Long term end-stage renal disease and death following acute renal replacement therapy in the ICU

Overview of Renal Replacement Therapy Use in a General Intensive Care Unit

Objectives. Population-based studies regarding renal replacement therapy (RRT) used in critical care populations are useful to understand the trend and impact of medical care interventions. We describe the use of RRT and associated outcomes (mortality and length of intensive care stay) in a level 1 hospital. Design. A retrospective descriptive observational study. Patients. Critically ill patients admitted to the ICU from 1 January to 31 December 2018. Interventions. Age, gender, ward of admission, primary organ dysfunction at admission, length of hospital stay (LOS), mechanical ventilation, APACHE, SOFA and ISS scores, the use of vasopressors, transfusion, RRT and the number of RRT sessions were extracted. Results. 1703 critically ill patients were divided into two groups: the RRT-group (238 patients) and the non-RRT group (1465 patients). The mean age was 63.58 ± 17.52 (SD) in the final ICU studied patients (64.72 ± 16.64 SD in the RRT-group), 60.5% being male. Patients admitted from general surgery ward needing RRT were 41.4%. The specific scores, the use of vasopressors, transfusions and mortality were higher in the RRT-group. The ICU LOS was superior in the RRT-group, regardless of the primary organ dysfunction. Conclusions. RRT was practiced in 13.9% of patients (especially after age of 61), with mortality being the outcome for 66.8% of the RRT-group patients. All analyzed data were higher in the RRT group, especially for multiple trauma and surgical patients, or patients presenting cardiac or renal dysfunctions at admission. We found significant increased ISS scores in the RRT-group, a significant association between the need of vasopressors or transfusion requirement and RRT use, and an association in the number of RRT sessions and LOS (p < 0.001).

Lower short-term mortality in ICU patients on chronic dialysis than in those requiring acute dialysis

BACKGROUND

In ICU patients, we aimed to describe the outcomes of those with end-stage renal disease (ESRD) as compared to those requiring acute renal replacement therapy (RRT).

METHODS

Retrospective analysis of all adult patients admitted to a general, university hospital ICU from 2005 to 2012. ESRD was defined as use of chronic RRT >90 days prior to admission.

RESULTS

We included 5927 patients of whom 1004 (17%) received acute RRT and 161 (3%) had pre-existing ESRD requiring RRT. Thirty-day mortality was 42% vs 28% for acute RRT vs ESRD patients (adjusted hazard ratio (aHR) 0.90 (0.61-1.34)), and 16% for those not requiring RRT (aHR 0.91 (0.60-1.38) compared to ESRD patients). Ninety-day mortality was 55% vs 45% for acute RRT vs ESRD patients (aHR 0.96 (0.70-1.31)), and 22% for those not requiring RRT (aHR 1.19 (0.84-1.67) compared to ESRD patients). Ninety-day ESRD survivors were younger, less severely ill and needed less vasopressor treatment than 90-day ESRD non-survivors. Five-year mortality was 68% vs 69% for acute RRT vs ESRD patients (aHR 1.06 (0.81-1.39)), and 38% for those not requiring RRT (aHR 1.31 (0.99-1.74) compared to ESRD patients).

CONCLUSIONS

The crude mortality for patients with pre-existing ESRD was high. Short-term mortality was within range of those not receiving RRT when adjusted for confounders. The severity of acute illness and the burden of comorbidities may be more important than the lack of kidney function per se for the short-term prognosis of RRT patients in the ICU.

Use of life support in acutely admitted ICU patients. An international cohort study

BACKGROUND

Use of life support in intensive care unit (ICU) patients has been associated with increased risk of poor outcome. The prognostic importance of the duration of support is less studied. We assessed the use of life support and the association between its duration and 90-day mortality in a contemporary cohort of acutely admitted adult ICU patients.

METHODS

We performed a post-hoc analysis of the SUP-ICU 7-day inception cohort study (n = 1034), which was conducted in 97 ICUs in 11 countries. We included patients with an ICU stay of 3 days or more. We assessed the use of life support during the first 3 days in ICU and the crude and adjusted association between its duration and 90-day mortality using logistic regression analyses.

RESULTS

We included 690 patients; their 90-day mortality was 23%. During the first 3 days in ICU mechanical ventilation was used in 65%, vasopressors/inotropes in 57% and renal replacement therapy in 13%. Renal replacement therapy for 3 days or more was associated with a higher 90-day mortality as compared with 1 day of renal replacement therapy [odds ratio 6.5 (95% confidence interval 1.3 to 32.8)]. For mechanical ventilation and vasopressors/inotropes the odds ratios were 2.2 [0.9 to 5.3] and 1.2 [0.5 to 2.6], respectively.

CONCLUSIONS

Among acutely admitted adult ICU patients, a higher number of days of renal replacement therapy in the initial ICU stay were associated with increased risk of death within 90 days. We did not observe such an association for mechanical ventilation or vasopressor/inotropic therapy.