of AKI severity. NGAL and suPAR levels were disproportionately elevated in the IE group, suggesting a dominant role of innate immune dysregulation in this endotype. In contrast, bio-ADM, a marker of endothelial dysfunction, was the strongest risk-predictor of outcomes in CE. The combination of transcriptomic endotyping with protein-based biomarkers enhanced predictive accuracy for the primary endpoint and 7-day mortality, with the highest area under the receiver operating characteristic curve of 0.80 (95% CI 0.72-0.88) for endotyping + bio-ADM and 0.85 (95% CI 0.78-0.93) for endotyping and suPAR, respectively. Combinations of endotyping with functional and non-functional biomarkers particularly improved mortality-related risk stratification.

CONCLUSIONS

Combining transcriptomic endotyping with protein-based biomarker profiling enhances risk-stratification in SA-AKI, offering a promising strategy for personalized treatment and trial enrichment in the future. Further research should validate these findings and explore therapeutic applications.

Selection of timing of continuous renal replacement therapy in patients with acute kidney injury: A meta-analysis of randomized controlled trials

Acute kidney injury (AKI) is associated with high death rates and unfavorable outcomes. Previous studies evaluating the effect of the timing of CRRT therapy on the prognosis of patients with AKI have shown inconsistent results. Consequently, we aimed to assess the impact of continuous renal replacement therapy (CRRT) initiation on the outcomes of patients with AKI. This meta-analysis identified eligible randomized controlled trials (RCTs) via comprehensive searches of PubMed, Embase, and the Cochrane databases from their creation until June 1, 2024. Outcomes, including 28-, 60-, and 90-day mortality and adverse event incidence, were compared between the early and delayed CRRT groups post-randomization. Twelve RCTs (n = 1,244) were included. Meta-analysis indicated that early initiation of CRRT did not significantly affect 28-day mortality (RR 0.91 [0.79, 1.06]; p =  0.23; I2 =  0). Early CRRT initiation correlated with a shorter length of ICU stay [MD -3.24 (-5.14, -1.35); p = 0.0008; I2 = 36%] but did not significantly affect hospital stay duration [MD -7.00 (-14.60, 0.60); p = 0.07; I2 = 38%]. The early initiation of CRRT was associated with a significant reduction in RRT dependency at discharge [RR 0.57 (0.32, 0.99); P = 0.05; I2 = 0%; P = 0.47]. Compared to delayed CRRT, early CRRT was associated with higher incidence rates of hypotension [RR 1.26 (1.06, 1.50); p = 0.008; I2 = 0%], thrombocytopenia [RR 1.53 (1.11, 2.10); p = 0.009; I2 = 0%], and hypophosphatemia [RR 3.35 (2.18, 5.15); p < 0.00001; I2 = 11%]. Our findings suggest that although early CRRT initiation is associated with short intensive care unit stays and reduced RRT dependence, it has no significant effect on mortality and is in fact associated with higher incidence rates of hypotension, thrombocytopenia, and hypophosphatemia. Therefore, early CRRT should be used clinically with caution and consideration of potential adverse effects.

Time to Renal Replacement Therapy Initiation in Critically Ill Patients With Acute Kidney Injury: A Secondary Analysis of the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial

OBJECTIVES

Among critically ill patients with severe acute kidney injury (AKI) who lack emergent indications for renal replacement therapy (RRT), a strategy of preemptive RRT initiation does not lead to improved outcomes. However, for patients with persistent AKI and without urgent indications for RRT, the safety of prolonged delays in RRT initiation is unclear. We sought to assess the association between progressively longer delays in RRT initiation and clinical outcomes.

DESIGN

A post hoc secondary analysis.

SETTING

The multinational STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial.

PATIENTS

Participants allocated to the standard strategy of the STARRT-AKI trial.

INTERVENTIONS

The exposure was time from randomization to RRT initiation, evaluated in quartiles and as a continuous variable.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was all-cause mortality at 90 days. Secondary outcomes were RRT dependence, RRT-free days, and hospital-free days, all at 90 days, as well length of ICU and hospital stay. Of the 1462 participants allocated to the standard strategy group, 903 (62%) received RRT. Median time (interquartile range) to RRT initiation was 12.1 hours (8.3-13.8 hr), 24.5 hours (21.8-26.5 hr), 46.8 hours (35.2-52.1 hr), and 96.1 hours (76.7-139.2 hr) in quartiles 1-4, respectively. Prolonged time to RRT initiation was associated with a lower risk of death at 90 days (quartile 4 vs. 1: adjusted odds ratio, 0.63 [95% CI, 0.42-0.94]); further analyses using cubic splines and inverse probability weighting to account for immortal time bias showed no association with the risk of death. There was no association between time to RRT initiation and RRT-free days, hospital-free days, or lengths of ICU or hospital stay. Longer delay to RRT initiation had a linear association with RRT dependence at 90 days.

CONCLUSIONS

Among patients with no urgent indications and who received RRT in the standard strategy of the STARRT-AKI trial, longer deferral of RRT initiation was not associated with a higher risk of mortality.

Neutrophil Gelatinase-Associated Lipocalin: Biological Aspects and Potential Diagnostic Use in Acute Kidney Injury

Acute kidney injury (AKI) is a syndrome characterized by a rise in creatinine or a decrease in urinary flow, according to the Kidney Disease Improving Global Outcomes (KDIGO) definition. It is diagnosed in 15% of inpatients and 50% of patients in the intensive care unit (ICU), and it is related to increased mortality. As part of a global effort aimed at the elimination of preventable deaths from AKI, there is a growing interest in identifying biomarkers that can be point-of-care and that are not influenced by the variability in patient characteristics in a relevant way. Neutrophil gelatinase-associated lipocalin (NGAL), particularly in its 25 kDa form, which is exclusively released by renal tubules, has emerged as a promising biomarker with potential use in the diagnosis of AKI in the critically ill, including its use in guiding the initiation and/or weaning of renal replacement therapy (RRT). The objective of this review is to summarize the current understanding of NGAL in acute settings, emphasizing biological and genomic insights.

Occurrence rate and risk factors for acute kidney injury after lung transplantation: a systematic review and meta-analysis

Background

Compared with other solid organ transplantation, the morbidity rate of acute kidney injury is higher in lung transplantation. Our research was designed to examine the occurrence rate and risk factors for acute kidney injury after lung transplantation through a systematic review and meta-analysis.

Methodology

We conducted a database search for case-control studies and cohort studies on the occurrence rate and risk factors for acute kidney injury after lung transplantation up to August 19, 2023. Stata 15.0 was used for data analysis.

Results

Nineteen case-control or cohort studies were included, involving 1,755 cases of acute kidney injury after lung transplantation and 1,404 cases of non-acute kidney injury after lung transplantation. Based on the meta-analysis, the risk factors for acute kidney injury after lung transplantation included pulmonary fibrosis (OR, 1.34; CI [1.09-1.65]), hypertension (OR, 1.30; CI [1.07-1.58]), pre-op mechanical ventilation (OR, 3.30; CI [1.84-5.90]), pre-op extracorporeal membrane oxygenation (OR, 3.70; CI [2.51-5.45]), double lung transplantation (OR, 1.91; CI [1.45-2.53]), cardiopulmonary bypass support (OR, 1.82; CI [1.38-2.40]), cardiovascular events (OR, 1.50; CI [1.15-1.96]), intra-op hypotension (OR, 2.70; CI [1.42-5.14]), post-op extracorporeal membrane oxygenation (OR, 1.90; CI [1.20-3.01]), sepsis (OR, 3.20; CI [2.16-4.73]), dialysis (OR, 12.79; CI [6.11-26.8]).

Conclusions

Based on the existing evidence, clinical professionals can implement early detection, diagnosis and treatment of patients with acute kidney injury after lung transplantation, to improve the quality of life of these patients.

Ten tips on how to reduce iatrogenic acute kidney injury

Acute kidney injury (AKI) is a heterogeneous syndrome associated with worse clinical outcomes. Many treatments and procedures in the hospitalized patient can cause AKI. Hence, the incidence of iatrogenic AKI is expected to be high. In this review we provide 10 practical tips on how to manage and avoid iatrogenic AKI. We cover identification of vulnerable patients by epidemiological data and recommend the usage of renal stress biomarkers for enhanced screening of high-risk patients. Further, we discuss the limitations of current diagnostic criteria of AKI. As a key takeaway, we suggest the implementation of novel damage biomarkers in clinical routine to identify subclinical AKI, which may guide novel clinical management pathways. To further reduce the incidence of procedure-associated AKI, we advocate certain preventive measures. Foremost, this includes improvement of hemodynamics and avoidance of nephrotoxic drugs whenever possible. In cases of severe AKI, we provide tips for the implementation and management of renal replacement therapy and highlight the advantages of regional citrate anticoagulation. The furosemide stress test might be of help in recognizing patients who will require renal replacement therapy. Finally, we discuss the progression of AKI to acute and chronic kidney disease and the management of this growing issue. Both can develop after episodes of AKI and have major implications for patient co-morbidity and long-term renal and non-renal outcomes. Hence, we recommend long-term monitoring of kidney parameters after AKI.

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.

Acute kidney injury

Acute kidney injury (AKI) is a common, heterogeneous, multifactorial condition, which is part of the overarching syndrome of acute kidney diseases and disorders. This condition's incidence highest in low-income and middle-income countries. In the short term, AKI is associated with increased mortality, an increased risk of complications, extended stays in hospital, and high health-care costs. Long-term complications include chronic kidney disease, kidney failure, cardiovascular morbidity, and an increased risk of death. Several strategies are available to prevent and treat AKI in specific clinical contexts. Otherwise, AKI care is primarily supportive, focused on treatment of the underlying cause, prevention of further injury, management of complications, and short-term renal replacement therapy in case of refractory complications. Evidence confirming that AKI subphenotyping is necessary to identify precision-oriented interventions is growing. Long-term follow-up of individuals recovered from AKI is recommended but the most effective models of care remain unclear.

Factors Associated with the Initiation of Renal Replacement Therapy in Patients on VV-ECMO: A Case-Control Study

Acute Kidney Injury (AKI) is a common complication in patients with Acute Respiratory Distress Syndrome (ARDS) receiving VV-ECMO support, carrying a high risk of progression to Renal Replacement Therapy (RRT). Both AKI and RRT are linked to an increased risk of mortality. This study aims to evaluate the risk factors associated with the need for RRT in patients undergoing VV-ECMO. Methods: This is a retrospective case-control study involving patients on VV-ECMO therapy admitted to the intensive care unit (ICU) between 2019 and 2023. Patients on VV ECMO support, with or without RRT, were included and their severity scores and associated mortality were calculated. A multivariate logistic regression analysis was performed to assess the variable RRT using odds ratios (OR) with their corresponding confidence intervals (CI) for the outcome variables. Results: A total of 192 subjects were included, with a mortality rate of 39.6%. Of these, 68.7% were male, with an average ICU stay of 25.1 days and a need for RRT in 19.7% of cases. The multivariate analysis independently associated the use of vasopressors with RRT norepinephrine OR 5.61 (95% CI, 1.64-19.1) and vasopressin OR 4.64 (95% CI, 2.15-10.0)). An increase in creatinine levels before ECMO support is associated with an increased risk OR 2.21 (95% CI 1.54-3.18), and 24 h after ECMO support, the risk rises further adjusted odds ratio (AOR) 3.32 (95% IC 1.55-7.09). The accuracy of severity scores presented weak discrimination and similar behavior, except for DEOx for the primary outcome, with an AUC of 0.79 (95% CI, 0.72-0.87), and APACHE II with an AUC of 0.68 (95% CI, 0.59-0.78). Conclusions: The prediction of RRT in patients on VV-ECMO support was superior for DEOx, which is influenced by the use of vasopressors, creatinine levels, and platelet transfusion prior to cannulation. This could be useful for predicting early interventions in this patient population.

Eligibility Criteria of Randomized Clinical Trials in Critical Care Medicine

Importance

Eligibility criteria for randomized clinical trials (RCTs) are designed to select clinically relevant patient populations. However, not all eligibility criteria are strongly justified, potentially excluding marginalized groups, and limiting the generalizability of trial findings.

Objective

To summarize and evaluate the justification of exclusion criteria in published RCTs in critical care medicine.

Evidence Review

A systematic sampling review of parallel-group RCTs published in the top 5 general internal medicine journals by impact factor (The Lancet, New England Journal of Medicine, Journal of the American Medical Association, British Medical Journal, and Annals of Internal Medicine) between January 1, 2018, and February 23, 2023, was conducted. RCTs enrolling adults in intensive care units (ICUs) and RCTs enrolling critically ill patients who required life-sustaining interventions typically initiated in the ICU were included. All study exclusion criteria were categorized as either poorly justified, potentially justified, or strongly justified, adapting previously established criteria, independently and in duplicate.

Findings

In total, 225 studies were identified, 75 of which were included. The median (IQR) number of exclusion criteria per trial was 19 (14-24), with 1455 total exclusion criteria. Common exclusion criteria were related to the risk of adverse reaction to interventions (302 criteria [20.8%]), followed by inability to obtain consent (120 criteria [8.2%]), and treatment limitation decisions (97 criteria [6.7%]). Most exclusion criteria were either strongly justified (1080 criteria [74.2%]) or potentially justified (297 criteria [20.4%]), whereas 5.4% (78 criteria) were poorly justified. Of the 78 poorly justified exclusion criteria, the most common were pregnancy (19 criteria [24.4%]), communication barriers (11 criteria [14.1%]), lactation (10 criteria [12.8%]), and lack of health insurance (10 criteria [12.8%]). Overall, 45 of 75 studies (60.0%) had at least 1 poorly justified exclusion criteria.

Conclusions and Relevance

Most exclusion criteria in critical care medicine RCTs were strongly justifiable. Across poorly justified criteria, the most common exclusions were pregnant or lactating persons, those with communication barriers, and individuals without health insurance. This highlights the need to carefully consider exclusion criteria when designing trials to minimize the inappropriate exclusion of participants and enhance generalizability.

SACrA score to predict the initiation of renal replacement therapy in critically ill patients: a single-center retrospective study

BACKGROUND

Acute kidney injury (AKI) is a prevalent complication in critically ill patients that affects the timing of renal replacement therapy (RRT) initiation. This study aimed to develop and validate the SACrA score for predicting non-emergent initiations (BUN ≥112 mg/dL or oliguria for >72 h) of RRT in critically ill patients.

METHODS

We conducted a retrospective cohort study using data from two cohorts. The derivation cohort included patients admitted to the ICU between November 2021 and December 2023, whereas the validation cohort included patients admitted between September 2019 and October 2021. The primary outcome was non-emergent RRT initiation. The multivariate logistic regression with stepwise selection based on the Akaike information criterion finalized the model, including the variables, such as sex, albumin (Alb), creatinine (Cr), and APACHE II score (SACrA).

RESULTS

The derivation and validation cohorts comprised 470 and 476 patients, respectively. The SACrA score showed a strong predictive performance for non-emergent RRT initiation in both the cohorts. Cohort 1 had an ROC-AUC of 0.971, with a calibration slope of 0.982 and an intercept of 0.009, whereas cohort 2 had an ROC-AUC of 0.918, with a calibration slope of 0.988 and an intercept of 0.004.

CONCLUSIONS

The SACrA score is a robust tool for predicting non-emergent RRT initiation in critically ill patients using readily available clinical variables. Though additional data are needed to validate the SACrA score, our analysis suggests the tool may help clinicians make informed decisions, reduce unnecessary RRT, and thereby improve patient outcomes.

[What is confirmed in the treatment of sepsis? : An update]

BACKGROUND

Sepsis is defined as "being evoked as a life-threatening organ dysfunction caused by an inadequate host response to infection". The most recent German S3 guidelines were published in 2018 and the Surviving Sepsis Campaign (SSC) last published the current recommendations for the treatment of sepsis and septic shock in 2021.

OBJECTIVE

This article explores and discusses which evidence in the treatment of sepsis and septic shock has been confirmed.

MATERIAL AND METHODS

Discussion of the 2018 German S3 guidelines, supplementation of the content of the 2021 international guidelines and recent research results since 2021.

RESULTS

The primary objective for managing sepsis and septic shock still includes rapid identification, early initiation of anti-infective treatment, and focus cleansing when feasible. In addition, the focus is on hemodynamic stabilization, including the early use of vasopressors for prevention of hypervolemia and, if necessary, the use of organ support procedures. Supportive treatment, such as the administration of corticosteroids and the use of apheresis, can be advantageous in specific scenarios. The focus is increasingly shifting towards post-intensive care unit (ICU) follow-up care, improving the quality of life after surviving sepsis and the close involvement of relatives of the patient.

CONCLUSION

Despite the fact that considerable progress has been made in understanding the pathophysiology and treatment of sepsis, the early administration of anti-infective agents, focus control, nuanced volume therapy and the use of catecholamines continue to be fundamental to sepsis management. New recommendations emphasize the early use of vasopressors (primarily norepinephrine) and the administration of corticosteroids, especially in cases of septic shock and pneumonia.

CRRT Is More Than Just Continuous Renal Replacement Therapy

The physiology of the kidney has long been understood, and its mechanisms are well described. The pathology of renal failure is also a deeply researched area. It seems logical, therefore, to create devices that can replace the lost normal function of the kidney. Using the physical processes that take place in the kidney, such as diffusion or convection across a membrane, various renal replacement therapies (RRT) have been created. There are those that are used intermittently and those that are used for longer periods. What they have in common is that all RRTs have the same purpose; to replace the excretory function of the kidney that has been lost. CRRT is an extracorporeal renal replacement therapy that effectively replicates the excretory function of the kidneys in cases of acute renal failure. However, it has become increasingly evident that this rapidly advancing treatment modality offers benefits beyond merely substituting kidney function, with its applications continuing to expand significantly with non-renal and other indications. The use of these devices has raised new questions, many of which are still not clearly answered. When should this start? Who should receive it? How long should it last? What indication should it be for? What modality should it be with? How does it change the pharmacokinetics of the medicines? To answer these questions, it is first worth understanding the mechanisms behind the processes and the factors that influence them. This should not only focus on the procedures used in RRT therapies, but also consider the patient's condition and the physicochemical properties of the drugs. In this review, we aim to provide a literature summary to highlight the factors that may influence the success of RRT therapies.

Fluid deresuscitation in critically ill children: comparing perspectives of intensivists and nephrologists

Introduction

Fluid accumulation, presently defined as a pathologic state of overhydration/volume overload associated with clinical impact, is common and associated with worse outcomes. At times, deresuscitation, the active removal of fluid via diuretics or ultrafiltration, is necessary. There is no consensus regarding deresuscitation in children admitted to the pediatric intensive care unit. Little is known regarding perceptions and practices among pediatric intensivists and nephrologists regarding fluid provision and deresuscitation.

Methods

Cross-sectional electronic survey of pediatric nephrologists and intensivists from academic societies in the United States designed to better understand fluid management between disciplines. A clinical vignette was used to characterize the perceptions of optimal timing and method of deresuscitation initiation at four timepoints that correspond to different stages of shock.

Results

In total, 179 respondents (140 intensivists, 39 nephrologists) completed the survey. Most 75.4% (135/179) providers believe discussing fluid balance and initiating fluid deresuscitation in pediatric intensive care unit (PICU) patients is "very important". The first clinical vignette time point (corresponding to resuscitation phase of early shock) had the most dissimilarity between intensivists and nephrologists (p = 0.01) with regards to initiation of deresuscitation. However, providers demonstrated increasing agreement in their responses to initiate deresuscitation as the clinical vignette progressed. Compared to intensivists, nephrologists were more likely to choose "dialysis or ultrafiltration" as a deresuscitation method during the optimization [10.3 vs. 2.9% (p = 0.07)], stabilization [18.0% vs. 3.6% (p < 0.01)], and evacuation [48.7% vs. 23.6% (p < 0.01)] phases of shock. Conversely, intensivists were more likely to utilize scheduled diuretics than nephrologists [47.1% vs. 28.2% (p = 0.04)] later on in the patient course.

Discussion

Most physicians believe that discussing fluid balance and deresuscitation is important. Nevertheless, when to initiate deresuscitation and how to accomplish it differed between nephrologist and intensivists. Widely understood and operationalizable definitions, further research, and eventually evidence-based guidelines are needed to help guide care.

Cytokine adsorption in patients with acute-on-chronic liver failure (CYTOHEP): A single center, open-label, three-arm, randomized, controlled intervention pilot trial

BACKGROUND

To investigate the efficacy of bilirubin reduction by hemoadsorption with CytoSorb® in patients with acute-on-chronic liver failure (ACLF) receiving continuous renal replacement therapy (CRRT).

METHODS

A prospective, randomized, single-center, open-label, controlled pilot trial. Patients with ACLF, acute kidney injury, and serum bilirubin ≥5 mg/dL were assigned 1:1:1 to one of three study groups (CRRT with or without hemoadsorption, no CRRT). In the hemoadsorption group, the CytoSorb adsorber was incorporated into the CRRT system, replaced after 12, 24, and 48 h, and removed after 72 h. The primary endpoint was the serum bilirubin level after 72 h.

RESULTS

CYTOHEP was terminated early due to difficulties in recruiting patients and ethical concerns. Three of 9 patients (33%) were treated in each group. Comparing the three groups, mean bilirubin levels after 72 h were lower by -8.0 mg/dL in the "CRRT with hemoadsorption" group compared to "CRRT without hemoadsorption" (95% CI, -21.3 to 5.3 mg/dL; p = 0.17). The corresponding mean difference between "CRRT without hemoadsorption" and "no CRRT" was -1.4 mg/dL (95% CI, -14.2 to 11.5 mg/dL; p = 0.78). Comparing "CRRT with hemoadsorption" and "no CRRT," it was -9.4 mg/dL (95% CI, -20.8 to 2.1 mg/dL; p = 0.0854). Only 1/9 patients (11%, "no CRRT" group) survived day 30 after study inclusion but died on day 89. IL-6, liver function parameters, and clinical scores were similar between the study groups.

CONCLUSIONS

CYTOHEP failed to demonstrate that extracorporeal hemoadsorption combined with CRRT can reduce serum bilirubin in ACLF patients with acute kidney failure.

Chemokine (C-C Motif) Ligand 14 to Predict Persistent Severe Acute Kidney Injury: A Systematic Review and Meta-Analysis

INTRODUCTION

In this systematic review and meta-analysis, we aimed to review available data and provide pooled estimates of the predictive performance of urinary chemokine (C-C motif) ligand (uCCL14) for persistent (≥48 h) severe acute kidney injury (PS-AKI).

METHODS

We searched MEDLINE, PubMed, Cochrane Library, and EMBASE for studies published up to April 11, 2023. We considered all studies including adults and reporting on the ability of uCCL14 to predict PS-AKI as defined by AKI persisting for 48 or 72 h. Data extraction was performed by one investigator using a standardized form. It was checked for adequacy and completeness by another investigator.

RESULTS

After screening, we identified 13 relevant studies. Among those, four (561 patients) provided sufficient data regarding the outcome of interest and were included. Considering each study cutoff value, pooled sensitivity and specificity were 0.85 (95% CI: 0.77-0.90, I2 = 34.1%) and 0.96 (95% CI: 0.94-0.98, I2 = 53.7%), respectively. Pooled positive likelihood ratio (LR), negative LR, and diagnostic odds ratio were 8.98 (95% CI: 4.92-16.37, I2 = 23%), 0.25 (95% CI: 0.17-0.37, I2 = 0%), and 14.98 (95% CI: 3.55-63.27, I2 = 72.9%), respectively. The area under the curve estimated by summary receiver operating characteristics was 0.86 (95% CI: 0.70-0.95). Heterogeneity induced by the threshold effect was low (Spearman's correlation coefficient: -0.30, p value = 0.62) but significant for non-threshold effect. Risk of bias and concern for applicability according to the QUADAS-2 criteria was generally low. High risk in the index test due to the absence of prespecified thresholds was a concern for most studies.

CONCLUSION

Based on current evidence, uCCL14 appears to have a good predictive performance for the occurrence of PS-AKI. Interventional trials to study a biomarker-guided application of AKI care bundles and RRT are indicated.

Review of Advancements in Managing Cardiogenic Shock: From Emergency Care Protocols to Long-Term Therapeutic Strategies

Cardiogenic shock (CS) is a complex multifactorial clinical syndrome of end-organ hypoperfusion that could be associated with multisystem organ failure, presenting a diverse range of causes and symptoms. Despite improving survival in recent years due to new advancements, CS still carries a high risk of severe morbidity and mortality. Recent research has focused on improving early detection and understanding of CS through standardized team approaches, detailed hemodynamic assessment, and selective use of temporary mechanical circulatory support devices, leading to better patient outcomes. This review examines CS pathophysiology, emerging classifications, current drug and device therapies, standardized team management strategies, and regionalized care systems aimed at optimizing shock outcomes. Furthermore, we identify gaps in knowledge and outline future research needs.

Acute Management of Sepsis beyond 24 Hours

Sepsis manifests as a dysregulated immune response to an infection, leading to tissue damage, organ failure, and potentially death or long-term health issues. Sepsis remains a major health challenge globally, causing approximately 50 million cases and 11 million deaths annually. Early management of sepsis focuses on source control, antimicrobial treatment, and supporting vital organ function. Subsequent care includes metabolic, nutritional, and immune therapies to address the complex needs of septic patients. Metabolic management is based on obtaining moderate glucose targets. Nutritional support aims to mitigate hypercatabolism and muscle wasting, but aggressive early nutrition does not improve outcomes and could even be harmful. Immune modulation is crucial due to the dual nature of sepsis-induced immune responses. Corticosteroids have shown benefits in shock and organ dysfunction reversal and in mortality reduction with current guidelines recommending them in vasopressor therapy-dependent patients. In conclusion, sepsis management beyond the initial hours requires a multifaceted approach, focusing on metabolic, nutritional, and immune system support tailored to individual patient needs to enhance survival and recovery.

When to start renal replacement therapy in acute kidney injury: What are we waiting for?

Acute kidney injury remains a serious condition with a high mortality risk. In the absence of any new drugs, renal replacement therapy (RRT) is the most important treatment option. Randomized controlled trials have concluded that in critically ill patients without an emergency indication for RRT, a watchful waiting strategy is safe; however, further delays in RRT did not seem to confer any benefit, rather was associated with potential harm. During this process, balancing the risks of complications due to an unnecessary intervention with the risk of not correcting a potentially life-threatening complication remains a challenge. Dynamic renal function assessment, especially dynamic assessment of renal demand-capacity matching, combined with renal biomarkers such as neutrophil gelatinase-associated lipocalin and furosemide stress test, is helpful to identify which patients and when the patients may benefit from RRT.

Association of continuous kidney replacement therapy timing and mortality in critically ill children

BACKGROUND

Acute kidney injury (AKI) is a common complication of critical illness and associated with high morbidity and mortality. Optimal timing of continuous kidney replacement therapy (CKRT) in children is unknown. We aimed to measure the association between timing of initiation and mortality.

METHODS

This is a single-center retrospective cohort study of pediatric patients receiving CKRT from 2013 to 2019. The primary exposure, time to CKRT initiation, was measured from onset of stage 3 AKI during hospitalization (defined using Kidney Disease: Improving Global Outcomes creatinine and urine output criteria) and analyzed as both a continuous and categorical variable. The primary outcome was ICU mortality.

RESULTS

Ninety-nine patients met criteria for analysis. Overall mortality was 39% (39/99). Median time from stage 3 AKI onset to CKRT initiation was 1.5 days in survivors and 5.5 days in nonsurvivors (p < 0.001). In multivariable analysis, increased time to CKRT initiation was independently associated with mortality [OR 1.02 per hour (95% CI 1.01-1.04), p < 0.001]. Longer time to CKRT initiation was associated with higher odds of mortality in ascending time intervals. Patients started on CKRT > 2 days compared to < 2 days after stage 3 AKI onset had higher mortality (65% vs. 5%, p < 0.001), longer median ICU length of stay (25 vs. 12 d, p < 0.001), longer median CKRT duration (11 vs. 5 d, p < 0.001), and fewer AKI-free days (0 vs. 14 d, p < 0.001).

CONCLUSIONS

Longer time to initiation of CKRT after development of severe AKI is independently associated with mortality. Consideration of early CKRT in this high-risk population may be a strategy to reduce mortality and improve recovery of kidney function. However, there remains significant heterogeneity in the definition of early versus late initiation and the optimal timing of CKRT remains unknown.

APASL clinical practice guidelines on the management of acute kidney injury in acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is a syndrome that is characterized by the rapid development of organ failures predisposing these patients to a high risk of short-term early death. The main causes of organ failure in these patients are bacterial infections and systemic inflammation, both of which can be severe. For the majority of these patients, a prompt liver transplant is still the only effective course of treatment. Kidneys are one of the most frequent extrahepatic organs that are affected in patients with ACLF, since acute kidney injury (AKI) is reported in 22.8-34% of patients with ACLF. Approach and management of kidney injury could improve overall outcomes in these patients. Importantly, patients with ACLF more frequently have stage 3 AKI with a low rate of response to the current treatment modalities. The objective of the present position paper is to critically review and analyze the published data on AKI in ACLF, evolve a consensus, and provide recommendations for early diagnosis, pathophysiology, prevention, and management of AKI in patients with ACLF. In the absence of direct evidence, we propose expert opinions for guidance in managing AKI in this very challenging group of patients and focus on areas of future research. This consensus will be of major importance to all hepatologists, liver transplant surgeons, and intensivists across the globe.

Treatment of Acute Kidney Injury: A Review of Current Approaches and Emerging Innovations

Acute kidney injury (AKI) is a complex and life-threatening condition with multifactorial etiologies, ranging from ischemic injury to nephrotoxic exposures. Management is founded on treating the underlying cause of AKI, but supportive care-via fluid management, vasopressor therapy, kidney replacement therapy (KRT), and more-is also crucial. Blood pressure targets are often higher in AKI, and these can be achieved with fluids and vasopressors, some of which may be more kidney-protective than others. Initiation of KRT is controversial, and studies have not consistently demonstrated any benefit to early start dialysis. There are no targeted pharmacotherapies for AKI itself, but some do exist for complications of AKI; additionally, medications become a key aspect of AKI management because changes in renal function and dialysis support can lead to issues with both toxicities and underdosing. This review will cover existing literature on these and other aspects of AKI treatment. Additionally, this review aims to identify gaps and challenges and to offer recommendations for future research and clinical practice.

Personalizing renal replacement therapy initiation in the intensive care unit: a reinforcement learning-based strategy with external validation on the AKIKI randomized controlled trials

OBJECTIVE

The timely initiation of renal replacement therapy (RRT) for acute kidney injury (AKI) requires sequential decision-making tailored to individuals' evolving characteristics. To learn and validate optimal strategies for RRT initiation, we used reinforcement learning on clinical data from routine care and randomized controlled trials.

MATERIALS AND METHODS

We used the MIMIC-III database for development and AKIKI trials for validation. Participants were adult ICU patients with severe AKI receiving mechanical ventilation or catecholamine infusion. We used a doubly robust estimator to learn when to start RRT after the occurrence of severe AKI for three days in a row. We developed a "crude strategy" maximizing the population-level hospital-free days at day 60 (HFD60) and a "stringent strategy" recommending RRT when there is significant evidence of benefit for an individual. For validation, we evaluated the causal effects of implementing our learned strategies versus following current best practices on HFD60.

RESULTS

We included 3748 patients in the development set and 1068 in the validation set. Through external validation, the crude and stringent strategies yielded an average difference of 13.7 [95% CI -5.3 to 35.7] and 14.9 [95% CI -3.2 to 39.2] HFD60, respectively, compared to current best practices. The stringent strategy led to initiating RRT within 3 days in 14% of patients versus 38% under best practices.

DISCUSSION

Implementing our strategies could improve the average number of days that ICU patients spend alive and outside the hospital while sparing RRT for many.

CONCLUSION

We developed and validated a practical and interpretable dynamic decision support system for RRT initiation in the ICU.

CCL14 Predicts Oliguria and Dialysis Requirement in Patients with Moderate to Severe Acute Kidney Injury

INTRODUCTION

AKI is a frequent complication of critical illness and portends poor outcome. CCL14 is a validated predictor of persistent severe AKI in critically ill patients. We examined the association of CCL14 with urine output within 48 h.

METHODS

In pooled data from 2 studies of critically ill patients with KDIGO stage 2-3 AKI, CCL14 was measured by NEPHROCLEAR™ CCL14 Test on the Astute 140® Meter (low, intermediate, and high categories [1.3 and 13 ng/mL]). Average hourly urine output over 48 h, stage 3 AKI per urine output criterion on day 2, and composite of dialysis or death within 7 days were examined using multivariable mixed and logistic regression models.

RESULTS

Of the 497 subjects with median age of 65 (56-74) years, 49% (242/497) were on diuretics. CCL14 concentration was low in 219 (44%), intermediate in 217 (44%), and high in 61 (12%) patients. In mixed regression analysis, hourly urine output over time was different within each CCL14 risk category based on diuretic use due to significant three-way interaction (p < 0.001). In logistic regression analysis, CCL14 risk category was independently associated with low urine output on day 2 per KDIGO stage 3 (adjusted for diuretic use and baseline clinical variables), and composite of dialysis or death within 7 days (adjusted for urine output within 48 h of CCL14 measurement).

CONCLUSIONS

CCL14 measured in patients with moderate to severe AKI is associated with urine output trajectory within 48 h, oliguria on day 2, and dialysis within 7 days.

Current Fluid Management Practice in Critically Ill Adults on Continuous Renal Replacement Therapy: A Binational, Observational Study

INTRODUCTION

In critically ill patients undergoing continuous renal replacement therapy (CRRT), a positive fluid balance (FB) is associated with adverse outcomes. However, current FB management practices in CRRT patients are poorly understood. We aimed to study FB and its components in British and Australian CRRT patients to inform future trials.

METHODS

We obtained detailed electronic health record data on all fluid-related variables during CRRT and hourly FB for the first 7 days of treatment.

RESULTS

We studied 1,616 patients from three tertiary intensive care units (ICUs) in two countries. After the start of CRRT, the mean cumulative FB became negative at 31 h and remained negative over 7 days to a mean nadir of -4.1 L (95% confidence interval (CI) of -4.6 to -3.5). The net ultrafiltration (NUF) rate was the dominant fluid variable (-67.7 mL/h; standard deviation (SD): 75.7); however, residual urine output (-34.7 mL/h; SD: 54.5), crystalloid administration (48.1 mL/h; SD: 44.6), and nutritional input (36.4 mL/h; SD: 29.7) significantly contributed to FB. Patients with a positive FB after 72 h of CRRT were more severely ill, required high-dose vasopressors, and had high lactate concentrations (5.0 mmol/L; interquartile range: 2.3-10.5). A positive FB was independently associated with increased hospital mortality (odds ratio: 1.70; 95% CI; p = 0.004).

CONCLUSION

In the study ICUs, most CRRT patients achieved a predominantly NUF-dependent negative FB. Patients with a positive FB at 72 h had greater illness severity and haemodynamic instability. Achieving equipoise for conducting trials that target a negative early FB in such patients may be difficult.

Failing kidneys: renal replacement therapies in the ICU

Acute kidney injury (AKI) is one of the most common organ dysfunctions impacting ICU (intensive care unit) patients. Early diagnosis using the various classification systems and interventions that can be aided by use of biomarkers are key in improving outcomes. Once the patient meets criteria of AKI, many patient specific factors determine the optimal timing for and mode of renal replacement therapy. There are several special considerations in surgical ICU patients with AKI including management of intracranial hypertension in those with cerebral edema, anticoagulation in high-risk bleeding patients, and use of contrast imaging. This article provides a focused review of the essential aspects of diagnosis and management of AKI in the critically ill or injured surgical patient.

Management of cardiogenic shock: a narrative review

Cardiogenic shock (CS) is characterized by low cardiac output and sustained tissue hypoperfusion that may result in end-organ dysfunction and death. CS is associated with high short-term mortality, and its management remains challenging despite recent advances in therapeutic options. Timely diagnosis and multidisciplinary team-based management have demonstrated favourable effects on outcomes. We aimed to review evidence-based practices for managing patients with ischemic and non-ischemic CS, detailing the multi-organ supports needed in this critically ill patient population.

Acute kidney injury in patients with burns

Burn injury is associated with a high risk of acute kidney injury (AKI) with a prevalence of AKI among patients with burns of 9-50%. Despite an improvement in burn injury survival in the past decade, AKI in patients with burns is associated with an extremely poor short-term and long-term prognosis, with a mortality of >80% among those with severe AKI. Factors that contribute to the development of AKI in patients with burns include haemodynamic alterations, burn-induced systemic inflammation and apoptosis, haemolysis, rhabdomyolysis, smoke inhalation injury, drug nephrotoxicity and sepsis. Early and late AKI after burn injury differ in their aetiologies and outcomes. Sepsis is the main driver of late AKI in patients with burns and late AKI has been associated with higher mortality than early AKI. Prevention of early AKI involves correction of hypovolaemia and avoidance of nephrotoxic drugs (for example, hydroxocobalamin), whereas prevention of late AKI involves prevention and early recognition of sepsis as well as avoidance of nephrotoxins. Treatment of AKI in patients with burns remains supportive, including prevention of fluid overload, treatment of electrolyte disturbance and use of kidney replacement therapy when indicated.

Renal replacement therapy initiation strategies in comatose patients with severe acute kidney injury: a secondary analysis of a multicenter randomized controlled trial

PURPOSE

The effect of renal replacement therapy (RRT) in comatose patients with acute kidney injury (AKI) remains unclear. We compared two RRT initiation strategies on the probability of awakening in comatose patients with severe AKI.

METHODS

We conducted a post hoc analysis of a trial comparing two delayed RRT initiation strategies in patients with severe AKI. Patients were monitored until they had oliguria for more than 72 h and/or blood urea nitrogen higher than 112 mg/dL and then randomized to a delayed strategy (RRT initiated after randomization) or a more-delayed one (RRT initiated if complication occurred or when blood urea nitrogen exceeded 140 mg/dL). We included only comatose patients (Richmond Agitation-Sedation scale [RASS] < - 3), irrespective of sedation, at randomization. A multi-state model was built, defining five mutually exclusive states: death, coma (RASS < - 3), incomplete awakening (RASS [- 3; - 2]), awakening (RASS [- 1; + 1] two consecutive days), and agitation (RASS >  + 1). Primary outcome was the transition from coma to awakening during 28 days after randomization.

RESULTS

A total of 168 comatose patients (90 delayed and 78 more-delayed) underwent randomization. The transition intensity from coma to awakening was lower in the more-delayed group (hazard ratio [HR] = 0.36 [0.17-0.78]; p = 0.010). Time spent awake was 10.11 days [8.11-12.15] and 7.63 days [5.57-9.64] in the delayed and the more-delayed groups, respectively. Two sensitivity analyses were performed based on sedation status and sedation practices across centers, yielding comparable results.

CONCLUSION

In comatose patients with severe AKI, a more-delayed RRT initiation strategy resulted in a lower chance of transitioning from coma to awakening.

Programs and processes for advancing pediatric acute kidney support therapy in hospitalized and critically ill children: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference

Pediatric acute kidney support therapy (paKST) programs aim to reliably provide safe, effective, and timely extracorporeal supportive care for acutely and critically ill pediatric patients with acute kidney injury (AKI), fluid and electrolyte derangements, and/or toxin accumulation with a goal of improving both hospital-based and lifelong outcomes. Little is known about optimal ways to configure paKST teams and programs, pediatric-specific aspects of delivering high-quality paKST, strategies for transitioning from acute continuous modes of paKST to facilitate rehabilitation, or providing effective short- and long-term follow-up. As part of the 26th Acute Disease Quality Initiative Conference, the first to focus on a pediatric population, we summarize here the current state of knowledge in paKST programs and technology, identify key knowledge gaps in the field, and propose a framework for current best practices and future research in paKST.

Endothelium-related biomarkers enhanced prediction of kidney support therapy in critically ill patients with non-oliguric acute kidney injury

Acute kidney injury (AKI) is a common condition in hospitalized patients who often requires kidney support therapy (KST). However, predicting the need for KST in critically ill patients remains challenging. This study aimed to analyze endothelium-related biomarkers as predictors of KST need in critically ill patients with stage 2 AKI. A prospective observational study was conducted on 127 adult ICU patients with stage 2 AKI by serum creatinine only. Endothelium-related biomarkers, including vascular cell adhesion protein-1 (VCAM-1), angiopoietin (AGPT) 1 and 2, and syndecan-1, were measured. Clinical parameters and outcomes were recorded. Logistic regression models, receiver operating characteristic (ROC) curves, continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were used for analysis. Among the patients, 22 (17.2%) required KST within 72 h. AGPT2 and syndecan-1 levels were significantly greater in patients who progressed to the KST. Multivariate analysis revealed that AGPT2 and syndecan-1 were independently associated with the need for KST. The area under the ROC curve (AUC-ROC) for AGPT2 and syndecan-1 performed better than did the constructed clinical model in predicting KST. The combination of AGPT2 and syndecan-1 improved the discrimination capacity of predicting KST beyond that of the clinical model alone. Additionally, this combination improved the classification accuracy of the NRI and IDI. AGPT2 and syndecan-1 demonstrated predictive value for the need for KST in critically ill patients with stage 2 AKI. The combination of AGPT2 and syndecan-1 alone enhanced the predictive capacity of predicting KST beyond clinical variables alone. These findings may contribute to the early identification of patients who will benefit from KST and aid in the management of AKI in critically ill patients.

Global Scientific Trends in Continuous Renal Replacement Therapy from 2000 to 2023: A Bibliometric and Visual Analysis

INTRODUCTION

Continuous renal replacement therapy (CRRT) is one of the most widely used blood purification and organ support methods in the ICU. However, the development process, the current status, hotspots, and future trends of CRRT remain unclear.

METHOD

The WoSCC database was used to analyze CRRT research evolution and theme trends. VOSviewer was used to construct coauthorship, co-occurrence, co-citation, and network visualizations. CiteSpace is used to detect bursts for co-occurrence items. Several important subtopics were reviewed and discussed in more detail.

RESULTS

Global publications increased from 56 in 2000 to 398 in 2023, a 710.71% increase. Blood Purification published the most manuscripts, followed by the International Journal of Artificial Organs. The USA, the San Bortolo Hospital, and Bellomo were the most productive and impactful institution, country, and author, respectively. Based on co-occurrence cluster analysis, five clusters emerged: (1) clinical applications and management of CRRT; (2) sepsis and CRRT; (3) CRRT anticoagulant management; (4) CRRT and antibiotic pharmacokinetics and pharmacodynamics; and (5) comparison of CRRT and intermittent hemodialysis. COVID-19, initiation, ECOMO, cefepime, guidelines, cardiogenic shock, biomarker, and outcome were the latest high-frequency keywords or strongest bursts, indicating the emerging frontiers of CRRT.

CONCLUSIONS

There has been widespread publication and citation of CRRT research in the past 2 decades. We provide an overview of current trends, global collaboration patterns, basic knowledge, research hotspots, and emerging frontiers.

Meaning and Management of Perioperative Oliguria

Perioperative oliguria is an alarm signal. The initial assessment includes closer patient monitoring, evaluation of volemic status, risk-benefit of fluid challenge or furosemide stress test, and investigation of possible perioperative complications.

Elevated strong ion gap: A predictor of the initiation of continuous renal replacement therapy in acute kidney injury

BACKGROUND

There is no optimal timing for continuous renal replacement therapy (CRRT) in acute kidney injury (AKI). AKI is a reason for the increased unmeasured anions, which refers to the increased organic acids in the blood, and they can be detected by calculating strong ion gap (SIG). SIG level at the moment of the AKI diagnosis may be a predictor for the initiation of CRRT.

METHODS

Patients who were diagnosed with AKI in the first week of the intensive care unit (ICU) period were included in this prospective observational study. At the moment of the AKI diagnosis, blood gas samples were recorded, and SIG was calculated.

RESULTS

The median level of SIG at the moment of the AKI diagnosis of CRRT (+) patients was significantly higher than CRRT (-) patients (7.4 and 3.2 mmol L-1, respectively). In the multivariate Cox regression analysis, the likelihood of the initiation of CRRT was increased 1.16-fold (1.01-1.33) and 4.0-fold (1.9-8.7) by only 1 mmol L-1 increases in SIG and SIG ≥6 mmol L-1 at the moment of AKI diagnosis, respectively (p = 0.035 and p < 0.001).

CONCLUSIONS

Increased SIG at the moment of the AKI diagnosis in patients with AKI may be a predictive marker to initiate CRRT.

Continuous renal replacement therapy in neonates and children: what does the pediatrician need to know? An overview from the Critical Care Nephrology Section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

Continuous renal replacement therapy (CRRT) is the preferred method for renal support in critically ill and hemodynamically unstable children in the pediatric intensive care unit (PICU) as it allows for gentle removal of fluids and solutes. The most frequent indications for CRRT include acute kidney injury (AKI) and fluid overload (FO) as well as non-renal indications such as removal of toxic metabolites in acute liver failure, inborn errors of metabolism, and intoxications and removal of inflammatory mediators in sepsis. AKI and/or FO are common in critically ill children and their presence is associated with worse outcomes. Therefore, early recognition of AKI and FO is important and timely transfer of patients who might require CRRT to a center with institutional expertise should be considered. Although CRRT has been increasingly used in the critical care setting, due to the lack of standardized recommendations, wide practice variations exist regarding the main aspects of CRRT application in critically ill children.     Conclusion: In this review, from the Critical Care Nephrology section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC), we summarize the key aspects of CRRT delivery and highlight the importance of adequate follow up among AKI survivors which might be of relevance for the general pediatric community. What is Known: • CRRT is the preferred method of renal support in critically ill and hemodynamically unstable children in the PICU as it allows for gentle removal of fluids and solutes. • Although CRRT has become an important and integral part of modern pediatric critical care, wide practice variations exist in all aspects of CRRT. What is New: • Given the lack of literature on guidance for a general pediatrician on when to refer a child for CRRT, we recommend timely transfer to a center with institutional expertise in CRRT, as both worsening AKI and FO have been associated with increased mortality. • Adequate follow-up of PICU patients with AKI and CRRT is highlighted as recent findings demonstrate that these children are at increased risk for adverse long-term outcomes.

Navigating the Labyrinth: Intensive Care Challenges for Patients with Acute-on-Chronic Liver Failure

Acute-on-chronic liver failure (ACLF) refers to the deterioration of liver function in individuals who already have chronic liver disease. In the setting of ACLF, liver damage leads to the failure of other organs and is associated with increased short-term mortality. Optimal medical management of patients with ACLF requires implementing complex treatment strategies, often in an intensive care unit (ICU). Failure of organs other than the liver distinguishes ACLF from other critical illnesses. Although there is growing evidence supporting the current approach to ACLF management, the mortality associated with this condition remains unacceptably high. In this review, we discuss considerations for ICU care of patients with ACLF and highlight areas for further research.

Automated Electronic Alert for the Care and Outcomes of Adults With Acute Kidney Injury: A Randomized Clinical Trial

Importance

Despite the expansion of published electronic alerts for acute kidney injury (AKI), there are still concerns regarding their effect on the clinical outcomes of patients.

Objective

To evaluate the effect of the AKI alert combined with a care bundle on the care and clinical outcomes of patients with hospital-acquired AKI.

Design, Setting, and Participants

This single-center, double-blind, parallel-group randomized clinical trial was conducted in a tertiary teaching hospital in Nanjing, China, from August 1, 2019, to December 31, 2021. The inclusion criteria were inpatient adults aged 18 years or older with AKI, which was defined using the Kidney Disease: Improving Global Outcomes creatinine criteria. Participants were randomized 1:1 to either the alert group or the usual care group, which were stratified by medical vs surgical ward and by intensive care unit (ICU) vs non-ICU setting. Analyses were conducted on the modified intention-to-treat population.

Interventions

A programmatic AKI alert system generated randomization automatically and sent messages to the mobile telephones of clinicians (alert group) or did not send messages (usual care group). A care bundle accompanied the AKI alert and consisted of general, nonindividualized, and nonmandatory AKI management measures.

Main Outcomes and Measures

The primary outcome was maximum change in estimated glomerular filtration rate (eGFR) within 7 days after randomization. Secondary patient-centered outcomes included death, dialysis, AKI progression, and AKI recovery. Care-centered outcomes included diagnostic and therapeutic interventions for AKI.

Results

A total of 2208 patients (median [IQR] age, 65 [54-72] years; 1560 males [70.7%]) were randomized to the alert group (n = 1123) or the usual care group (n = 1085) and analyzed. Within 7 days of randomization, median (IQR) maximum absolute changes in eGFR were 3.7 (-6.4 to 19.3) mL/min/1.73 m2 in the alert group and 2.9 (-9.2 to 16.9) mL/min/1.73 m2 in the usual care group (P = .24). This result was robust in all subgroups in an exploratory analysis. For care-centered outcomes, patients in the alert group had more intravenous fluids (927 [82.6%] vs 670 [61.8%]; P < .001), less exposure to nonsteroidal anti-inflammatory drugs (56 [5.0%] vs 119 [11.0%]; P < .001), and more AKI documentation at discharge (560 [49.9%] vs 296 [27.3%]; P < .001) than patients in the usual care group. No differences were observed in patient-centered secondary outcomes between the 2 groups.

Conclusions and Relevance

Results of this randomized clinical trial showed that the electronic AKI alert did not improve kidney function or other patient-centered outcomes but changed patient care behaviors. The findings warrant the use of a combination of high-quality interventions and AKI alert in future clinical practice.

Trial Registration

ClinicalTrials.gov Identifier: NCT03736304.

Blood Purification in Patients with Sepsis Associated with Acute Kidney Injury: A Narrative Review

Sepsis leads to organ dysfunction. Acute kidney injury, a common type of organ dysfunction, is associated with a high mortality rate in patients with sepsis. Kidney replacement therapy can correct the metabolic, electrolyte, and fluid imbalances caused by acute kidney injury. While this therapy can improve outcomes, evidence of its beneficial effects is lacking. Herein, we review the indications for blood purification therapy, including kidney replacement therapy, and the current knowledge regarding acute kidney injury in terms of renal and non-renal indications. While renal indications have been well-documented, indications for blood purification therapy in sepsis (non-renal indications) remain controversial. Excessive inflammation is an important factor in the development of sepsis; blood purification therapy has been shown to reduce inflammatory mediators and improve hemodynamic instability. Given the pathophysiology of sepsis, blood purification therapy may decrease mortality rates in these patients. Further trials are needed in order to establish the effectiveness of blood purification therapy for sepsis.

The Evolution and Future of Intensive Care Management in the Era of Telecritical Care and Artificial Intelligence

Critical care practice has been embodied in the healthcare system since the institutionalization of intensive care units (ICUs) in the late '50s. Over time, this sector has experienced many changes and improvements in providing immediate and dedicated healthcare as patients requiring intensive care are often frail and critically ill with high mortality and morbidity rates. These changes were aided by innovations in diagnostic, therapeutic, and monitoring technologies, as well as the implementation of evidence-based guidelines and organizational structures within the ICU. In this review, we examine these changes in intensive care management over the past 40 years and their impact on the quality of care available to patients. Moreover, the current state of intensive care management is characterized by a multidisciplinary approach and the use of innovative technologies and research databases. Advancements such as telecritical care and artificial intelligence are being increasingly explored, especially since the COVID-19 pandemic, to reduce the length of hospitalization and ICU mortality. With these advancements in intensive care and ever-changing patient needs, critical care experts, hospital managers, and policymakers must also explore appropriate organizational structures and future enhancements within the ICU.

Critically ill patients with acute kidney injury: clinical determinants and post-mortem histology

Background

Acute kidney injury (AKI) requiring renal replacement therapy (RRT) in the intensive care unit (ICU) portends a poor prognosis. We aimed to better characterize predictors of survival and the mechanism of kidney failure in these patients.

Methods

This was a retrospective observational study using clinical and radiological electronic health records, analysed by univariable and multivariable binary logistic regression. Histopathological examination of post-mortem renal tissue was performed.

Results

Among 157 patients with AKI requiring RRT, higher serum creatinine at RRT initiation associated with increased ICU survival [odds ratio (OR) 0.33, 95% confidence interval (CI) 0.17-0.62, P = .001]; however, muscle mass (a marker of frailty) interacted with creatinine (P = .02) and superseded creatinine as a predictor of survival (OR 0.26, 95% CI 0.08-0.82; P = .02). Achieving lower cumulative fluid balance (mL/kg) predicted ICU survival (OR 1.01, 95% CI 1.00-1.01, P < .001), as supported by sensitivity analyses showing improved ICU survival with the use of furosemide (OR 0.40, 95% CI 0.18-0.87, P = .02) and increasing net ultrafiltration (OR 0.97, 95% CI 0.95-0.99, P = .02). A urine output of >500 mL/24 h strongly predicted successful liberation from RRT (OR 0.125, 95% CI 0.05-0.35, P < .001). Post-mortem reports were available for 32 patients; clinically unrecognized renal findings were described in 6 patients, 1 of whom had interstitial nephritis. Experimental staining of renal tissue from patients with sepsis-associated AKI (S-AKI) showed glomerular loss of synaptopodin (P = .02).

Conclusions

Confounding of creatinine by muscle mass undermines its use as a marker of AKI severity in clinical studies. Volume management and urine output are key determinants of outcome. Loss of synaptopodin implicates glomerular injury in the pathogenesis of S-AKI.

Probiotics in septic acute kidney injury, a double blind, randomized control trial

INTRODUCTION

During acute kidney injury (AKI) due to sepsis, the intestinal microbiota changes to dysbiosis, which affects the kidney function recovery (KFR) and amplifies the injury. Therefore, the administration of probiotics could improve dysbiosis and thereby increase the probability of KFR.

METHODS

In this double-blind clinical trial, patients with AKI associated with sepsis were randomized (1:1) to receive probiotics or placebo for 7 consecutive days, with the objectives of evaluate the effect on KFR, mortality, kidney replacement therapy (KRT), urea, urine volume, serum electrolytes and adverse events at day 7.

RESULTS

From February 2019 to March 2022, a total of 92 patients were randomized, 48 to the Probiotic and 44 to Placebo group. When comparing with placebo, those in the Probiotics did not observe a higher KFR (HR 0.93, 0.52-1.68, p = 0.81), nor was there a benefit in mortality at 6 months (95% CI 0.32-1.04, p = 0.06). With probiotics, urea values decreased significantly, an event not observed with placebo (from 154 to 80 mg/dl, p = 0.04 and from 130 to 109 mg/dl, p = 0.09, respectively). Urinary volume, need for KRT, electrolyte abnormalities, and adverse events were similar between groups. (ClinicalTrial.gov NCT03877081) (registered 03/15/2019).

CONCLUSION

In AKI related to sepsis, probiotics for 7 consecutive days did not increase the probability of KFR, nor did other variables related to clinical improvement, although they were safe.

Acute kidney injury biomarker olfactomedin 4 predicts furosemide responsiveness

BACKGROUND

Acute kidney injury (AKI) is associated with increased morbidity and mortality in critically ill patients. Olfactomedin 4 (OLFM4), a secreted glycoprotein expressed in neutrophils and stressed epithelial cells, is upregulated in loop of Henle (LOH) cells following AKI. We hypothesized that urine OLFM4 (uOLFM4) will increase in patients with AKI and may predict furosemide responsiveness.

METHODS

Urine from critically ill children was collected prospectively and tested for uOLFM4 concentrations with a Luminex immunoassay. Severe AKI was defined by KDIGO (stage 2/3) serum creatinine criteria. Furosemide responsiveness was defined as > 3 mL/kg/h of urine output in the 4 h after a 1 mg/kg IV furosemide dose administered as part of standard of care.

RESULTS

Fifty-seven patients contributed 178 urine samples. Irrespective of sepsis status or AKI cause, uOLFM4 concentrations were higher in patients with AKI (221 ng/mL [IQR 93-425] vs. 36 ng/mL [IQR 15-115], p = 0.007). uOLFM4 concentrations were higher in patients unresponsive to furosemide (230 ng/mL [IQR 102-534] vs. 42 ng/mL [IQR 21-161], p = 0.04). Area under the receiver operating curve for association with furosemide responsiveness was 0.75 (95% CI, 0.60-0.90).

CONCLUSIONS

AKI is associated with increased uOLFM4. Higher uOLFM4 is associated with a lack of response to furosemide. Further testing is warranted to determine whether uOLFM4 could identify patients most likely to benefit from earlier escalation from diuretics to kidney replacement therapy to maintain fluid balance. A higher resolution version of the Graphical abstract is available as Supplementary information.

Extracorporeal blood purification therapies for sepsis-associated acute kidney injury in critically ill patients: expert opinion from the SIAARTI-SIN joint commission

Sepsis-Associated Acute Kidney Injury is a life-threatening condition leading to high morbidity and mortality in critically ill patients admitted to the intensive care unit. Over the past decades, several extracorporeal blood purification therapies have been developed for both sepsis and sepsis-associated acute kidney injury management. Despite the widespread use of extracorporeal blood purification therapies in clinical practice, it is still unclear when to start this kind of treatment and how to define its efficacy. Indeed, several questions on sepsis-associated acute kidney injury and extracorporeal blood purification therapy still remain unresolved, including the indications and timing of renal replacement therapy in patients with septic vs. non-septic acute kidney injury, the optimal dialysis dose for renal replacement therapy modalities in sepsis-associated acute kidney injury patients, and the rationale for using extracorporeal blood purification therapies in septic patients without acute kidney injury. Moreover, the development of novel extracorporeal blood purification therapies, including those based on the use of adsorption devices, raised the attention of the scientific community both on the clearance of specific mediators released by microorganisms and by injured cells and potentially involved in the pathogenic mechanisms of organ dysfunction including sepsis-associated acute kidney injury, and on antibiotic removal. Based on these considerations, the joint commission of the Italian Society of Anesthesiology and Critical Care (SIAARTI) and the Italian Society of Nephrology (SIN) herein addressed some of these issues, proposed some recommendations for clinical practice and developed a common framework for future clinical research in this field.