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Liang Q, Xu X, Ding S, Wu J, Huang M. Prediction of successful weaning from renal replacement therapy in critically ill patients based on machine learning. Ren Fail 2024; 46:2319329. [PMID: 38416516 PMCID: PMC10903749 DOI: 10.1080/0886022x.2024.2319329] [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: 10/23/2023] [Accepted: 02/10/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Predicting the successful weaning of acute kidney injury (AKI) patients from renal replacement therapy (RRT) has emerged as a research focus, and we successfully built predictive models for RRT withdrawal in patients with severe AKI by machine learning. METHODS This retrospective single-center study utilized data from our general intensive care unit (ICU) Database, focusing on patients diagnosed with severe AKI who underwent RRT. We evaluated RRT weaning success based on patients being free of RRT in the subsequent week and their overall survival. Multiple logistic regression (MLR) and machine learning algorithms were adopted to construct the prediction models. RESULTS A total of 976 patients were included, with 349 patients successfully weaned off RRT. Longer RRT duration (7.0 vs. 9.6 d, p = 0.002, OR = 0.94), higher serum cystatin C levels (1.2 vs. 3.2 mg/L, p < 0.001, OR = 0.46), and the presence of septic shock (28.1% vs. 41.5%, p < 0.001, OR = 0.63) were associated with reduced likelihood of RRT weaning. Conversely, a positive furosemide stress test (FST) (60.2% vs. 40.7%, p < 0.001, OR = 2.75) and higher total urine volume 3 d before RRT withdrawal (755 vs. 125 mL/d, p < 0.001, OR = 2.12) were associated with an increased likelihood of successful weaning from RRT. Next, we demonstrated that machine learning models, especially Random Forest and XGBoost, achieving an AUROC of 0.95. The XGBoost model exhibited superior accuracy, yielding an AUROC of 0.849. CONCLUSION High-risk factors for unsuccessful RRT weaning in severe AKI patients include prolonged RRT duration. Machine learning prediction models, when compared to models based on multivariate logistic regression using these indicators, offer distinct advantages in predictive accuracy.
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Affiliation(s)
- Qiqiang Liang
- General Intensive Care Unit, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, PR China
| | - Xin Xu
- General Intensive Care Unit, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, PR China
| | - Shuo Ding
- General Intensive Care Unit, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, PR China
| | - Jin Wu
- General Intensive Care Unit, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, PR China
| | - Man Huang
- General Intensive Care Unit, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, PR China
- Key Laboratory of Multiple Organ Failure, China National Ministry of Education, Hangzhou, PR China
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2
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Stenson EK, Alhamoud I, Alobaidi R, Bottari G, Fernandez S, Fuhrman DY, Guzzi F, Haga T, Kaddourah A, Marinari E, Mohamed T, Morgan C, Mottes T, Neumayr T, Ollberding NJ, Raggi V, Ricci Z, See E, Stanski NL, Zang H, Zangla E, Gist KM. Factors associated with successful liberation from continuous renal replacement therapy in children and young adults: analysis of the worldwide exploration of renal replacement outcomes collaborative in Kidney Disease Registry. Intensive Care Med 2024; 50:861-872. [PMID: 38436726 PMCID: PMC11164640 DOI: 10.1007/s00134-024-07336-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/25/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE Continuous renal replacement therapy (CRRT) is used for supportive management of acute kidney injury (AKI) and disorders of fluid balance (FB). Little is known about the predictors of successful liberation in children and young adults. We aimed to identify the factors associated with successful CRRT liberation. METHODS The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease study is an international multicenter retrospective study (32 centers, 7 nations) conducted from 2015 to 2021 in children and young adults (aged 0-25 years) treated with CRRT for AKI or FB disorders. Patients with previous dialysis dependence, tandem extracorporeal membrane oxygenation use, died within the first 72 h of CRRT initiation, and those who never had liberation attempted were excluded. Patients were categorized based on first liberation attempt: reinstituted (resumption of any dialysis within 72 h) vs. success (no receipt of dialysis for ≥ 72 h). Multivariable logistic regression was used to identify factors associated with successful CRRT liberation. RESULTS A total of 622 patients were included: 287 (46%) had CRRT reinstituted and 335 (54%) were successfully liberated. After adjusting for sepsis at admission and illness severity parameters, several factors were associated with successful liberation, including higher VIS (vasoactive-inotropic score) at CRRT initiation (odds ratio [OR] 1.35 [1.12-1.63]), higher PELOD-2 (pediatric logistic organ dysfunction-2) score at CRRT initiation (OR 1.71 [1.24-2.35]), higher urine output prior to CRRT initiation (OR 1.15 [1.001-1.32]), and shorter CRRT duration (OR 0.19 [0.12-0.28]). CONCLUSIONS Inability to liberate from CRRT was common in this multinational retrospective study. Modifiable and non-modifiable factors were associated with successful liberation. These results may inform the design of future clinical trials to optimize likelihood of CRRT liberation success.
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Affiliation(s)
- Erin K Stenson
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Issa Alhamoud
- Carver College of Medicine, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | | | | | - Sarah Fernandez
- School of Medicine, Gregorio Marañón University Hospital, Madrid, Spain
| | - Dana Y Fuhrman
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | | | - Taiki Haga
- Osaka City General Hospital, Osaka, Japan
| | | | | | - Tahagod Mohamed
- Nationwide Children's Hospital, The Kidney and Urinary Tract Center, The Ohio State University College of Medicine, Columbus, OH, USA
| | | | - Theresa Mottes
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Tara Neumayr
- St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - Nicholas J Ollberding
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Valeria Raggi
- Bambino Gesù, Children's Hospital, IRCCS, Rome, Italy
| | - Zaccaria Ricci
- Department of Pediatrics, Pediatric Intensive Care Unit, Meyer Children's Hospital, IRCCS, Florence, Italy
| | - Emily See
- Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Melbourne, VIC, Australia
| | - Natalja L Stanski
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Huaiyu Zang
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Katja M Gist
- St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO, USA
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Raina R, Nair N, Pelletier J, Nied M, Whitham T, Doshi K, Beck T, Dantes G, Sethi SK, Kim YH, Bunchman T, Alhasan K, Lima L, Guzzo I, Fuhrman D, Paden M. Concurrent use of continuous kidney replacement therapy during extracorporeal membrane oxygenation: what pediatric nephrologists need to know-PCRRT-ICONIC practice points. Pediatr Nephrol 2024:10.1007/s00467-024-06311-x. [PMID: 38386072 DOI: 10.1007/s00467-024-06311-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/15/2024] [Accepted: 01/27/2024] [Indexed: 02/23/2024]
Abstract
Extracorporeal membrane oxygenation (ECMO) provides temporary cardiorespiratory support for neonatal, pediatric, and adult patients when traditional management has failed. This lifesaving therapy has intrinsic risks, including the development of a robust inflammatory response, acute kidney injury (AKI), fluid overload (FO), and blood loss via consumption and coagulopathy. Continuous kidney replacement therapy (CKRT) has been proposed to reduce these side effects by mitigating the host inflammatory response and controlling FO, improving outcomes in patients requiring ECMO. The Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup and the International Collaboration of Nephrologists and Intensivists for Critical Care Children (ICONIC) met to highlight current practice standards for ECMO use within the pediatric population. This review discusses ECMO modalities, the pathophysiology of inflammation during an ECMO run, its adverse effects, various anticoagulation strategies, and the technical aspects and outcomes of implementing CKRT during ECMO in neonatal and pediatric populations. Consensus practice points and guidelines are summarized. ECMO should be utilized in patients with severe acute respiratory failure despite the use of conventional treatment modalities. The Extracorporeal Life Support Organization (ELSO) offers guidelines for ECMO initiation and management while maintaining a clinical registry of over 195,000 patients to assess outcomes and complications. Monitoring and preventing fluid overload during ECMO and CKRT are imperative to reduce mortality risk. Clinical evidence, resources, and experience of the nephrologist and healthcare team should guide the selection of ECMO circuit.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA.
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
| | - Nikhil Nair
- Case Western University School of Medicine, Cleveland, OH, USA
| | - Jonathan Pelletier
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH, USA
- Department of Pediatrics, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Matthew Nied
- Department of Internal Medicine, Case Western Reserve / University Hospitals, Cleveland, OH, USA
| | - Tarik Whitham
- Department of Pediatrics, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Kush Doshi
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Tara Beck
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital, Pittsburgh, PA, USA
| | - Goeto Dantes
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Sidharth Kumar Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Yap Hui Kim
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Timothy Bunchman
- Department of Pediatric Nephrology, Children's Hospital of Richmond, Richmond, VA, USA
| | - Kahild Alhasan
- Pediatric Nephrology, King Saud University, Riyadh, Saudi Arabia
| | - Lisa Lima
- Department of Pediatric Critical Care, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Dana Fuhrman
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital, Pittsburgh, PA, USA
| | - Matthew Paden
- Department of Pediatric Critical Care, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Fuhrman DY, Stenson EK, Alhamoud I, Alobaidi R, Bottari G, Fernandez S, Guzzi F, Haga T, Kaddourah A, Marinari E, Mohamed TH, Morgan CJ, Mottes T, Neumayr TM, Ollberding NJ, Raggi V, Ricci Z, See E, Stanski NL, Zang H, Zangla E, Gist KM. Major Adverse Kidney Events in Pediatric Continuous Kidney Replacement Therapy. JAMA Netw Open 2024; 7:e240243. [PMID: 38393726 PMCID: PMC10891477 DOI: 10.1001/jamanetworkopen.2024.0243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/26/2023] [Indexed: 02/25/2024] Open
Abstract
Importance Continuous kidney replacement therapy (CKRT) is increasingly used in youths with critical illness, but little is known about longer-term outcomes, such as persistent kidney dysfunction, continued need for dialysis, or death. Objective To characterize the incidence and risk factors, including liberation patterns, associated with major adverse kidney events 90 days after CKRT initiation (MAKE-90) in children, adolescents, and young adults. Design, Setting, and Participants This international, multicenter cohort study was conducted among patients aged 0 to 25 years from The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) registry treated with CKRT for acute kidney injury or fluid overload from 2015 to 2021. Exclusion criteria were dialysis dependence, concurrent extracorporeal membrane oxygenation use, or receipt of CKRT for a different indication. Data were analyzed from May 2 to December 14, 2023. Exposure Patient clinical characteristics and CKRT parameters were assessed. CKRT liberation was classified as successful, reinstituted, or not attempted. Successful liberation was defined as the first attempt at CKRT liberation resulting in 72 hours or more without return to dialysis within 28 days of CKRT initiation. Main Outcomes and Measures MAKE-90, including death or persistent kidney dysfunction (dialysis dependence or ≥25% decline in estimated glomerular filtration rate from baseline), were assessed. Results Among 969 patients treated with CKRT (529 males [54.6%]; median [IQR] age, 8.8 [1.7-15.0] years), 630 patients (65.0%) developed MAKE-90. On multivariable analysis, cardiac comorbidity (adjusted odds ratio [aOR], 1.60; 95% CI, 1.08-2.37), longer duration of intensive care unit admission before CKRT initiation (aOR for 6 days vs 1 day, 1.07; 95% CI, 1.02-1.13), and liberation pattern were associated with MAKE-90. In this analysis, patients who successfully liberated from CKRT within 28 days had lower odds of MAKE-90 compared with patients in whom liberation was attempted and failed (aOR, 0.32; 95% CI, 0.22-0.48) and patients without a liberation attempt (aOR, 0.02; 95% CI, 0.01-0.04). Conclusions and Relevance In this study, MAKE-90 occurred in almost two-thirds of the population and patient-level risk factors associated with MAKE-90 included cardiac comorbidity, time to CKRT initiation, and liberation patterns. These findings highlight the high incidence of adverse outcomes in this population and suggest that future prospective studies are needed to better understand liberation patterns and practices.
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Affiliation(s)
- Dana Y. Fuhrman
- University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Erin K. Stenson
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora
| | - Issa Alhamoud
- University of Iowa Stead Family Children’s Hospital, Carver College of Medicine, Iowa City
| | | | | | - Sarah Fernandez
- Gregorio Marañón University Hospital, School of Medicine, Madrid, Spain
| | | | - Taiki Haga
- Osaka City General Hospital, Osaka, Japan
| | - Ahmad Kaddourah
- Sidra Medicine, Doha, Qatar
- Weill Cornell Medical College, Ar-Rayyan, Qatar
| | | | - Tahagod H. Mohamed
- Nationwide Children’s Hospital, The Heart Center, The Ohio State University College of Medicine, Columbus
| | | | - Theresa Mottes
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Tara M. Neumayr
- Washington University School of Medicine, St Louis Children’s Hospital, St Louis, Missouri
| | - Nicholas J. Ollberding
- Cincinnati Children’s Hospital Medical Center; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Valeria Raggi
- Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | | | - Emily See
- Royal Children’s Hospital, University of Melbourne, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Natalja L. Stanski
- Cincinnati Children’s Hospital Medical Center; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Huaiyu Zang
- Cincinnati Children’s Hospital Medical Center; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Katja M. Gist
- Cincinnati Children’s Hospital Medical Center; University of Cincinnati College of Medicine, Cincinnati, Ohio
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5
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Klouche K, Brunot V, Larcher R, Lautrette A. Weaning from Kidney Replacement Therapy in the Critically Ill Patient with Acute Kidney Injury. J Clin Med 2024; 13:579. [PMID: 38276085 PMCID: PMC10816626 DOI: 10.3390/jcm13020579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 01/27/2024] Open
Abstract
Around 10% of critically ill patients suffer acute kidney injury (AKI) requiring kidney replacement therapy (KRT), with a mortality rate approaching 50%. Although most survivors achieve sufficient renal recovery to be weaned from KRT, there are no recognized guidelines on the optimal period for weaning from KRT. A systematic review was conducted using a peer-reviewed strategy, combining themes of KRT (intermittent hemodialysis, CKRT: continuous veno-venous hemo/dialysis/filtration/diafiltration, sustained low-efficiency dialysis/filtration), factors predictive of successful weaning (defined as a prolonged period without new KRT) and patient outcomes. Our research resulted in studies, all observational, describing clinical and biological parameters predictive of successful weaning from KRT. Urine output prior to KRT cessation is the most studied variable and the most widely used in practice. Other predictive factors, such as urinary urea and creatinine and new urinary and serum renal biomarkers, including cystatin C and neutrophil gelatinase-associated lipocalin (NGAL), were also analyzed in the light of recent studies. This review presents the rationale for early weaning from KRT, the parameters that can guide it, and its practical modalities. Once the patient's clinical condition has stabilized and volume status optimized, a diuresis greater than 500 mL/day should prompt the intensivist to consider weaning. Urinary parameters could be useful in predicting weaning success but have yet to be validated.
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Affiliation(s)
- Kada Klouche
- Intensive Care Unit Département, Lapeyronie University Hospital Montpellier, 34295 Montpellier, France; (V.B.); (R.L.)
- Phymedexp, Faculty of Medicine, Université de Montpellier, Inserm, Centre National de Recherche Scientifique (CNRS), CHRU de Montpellier, 34295 Montpellier, France
| | - Vincent Brunot
- Intensive Care Unit Département, Lapeyronie University Hospital Montpellier, 34295 Montpellier, France; (V.B.); (R.L.)
| | - Romaric Larcher
- Intensive Care Unit Département, Lapeyronie University Hospital Montpellier, 34295 Montpellier, France; (V.B.); (R.L.)
- Phymedexp, Faculty of Medicine, Université de Montpellier, Inserm, Centre National de Recherche Scientifique (CNRS), CHRU de Montpellier, 34295 Montpellier, France
| | - Alexandre Lautrette
- Centre de Lutte Contre le Cancer Jean PERRIN, Médecine Intensive Réanimation, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France;
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Li Y, Deng X, Feng J, Xu B, Chen Y, Li Z, Guo X, Guan T. Predictors for short-term successful weaning from continuous renal replacement therapy: a systematic review and meta-analysis. Ren Fail 2023; 45:2176170. [PMID: 36762988 PMCID: PMC9930790 DOI: 10.1080/0886022x.2023.2176170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
The systemic review and meta-analysis aimed to identify the predictors for short-term successful weaning from CRRT in severe AKI patients. PubMed, Embase, the Cochrane Library, and grey literature were searched for relevant studies investigating variables for short-term successful weaning from CRRT to August 2022. Our criteria included patients with AKI who required CRRT but excluded patients with kidney failure. The pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated using fixed-effect (I2≤50% and P-value of the Q statistic > 0.1) or random-effect models (I2>50% or p-value of the Q statistic ≤ 0.1) as appropriate. Our search yielded 11 studies and described 11 variables. The pooled analysis showed that chronic kidney disease (OR = 0.638, 95% CI: 0.491-0.829), CRRT duration (OR = 0.913, 95% CI: 0.882-0.946), and urine output at the cessation of CRRT (per 100 mL/day increase) (OR = 1.084, 95% CI: 1.061-1.108) were predictive factors for short-term successful weaning from CRRT. Male (OR = 0.827, 95% CI: 0.627-1.092), diabetes mellitus (OR = 0.970, 95% CI: 0.761-1.237), and sepsis (OR = 0.911, 95% CI: 0.717-1.158) were unrelated to the short-term weaning from CRRT. The relationship between hypertension, use of vasopressors or inotropes at the starting of CRRT, use of vasopressors or inotropes at the cessation of CRRT, use of diuretics at the cessation of CRRT, serum creatinine at the cessation of CRRT, and short-term weaning from CRRT remains unclear. Additional prospective studies are needed to evaluate this relationship further.
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Affiliation(s)
- Yu Li
- Department of Nephrology, Zhongshan Hospital affiliated to Xiamen University, Xiamen, China
| | - Xiaoqi Deng
- Department of Nephrology, Zhongshan Hospital affiliated to Xiamen University, Xiamen, China
| | - Jiaxing Feng
- Department of Gastroenterology, Zhongshan Hospital affiliated to Xiamen University, Xiamen, China
| | - Bo Xu
- Department of Nephrology, Zhongshan Hospital affiliated to Xiamen University, Xiamen, China
| | - Yulei Chen
- School of Medicine, Xiamen University, Xiamen, China
| | - Zhanying Li
- School of Medicine, Xiamen University, Xiamen, China
| | - Xiaodan Guo
- Department of Nephrology, Zhongshan Hospital affiliated to Xiamen University, Xiamen, China,Xiaodan Guo Department of Nephrology, Zhongshan Hospital affiliated to Xiamen University, 201 Hubin South Road, Xiamen, 361004, China
| | - Tianjun Guan
- Department of Nephrology, Zhongshan Hospital affiliated to Xiamen University, Xiamen, China,CONTACT Tianjun Guan Department of Nephrology, Zhongshan Hospital affiliated to Xiamen University, 201 Hubin South Road, Xiamen, 361004, China
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Boyer N, Perschinka F, Joannidis M, Forni LG. When to discontinue renal replacement therapy. what do we know? Curr Opin Crit Care 2023; 29:559-565. [PMID: 37909367 DOI: 10.1097/mcc.0000000000001101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
PURPOSE OF REVIEW Acute kidney injury is common in intensive care patients. Supportive care involves the use of renal replacement therapies as organ support. Initiation of renal replacement therapy has been the subject of much interest over the last few years with several randomised controlled studies examining the optimal time to commence treatment. In contrast to this, little evidence has been generated regarding cessation of therapy. Given that this treatment is complex, not without risk and expensive it seems timely that efforts should be expended at examining this vexing issue. RECENT FINDINGS Although several studies have been reported examining the successful discontinuation of renal replacement therapies all studies reported to-date are observational in nature. Conventional biochemical criteria have been used as well as physiological parameters including urine output. More recently, more novel biomarkers of renal function have been studied. Although to-date no optimal variable nor threshold for discontinuation can be established. SUMMARY Several variables have been described which may have a role in determining which patients may be successfully weaned from renal replacement therapy. However, few have been exposed to vigorous examination and evidence is sparse in support of any potential approach although urine output currently is the most often described. More recently novel biomarkers have also been examined but again are limited by study design and heterogeneity. Further research is clearly needed focussing on proposed variables preferably in multivariate models to improve predictive ability and successful cessation of therapy.
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Affiliation(s)
- Naomi Boyer
- Department of Critical Care and Surrey Peri-Operative, Anaesthesia and Critical Care Collaborative Research Group, Royal Surrey Hospital, Guildford, Surrey, UK
| | - F Perschinka
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Austria
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Austria
| | - Lui G Forni
- Department of Critical Care and Surrey Peri-Operative, Anaesthesia and Critical Care Collaborative Research Group, Royal Surrey Hospital, Guildford, Surrey, UK
- School of Medicine, Kate Granger Building, University of Surrey, Guildford, Surrey, UK
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8
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Gleeson PJ, Crippa IA, Sannier A, Koopmansch C, Bienfait L, Allard J, Sexton DJ, Fontana V, Rorive S, Vincent JL, Creteur J, Taccone FS. Critically ill patients with acute kidney injury: clinical determinants and post-mortem histology. Clin Kidney J 2023; 16:1664-1673. [PMID: 37779855 PMCID: PMC10539222 DOI: 10.1093/ckj/sfad113] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Indexed: 10/03/2023] Open
Abstract
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.
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Affiliation(s)
- Patrick James Gleeson
- Department of Intensive Care Medicine, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Université de Paris Cité, INSERM UMR1149 & CNRS EMR8252, Centre de Recherche sur l'Inflammation, Inflamex Laboratory of Excellence, Paris, France
- Department of Renal Medicine, Cork University Hospital, Cork, Ireland
| | - Ilaria Alice Crippa
- Department of Intensive Care Medicine, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Department of Anesthesiology, San Marco Hospital, San Donato Group, Zingonia, Bergame, Italy
| | - Aurélie Sannier
- AP-HP, Nord/Université de Paris, Hôpital Bichat-Claude Bernard, Service d'Anatomie-Pathologique, Paris, France
| | - Caroline Koopmansch
- Department of Pathology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Institut de Pathologie et de Génétique, Avenue George Lemaître, Gosselies, Belgium
| | - Lucie Bienfait
- Department of Pathology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Justine Allard
- DIAPath, Center for Microscopy and Molecular Imaging, Université Libre de Bruxelles, Gosselies, Belgium
| | - Donal J Sexton
- Trinity Health Kidney Center, Trinity College Dublin, Dublin, Ireland
- Department of Nephrology, St James’ Hospital, Dublin, Ireland
| | - Vito Fontana
- Department of Intensive Care Medicine, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Department of Intensive Care Medicine, Clinique Saint-Jean, Brussels, Belgium
| | - Sandrine Rorive
- Department of Pathology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care Medicine, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care Medicine, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Yoshida T, Matsuura R, Komaru Y, Miyamoto Y, Yoshimoto K, Hamasaki Y, Noiri E, Nangaku M, Doi K. Different Roles of Functional and Structural Renal Markers Measured at Discontinuation of Renal Replacement Therapy for Acute Kidney Injury. Blood Purif 2023; 52:786-792. [PMID: 37757763 PMCID: PMC10777711 DOI: 10.1159/000532034] [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: 12/24/2022] [Accepted: 07/03/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Severe acute kidney injury (AKI) requiring renal replacement therapy (RRT) has been associated with an unacceptably high mortality of 50% or more. Successful discontinuation of RRT is thought to be linked to better outcomes. Although functional and structural renal markers have been evaluated in AKI, little is known about their roles in predicting outcomes at the time of RRT discontinuation. METHODS In this prospective single-center cohort study, we analyzed patients who received continuous RRT (CRRT) for AKI between August 2016 and March 2018 in the intensive care unit of the University of Tokyo Hospital (Tokyo, Japan). Clinical parameters and urine samples were obtained at CRRT discontinuation. Successful CRRT discontinuation was defined as neither resuming CRRT for 48 h nor receiving intermittent hemodialysis for 7 days from the CRRT termination. Major adverse kidney events (MAKEs) were defined as death, requirement for dialysis, or a decrease in the estimated glomerular filtration rate (eGFR) of more than 25% from the baseline at day 90. RESULTS Of 73 patients, who received CRRT for AKI, 59 successfully discontinued CRRT and 14 could not. Kinetic eGFR, urine volume, urinary neutrophil gelatinase-associated lipocalin (NGAL), and urinary L-type fatty acid binding protein were predictive for CRRT discontinuation. Of these factors, urine volume had the highest area under the curve (AUC) 0.91 with 95% confidence interval [0.80-0.96] for successful CRRT discontinuation. For predicting MAKEs at day 90, the urinary NGAL showed the highest AUC 0.76 [0.62-0.86], whereas kinetic eGFR and urine volume failed to show statistical significance (AUC 0.49 [0.35-0.63] and AUC 0.59 [0.44-0.73], respectively). CONCLUSIONS Our prospective study confirmed that urine volume, a functional renal marker, predicted successful discontinuation of RRT and that urinary NGAL, a structural renal marker, predicted long-term renal outcomes. These observations suggest that the functional and structural renal makers play different roles in predicting the outcomes of severe AKI requiring RRT.
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Affiliation(s)
- Teruhiko Yoshida
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan,
| | - Ryo Matsuura
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Yohei Komaru
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshihisa Miyamoto
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Kohei Yoshimoto
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshifumi Hamasaki
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Eisei Noiri
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
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10
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Wei EY, Vuong KT, Lee E, Liu L, Ingulli E, Coufal NG. Predictors of successful discontinuation of continuous kidney replacement therapy in a pediatric cohort. Pediatr Nephrol 2022:10.1007/s00467-022-05782-0. [PMID: 36315275 DOI: 10.1007/s00467-022-05782-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/30/2022] [Accepted: 09/30/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Recognizing the optimal time to discontinue continuous kidney replacement therapy (CKRT) is necessary to advance patient recovery and mitigate complications. The aim of this study was to identify predictors of successful CKRT cessation in pediatric patients. METHODS All patients requiring CKRT between January 2010 and March 2021 were evaluated. Patients on peritoneal or hemodialysis, who transferred between institutions, or who did not trial off CKRT were excluded. Successful discontinuation was defined as remaining off CKRT for at least 7 days. Demographics, admission diagnoses, PRISM III scores, and reasons for CKRT initiation were obtained. Clinical and biochemical variables were evaluated at CKRT initiation and discontinuation and in the 12-h period following discontinuation. Comparisons were conducted using Wilcoxon rank sum and Fisher's exact tests for continuous and categorical variables, respectively. A logistic regression model was fitted to identify significant factors. RESULTS Ninety-nine patients underwent a trial off CKRT. Admission and initiation characteristics of the success and failure groups were similar. Patients who required re-initiation (n = 26) had longer ICU lengths of stay (27.2 vs. 44.5 days, p = 0.046) and higher in-hospital mortality (15.1% vs. 46.2%, p = 0.002). Urine output greater than 0.5 mL/kg/h irrespective of diuretic administration in the 6-h period before CKRT discontinuation was a significant predictor (AUC 0.72, 95% CI 0.60-0.84, p = 0.0009). CONCLUSIONS Determining the predictors of sustained CKRT discontinuation is critical. Urine output greater than 0.5 mL/kg/h in this pediatric cohort predicted successful discontinuation. Future studies are needed to validate this threshold in disease- and age-specific cohorts and evaluate additional biomarkers of kidney injury. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Elizabeth Y Wei
- Department of Pediatrics, Division of Critical Care, University of California San Diego, 3020 Children's Way, MC 5065, San Diego, CA, 92123, USA. .,Rady Children's Hospital, San Diego, CA, USA.
| | - Kim T Vuong
- Rady Children's Hospital, San Diego, CA, USA.,Department of Pediatrics, University of California San Diego, San Diego, CA, USA
| | - Euyhyun Lee
- Altman Clinical and Translational Research Institute, University of California San Diego, San Diego, CA, USA
| | - Lin Liu
- Altman Clinical and Translational Research Institute, University of California San Diego, San Diego, CA, USA.,Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, CA, USA
| | - Elizabeth Ingulli
- Rady Children's Hospital, San Diego, CA, USA.,Department of Pediatrics, Division of Nephrology, University of California San Diego, San Diego, CA, USA
| | - Nicole G Coufal
- Department of Pediatrics, Division of Critical Care, University of California San Diego, 3020 Children's Way, MC 5065, San Diego, CA, 92123, USA.,Rady Children's Hospital, San Diego, CA, USA
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11
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Liu C, Peng Z, Dong Y, Li Z, Song X, Liu X, Andrijasevic NM, Gajic O, Albright RC, Kashani KB. Continuous Renal Replacement Therapy Liberation and Outcomes of Critically Ill Patients With Acute Kidney Injury. Mayo Clin Proc 2021; 96:2757-2767. [PMID: 34686364 DOI: 10.1016/j.mayocp.2021.05.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 04/08/2021] [Accepted: 05/27/2021] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To examine the association between continuous renal replacement therapy (CRRT) liberation and clinical outcomes among patients with acute kidney injury (AKI) requiring CRRT. METHODS This single-center, retrospective cohort study included adult patients admitted to intensive care units with AKI and treated with CRRT from January 1, 2007, to May 4, 2018. Based on the survival and renal replacement therapy (RRT) status at 72 hours after the first CRRT liberation, we classified patients into liberated, reinstituted, and those who died. We observed patients for 90 days after CRRT initiation to compare the major adverse kidney events (MAKE90). RESULTS Of 1135 patients with AKI, 228 (20%), 437 (39%), and 470 (41%) were assigned to liberated, reinstituted, and nonsurvival groups, respectively. The MAKE90, mortality, and RRT independence rates of the cohort were 62% (707 cases), 59% (674 cases), and 40% (453 cases), respectively. Compared with reinstituted patients, the liberated group had a lower MAKE90 (29% vs 39%; P=.009) and higher RRT independence rate (73% vs 65%; P=.04) on day 90, but without significant difference in 90-day mortality (26% vs 33%; P=.05). After adjustments for confounders, successful CRRT liberation was not associated with lower MAKE90 (odds ratio, 0.71; 95% CI, 0.48 to 1.04; P=.08) but was independently associated with improved kidney recovery at 90-day follow-up (hazard ratio, 1.81; 95% CI, 1.41 to 2.32; P<.001). CONCLUSION Our study demonstrated a high occurrence of CRRT liberation failure and poor 90-day outcomes in a cohort of AKI patients treated with CRRT.
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Affiliation(s)
- Chang Liu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Zhiyong Peng
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Zhuo Li
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL
| | - Xuan Song
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Xinyan Liu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Robert C Albright
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Kianoush B Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN.
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12
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Liu C, Zhang HT, Yue LJ, Li ZS, Pan K, Chen Z, Gu SP, Pan T, Pan J, Wang DJ. Risk factors for mortality in patients undergoing continuous renal replacement therapy after cardiac surgery. BMC Cardiovasc Disord 2021; 21:509. [PMID: 34674651 PMCID: PMC8529736 DOI: 10.1186/s12872-021-02324-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 10/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate the risk factors for mortality in patients with acute kidney injury requiring continuous renal replacement therapy (AKI-CRRT) after cardiac surgery. METHODS In this retrospective study, patients who underwent AKI-CRRT after cardiac surgery in our centre from January 2015 to January 2020 were included. Univariable and multivariable analyses were performed to identify the risk factors for in-hospital mortality. RESULTS A total of 412 patients were included in our study. Of these, 174 died after AKI-CRRT, and the remaining 238 were included in the survival control group. Multivariable logistic regression analysis revealed that EuroSCORE > 7 (odds ratio [OR], 3.72; 95% confidence interval [CI], 1.92-7.24; p < 0.01), intraoperative bleeding > 1 L (OR, 2.14; 95% CI, 1.19-3.86; p = 0.01) and mechanical ventilation time > 70 h (OR, 5.03; 95% CI, 2.40-10.54; p < 0.01) were independent risk factors for in-hospital mortality in patients who had undergone AKI-CRRT. Our study also found that the use of furosemide after surgery was a protective factor for such patients (odds ratio, 0.48; 95% confidence interval, 0.25-0.92; p = 0.03). CONCLUSIONS In summary, the mortality of patients with AKI-CRRT after cardiac surgery remains high. The EuroSCORE, intraoperative bleeding and mechanical ventilation time were independent risk factors for in-hospital mortality. Continuous application of furosemide may be associated with a better outcome.
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Affiliation(s)
- Chang Liu
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China.,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Hai-Tao Zhang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100010, China
| | - Li-Jun Yue
- Department of Traditional Chinese Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Ze-Shi Li
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100010, China
| | - Ke Pan
- Nanjing Drum Tower Hospital, The Affiliated Clinical College of Xuzhou Medical University, Nanjing, 210008, Jiangsu, China
| | - Zhong Chen
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, 210008, Jiangsu, China
| | - Su-Ping Gu
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Tuo Pan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100010, China.,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Jun Pan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China. .,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China.
| | - Dong-Jin Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China. .,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100010, China. .,Nanjing Drum Tower Hospital, The Affiliated Clinical College of Xuzhou Medical University, Nanjing, 210008, Jiangsu, China. .,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, 210008, Jiangsu, China. .,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China.
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13
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Predicting successful continuous renal replacement therapy liberation in critically ill patients with acute kidney injury. J Crit Care 2021; 66:6-13. [PMID: 34358675 DOI: 10.1016/j.jcrc.2021.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/15/2021] [Accepted: 07/17/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE No standardized criteria for continuous renal replacement therapy (CRRT) liberation have been established. We sought to develop and internally validate prediction models for successful CRRT liberation in critically ill patients with acute kidney injury (AKI). MATERIALS AND METHODS This single-center, retrospective cohort study included adult patients admitted to intensive care units (ICUs) with AKI and treated with CRRT from January 1, 2007, to May 4, 2018, at a tertiary referral hospital. The cohort was randomly divided into derivation and validation sets. The outcomes were successful CRRT liberation, defined as renal replacement therapy (RRT)-free survival within 72 h after the liberation and hospital discharge. Multivariate logistic regression models were developed and internally validated. RESULTS Of 1135 AKI patients requiring CRRT, successful CRRT liberation and RRT-free survival at hospital discharge were observed in 228 (20%) and 395 (35%) individuals, respectively. The independent predictors included mean hourly urine output within 12 h before liberation, mean serum creatinine value within 24 h before liberation, cumulative fluid balance from ICU admission to liberation, CRRT duration before liberation, and the requirement of vasoactive agents within 24 h before liberation. The models demonstrated good discrimination (AUROC, 0.76 and 0.78; positive predictive value, 36% and 48%; negative predictive value, 92% and 94%; respectively) and calibration in the validation set. CONCLUSIONS These validated models could assist the decision-making related to the CRRT liberation in critically ill patients with AKI.
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14
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Chávez-Íñiguez JS, Maggiani-Aguilera P, Pérez-Flores C, Claure-Del Granado R, De la Torre-Quiroga AE, Martínez-Gallardo González A, Navarro-Blackaller G, Medina-González R, Raimann JG, Yanowsky-Escatell FG, García-García G. Nephrologist Interventions to Avoid Kidney Replacement Therapy in Acute Kidney Injury. Kidney Blood Press Res 2021; 46:629-638. [PMID: 34315155 DOI: 10.1159/000517615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/04/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Based on the pathophysiology of acute kidney injury (AKI), it is plausible that certain early interventions by the nephrologist could influence its trajectory. In this study, we investigated the impact of 5 early nephrology interventions on starting kidney replacement therapy (KRT), AKI progression, and death. METHODS In a prospective cohort at the Hospital Civil of Guadalajara, we followed up for 10 days AKI patients in whom a nephrology consultation was requested. We analyzed 5 early interventions of the nephrology team (fluid adjustment, nephrotoxic withdrawal, antibiotic dose adjustment, nutritional adjustment, and removal of hyperchloremic solutions) after the propensity score and multivariate analysis for the risk of starting KRT (primary objective), AKI progression to stage 3, and death (secondary objectives). RESULTS From 2017 to 2020, we analyzed 288 AKI patients. The mean age was 55.3 years, 60.7% were male, AKI KDIGO stage 3 was present in 50.5% of them, sepsis was the main etiology 50.3%, and 72 (25%) patients started KRT. The overall survival was 84.4%. Fluid adjustment was the only intervention associated with a decreased risk for starting KRT (odds ratio [OR]: 0.58, 95% confidence interval [CI]: 0.48-0.70, and p ≤ 0.001) and AKI progression to stage 3 (OR: 0.59, 95% CI: 0.49-0.71, and p ≤ 0.001). Receiving vasopressors and KRT were associated with mortality. None of the interventions studied was associated with reducing the risk of death. CONCLUSIONS In this prospective cohort study of AKI patients, we found for the first time that early nephrologist intervention and fluid prescription adjustment were associated with lower risk of starting KRT and progression to AKI stage 3.
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Affiliation(s)
- Jonathan S Chávez-Íñiguez
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Pablo Maggiani-Aguilera
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Christian Pérez-Flores
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Rolando Claure-Del Granado
- Division of Nephrology, Hospital Obrero #2 - C.N.S., Cochabamba, Bolivia.,Universidad Mayor de San Simon, School of Medicine, Cochabamba, Bolivia
| | - Andrés E De la Torre-Quiroga
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Alejandro Martínez-Gallardo González
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Guillermo Navarro-Blackaller
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Ramón Medina-González
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico
| | | | | | - Guillermo García-García
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
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15
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Intra-dialytic hypotension following the transition from continuous to intermittent renal replacement therapy. Ann Intensive Care 2021; 11:96. [PMID: 34146164 PMCID: PMC8214642 DOI: 10.1186/s13613-021-00885-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 06/07/2021] [Indexed: 12/24/2022] Open
Abstract
Background Transition from continuous renal replacement therapy (CRRT) to intermittent renal replacement therapy (IRRT) can be associated with intra-dialytic hypotension (IDH) although data to inform the definition of IDH, its incidence and clinical implications, are lacking. We aimed to describe the incidence and factors associated with IDH during the first IRRT session following transition from CRRT and its association with hospital mortality. This was a retrospective single-center cohort study in patients with acute kidney injury for whom at least one CRRT-to-IRRT transition occurred while in intensive care. We assessed associations between multiple candidate definitions of IDH and hospital mortality. We then evaluated the factors associated with IDH. Results We evaluated 231 CRRT-to-IRRT transitions in 213 critically ill patients with AKI. Hospital mortality was 43.7% (n = 93). We defined IDH during the first IRRT session as 1) discontinuation of IRRT for hemodynamic instability; 2) any initiation or increase in vasopressor/inotropic agents or 3) a nadir systolic blood pressure of < 90 mmHg. IDH during the first IRRT session occurred in 50.2% of CRRT-to-IRRT transitions and was independently associated with hospital mortality (adjusted odds ratio [OR]: 2.71; CI 1.51–4.84, p < 0.001). Clinical variables at the time of CRRT discontinuation associated with IDH included vasopressor use, higher cumulative fluid balance, and lower urine output. Conclusions IDH events during CRRT-to-IRRT transition occurred in nearly half of patients and were independently associated with hospital mortality. We identified several characteristics that anticipate the development of IDH following the initiation of IRRT. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00885-7.
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Baeg SI, Jeon J, Yoo H, Na SJ, Kim K, Chung CR, Yang JH, Jeon K, Lee JE, Huh W, Suh GY, Kim YG, Kim DJ, Jang HR. A Scoring Model with Simple Clinical Parameters to Predict Successful Discontinuation of Continuous Renal Replacement Therapy. Blood Purif 2021; 50:779-789. [PMID: 33735858 DOI: 10.1159/000512350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/14/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) is the standard treatment for severe acute kidney injury in critically ill patients. However, a practical consensus for discontinuing CRRT is lacking. We aimed to develop a prediction model with simple clinical parameters for successful discontinuation of CRRT. METHODS Adult patients who received CRRT at Samsung Medical Center from 2007 to 2017 were included. Patients with preexisting ESRD and patients who progressed to ESRD within 1 year or died within 7 days after CRRT were excluded. Successful discontinuation of CRRT was defined as no requirement for renal replacement therapy for 7 days after discontinuing CRRT. Patients were assigned to either a success group or failure group according to whether discontinuation of CRRT was successful or not. RESULTS A total of 1,158 patients were included in the final analyses. The success group showed greater urine output on the day before CRRT discontinuation (D-1) and the discontinuation day (D0). Multivariable analysis identified that urine output ≥300 mL on D-1, and mean arterial pressure 50∼78 mm Hg, serum potassium <4.1 mmol/L, and BUN <35 mg/dL (12.5 mmol/L) on D0 were predictive factors for successful discontinuation of CRRT. A scoring system using the 4 variables above (area under the receiver operating curve: 0.731) was developed. CONCLUSIONS Scoring system composed of urine output ≥300 mL/day on D-1, and adequate blood pressure, serum potassium <4.1 mmol/L, and BUN <35 mg/dL (12.5 mmol/L) on D0 was developed to predict successful discontinuation of CRRT.
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Affiliation(s)
- Song In Baeg
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Junseok Jeon
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Heejin Yoo
- Statistics and Data Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyunga Kim
- Statistics and Data Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung Eun Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Wooseong Huh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yoon-Goo Kim
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dae Joong Kim
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hye Ryoun Jang
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea,
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Current Approach to Successful Liberation from Renal Replacement Therapy in Critically Ill Patients with Severe Acute Kidney Injury: The Quest for Biomarkers Continues. Mol Diagn Ther 2020; 25:1-8. [PMID: 33099671 PMCID: PMC8154765 DOI: 10.1007/s40291-020-00498-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 11/18/2022]
Abstract
Recovery of sufficient kidney function to liberate patients with severe acute kidney injury (AKI-D) from renal replacement therapy (RRT) is recognized as a vital patient-centred outcome. However, no clinical consensus guideline provides specific recommendations on when and how to stop RRT in anticipation of renal recovery from AKI-D. Currently, wide variations in clinical practice regarding liberation from RRT result in early re-start of RRT to treat uraemia after premature liberation or in the unnecessary prolonged exposure of unwell patients after late liberation. Observational studies, predominantly retrospective in nature, have attempted to assess numerous surrogate markers of kidney function or of biomarkers of kidney damage to predict successful liberation from RRT. However, a substantial heterogeneity in the timing of measurement and cut-off values of most biomarkers across studies allows no pooling of data, and impedes the comparison of outcomes from such studies. The accuracy of most traditional and novel biomarkers cannot be assessed reliably. Currently, the decision to discontinue RRT in AKI-D patients relies on daily clinical assessments of the patient’s status supplemented by measurement of creatinine clearance (> 15 ml/min) and 24-h urine output (> 2000 ml/min with diuretics). Clinical trials objectively comparing the success of validated biomarkers for guiding optimal timed liberation from RRT in AKI-D will be required to provide high-quality evidence for guidelines.
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Jentzer JC, Bihorac A, Brusca SB, Del Rio-Pertuz G, Kashani K, Kazory A, Kellum JA, Mao M, Moriyama B, Morrow DA, Patel HN, Rali AS, van Diepen S, Solomon MA. Contemporary Management of Severe Acute Kidney Injury and Refractory Cardiorenal Syndrome: JACC Council Perspectives. J Am Coll Cardiol 2020; 76:1084-1101. [PMID: 32854844 PMCID: PMC11032174 DOI: 10.1016/j.jacc.2020.06.070] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 12/14/2022]
Abstract
Acute kidney injury (AKI) and cardiorenal syndrome (CRS) are increasingly prevalent in hospitalized patients with cardiovascular disease and remain associated with poor short- and long-term outcomes. There are no specific therapies to reduce mortality related to either AKI or CRS, apart from supportive care and volume status management. Acute renal replacement therapies (RRTs), including ultrafiltration, intermittent hemodialysis, and continuous RRT are used to manage complications of medically refractory AKI and CRS and may restore normal electrolyte, acid-base, and fluid balance before renal recovery. Patients who require acute RRT have a significant risk of mortality and long-term dialysis dependence, emphasizing the importance of appropriate patient selection. Despite the growing use of RRT in the cardiac intensive care unit, there are few resources for the cardiovascular specialist that integrate the epidemiology, diagnostic workup, and medical management of AKI and CRS with an overview of indications, multidisciplinary team management, and transition off of RRT.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Azra Bihorac
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida
| | - Samuel B Brusca
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Gaspar Del Rio-Pertuz
- Department of Critical Care Medicine and Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Amir Kazory
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida
| | - John A Kellum
- Department of Critical Care Medicine and Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
| | - Brad Moriyama
- Department of Critical Care Medicine, Special Volunteer, National Institutes of Health, Bethesda, Maryland
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hena N Patel
- Division of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Aniket S Rali
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland; Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
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Hansrivijit P, Yarlagadda K, Puthenpura MM, Ghahramani N, Thongprayoon C, Vaitla P, Cheungpasitporn W. A meta-analysis of clinical predictors for renal recovery and overall mortality in acute kidney injury requiring continuous renal replacement therapy. J Crit Care 2020; 60:13-22. [PMID: 32731101 DOI: 10.1016/j.jcrc.2020.07.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 07/03/2020] [Accepted: 07/12/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE To determine clinical predictors for continuous renal replacement therapy (CRRT) discontinuation in patients with acute kidney injury (AKI). MATERIALS AND METHODS Ovid MEDLINE, EMBASE, and Cochrane Library were searched. The protocol is registered on researchregistry.com (reviewregistry909). Our criteria included non-end-stage kidney disease adults who required CRRT for AKI. Renal recovery was defined by CRRT discontinuation. Risk of bias was assessed using ROBINS-I tool. RESULTS We classified our analyses into renal recovery cohort and overall mortality cohort. All studies were observational. For renal recovery cohort, increasing urine output at time of CRRT discontinuation, elevated initial SOFA score and serum creatinine at CRRT initiation were predictive of renal recovery with OR 1.021 (95%CI = 1.011-1.031), 0.869 (95%CI = 0.811-0.932) and 0.995 (95%CI = 0.996-0.999), respectively. For overall mortality cohort, age and presence of sepsis were significantly associated with overall mortality with OR of 1.028 (95%CI = 1.008-1.048) and 2.160 (95%CI = 0.973-1.932), respectively. CONCLUSIONS Urine output at CRRT discontinuation, lower initial SOFA score, and lower serum creatinine levels at CRRT initiation were associated with higher likelihood of renal recovery. Increasing age and the presence of sepsis were associated with increased overall mortality from AKI on CRRT. However, there were limited data on co-morbidities which might preclude their inclusion in our analysis.
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Affiliation(s)
- Panupong Hansrivijit
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA 17104, USA.
| | - Keerthi Yarlagadda
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA 17104, USA.
| | - Max M Puthenpura
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA 19129, USA.
| | - Nasrollah Ghahramani
- Division of Nephrology, Department of Medicine, Penn State University College of Medicine, Hershey, PA 17033, USA.
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
| | - Pradeep Vaitla
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS 39216, USA.
| | - Wisit Cheungpasitporn
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS 39216, USA
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20
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Katulka RJ, Al Saadon A, Sebastianski M, Featherstone R, Vandermeer B, Silver SA, Gibney RTN, Bagshaw SM, Rewa OG. Determining the optimal time for liberation from renal replacement therapy in critically ill patients: a systematic review and meta-analysis (DOnE RRT). Crit Care 2020; 24:50. [PMID: 32054522 PMCID: PMC7020497 DOI: 10.1186/s13054-020-2751-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/27/2020] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Renal replacement therapy (RRT) is associated with high mortality and costs; however, no clinical guidelines currently provide specific recommendations for clinicians on when and how to stop RRT in recovering patients. Our objective was to systematically review the current evidence for clinical and biochemical parameters that can be used to predict successful discontinuation of RRT. METHODS A systematic review and meta-analysis were performed with a peer-reviewed search strategy combining the themes of renal replacement therapy (IHD, CRRT, SLED), predictors of successful discontinuation or weaning (defined as an extended period of time free from further RRT), and patient outcomes. Major databases were searched and citations were screened using predefined criteria. Studied parameters were reported and, where possible, data was analyzed in the pooled analysis. RESULTS Our search yielded 23 studies describing 16 variables for predicting the successful discontinuation of RRT. All studies were observational in nature. None were externally validated. Fourteen studies described conventional biochemical criteria used as surrogates of glomerular filtration rate (serum urea, serum creatinine, creatinine clearance, urine urea excretion, urine creatinine excretion). Thirteen studies described physiologic parameters such as urine output before and after cessation of RRT, and 13 studies reported on newer kidney biomarkers, such as serum cystatin C and serum neutrophil gelatinase-associated lipocalin (NGAL). Six studies reported sensitivity and specificity characteristics of multivariate models. Urine output prior to discontinuation of RRT was the most-studied variable, with nine studies reporting. Pooled analysis found a sensitivity of 66.2% (95% CI, 53.6-76.9%) and specificity of 73.6% (95% CI, 67.5-79.0%) for urine output to predict successful RRT discontinuation. Due to heterogeneity in the thresholds of urine output used across the studies, an optimal threshold value could not be determined. CONCLUSIONS Numerous variables have been described to predict successful discontinuation of RRT; however, available studies are limited by study design, variable heterogeneity, and lack of prospective validation. Urine output prior to discontinuation of RRT was the most commonly described and robust predictor. Further research should focus on the determination and validation of urine output thresholds, and the evaluation of additional clinical and biochemical parameters in multivariate models to enhance predictive accuracy.
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Affiliation(s)
- Riley Jeremy Katulka
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124E Clinical Sciences Building 8440 112 St. NW, Edmonton, Alberta, T6G 2B7, Canada
| | - Abdalrhman Al Saadon
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124E Clinical Sciences Building 8440 112 St. NW, Edmonton, Alberta, T6G 2B7, Canada
| | - Meghan Sebastianski
- Alberta Strategy for Patient-Oriented Research (SPOR) SUPPORT Unit Knowledge Translation Platform, University of Alberta, 4-472 Edmonton Clinic Health Academy, 11405 - 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Robin Featherstone
- Alberta Strategy for Patient-Oriented Research (SPOR) SUPPORT Unit Knowledge Translation Platform, University of Alberta, 4-472 Edmonton Clinic Health Academy, 11405 - 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
- Alberta Research Center for Health Evidence (ARCHE), University of Alberta, 4-496 Edmonton Clinic Health Academy, 11405 - 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Ben Vandermeer
- Alberta Strategy for Patient-Oriented Research (SPOR) SUPPORT Unit Knowledge Translation Platform, University of Alberta, 4-472 Edmonton Clinic Health Academy, 11405 - 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
- Alberta Research Center for Health Evidence (ARCHE), University of Alberta, 4-496 Edmonton Clinic Health Academy, 11405 - 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Samuel A Silver
- Division of Nephrology, Department of Medicine, Queen's University, 94 Stuart Street, Kingston, Ontario, K7L 3N6, Canada
| | - R T Noel Gibney
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124E Clinical Sciences Building 8440 112 St. NW, Edmonton, Alberta, T6G 2B7, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124E Clinical Sciences Building 8440 112 St. NW, Edmonton, Alberta, T6G 2B7, Canada
| | - Oleksa G Rewa
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124E Clinical Sciences Building 8440 112 St. NW, Edmonton, Alberta, T6G 2B7, Canada.
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Dai X, Chen J, Li W, Bai Z, Li X, Wang J, Li Y. Association Between Furosemide Exposure and Clinical Outcomes in a Retrospective Cohort of Critically Ill Children. Front Pediatr 2020; 8:589124. [PMID: 33585362 PMCID: PMC7874070 DOI: 10.3389/fped.2020.589124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 12/16/2020] [Indexed: 12/29/2022] Open
Abstract
Furosemide is commonly prescribed in critically ill patients to increase the urine output and prevent fluid overload (FO) and acute kidney injury (AKI), but not supported by conclusive evidence. There remain conflicting findings on whether furosemide associates with AKI and adverse outcomes. Information on the impact of furosemide on adverse outcomes in a general population of pediatric intensive care unit (PICU) is limited. The aim of the cohort study was to investigate the associations of furosemide with AKI and clinical outcomes in critically ill children. Study Design: We retrospectively reviewed a cohort of 456 critically ill children consecutively admitted to PICU from January to December 2016. The exposure of interest was the use of furosemide in the first week after admission. FO was defined as ≥5% of daily fluid accumulation, and mean FO was considered significant when mean daily fluid accumulation during the first week was ≥5%. The primary outcomes were AKI in the first week after admission and mortality during PICU stay. AKI diagnosis was based on Kidney Disease: Improving Global Outcomes criteria with both serum creatinine and urine output. Results: Furosemide exposure occurred in 43.4% of all patients (n = 456) and 49.3% of those who developed FO (n = 150) in the first week after admission. Patients who were exposed to furosemide had significantly less degree of mean daily fluid accumulation than those who were not (1.10 [-0.33 to 2.61%] vs. 2.00 [0.54-3.70%], P < 0.001). There was no difference in the occurrence of AKI between patients who did and did not receive furosemide (22 of 198 [11.1%] vs. 36 of 258 [14.0%], P = 0.397). The mortality rate was 15.4% (70 of 456), and death occurred more frequently among patients who received furosemide than among those who did not (21.7 vs. 10.5%, P = 0.002). Furosemide exposure was associated with increased odds for mortality in a multivariate logistic regression model adjusted for body weight, gender, illness severity assessed by PRISM III score, the presence of mean FO, and AKI stage [adjusted odds ratio (AOR) 1.95; 95%CI, 1.08-3.52; P = 0.026]. Conclusion: Exposure to furosemide might be associated with increased risk for mortality, but not AKI, in critically ill children.
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Affiliation(s)
- Xiaomei Dai
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, Suzhou, China
| | - Jiao Chen
- Pediatric Intensive Care Unit, Children's Hospital of Soochow University, Suzhou, China
| | - Wenjing Li
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, Suzhou, China
| | - Zhenjiang Bai
- Pediatric Intensive Care Unit, Children's Hospital of Soochow University, Suzhou, China
| | - Xiaozhong Li
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, Suzhou, China
| | - Jian Wang
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, China
| | - Yanhong Li
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, Suzhou, China.,Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, China
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22
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Stads S, Kant KM, de Jong MFC, de Ruijter W, Cobbaert CM, Betjes MGH, Gommers D, Oudemans-van Straaten HM. Predictors of 90-Day Restart of Renal Replacement Therapy after Discontinuation of Continuous Renal Replacement Therapy, a Prospective Multicenter Study. Blood Purif 2019; 48:243-252. [PMID: 31330511 PMCID: PMC6878749 DOI: 10.1159/000501387] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 06/04/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Restart of renal replacement therapy (RRT) after initial discontinuation of continuous RRT (CRRT) is frequently needed. The aim of the present study was to evaluate whether renal markers after discontinuation of CRRT can predict restart of RRT within 90 days. METHODS Prospective multicenter observational study in 90 patients, alive, still on the intensive care unit at day 2 after discontinuation of CRRT for expected recovery with urinary neutrophil gelatinase-associated lipocalin (NGAL) available. The endpoint was restart of RRT within 90 days. Baseline and renal characteristics were compared between outcome groups no restart or restart of RRT. Logistic regression and receiver operator characteristic curve analysis were performed to determine the best predictive and discriminative variables. RESULTS Restart of RRT was needed in 32/90 (36%) patients. Compared to patients not restarting, patients restarting RRT demonstrated a higher day 2 urinary NGAL, lower day 2 urine output, and higher incremental creatinine ratio (day 2/0). In multivariate analysis, only incremental creatinine ratio (day 2/0) remained independently associated with restart of RRT (OR 5.28, 95% CI 1.45-19.31, p = 0.012). The area under curve for incremental creatinine ratio to discriminate for restart of RRT was 0.76 (95% CI 0.64-0.88). The optimal cutoff was 1.49 (95% CI 1.44-1.62). CONCLUSION In this prospective multicenter study, incremental creatinine ratio (day 2/0) was the best predictor for restart of RRT. Patients with an incremental creatinine ratio at day 2 of 1.5 times creatinine at discontinuation are likely to need RRT within 90 days. These patients might benefit from nephrological follow-up.
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Affiliation(s)
- Susanne Stads
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands,
- Department of Intensive Care, Ikazia Hospital, Rotterdam, The Netherlands,
| | - K Merijn Kant
- Department of Intensive Care, Amphia Hospital Breda, Breda, The Netherlands
| | - Margriet F C de Jong
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Wouter de Ruijter
- Department of Intensive Care, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Christa M Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Michiel G H Betjes
- Department of Nephrology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
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23
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Tourneur JM, Weissbrich C, Putensen C, Hilbert T. Feasibility of a protocol to wean patients from continuous renal replacement therapy: A retrospective pilot observation. J Crit Care 2019; 53:236-243. [PMID: 31280144 DOI: 10.1016/j.jcrc.2019.06.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/13/2019] [Accepted: 06/29/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE To evaluate the feasibility of a protocol-based algorithm to wean acute kidney injury (AKI) patients from continuous renal replacement therapy (CRRT). METHODS The protocol was introduced on one of two similarly equipped ICUs, while on the other (reference) ICU, CRRT discontinuation was based on clinical judgement. Patients were allocated to either ICU and were subjected to physician- or protocol-directed weaning, respectively. According to the algorithm, periodical withdrawal trials (WTs) were mandatory. Interventions were recommended (administration of diuretics, fluid, vasopressors, inotropes, or human albumin) to achieve specific goals (sufficient urine output, balanced fluid status, adequate renal perfusion pressure, optimal oxygen delivery, normoalbuminemia). Clearly stated criteria defined when to abort a WT and to resume RRT for one cycle, followed by another WT. RESULTS Urine output and ScvO2 during WTs were higher with protocol-directed weaning, as well as the amount of administered fluids. WT abort ratio was 48% with a tendency to prolonged WT duration, compared to 64% in the reference patients. No relevant adverse side effects were observed. CONCLUSION Our data show the feasibility of a structured approach to wean AKI patients from RRT that bundles established interventions and brings the weaning into the physician's focus.
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Affiliation(s)
- Julia-Marie Tourneur
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127 Bonn, Germany
| | - Carsten Weissbrich
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127 Bonn, Germany
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127 Bonn, Germany
| | - Tobias Hilbert
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127 Bonn, Germany.
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