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Shawwa K, Kompotiatis P, Sakhuja A, McCarthy P, Kashani KB. Prolonged exposure to continuous renal replacement therapy in patients with acute kidney injury. J Nephrol 2022; 35:585-595. [PMID: 34160782 PMCID: PMC8695624 DOI: 10.1007/s40620-021-01097-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/10/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Little is known about the process of deciding to discontinue continuous renal replacement therapy (CRRT) in patients with acute kidney injury (AKI) and the impact of CRRT duration on outcomes. METHODS We report the clinical parameters of prolonged CRRT exposure and predictors of doubling of serum creatinine or need for dialysis at 90 days after CRRT with propensity score matching, including covariates that were likely to influence patients in the prolonged CRRT group. RESULTS Among 104 survey responders, most use urine output (87%) to guide CRRT discontinuation, 24% use improvement in clinical or hemodynamic status. In the cohort study, of 854 included patients, 465 participated in the assessment of kidney recovery. Patients with prolonged CRRT had higher SOFA scores (11.9 vs. 11.2) and were more likely to be mechanically ventilated (99% vs. 84%) at CRRT initiation compared to patients without prolonged CRRT, p-value < 0.05. In multivariable logistic regression, daily urine output and cumulative fluid balance leading to CRRT discontinuation or day seven were independently associated with lower [OR 0.87 per 200 ml/day increase] and higher odds [OR 1.03 per 1-L increase] of requiring prolonged CRRT, respectively. After propensity score matching, prolonged exposure to CRRT was independently associated with increased risk of doubling serum creatinine or dialysis at 90 days, OR 3.1 (95% CI 1.23-8.3 p = 0.017). CONCLUSIONS Resolution of critical illness and signs of kidney recovery are important factors when considering CRRT discontinuation. Prolonged CRRT exposure may be associated with less chance of kidney recovery among survivors.
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Affiliation(s)
- Khaled Shawwa
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA,Section of Nephrology, Department of Medicine, West Virginia University, Morgantown, WV, USA
| | - Panagiotis Kompotiatis
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Ankit Sakhuja
- Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Paul McCarthy
- Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Kianoush B. Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA,Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Applying cefepime population pharmacokinetics on critically ill patients receiving continuous renal replacement therapy. Antimicrob Agents Chemother 2021; 66:e0161121. [PMID: 34662194 DOI: 10.1128/aac.01611-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Patients admitted to the intensive care unit (ICU) may need continuous renal replacement therapy (CRRT) due to acute kidney injury or worsening of underlying chronic kidney disease. This will affect their antimicrobial exposure and may have a significant impact on the treatment. We aim to develop a cefepime pharmacokinetic (PK) model in CRRT ICU patients and generate the posterior predictions for a group and assess their therapy outcomes. Adult patients, admitted to the ICU, received cefepime, and had its concentration measured while on CRRT were included from three different datasets. In two datasets, samples were collected from the predialyzer, postdialyzer ports, and effluent fluid at different times within the same dosing interval. The third dataset had only cefepime plasma concentration measured as part of clinical service. Patients' demographics, cefepime regimens and concentration, CRRT parameters, and therapy outcomes were recorded. NPAG was used for population PK and posterior predictions. A total of 125 patients were included. Cefepime was described by a five-compartment model, and the CRRT flow rates described the rates of cefepime transfer between compartments. The posterior predictions were generated for the third dataset and the median (range) fT>MIC was 100% (27%-100%) and fT>4×MIC was 64% (0%-100%). The mortality rate was 53%. There was no difference in target attainment in terms of clinical cure and 30-day mortality. This model can be used as a precision dosing tool in CRRT patients. Future studies may address other PK/PD targets in a larger population.
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Predictive Factors of Duration of Continuous Renal Replacement Therapy in Acute Kidney Injury Survivors. Shock 2019; 52:598-603. [DOI: 10.1097/shk.0000000000001328] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Kuo G, Chen SW, Fan PC, Wu VCC, Chou AH, Lee CC, Chu PH, Tsai FC, Tian YC, Chang CH. Analysis of survival after initiation of continuous renal replacement therapy in patients with extracorporeal membrane oxygenation. BMC Nephrol 2019; 20:318. [PMID: 31412791 PMCID: PMC6694695 DOI: 10.1186/s12882-019-1516-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 08/08/2019] [Indexed: 01/29/2023] Open
Abstract
Background No study has specifically investigated the duration of continuous renal replacement therapy (CRRT) in patients who experienced acute kidney injury during extracorporeal membrane oxygenation (ECMO) support. However, there are concerns that prolonged CRRT may be futile. Methods We conducted a retrospective population-based cohort study using Taiwan National Health Insurance Research Database data collected between January 1, 2007 and December 31, 2013. Patients who received ECMO and CRRT during the study period were included. We divided patients into three groups based on the duration of CRRT received: ≤ 3 days, 4–6 days, and ≥ 7 days. The outcomes were all-cause mortality, end-stage renal disease, ventilator dependency, and readmission rate. Results There were 247, 134 and 187 patients who survived the hospitalization in the CRRT for ≤3 days, 4–6 days and > 7 days respectively. Survival after discharge did not differ significantly between CRRT for 4–6 days vs. ≤ 3 days (adjusted hazard ratio [aHR] 1.16, 95% confidence interval [CI] 0.85–1.57), between CRRT for > 7 days vs. ≤ 3 days (aHR 1.001, 95% CI 0.73–1.38) and between CRRT for > 7 days vs. 4–6 days (aHR 0.87, 95% CI 0.62–1.22). The patients who received CRRT for ≥7 days had a higher risk of ESRD than did those who received CRRT for ≤3 days (adjusted hazard ratio [aHR] 3.46, 95% confidence interval [CI] 1.47–8.14) and for 4–6 days (aHR 3.10, 95% CI 1.03–9.29). The incidence of ventilator dependence was higher in the patients with CRRT ≥7 days than in those with ≤3 days (aHR 2.45, 95% CI 1.32–4.54). The CRRT ≥7 days group also exhibited a higher readmission rate than did the 4–6 days and ≤ 3 days groups (aHR 1.43, 95% CI 1.04–1.96 and aHR 1.67, 95% CI 1.13–2.47, respectively). Conclusions Our study found similar long-term survival but increased ESRD and ventilator dependency among ECMO patients who underwent CRRT for ≥7 days. These results offer reason to be concerned that this aggressive life support may maintain patient survival but do so at the cost of long-term disabilities and a lower quality of life. Electronic supplementary material The online version of this article (10.1186/s12882-019-1516-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- George Kuo
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, College of Medicine, Chang Gung University, No.5, Fuxing Street, Guishan District, Taoyuan City, Taiwan, 33305
| | - Shao-Wei Chen
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan
| | - Pei-Chun Fan
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, College of Medicine, Chang Gung University, No.5, Fuxing Street, Guishan District, Taoyuan City, Taiwan, 33305
| | - Victor Chien-Chia Wu
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan
| | - An-Hsun Chou
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Chia Lee
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, College of Medicine, Chang Gung University, No.5, Fuxing Street, Guishan District, Taoyuan City, Taiwan, 33305
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan
| | - Feng-Chun Tsai
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan
| | - Ya-Chung Tian
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, College of Medicine, Chang Gung University, No.5, Fuxing Street, Guishan District, Taoyuan City, Taiwan, 33305
| | - Chih-Hsiang Chang
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, College of Medicine, Chang Gung University, No.5, Fuxing Street, Guishan District, Taoyuan City, Taiwan, 33305.
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Factors Associated with Early Mortality in Critically Ill Patients Following the Initiation of Continuous Renal Replacement Therapy. J Clin Med 2018; 7:jcm7100334. [PMID: 30297660 PMCID: PMC6210947 DOI: 10.3390/jcm7100334] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 09/30/2018] [Accepted: 10/05/2018] [Indexed: 01/11/2023] Open
Abstract
Continuous renal replacement therapy (CRRT) is an important modality to support critically ill patients, and the need for CRRT treatment has been increasing. However, CRRT management is costly, and the associated resources are limited. Thus, it remains challenging to identify patients that are likely to have a poor outcome, despite active treatment with CRRT. We sought to elucidate the factors associated with early mortality after CRRT initiation. We analyzed 240 patients who initiated CRRT at an academic medical center between September 2016 and January 2018. We compared baseline characteristics between patients who died within seven days of initiating CRRT (early mortality), and those that survived more than seven days beyond the initiation of CRRT. Of the patients assessed, 130 (54.2%) died within seven days of CRRT initiation. Multivariate logistic regression models revealed that low mean arterial pressure, low arterial pH, and high Sequential Organ Failure Assessment score before CRRT initiation were significantly associated with increased early mortality in patients requiring CRRT. In conclusion, the mortality within seven days following CRRT initiation was very high in this study. We identified several factors that are associated with early mortality in patients undergoing CRRT, which may be useful in predicting early outcomes, despite active treatment with CRRT.
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Zhang J, Li Y, Peng Z. Prognostic Factors and Efficacy for Continuous Renal Replacement Therapy in Critically Ill Patients: A Chinese Single-Center Retrospective Study. Blood Purif 2017; 45:53-60. [PMID: 29216644 DOI: 10.1159/000481769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 09/23/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is controversy about the efficacy and prognostic factors for continuous renal replacement therapy (CRRT) in China due to practice variation. Our aim is to investigate these questions. METHOD A total of 613 adult patients receiving CRRT in last 3 years from one Chinese ICU were enrolled. The analysis of demographic data, vital signs, and laboratory tests prior to CRRT and outcomes were performed. The data between pre- and post-CRRT were compared for efficacy analysis. RESULTS Prior to CRRT, partial pressure of carbon dioxide (PCO2), systolic blood pressure (SBP), gender, age, bilirubin, cystatin C, and mechanical ventilation were correlated with in-hospital mortality. In a binary logistic regression, PCO2, SBP, age, and gender were significant in predicting mortality. Cox regression analysis demonstrated PCO2 independent association with mortality, and lower SBP worse mortality. CRRT could eliminate the fluid and metabolites. CONCLUSION CO2 retention and low SBP prior to CRRT were associated with increased mortality. CRRT significantly improved hemeostasis.
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Yetimakman AF, Kesici S, Tanyildiz M, Bayrakci US, Bayrakci B. A Report of 7-Year Experience on Pediatric Continuous Renal Replacement Therapy. J Intensive Care Med 2017; 34:985-989. [PMID: 28820041 DOI: 10.1177/0885066617724339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Continuous renal replacement therapies (CRRTs) either as continuous venovenous hemofiltration (CVVH) or hemodiafiltration (CVVHD) are used frequently in critically ill children. Many clinical variables and technical issues are known to affect the result. The factors that could be modified to increase the survival of renal replacement are sought. As a contribution, we present the data on 104 patients who underwent CRRT within a 7-year period. MATERIALS AND METHOD A total of 104 patients admitted between 2009 and 2016 were included in the study. The demographic information, admittance pediatric risk of mortality (PRISM) scores, indication for CRRT, presence of fluid overload, CRRT modality, durations of CRRT, and pediatric intensive care unit (PICU) stay were compared between survivors and nonsurvivors. RESULTS The overall rate of survival was 51%. Patients with fluid overload had significantly increased rate of death, CRRT duration, and PICU stay. Multiorgan dysfunction syndrome as the indication for CRRT was significantly related to decreased survival when compared to acute renal failure and acute attacks of metabolic diseases. The CRRT modality was not different between survivors and nonsurvivors. Standardized mortality ratio of the group was calculated to be 0.8. CONCLUSION The CRRT in critically ill patients is successful in achieving fluid removal and correction of metabolic imbalances caused by organ failures or attacks of inborn errors of metabolism. It has a positive effect on expected mortality in high-risk PICU patients. To affect the outcome, follow-up should be focused on starting therapy in early stages of fluid overload. Prospective studies defining relative importance of risk factors causing mortality can assist in building up guidelines to affect the outcome.
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Affiliation(s)
- Ayse Filiz Yetimakman
- Department of Pediatric Intensive Care Medicine, Hacettepe University, Ankara, Turkey
| | - Selman Kesici
- Department of Pediatric Intensive Care, Dr Sami Ulus Maternity and Children's Training and Research Hospital, Ankara, Turkey
| | - Murat Tanyildiz
- Department of Pediatric Intensive Care Medicine, Hacettepe University, Ankara, Turkey
| | - Umut Selda Bayrakci
- Department of Pediatric Nephrology, Ankara Children's and Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Benan Bayrakci
- Department of Pediatric Intensive Care Medicine, Hacettepe University, Ankara, Turkey
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Lu J, Wang X, Chen Q, Chen M, Cheng L, Jiang H, Sun Z. D-dimer Is a Predictor of 28-Day Mortality in Critically Ill Patients Receiving Continuous Renal Replacement Therapy. Arch Med Res 2017; 47:356-364. [PMID: 27751369 DOI: 10.1016/j.arcmed.2016.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 08/08/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND AIMS Continuous renal replacement therapy (CRRT) is an important treatment in the intensive care unit (ICU). Nevertheless, the outcome of CRRT remains unclear. It is important to find a useful and easy indicator to predict the prognosis in patients on CRRT treatment. We undertook this study to observe the association between serum D-dimer level and mortality of ICU patients in the treatment of CRRT. METHODS A total of 149 patients who received CRRT were enrolled in our study. We observed the correlation of D-dimer with the information of biochemical parameters, acute physiology and chronic health evaluation II (APACHE II) score. We analyzed the association between serum D-dimer level before CRRT and 28-d mortality retrospectively. Furthermore, we used Cox regression analysis to assess whether D-dimer could be the independent risk factor for mortality. RESULTS There were significant correlations between D-dimer and C-reaction protein (r2 = 0.033, p = 0.026), creatinine (r2 = 0.066, p = 0.002) and APACHE II (r2 = 0.036, p = 0.021). The difference in 28-d mortality risk between elevated D-dimer group and normal D-dimer group was significant (HR 2.872, 95% CI 1.563-5.278, p = 0.001), and the elevated D-dimer level was an independent risk factor for 28-d mortality (HR 2.067, 95% CI 1.104-3.872, p = 0.023). The difference in 28-d mortality was significant between groups (p <0.001). ROC curves showed that the area under the curve (AUC) of D-dimer was 0.763. CONCLUSION The present study demonstrates that serum D-dimer could be a useful and easy prognostic variable of 28-d mortality in critically ill patients who received CRRT.
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Affiliation(s)
- Jun Lu
- Intensive Care Unit, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, China
| | - Xing Wang
- Intensive Care Unit, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, China
| | - Qiuhua Chen
- Intensive Care Unit, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, China
| | - Mingqi Chen
- Intensive Care Unit, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, China
| | - Lu Cheng
- Intensive Care Unit, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, China
| | - Hua Jiang
- Intensive Care Unit, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, China
| | - Zhiguang Sun
- The First Clinical College, Nanjing University of Traditional Chinese Medicine, Nanjing, China.
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Yang T, Sun S, Lin L, Han M, Liu Q, Zeng X, Zhao Y, Li Y, Su B, Huang S, Yang L. Predictive Factors Upon Discontinuation of Renal Replacement Therapy for Long-Term Chronic Dialysis and Death in Acute Kidney Injury Patients. Artif Organs 2017; 41:1127-1134. [PMID: 28544060 DOI: 10.1111/aor.12927] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/13/2016] [Accepted: 01/10/2017] [Indexed: 02/05/2023]
Abstract
The specific timing for discontinuing renal replacement therapy (RRT) in acute kidney injury (AKI) patients is debatable. The predictive abilities of variables at the time of discontinuation of RRT for the long-term prognoses of patients have not been explored. This study aimed to explore the prognostic factors upon discontinuation of RRT for long-term chronic dialysis and death of patients with acute RRT-requiring AKI, thus improving decision making regarding the discontinuation of RRT and the follow-up of patients thereafter. A cohort of 302 AKI patients who required acute RRT and remained alive and free of dialysis for at least 30 days after discharge from January 2009 to December 2012 were followed up. The predictive abilities of general characteristics, RRT details, and variables upon discontinuation of RRT for long-term chronic dialysis and all-cause death were evaluated using Cox proportional hazards models. Kaplan-Meier analysis with a log-rank test was used to compare the survival curves between the strata of levels of good predictors upon discontinuation of RRT. After a median follow-up time of 4.1 years, 20 (6.6%) patients initiated chronic dialysis and 56 (18.5%) patients died. A higher CysC level upon discontinuation of RRT (HR 1.520, 95% CI 1.082-2.135; P = 0.016), comorbid chronic kidney disease, and a higher non-renal Charlson comorbidity index (CCI) were independently predictive for chronic dialysis. The hemoglobin level upon discontinuation of RRT was inversely predictive of death (HR 0.986, 95% CI 0.973-0.999; P = 0.035), and comorbid malignancy, the presence of multiple organ dysfunction syndrome, and a higher non-renal CCI also predicted death. Urine output upon discontinuation of RRT was marginally inversely predictive of death (HR 0.997, 95% CI 0.994-1.000; P = 0.056). Patients who discontinued RRT with CysC levels <2.97 mg/L, hemoglobin levels >85 g/L, and urine output >1130 mL/24 h showed significantly higher non-chronic dialysis and survival rates according to a log-rank test. Our study suggested that upon discontinuation of RRT, higher serum CysC levels had the most promising predictive value for long-term chronic dialysis, and lower hemoglobin levels predicted long-term death; lower urine output also marginally predicted long-term death. Based on the remission of the comprehensive condition, lower CysC levels and higher hemoglobin levels and urine output should be considered in the decision to stop RRT. Patients showing worse levels of these indices upon discontinuation of RRT should undergo stricter follow-up and treatment to improve long-term outcomes.
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Affiliation(s)
- Tingting Yang
- Division of Nephrology, West China Hospital of Sichuan University, Sichuan, People's Republic of China
| | - Si Sun
- Division of Nephrology, West China Hospital of Sichuan University, Sichuan, People's Republic of China
| | - Liping Lin
- Division of Nephrology, West China Hospital of Sichuan University, Sichuan, People's Republic of China
| | - Mei Han
- Division of Nephrology, West China Hospital of Sichuan University, Sichuan, People's Republic of China
| | - Qiang Liu
- Division of Nephrology, West China Hospital of Sichuan University, Sichuan, People's Republic of China
| | - Xiaoxi Zeng
- Division of Nephrology, West China Hospital of Sichuan University, Sichuan, People's Republic of China
| | - Yuliang Zhao
- Division of Nephrology, West China Hospital of Sichuan University, Sichuan, People's Republic of China
| | - Yupei Li
- Division of Nephrology, West China Hospital of Sichuan University, Sichuan, People's Republic of China
| | - Baihai Su
- Division of Nephrology, West China Hospital of Sichuan University, Sichuan, People's Republic of China
| | - Songmin Huang
- Division of Nephrology, West China Hospital of Sichuan University, Sichuan, People's Republic of China
| | - Lichuan Yang
- Division of Nephrology, West China Hospital of Sichuan University, Sichuan, People's Republic of China
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Delta neutrophil index is an independent predictor of mortality in septic acute kidney injury patients treated with continuous renal replacement therapy. BMC Nephrol 2017; 18:94. [PMID: 28320333 PMCID: PMC5358045 DOI: 10.1186/s12882-017-0507-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 03/09/2017] [Indexed: 12/19/2022] Open
Abstract
Background Delta neutrophil index (DNI), representing an elevated fraction of circulating immature granulocytes in acute infection, has been reported as a useful marker for predicting mortality in patients with sepsis. The aim of this study was to evaluate the prognostic value of DNI in predicting mortality in septic acute kidney injury (S-AKI) patients treated with continuous renal replacement therapy (CRRT). Method This is a retrospective analysis of consecutively CRRT treated patients. We enrolled 286 S-AKI patients who underwent CRRT and divided them into three groups based on the tertiles of DNI at CRRT initiation (high, DNI > 12.0%; intermediate, 3.6–12.0%; low, < 3.6%). Patient survival was estimated with the Kaplan-Meier method and Cox proportional hazards models to determine the effect of DNI on the mortality of S-AKI patients. Results Patients in the highest tertile of DNI showed higher Acute Physiology and Chronic Health Evaluation II score (highest tertile, 27.9 ± 7.0; lowest tertile, 24.6 ± 8.3; P = 0.003) and Sequential Organ Failure Assessment score (highest tertile, 14.1 ± 3.0; lowest tertile, 12.1 ± 4.0; P = 0.001). The 28-day mortality rate was significantly higher in the highest tertile group than in the lower two tertile groups (P < 0.001). In the multiple Cox proportional hazard model, DNI was an independent predictor for mortality after adjusting multiple confounding factors (hazard ratio, 1.010; 95% confidence interval, 1.001–1.019; P = 0.036). Conclusion This study suggests that DNI is independently associated with mortality of S-AKI patients on CRRT.
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Lee JH, Kim HY, Bae EH, Kim SW, Ma SK. Biomarkers Predicting Survival of Sepsis Patients Treated with Continuous Renal Replacement Therapy. Chonnam Med J 2017; 53:64-68. [PMID: 28184340 PMCID: PMC5299131 DOI: 10.4068/cmj.2017.53.1.64] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 10/18/2016] [Accepted: 10/19/2016] [Indexed: 11/22/2022] Open
Abstract
The present study investigated the prognostic factors predicting survival of patients with sepsis and acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT). This retrospective observational study included 165 sepsis patients treated with CRRT. The patients were divided into two groups; the survivor group (n=73, 44.2%) vs. the nonsurvivor group (n=92, 55.8%). AKI was defined by the 2012 Kidney Disease: Improving Global Outcomes Clinical Practice Guidelines. We analyzed medical histories, clinical characteristics and laboratory findings of the enrolled patients when they started CRRT. In addition, we performed binary logistic regression and cox regression analysis. In the survivor group, urine output during the first day was significantly higher compared with the nonsurvivor group (55.7±66.3 vs. 26.6±46.4, p=0.001). Patients with urine output <30 mL/hour during the 1st day showed worse outcomes than ≥30 mL/hour in the logistic regression (hazard ratio 2.464, 95% confidence interval 1.152-5.271, p=0.020) and the cox regression analysis (hazard ratio 1.935, 95% confidence interval 1.147-3.263, p=0.013). In conclusion, urine output may predict survival of septic AKI patients undergoing CRRT. In these patients, urine output <30 mL/hour during the first day was the strongest risk factor for in-hospital mortality.
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Affiliation(s)
- Jeong Ho Lee
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Ha Yeon Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Eun Hui Bae
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Seong Kwon Ma
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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Lee ST, Cho H. Fluid overload and outcomes in neonates receiving continuous renal replacement therapy. Pediatr Nephrol 2016; 31:2145-52. [PMID: 26975386 DOI: 10.1007/s00467-016-3363-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 02/23/2016] [Accepted: 02/24/2016] [Indexed: 01/20/2023]
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) has emerged as the modality of choice for the management of high-risk neonates with acute kidney injury (AKI), inborn errors of metabolism and multi-organ dysfunction. The aim of this study was to evaluate fluid overload (FO) and investigate the factors associated with outcomes in neonates undergoing CRRT. METHODS We retrospectively reviewed the medical records of 34 neonates with AKI who were admitted to the neonatal intensive care unit (NICU) of Samsung Medical Center, Seoul, Republic of Korea between January 2007 and December 2014 where they underwent at least 24 h of CRRT. RESULTS The survival rates of patients with an FO of ≥30 % at the time of CRRT initiation were lower than those of patients with an FO of <30 % at the same time-point. Univariate Cox regression analysis revealed that a higher percentage FO at CRRT initiation and decreased urine output at the end of CRRT were associated with mortality, and multivariate Cox regression analysis indicated that mortality was associated with decreased urine output at the end of CRRT. Univariate linear regression analysis revealed that the length of hospital stay was associated with higher levels of serum creatinine at CRRT initiation, longer stay in the NICU prior to initiation of CRRT, longer duration of CRRT and lower body weight at the time of NICU admission. CONCLUSIONS Neonates with a higher percentage FO and higher levels of serum creatinine at CRRT initiation showed poor outcomes. Early initiation of CRRT before the development of severe FO or azotemia might improve the outcomes of neonates requiring CRRT.
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Affiliation(s)
- Sang Taek Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 135-710, South Korea
| | - Heeyeon Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 135-710, South Korea.
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Besharatian BD, Berns JS. More May be Less; Yet Another Way which More Intense Renal Replacement Therapy May Not be Better. Semin Dial 2016; 29:515-517. [PMID: 27726171 DOI: 10.1111/sdi.12556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Behdad D Besharatian
- Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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Mc Causland FR, Asafu-Adjei J, Betensky RA, Palevsky PM, Waikar SS. Comparison of Urine Output among Patients Treated with More Intensive Versus Less Intensive RRT: Results from the Acute Renal Failure Trial Network Study. Clin J Am Soc Nephrol 2016; 11:1335-1342. [PMID: 27449661 PMCID: PMC4974887 DOI: 10.2215/cjn.10991015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 04/04/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Intensive RRT may have adverse effects that account for the absence of benefit observed in randomized trials of more intensive versus less intensive RRT. We wished to determine the association of more intensive RRT with changes in urine output as a marker of worsening residual renal function in critically ill patients with severe AKI. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Acute Renal Failure Trial Network Study (n=1124) was a multicenter trial that randomized critically ill patients requiring initiation of RRT to more intensive (hemodialysis or sustained low-efficiency dialysis six times per week or continuous venovenous hemodiafiltration at 35 ml/kg per hour) versus less intensive (hemodialysis or sustained low-efficiency dialysis three times per week or continuous venovenous hemodiafiltration at 20 ml/kg per hour) RRT. Mixed linear regression models were fit to estimate the association of RRT intensity with change in daily urine output in survivors through day 7 (n=871); Cox regression models were fit to determine the association of RRT intensity with time to ≥50% decline in urine output in all patients through day 28. RESULTS Mean age of participants was 60±15 years old, 72% were men, and 30% were diabetic. In unadjusted models, among patients who survived ≥7 days, mean urine output was, on average, 31.7 ml/d higher (95% confidence interval, 8.2 to 55.2 ml/d) for the less intensive group compared with the more intensive group (P=0.01). More intensive RRT was associated with 29% greater unadjusted risk of decline in urine output of ≥50% (hazard ratio, 1.29; 95% confidence interval, 1.10 to 1.51). CONCLUSIONS More intensive versus less intensive RRT is associated with a greater reduction in urine output during the first 7 days of therapy and a greater risk of developing a decline in urine output of ≥50% in critically ill patients with severe AKI.
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Affiliation(s)
- Finnian R. Mc Causland
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Josephine Asafu-Adjei
- Department of Biostatistics, School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Rebecca A. Betensky
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Paul M. Palevsky
- Renal Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; and
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sushrut S. Waikar
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Fortrie G, Stads S, Aarnoudse AJH, Zietse R, Betjes MG. Long-term sequelae of severe acute kidney injury in the critically ill patient without comorbidity: a retrospective cohort study. PLoS One 2015; 10:e0121482. [PMID: 25799318 PMCID: PMC4370474 DOI: 10.1371/journal.pone.0121482] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 02/01/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Acute kidney injury (AKI) necessitating renal replacement therapy (RRT) is associated with high mortality and increased risk for end stage renal disease. However, it is unknown if this applies to patients with a preliminary unremarkable medical history. The purpose of this study was to describe overall and renal survival in critically ill patients with AKI necessitating RRT stratified by the presence of comorbidity. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS A retrospective cohort study was performed, between 1994 and 2010, including all adult critically ill patients with AKI necessitating RRT, stratified by the presence of comorbidity. Logistic regression, survival curve and cox proportional hazards analyses were used to evaluate overall and renal survival. Standardized mortality rate (SMR) analysis was performed to compare long-term survival to the predicted survival in the Dutch population. RESULTS Of the 1067 patients included only 96(9.0%) had no comorbidity. Hospital mortality was 56.6% versus 43.8% in patients with and without comorbidity, respectively. In those who survived hospitalization 10-year survival was 45.0% and 86.0%, respectively. Adjusted for age, sex and year of treatment, absence of comorbidity was not associated with hospital mortality (OR=0.74, 95%-CI=0.47-1.15), while absence of comorbidity was associated with better long-term survival (adjusted HR=0.28, 95%-CI = 0.14-0.58). Compared to the Dutch population, patients without comorbidity had a similar mortality risk (SMR=1.6, 95%-CI=0.7-3.2), while this was increased in patients with comorbidity (SMR=4.8, 95%-CI=4.1-5.5). Regarding chronic dialysis dependency, 10-year renal survival rates were 76.0% and 92.9% in patients with and without comorbidity, respectively. Absence of comorbidity was associated with better renal survival (adjusted HR=0.24, 95%-CI=0.07-0.76). CONCLUSIONS While hospital mortality remains excessively high, the absence of comorbidity in critically ill patients with RRT-requiring AKI is associated with a relative good long-term prognosis in those who survive hospitalization.
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Affiliation(s)
- Gijs Fortrie
- Department of Internal Medicine, Division of Nephrology, Erasmus Medical Center, Rotterdam, The Netherlands
- * E-mail:
| | - Susanne Stads
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Albert-Jan H. Aarnoudse
- Department of Internal Medicine, Division of Nephrology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Robert Zietse
- Department of Internal Medicine, Division of Nephrology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Michiel G. Betjes
- Department of Internal Medicine, Division of Nephrology, Erasmus Medical Center, Rotterdam, The Netherlands
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Iwagami M, Yasunaga H, Noiri E, Horiguchi H, Fushimi K, Matsubara T, Yahagi N, Nangaku M, Doi K. Current state of continuous renal replacement therapy for acute kidney injury in Japanese intensive care units in 2011: analysis of a national administrative database. Nephrol Dial Transplant 2015; 30:988-95. [PMID: 25795153 DOI: 10.1093/ndt/gfv069] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 02/23/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Nationwide data for the prevalence and outcomes of patients receiving continuous renal replacement therapy (CRRT) in intensive care units (ICUs) are scarce. This study assessed the status of CRRT in Japanese ICUs using a nationwide administrative claim database. METHODS Data were extracted from the Japanese Diagnosis Procedure Combination database for 2011. From a cohort of critically ill patients aged 12 years or older who were admitted to ICUs for 3 days or longer, acute kidney injury (AKI) patients treated with CRRT were identified. The period prevalence of CRRT and in-hospital mortality were calculated. Logistic regression analysis identified factors associated with in-hospital mortality. RESULTS Of 165 815 ICU patients, 6478 (3.9%) received CRRT for AKI. The most frequent admission diagnosis category was diseases of the circulatory system (n = 3074). The overall in-hospital mortality rate of the CRRT-treated AKI patients was 50.6%. Clustering patients into four groups by background revealed the lowest in-hospital mortality rate of 41.5% for the cardiovascular surgery group (n = 1043) compared with 53.5% for the nonsurgical cardiovascular group (n = 2031), 51.7% for the sepsis group (n = 1863) and 51.6% for other cases (n = 1541). Multiple logistic regression analysis showed a significant association of these four group classifications with in-hospital mortality in addition to age, hospital characteristics (type and volume), time from hospital admission to CRRT initiation and interventions performed on the day of CRRT initiation. CONCLUSIONS Using a large Japanese nationwide database, this study revealed remarkably high in-hospital mortality of CRRT-treated AKI patients, although the period prevalence of CRRT for AKI in ICUs was low.
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Affiliation(s)
- Masao Iwagami
- Department of Hemodialysis and Apheresis, The University of Tokyo Hospital, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Health Economics and Epidemiology Research, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Eisei Noiri
- Department of Hemodialysis and Apheresis, The University of Tokyo Hospital, Tokyo, Japan Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiromasa Horiguchi
- Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization Headquarters, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Informatics and Policy, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Takehiro Matsubara
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Naoki Yahagi
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaomi Nangaku
- Department of Hemodialysis and Apheresis, The University of Tokyo Hospital, Tokyo, Japan Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Kent Doi
- Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
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17
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Eatroff AE, Langston CE, Chalhoub S, Poeppel K, Mitelberg E. Long-term outcome of cats and dogs with acute kidney injury treated with intermittent hemodialysis: 135 cases (1997-2010). J Am Vet Med Assoc 2013; 241:1471-8. [PMID: 23176239 DOI: 10.2460/javma.241.11.1471] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the long-term outcome for small animal patients with acute kidney injury (AKI) treated with intermittent hemodialysis (IHD). DESIGN Retrospective case series. ANIMALS 42 cats and 93 dogs treated with IHD for AKI. PROCEDURES Medical records of cats and dogs treated with IHD for AKI from January 1997 to October 2010 were reviewed. Standard methods of survival analysis with Kaplan-Meier product limit curves were used. The log-rank, Mann-Whitney, and Kruskal-Wallis tests were used to determine whether outcome, number of IHD treatments, or duration of hospitalization was different when dogs and cats were classified according to specific variables. RESULTS The overall survival rate at the time of hospital discharge was 50% (21/42) for cats and 53% (49/93) for dogs. The overall survival rate 30 days after hospital discharge was 48% (20/42) for cats and 42% (39/93) for dogs. The overall survival rate 365 days after hospital discharge was 38% (16/42) for cats and 33% (31/93) for dogs. For all-cause mortality, the median survival time was 7 days (95% confidence interval, 0 to 835 days) for cats and 9 days (95% confidence interval, 0 to 55 days) for dogs. CONCLUSIONS AND CLINICAL RELEVANCE Cats and dogs with AKI treated with IHD have survival rates similar to those of human patients. Although there was a high mortality rate prior to hospital discharge, those patients that survived to discharge had a high probability of long-term survival.
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Affiliation(s)
- Adam E Eatroff
- Bobst Hospital, The Animal Medical Center, 510 E 62nd St, New York, NY 10065, USA.
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Fortrie G, Stads S, de Geus HR, Groeneveld AJ, Zietse R, Betjes MG. Determinants of renal function at hospital discharge of patients treated with renal replacement therapy in the intensive care unit. J Crit Care 2013; 28:126-32. [DOI: 10.1016/j.jcrc.2012.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 10/15/2012] [Accepted: 10/17/2012] [Indexed: 10/27/2022]
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Haas CS, Lehne W, Muck P, Boehm A, Rupp J, Steinhoff J, Lehnert H. Acute kidney injury and thrombocytopenic fever--consider the infrequent causes. Am J Emerg Med 2013; 31:441.e5-9. [PMID: 23407036 DOI: 10.1016/j.ajem.2012.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 04/04/2012] [Indexed: 11/19/2022] Open
Affiliation(s)
- Christian S Haas
- Department of Medicine I, University of Luebeck, 23538 Luebeck, Germany.
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20
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Ng KP, Chanouzas D, Fallouh B, Baharani J. Short and long-term outcome of patients with severe acute kidney injury requiring renal replacement therapy. QJM 2012; 105:33-9. [PMID: 21859774 DOI: 10.1093/qjmed/hcr133] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Severe acute kidney injury (AKI) occurs in 2-7% of all hospital admissions and is an independent poor prognostic marker. Nevertheless, information on the long-term outcome of AKI and the factors influencing this is limited. AIM To describe the short- and long-term outcome of patients requiring renal replacement therapy (RRT) for severe AKI and to examine factors affecting patient survival and renal recovery. DESIGN AND METHODS Single centre retrospective analysis of 481 consecutive patients over a period of 39 months. FOLLOW-UP 12 months. PRIMARY AND SECONDARY OUTCOMES overall mortality and RRT dependency at 30 days, 90 days and 1 year. RESULTS Survival at 30 days, 90 days and 1 year was 54.4, 47.2 and 37.6%, respectively. RRT independency at 30 days, 90 days and 1 year was 35.2, 27.2 and 25.8%, respectively. Of those RRT independent at 90 days, 55% had ongoing chronic kidney disease. There were two distinct groups of patients: Group A (haemofiltration in ITU) and Group B (intermittent haemodialysis in the renal unit). Patient survival was worse in Group A while RRT independence was higher. Independent predictors of survival included renal cause of AKI and lower CI score in Group A and renal or post-renal cause of AKI, younger age and the absence of malignancy in Group B. Independent predictors of renal recovery included the presence of sepsis in Group A and pre- or post-renal cause of AKI in Group B. CONCLUSIONS The short- and long-term survival outcome of severe AKI requiring RRT remains poor. Among those who survive, a significant number either continue to require RRT or have residual renal impairment necessitating ongoing follow-up.
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Affiliation(s)
- K P Ng
- Renal Department, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK.
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Vats HS, Dart RA, Okon TR, Liang H, Paganini EP. Does early initiation of continuous renal replacement therapy affect outcome: experience in a tertiary care center. Ren Fail 2011; 33:698-706. [PMID: 21787161 DOI: 10.3109/0886022x.2011.589945] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) requiring dialysis commonly occurs in critically ill patients and is associated with high mortality. Factors impacting outcomes of individuals with AKI who underwent continuous renal replacement therapy (CRRT), including early versus late initiation and duration of CRRT, were examined. METHODS Survival and recovery of renal function for patients with AKI in the intensive care unit were retrospectively examined over a 7-year period. Factors associated with mortality and renal recovery were analyzed based on severity of illness as defined by Cleveland Clinic Foundation (CCF) score. Univariate and multivariate logistic regression analysis with backward elimination was performed to determine the most significant risk factors. RESULTS Of patients who underwent CRRT, 230/330 met inclusion criteria. During index admission 112/230 (48.7%) patients died. Median survival was 15.5 days [95% confidence interval (12.0, 18.0)]. Among survivors, renal recovery occurred in 84/118 (71.2%). Renal recovery overall was observed in 90/230 subjects (39.13%). A higher baseline CCF score correlated with higher mortality and lower probability of renal recovery. Patients initiated on CRRT > 6 days after AKI diagnosis had significantly higher mortality compared with those initiated earlier (odds ratio = 11.66, p = 0.0305). Patients receiving CRRT >10 days had a higher mortality rate compared with those with shorter exposure (71.3% vs. 45.5%, respectively, p = 0.012). CONCLUSIONS CRRT remains an important dialysis modality in hemodynamically unstable patients with AKI. Mortality in these patients continues to be high. Renal recovery is high in survivors. Delay in initiation and length of CRRT exposure may portend poorer prognosis.
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Affiliation(s)
- Hemender S Vats
- Department of Internal Medicine, Marshfield Clinic Marshfield, Marshfield, WI 52713, USA.
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Schneider CP, Fertmann J, Miesen J, Wolf H, Flexeder C, Hofner B, Küchenhoff H, Jauch KW, Hartl WH. Short-term prognosis of critically ill surgical patients: the impact of duration of invasive organ support therapies. J Crit Care 2011; 27:73-82. [PMID: 21737240 DOI: 10.1016/j.jcrc.2011.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 04/01/2011] [Accepted: 05/08/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE We wanted to identify the importance of the duration of invasive ventilation and of renal replacement therapy for short-term prognosis of surgical patients treated in an intensive care unit (ICU). METHODS We analyzed adult patients (n = 1462) who had an ICU length of stay of more than 4 days and who were followed up until the end of the short-term phase after ICU admission. Duration of different invasive therapies was evaluated by constructing specific vectors that tested effects of time-dependent variables on outcome after a lag time of 7 days. MEASUREMENTS AND MAIN RESULTS Eight hundred eight patients (56.6%) were still alive at the end of the short-term phase. During the short-term phase, 85.3% of the 1462 patients required invasive ventilation, and 16.1%, a continuous renal replacement therapy. Besides the underlying disease and disease severity at ICU admission, the need for invasive ventilation or renal replacement therapy was associated with poorer outcome. Duration of invasive ventilation shortened survival if treatment lasted for more than 11 days (nonlinear association). In contrast, duration of renal replacement therapy was unimportant for short-term prognosis. CONCLUSION Prolonged duration of invasive ventilation but not of renal replacement therapy is inversely related to short-term survival.
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Affiliation(s)
- Christian P Schneider
- Department of Surgery, Campus Grosshadern, Ludwig-Maximilians University Munich, D-81377 Munich, Germany
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Oh HJ, Park JT, Kim JK, Yoo DE, Kim SJ, Han SH, Kang SW, Choi KH, Yoo TH. Red blood cell distribution width is an independent predictor of mortality in acute kidney injury patients treated with continuous renal replacement therapy. Nephrol Dial Transplant 2011; 27:589-94. [PMID: 21712489 DOI: 10.1093/ndt/gfr307] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND A potential independent association was recently demonstrated between high red blood cell distribution width (RDW) and the risk of all-cause mortality in patients with cardiovascular disease, although the mechanism remains unclear. However, there have been no reports on the relationship between RDW and mortality in acute kidney injury (AKI) patients treated with continuous renal replacement therapy (CRRT). In this study, we assessed whether RDW was associated with mortality in AKI patients on CRRT treatment in the intensive care unit (ICU). METHODS We enrolled 470 patients with AKI who were treated with CRRT at the Yonsei University Medical Center ICU from August 2007 to September 2009 in this study. We performed a retrospective analysis of demographic, biochemical parameters and patient outcomes. Following CRRT treatment, 28-day all-cause mortality was evaluated. RESULTS At the initiation of CRRT treatment, RDW level was significantly correlated with white blood cell count, hemoglobin (Hb) and total cholesterol. Patients with high RDW levels exhibited significantly higher 28-day mortality rates than patients with low RDW levels (P < 0.01). Baseline RDW level, Sequential Organ Failure Assessment (SOFA) score, low mean arterial pressure (MAP) and low cholesterol levels were independent risk factors for mortality. In multivariate Cox proportional hazard analyses, RDW at CRRT initiation was an independent predictor for 28-day all-cause mortality after adjusting for age, gender, MAP, Hb, albumin, total cholesterol, C-reactive protein and SOFA score. CONCLUSION Our study demonstrates that RDW could be an additive predictor for all-cause mortality in AKI patients on CRRT treatment in the ICU.
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Affiliation(s)
- Hyung Jung Oh
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea
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Santana Cabrera L, Sánchez-Palacios M, Villanueva Ortiz A, Martínez Cuéllar S. Pronóstico de los pacientes que precisaron técnicas continuas de reemplazamiento renal en una unidad de cuidados intensivos. Med Clin (Barc) 2011; 136:363-4. [DOI: 10.1016/j.medcli.2009.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2009] [Revised: 06/16/2009] [Accepted: 06/23/2009] [Indexed: 10/20/2022]
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Hussain S, Piering W, Mohyuddin T, Saleh M, Zhu YR, Hannan M, Hanan M, Cohen E. Outcome among patients with acute renal failure needing continuous renal replacement therapy: A single center study. Hemodial Int 2009; 13:205-14. [PMID: 19432695 DOI: 10.1111/j.1542-4758.2009.00342.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Outcome of acute renal failure (ARF) and use of continuous renal replacement therapy (CRRT) have shown a consistently high mortality. (1) Evaluate the short-term patient survival. (2) Evaluate dialysis-free survival. (3) Evaluate risk factors associated with overall survival and the continued need for intermittent dialysis. We identified adults (>/=18 years) needing CRRT, treated in the critical care units of Froedtert Medical and Lutheran Hospital from January 1, 2003 till December 31, 2005. Patients were divided into two major groups needing CRRT, end stage renal disease (ESRD) (chronic dialysis) and non-ESRD with ARF. Continuous renal replacement therapy was performed with an average of 2 L replacement fluid exchanges/h. Sigma stat software was used for analysis. Comparison was done for noncontinuous variables by chi-square and t test for categorical and continuous variables, respectively. A total of 110 (ESRD 24/non-ESRD 86) patients received CRRT during study period. Over all in-hospital mortality among non-ESRD patients was 63% vs. 46% for ESRD. Among non-ESRD patients who survived, 47% needed intermittent hemodialysis on intensive care unit discharge and 28% continued to need hemodialysis at last follow-up. Among non-ESRD patients alive at discharge, those who were dialysis dependent on last follow-up were older (64.5) than those who did not require dialysis on last follow-up (58.4) P=0.347. Non-ESRD patients who died were in the hospital for an average of 17.5 days compared with 29 days for those who were discharged from the hospital. Patients with ARF needing CRRT have high in-hospital mortality. A significant percentage of patients remained dialysis dependant on last follow-up.
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Affiliation(s)
- Syed Hussain
- Division of Nephrology, Medical College of Wisconsin & Clement J. Zablocki VAMC, Milwaukee, Wisconsin 53226, USA.
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The use of regional citrate anticoagulation for continuous venovenous hemodiafiltration in acute kidney injury. Crit Care Med 2008; 36:3024-9. [PMID: 18824904 DOI: 10.1097/ccm.0b013e31818b9100] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Continuous renal replacement therapy is commonly used in the treatment of acute kidney injury. Although the optimal anticoagulation system is not well defined, citrate has emerged as the most promising method. We evaluated the data of 143 patients with acute kidney injury subjected to citrate-based continuous venovenous hemodiafiltration. DESIGN Retrospective cohort study. SETTING Intensive care unit of tertiary care private hospital. PATIENTS Patients with acute kidney injury treated from February 2004 to July 2006. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The main cause of acute kidney injury was sepsis (58%). The mean dialysis dose was 36.6 mL/kg/hr allowing for excellent metabolic control (last tests: creatinine, 1.1 mg/dL; urea, 46 mg/dL). No significant bleeding, severe electrolyte, or calcium disorders were observed. Of the 418 filters used, almost 28,000 hrs of treatment, hemofilter patency was 68% at 72 hrs. Hospital mortality was 59%, and 22% of survivors were dialysis-dependent at the time of discharge. Within our sample, we identified 21 patients with liver failure (mean prothrombin time index, 21% vs. 67%, p < 0.001). This group presented with a lesser median systemic ionized calcium level (1.06 vs. 1.12 mmol/L, p < 0.001) and similar mean total calcium level (8.5 vs. 8.6 mg/dL, not significant), compared with patients without liver failure. These subjects also showed acidemia (median pH, 7.31 vs. 7.40, p < 0.001); however, they exhibited higher levels of lactate (median 29 vs. 16 mg/dL, p < 0.001), chloride (mean 109 vs. 107 mEq/L, p = 0.045) and had a trend to higher mortality rate (76% vs. 56%). CONCLUSIONS Besides a trend toward higher mortality rate observed in the group with liver failure, we found that citrate-based continuous venovenous hemodiafiltration allowed an effective dialysis dose and reasonable filter patency.
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Bae WK, Lim DH, Jeong JM, Jung HY, Kim SK, Park JW, Bae EH, Ma SK, Kim SW, Kim NH, Choi KC. Continuous renal replacement therapy for the treatment of acute kidney injury. Korean J Intern Med 2008; 23:58-63. [PMID: 18646507 PMCID: PMC2686975 DOI: 10.3904/kjim.2008.23.2.58] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Continuous renal replacement therapy (CRRT) has been widely used for treating critically ill patients with acute kidney injury (AKI). Whether CRRT is better than intermittent hemodialysis for the treatment of AKI remains controversial. We sought to identify the clinical features that can predict survival for the patients who are treated with CRRT. METHODS We analyzed the data of 125 patients who received CRRT between 2005 and 2007. We identified the demographic variables, the underlying diagnoses, the duration of CRRT, the mean arterial blood pressure (ABP) and the Simplified Acute Physiology Score (SAPS) II. The classification/staging system for acute kidney injury (AKI) was applied to all the patients, who were then divided into stage 1-3 subgroups. RESULTS The average age of the patients was 61.414.3 years and the mortality rate was 60% (75 of 125 patients). The survivors had a significantly higher mean ABP and a higher mean serum bicarbonate level, which were measured the day after CRRT, than the nonsurvivors (86.723.7 vs. 69.224.6 mm Hg, respectively, 21.43.5 vs. 16.45.4 mmol/L, respectively,; p<0.05 for each). The stage 3 AKI patients showed the worst parameters for the SAPS II score and the serum levels of creatinine and blood urea nitrogen. The mortality rate was higher for the stage 3 subgroup than the other groups (70.5%, p<0.05). CONCLUSIONS The patients with AKI and who require CRRT continue to have a high mortality rate. A higher mean ABP and a higher serum bicarbonate level measured the day after CRRT may predict a more favorable prognosis. The staging system for AKI can improve the ability to predict the outcomes of CRRT patients.
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Affiliation(s)
- Woo Kyun Bae
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Dae Hun Lim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Ji Min Jeong
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Hae Young Jung
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Seong Ku Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jeong Woo Park
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Eun Hui Bae
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Seong Kwon Ma
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Nam Ho Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Ki Chul Choi
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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28
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Wu VC, Ko WJ, Chang HW, Chen YW, Lin YF, Shiao CC, Chen YM, Chen YS, Tsai PR, Hu FC, Wang JY, Lin YH, Wu KD. Risk factors of early redialysis after weaning from postoperative acute renal replacement therapy. Intensive Care Med 2007; 34:101-8. [PMID: 17701162 DOI: 10.1007/s00134-007-0813-x] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2007] [Accepted: 07/12/2007] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aim of this study was to identify risk factors for redialysis in postoperative patients with acute renal failure (ARF) who had previously been weaned from acute dialysis. Although recovery of renal function is anticipated in patients with ARF, no data have been reported on successful weaning from acute dialysis. DESIGN AND SETTING Retrospective observational case-control study in a 64-bed surgical ICU. PATIENTS AND METHODS Success in discontinuing dialysis was defined as cessation from dialysis for at least 30 days. A total of 304 postoperative patients who underwent acute renal replacement therapy in a surgical ICU between July 2002 and April 2005 were included. SOFA score biochemical data and renal function parameters were assessed on the day after the last session of renal replacement therapy, designated as day 0 (D0). RESULTS We could wean 94 patients (30.9%) from acute dialysis for more than 5 days, and 64 of these (21.1%) were successfully weaned for at least 30days. The independent predictors for resuming dialysis within 30 days were: (a) longer duration of dialysis (OR 1.06), (b) higher SOFA score on D0 (OR 1.44), (c) oliguria (urine output <100cc/8h; OR 4.17) on D1, and (d) age over 65 years (OR 6.35). The area under the ROC curve was 0.880. Two-way analysis of variance with repeated measurements over time showed a larger decline in SOFA score and an increase in urine output in patients with successful cessation of dialysis. Kaplan-Meier analysis showed a significant difference in early resumption of dialysis between patients with or without oliguria at D0. CONCLUSIONS More than two-thirds of patients weaned from postoperative acute dialysis for more than 5 days were free of dialysis for at least 30 days. Less urine output, longer duration of dialysis, age over 65 years, and higher disease severity score are predictive of a patient's redialysis after initial weaning from acute dialysis.
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Affiliation(s)
- Vin-Cent Wu
- Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan
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