CLINICAL CHARACTERISTICS, OUTCOMES AND RISK FACTORS FOR DEATH AMONG CRITICALLY ILL PATIENTS WITH HIV-RELATED ACUTE KIDNEY INJURY

Short-Term Renal Replacement Therapy Outcomes of Critically Ill Patients of Acute Kidney Injury and Acute on Chronic Kidney Disease

BACKGROUND AND AIMS

Sustained low-efficiency dialysis (SLED) is a cost-effective alternative to continuous renal replacement therapy (CRRT) in critically ill acute kidney injury (AKI) patients, in addition to intermittent hemodialysis (IHD) as a mode of renal replacement therapy (RRT) in such patients. This single-center, prospective, observational study aimed to assess the short-term outcomes of SLED and IHD in such patients.

METHODOLOGY

Adult (>18 years) patients with AKI requiring dialysis were included from different ICUs of a tertiary care center. Patients were subjected to SLED or IHD according to the standard Kidney Disease: Improving Global Outcomes (KDIGO) 2012 criteria. Treatment duration and ultrafiltration rates were adjusted based on individual patient needs and hemodynamic stability was recorded. Dialysis-free survival, renal function recovery, and mortality rates at one month post discharge were analyzed among all RRT groups.

RESULTS

Out of 128 ICU patients requiring dialysis, 78 underwent SLED, while 43 received IHD. Overall, the mean age was 44.53 years. Patients were predominantly male (53.7%), with common co-morbidities such as hypertension (21.5%) and diabetes mellitus (18.2%). Sepsis (59.2%), hypoperfusion (16.7%), and pregnancy-related AKI (14.16%) were the predominant causes of AKI. Indications for RRT initiation included refractory fluid overload, metabolic acidosis, and refractory hyperkalemia. Patients in the IHD group were relatively younger, had fewer comorbidities, and had more females than those in the SLED group. Thirty-day mortality in the SLED group was significantly higher than that in the IHD group (61.2% versus 20.9%, p < 0.05). Multivariate regression analysis identified vasopressin requirement, mechanical ventilation, and Sequential Organ Failure Assessment (SOFA) scores > 12 as predictors of mortality.

CONCLUSION

Although IHD is an option of RRT in reasonably stable patients, SLED is also a cost-effective option for hemodynamically unstable AKI patients, particularly in resource-limited settings.

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

OBJECTIVES

Population-based studies regarding renal replacement therapy (RRT) used in critical care populations are useful to understand the trend and impact of medical care interventions. We describe the use of RRT and associated outcomes (mortality and length of intensive care stay) in a level 1 hospital.

DESIGN

A retrospective descriptive observational study.

PATIENTS

Critically ill patients admitted to the ICU from 1 January to 31 December 2018.

INTERVENTIONS

Age, gender, ward of admission, primary organ dysfunction at admission, length of hospital stay (LOS), mechanical ventilation, APACHE, SOFA and ISS scores, the use of vasopressors, transfusion, RRT and the number of RRT sessions were extracted.

RESULTS

1703 critically ill patients were divided into two groups: the RRT-group (238 patients) and the non-RRT group (1465 patients). The mean age was 63.58 ± 17.52 (SD) in the final ICU studied patients (64.72 ± 16.64 SD in the RRT-group), 60.5% being male. Patients admitted from general surgery ward needing RRT were 41.4%. The specific scores, the use of vasopressors, transfusions and mortality were higher in the RRT-group. The ICU LOS was superior in the RRT-group, regardless of the primary organ dysfunction.

CONCLUSIONS

RRT was practiced in 13.9% of patients (especially after age of 61), with mortality being the outcome for 66.8% of the RRT-group patients. All analyzed data were higher in the RRT group, especially for multiple trauma and surgical patients, or patients presenting cardiac or renal dysfunctions at admission. We found significant increased ISS scores in the RRT-group, a significant association between the need of vasopressors or transfusion requirement and RRT use, and an association in the number of RRT sessions and LOS (p < 0.001).

Death-related factors in HIV/AIDS patients undergoing hemodialysis in an intensive care unit

HIV-infected patients are at high risk for developing critical diseases, including opportunistic infections (OI), with consequent admission in intensive care units (ICU). Renal disfunctions are risk factors for death in HIV/AIDS patients, and survival rates in patients undergoing hemodialysis are smaller than the ones observed in the general population. In this context, this study aimed to investigate death-related factors in HIV/AIDS patients in an intensive care setting. This is a retrospective cross-sectional study performed through the analysis of medical records from 271 HIV/AIDS-diagnosed patients hospitalized in an intensive care unit of an infectious disease hospital, in Fortaleza, Ceara State, Brazil. Patients were divided into two groups: those who underwent dialysis during hospitalization and those who did not. Clinical and demographic parameters that could be associated with death were evaluated. Results indicated a prevalence of death of 19.1% (CI 95%: 14.8-24.3). The median age of patients was 47 years, with a male predominance (71.3%). The main causes of admission were pulmonary tuberculosis (16.9%), followed by neurotoxoplasmosis (14.9%). In the bivariate analysis, for those that did not undergo dialysis, age, fever, dyspnea, oliguria, disorientation, kidney injury, use of lamivudine and efavirenz, length of hospitalization, CD4 count, WBC count, platelet count, urea, sodium and LDH levels were the associated variables. In those who needed dialysis, the use of stavudine, abacavir and ritonavir, and the length of hospitalization were associated factors. Renal toxicity by the antiretroviral agents and length of hospitalization increased the risk of death among HIV patients under dialysis.

Clinical outcome of admitted HIV/AIDS patients in Ethiopian tertiary care settings: A prospective cohort study

Background

Acquired ImmunoDeficiency Syndrome (AIDS) related illnesses are the leading cause of death in the developing world. However; there is limited evidence regarding the incidence of mortality among admitted HIV patients in Ethiopia.

Objective

To determine the incidence of mortality and its predictors among admitted HIV/AIDS patients in selected tertiary care hospitals in Ethiopia.

Methods

A prospective cohort study involving 136 admitted HIV/AIDS patients from April 1 to August 31, 2018 was conducted in selected tertiary care hospitals in Ethiopia. Data were collected on socio-demographic, clinical characteristics, and drug related variables. Kaplan-Meier and Cox regression were used to compare survival experience of the patients and identify independent predictors of mortality. Hazard ratio was used as a measure of strength of association and p-value of <0.05 was considered to declare statistical significance.

Results

Of 136 patients, 80 (58.8%) were females. The overall in-hospital incidence of mortality was 2.83 per 1000 person-years. The incidences of mortality due to AIDS and non-AIDS related admissions were 6.1 [3.95, 8.67] and 5.3 [3.35, 8.23] per 1000 person-years respectively. The mean ± SD survival times among patients with AIDS and non-AIDS related illnesses were 32 ± 3.1 and 34 ± 3.3 days respectively (log rank p = 0.599). Being on non-invasive ventilation (AHR: 2.99, 95%CI; [1.24, 7.28]; p = 0.015) and having baseline body mass index (BMI) of less than 18.5 (AHR: 2.6, 95%CI; [1.03, 6.45]; p = 0.04) were independent predictors of mortality.

Conclusion

The study found high incidence of in-hospital mortality among admitted HIV/AIDS patients in Ethiopian tertiary care hospitals. Being on non-invasive ventilation and body mass index (BMI) of less than 18.5 were found to be independent predictors of mortality.

Risk factors and outcomes of acute kidney injury in South African critically ill adults: a prospective cohort study

Background

There is a marked paucity of data concerning AKI in Sub-Saharan Africa, where there is a substantial burden of trauma and HIV.

Methods

Prospective data was collected on all patients admitted to a multi-disciplinary ICU in South Africa during 2017. Development of AKI (before or during ICU admission) was recorded and renal recovery 90 days after ICU discharge was determined.

Results

Of 849 admissions, the mean age was 42.5 years and mean SAPS 3 score was 48.1. Comorbidities included hypertension (30.5%), HIV (32.6%), diabetes (13.3%), CKD (7.8%) and active tuberculosis (6.2%). The most common reason for admission was trauma (26%). AKI developed in 497 (58.5%). Male gender, illness severity, length of stay, vasopressor drugs and sepsis were independently associated with AKI. AKI was associated with a higher in-hospital mortality rate of 31.8% vs 7.23% in those without AKI. Age, active tuberculosis, higher SAPS 3 score, mechanical ventilation, vasopressor support and sepsis were associated with an increased adjusted odds ratio for death. HIV was not independently associated with AKI or hospital mortality. CKD developed in 14 of 110 (12.7%) patients with stage 3 AKI; none were dialysis-dependent.

Conclusions

In this large prospective multidisciplinary ICU cohort of younger patients, AKI was common, often associated with trauma in addition to traditional risk factors and was associated with good functional renal recovery at 90 days in most survivors. Although the HIV prevalence was high and associated with higher mortality, this was related to the severity of illness and not to HIV status per se.

Urinary versus plasma neutrophil gelatinase-associated lipocalin (NGAL) as a predictor of mortality for acute kidney injury in intensive care unit patients

OBJECTIVE

To examine urinary and plasma neutrophil gelatinase-associated lipocalin (NGAL) levels in predicting ICU mortality.

DESIGN

Prospective observational.

SETTING

University Critical Care setting.

PARTICIPANTS

50 patients with acute kidney injury (AKI).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Serial urinary and plasma concentrations of NGAL were measured. Twenty-five patients had early progression (EP) and 25 patients had early improvement (EI) of AKI. Plasma concentrations of NGAL in the EP group (N=25) were significantly higher than those in the EI group (129 [IQR; 20] vs. 111 [IQR; 32] ng/mL; P=0.009), while urine NGAL levels on admission were similar in both groups (61 [IQR; 20] vs. 65 [IQR; 20] ng/mL; P=0.767). Plasma NGAL concentrations rapidly decreased to 87 [32] ng/mL in the EI group (P<0.001) and while it remained elevated in the EP group (138 [21] ng/mL). Within 28-days, 50% of the patients died in the EP group, whereas no patient died in the EI group (P<0.001). Plasma NGAL was a fair predictor for progression of AKI (AUC; 0.719±0.063; P=0.006). 48-hour changes in plasma NGAL levels predicted death within 28-days of ICU admission (AUC; 0.874±0.048; P<0.001).

CONCLUSION

Early progression of AKI was associated with more death within 28 and 90days. While one time measurement of plasma NGAL levels at the time ICU admission may represent the kidney health status in critical care settings, it does not reliably predict mortality. On the other hand, changes in plasma NGAL within 48h of admission improve the value of this biomarker in predicting ICU mortality.