Reliability of serum creatinine-based formulae estimating renal function in non-critically ill surgery patients: Focus on augmented renal clearance

Impact of augmented renal clearance on anticoagulant therapy in critically ill patients with coronavirus disease 2019: A retrospective cohort study

INTRODUCTION

This study aimed to determine the impact of augmented renal clearance (ARC) on anticoagulation therapy in critically ill patients with coronavirus disease 2019 (COVID-19).

METHODS

This retrospective cohort study included adult patients with severe COVID-19 with ARC who had been treated at our hospital between 2020 and 2021. We measured the estimated glomerular filtration rate calculated by the Chronic Kidney Disease Epidemiology Collaboration formula (eGFRCKD-EPI) every morning, and ARC condition was defined as eGFRCKD-EPI ≥ 130 mL/min/1.73 m2. Multivariate regression analysis with Huber-White sandwich estimator was performed to examine the association of unfractionated heparin (UH) dosage between blood test timings with activated partial thromboplastin time (APTT) compared with and without ARC.

RESULTS

We identified 38 enrolled patients: seven and 31 in the ARC and non-ARC groups, respectively. In the ARC coexisting condition, a higher dose of UH, which corresponded to the total dose in 24 h from the previous day, was required to achieve the same APTT prolongation, with a significant difference (p < 0.001).

CONCLUSIONS

Our study suggests that careful monitoring and consideration of higher UH doses in critically ill patients with COVID-19 is necessary because anticoagulation failure can occur during ARC.

Does Cytokine-Release Syndrome Induced by CAR T-Cell Treatment Have an Impact on the Pharmacokinetics of Meropenem and Piperacillin/Tazobactam in Patients with Hematological Malignancies? Findings from an Observational Case-Control Study

Chimeric antigen receptor (CAR) T-cell therapy is a promising approach for some relapse/refractory hematological B-cell malignancies; however, in most patients, cytokine release syndrome (CRS) may occur. CRS is associated with acute kidney injury (AKI) that may affect the pharmacokinetics of some beta-lactams. The aim of this study was to assess whether the pharmacokinetics of meropenem and piperacillin may be affected by CAR T-cell treatment. The study included CAR T-cell treated patients (cases) and oncohematological patients (controls), who were administered 24-h continuous infusion (CI) meropenem or piperacillin/tazobactam, optimized by therapeutic drug monitoring, over a 2-year period. Patient data were retrospectively retrieved and matched on a 1:2 ratio. Beta-lactam clearance (CL) was calculated as CL = daily dose/infusion rate. A total of 38 cases (of whom 14 and 24 were treated with meropenem and piperacillin/tazobactam, respectively) was matched with 76 controls. CRS occurred in 85.7% (12/14) and 95.8% (23/24) of patients treated with meropenem and piperacillin/tazobactam, respectively. CRS-induced AKI was observed in only 1 patient. CL did not differ between cases and controls for both meropenem (11.1 vs. 11.7 L/h, p = 0.835) and piperacillin (14.0 vs. 10.4 L/h, p = 0.074). Our findings suggest that 24-h CI meropenem and piperacillin dosages should not be reduced a priori in CAR T-cell patients experiencing CRS.

Measuring Creatinine Clearance Is the Most Accurate Way for Calculating the Proper Continuous Infusion Meropenem Dose for Empirical Treatment of Severe Gram-Negative Infections among Critically Ill Patients

Assessment of glomerular filtration rate (GFR) is necessary for dose adjustments of beta-lactam that are excreted by the kidneys, such as meropenem. The aim of this study was to compare the daily dose of 24 h-continuous infusion (CI) meropenem when GFR was calculated by means of measured creatinine clearance (mCL_CR) or estimated by the CKDEPI (eGFR_CKDEPI), Cockcroft-Gault (eGFR_CG), and MDRD (eGFR_MDRD) equations. Adult critically ill patients who underwent therapeutic drug monitoring (TDM) for the assessment of 24 h-CI meropenem steady state concentration (Css) and for whom a 24 h-urine collection was performed were retrospectively enrolled. Meropenem clearance (CL_M) was regressed against mCL_CR, and meropenem daily dose was calculated based on the equation infusion rate = daily dose/CL_M. eGFR_CKDEPI, eGFR_CG, and eGFR_CKDEPI were regressed against mCL_CR in order to estimate CL_M. Forty-six patients who provided 133 meropenem Css were included. eGFR_CKDEPI overestimated mCL_CR up to 90 mL/min, then mCL_CR was underestimated. eGFR_CG and eGFR_MDRD overestimated mCL_CR across the entire range of GFR. In critically ill patients, dose adjustments of 24 h-CI meropenem should be based on mCL_CR. Equations for estimation of GFR may lead to gross under/overestimates of meropenem dosages. TDM may be highly beneficial, especially for critically ill patients with augmented renal clearance.

Impact of duration of perioperative antibiotic prophylaxis on development of fracture-related infection in open fractures

INTRODUCTION

Infection is a common complication of open fractures potentially leading to nonunion, functional loss, and even amputation. Perioperative antibiotic prophylaxis (PAP) is standard practice for infection prevention in the management of open fractures. However, optimal duration of PAP remains controversial. The objectives were to assess whether PAP duration is independently associated with infection in open fractures and if administration of PAP beyond the commonly-recommended limit of 72 h has any effect on the infection rate.

MATERIALS AND METHODS

Over a 14-year period from 2003 to 2017, 530 skeletally-mature patients with operatively-treated, non-pathologic, long-bone open fractures were treated at one institution. Twenty-eight patients were excluded because of death or loss to follow-up and the remaining 502 patients (with 559 open fractures) who completed a 24-month follow-up were included in this retrospective study. The outcome was fracture-related infection (FRI), defined by the criteria of a recent consensus definition. A logistic generalized estimating equations regression model was conducted, including PAP duration and variables selected by a least absolute shrinkage and selection operator (LASSO) method, to assess the association between PAP duration and FRI. Propensity score analysis using a 72-h cut-off was performed to further cope with confounding.

RESULTS

PAP duration, adjusted for the LASSO selected predictors, was independently associated with FRI (OR: 1.11 [95%CI, 1.04-1.19] for every one-day increase in PAP duration, p = 0.003). PAP duration longer than 72 h did not significantly increase the odds for FRI compared to shorter durations (p = 0.06, analysis adjusted for propensity score).

CONCLUSIONS

This study found no evidence that administration of prophylactic antibiotics beyond 72 h in patients with long-bone open fractures is warranted. Analyses adjusted for known confounders even revealed a higher risk for FRI for longer PAP. However, this effect cannot necessarily be considered as causal and further research is needed.

Discordance of renal drug dosing using estimated creatinine clearance and measured urine creatinine clearance in hospitalized adults: A retrospective cohort study

Background

Assessment of kidney function is fundamental to optimize drug dosing. The Cockcroft-Gault (CG) equation is widely used but has questionable validity for females, changing renal function, and the critical ill. Eight-hour urine collections (U_8h) offer direct measurement of creatinine clearance (CrCl) but lack the data for drug dosing. The primary objective of this study was to determine if there was a difference in renal drug dosing based on the estimation of CG CrCl (CrCl_CG) versus 8-h CrCl (CrCl_8h).

Methods

This was an observational, retrospective cohort study of adult patients admitted between March 2018 and September 2018 with a collection U_8h during hospitalization. The primary outcome was discordance of renal drug dosing defined as the percentage of U_8h for which at least one different active medication CrCl dosing cutoff would result using the CrCl_CG versus CrCl_8h. The secondary outcomes were correlation between CrCl_CG and CrCl_8h and percentage of CrCl_CG values outside ± 20% of the CrCl_8h.

Results

One hundred collections drawn from 85 unique patients (50.6% male, median age 55 [41-70] years, intensive care unit 88%) were included in the analysis. Median serum creatinine was 0.76 (0.52-1.06) mg/dL and blood urea nitrogen was 20 (14-28) mg/dL at time of collection_8h. Median CrCl_8h was 86.2 (43.5-140.3) mL/min versus 99.7 (56.5-166.9) mL/min CrCl_CG(P < 0.001) and discordance was 25%. The correlation between CrCl_8h and CrCl_CG was 0.76 (P < 0.001). Only 31% of CrCl_CG values were within ± 20% of the CrCl_8h value.

Conclusion

We found 25% discordance for drug dosing between CrCl_8h and CrCl_CG. Further studies are needed to determine the impact on clinical outcomes.

Risk Factors and Clinical Outcomes Associated With Augmented Renal Clearance in Trauma Patients

BACKGROUND

Augmented renal clearance (ARC; i.e., creatinine clearance [CL_Cr] ≥ 130 mL/min) has an incidence of 14%-80% in critically ill patients and has been associated with therapy failures for renally cleared drugs. However, the clinical implications of ARC are poorly defined. We hypothesize that modifiable risk factors that contribute to ARC can be identified in severely injured trauma patients and that these risk factors influence clinical outcome.

METHODS

In 207 trauma intensive care unit patients, 24-h CL_Cr was correlated with clinical estimates of glomerular filtration rate (by Cockroft-Gault, modification of diet in renal disease, or chronic kidney disease epidemiology), and clinical outcomes (infection, venous thromboembolism [VTE], length of stay, and mortality).

RESULTS

The population was 45 ± 20 y, 68% male, 77% blunt injury with injury severity score of 24 (17-30). Admission serum creatinine was 1.02 ± 0.35 mg/dL, CL_Cr was 154 ± 77 mL/min, VTE incidence was 15%, ARC incidence was 57%, and mortality was 11%. Clinical estimates of glomerular filtration rate by Cockroft-Gault, modification of diet in renal disease, chronic kidney disease epidemiology underestimated actual CL_Cr by 20%, 22%, or 15% (all P < 0.01). CL_Cr was higher in males and those who survived, and lower in those with hypertension, diabetes, positive cultures, receiving transfusions, or pressors (all P < 0.05). On multivariate analysis, male gender (odds ratio [OR] 2.9 [1.4-6.1]), age (OR 0.97 [0.95-0.99]), and packed red blood cells transfusion (OR 0.31 [0.15-0.66]) were the only independent predictors of ARC.

CONCLUSIONS

ARC occurs in more than half of all high-risk trauma intensive care unit patients and is underestimated by standard clinical equations. ARC was not associated with increased incidence of VTE or infection but rather is associated with younger healthier males and reduced mortality. ARC seems to be a beneficial compensatory response to trauma.