Continuous renal replacement therapy in elderly with acute kidney injury

Risk factors for unplanned weaning of continuous renal replacement therapy in ICU patients: a meta-analysis

OBJECTIVE

To systematically review the risk factors for unplanned weaning during continuous renal replacement therapy in ICU patients.

METHODS

A combination of subject words + free words was used to search the relevant literature published in CNKI, Wanfang, VIP, CBM, PubMed, EMbase, Web of Science, Cochrane Library, Mediline and other databases. The search period was from the establishment of the databases to June 25, 2024. Revman 5.4 software and Stata15.0 software was used to meta-analyze the risk factors for unplanned weaning during continuous renal replacement therapy in ICU patients.

RESULTS

A total of 23 studies were included in this meta-analysis, describing 15 variables, 3793 patients, and using 7197 filters. Meta-analysis results showed that risk factors for unplanned weaning during continuous renal replacement therapy in ICU patients were as follows: Low mean arterial pressure [OR = 1.02, 95%CI (1.00, 1.03), p < 0.05], hypothermia [OR = 3.40, 95%CI (1.78, 6.47), p < 0.05], age (≥60 years) [OR = 4.45, 95%CI (3.18, 6.22), p < 0.05], comorbid underlying disease [OR = 3.63, 95%CI (2.70, 4.88), p < 0.05], agitation [OR = 4.97, 95%CI (3.20, 7.74), p < 0.05], no anticoagulant use [OR = 1.65, 95%CI (1.25, 2.17), p < 0.05], short activated partial prothrombin time [OR = 1.23, 95%CI (1.13, 1.34), p < 0.05], hyper-hematocrit [OR = 1.73, 95%CI (1.13, 2.66), p = 0.01], low ionized calcium concentration [OR = 1.48, 95% CI (1.08, 2.02), p = 0.01], CRRT that was treated at a high dose [OR = 1.42, 95%CI (1.14, 1.76), p < 0.05], mechanical ventilation [OR = 4.25, 95%CI (2.67, 6.77), p < 0.05], and lack of dedicated care [OR = 5.08, 95%CI (2.51, 10.28), p < 0.05]. However, it is unclear whether platelet count, prothrombin activity, and blood flow velocity are risk factors for unplanned weaning during CRRT in ICU patients, and more studies are needed for further validation.

CONCLUSION

Available evidence suggests that a variety of factors contribute to unplanned weaning of CRRT in ICU patients. Early detection of these risk factors is essential for healthcare professionals to develop preventive and curative strategies.

REGISTRATION

This study is registered on the PROSERO website under registration number CRD42024543554.

Mortality of elderly patients with acute kidney injury undergoing continuous renal replacement therapy: is age a risk factor?

BACKGROUND

Whether advanced age is associated with poor outcomes of elderly patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) is controversial. This study aimed to evaluate age effect and predictors for mortality in elderly AKI patients undergoing CRRT.

METHODS

Data of 480 elderly AKI patients who underwent CRRT were retrospectively analyzed. Subjects were stratified into two groups according to age: younger-old (age, 65-74 years; n = 205) and older-old (age, ≥75 years; n = 275). Predictors for 28-day and 90-day mortality and age effects were analyzed using multivariable Cox regression analysis and propensity score matching.

RESULTS

Urine output at the start of CRRT (adjusted hazard ratio [aHR], 0.99; 95% confidence interval [CI], 0.99-1.00; p = 0.04), operation (aHR, 0.53; 95% CI, 0.30-0.93; p = 0.03), and use of an intra-aortic balloon pump (aHR, 3.60; 95% CI, 1.18-10.96; p = 0.02) were predictors for 28-day mortality. Ischemic heart disease (aHR, 1.74; 95% CI, 1.02-2.98; p = 0.04) and use of a ventilator (aHR, 0.56; 95% CI, 0.36-0.89; p = 0.01) were predictors for 90-day mortality. The older-old group did not exhibit a higher risk for 28- day or 90-day mortality than the younger-old group in multivariable or propensity score-matched models.

CONCLUSION

Advanced age was not a risk factor for mortality among elderly AKI patients undergoing CRRT, suggesting that advanced age should not be considered for therapeutic decisions in critically ill elderly patients with AKI requiring CRRT.

Effect of continuous renal replacement therapy on the clinical efficacy and pharmacokinetics of polymyxin B in the treatment of severe pulmonary infection

Objective

This study aimed to evaluate the pharmacokinetics of polymyxin B in patients with ventilator-associated pneumonia caused by multi-drug resistant bacteria, and to analyze the effect of continuous renal replacement therapy (CRRT) on pharmacokinetics of polymyxin B.

Methods

Thirty-five patients with ventilator-associated pneumonia caused by multi-drug resistant bacteria admitted to our hospital from June 2021 to January 2022 were selected as the subjects. The patients were divided into the standard group (n = 20) and the non-standard group (n = 15) based on the factors affecting the compliance of polymyxin B plasma concentration. The patients received with polymyxin B and the plasma concentration was monitored. According to the monitoring results, they were divided into the standard group and the non-standard group, to analyze the influencing factors of polymyxin B on the blood concentration. Besides, the patients were then divided into the control group (n = 28) and the observation group (n = 7) according to whether the patients received CRRT treatment. Patients in the control group treated with polymyxin B alone, while patients in the observation group received with polymyxin B and CRRT. The general data of patients in the two groups were compared. The levels of plasma concentration of polymyxin B measured before the next administration (Cmin), peak plasma concentration of polymyxin B measured immediately after end of infusion (Cmax) and intermediate plasma concentration measured 6 h after administration (midpoint of the dosing interval) (C1/2t) were detected and compared between the two groups. Correlation between pharmacokinetics and efficacy was analyzed by Spearman correlation. The incidence of complications and the 28-day mortality rate of the two groups were recorded.

Results

The age, body mass index (BMI) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores in the non-standard group were higher than these in the standard group (p < 0.05). BMI and APACHE II scores were independent risk factors affecting the pharmacokinetics of polymyxin B in patients with severe pulmonary infection (p < 0.05). There were no significant differences in age, BMI, APACHEII score, alanine aminotransferase level, aspartate aminotransferase level, albumin level, gender and diabetes ratio between the control group and the observation group (p > 0.05). The levels of Cmin, Cmax, and C1/2t in the observation group were lower than these in the control group (p < 0.001). The response rate was 50.00% in the control group and 36.36% in the observation group (p > 0.05). The levels of Cmin, Cmax, and C1/2t in the observation group were no significant correlation with the clinical efficacy (p > 0.05), while these in the control group were positive correlation with the clinical efficacy (r = 0.485, p < 0.05). There was no significant difference in the incidence of skin pigmentation, nephrotoxicity and 28-day mortality between the two groups (p > 0.05).

Conclusion

In patients with ventilator-associated pneumonia not receiving multidrug-resistant bacteria, the rate of achieving blood drug concentration with the usual recommended dose of polymyxin B was satisfactory. However, the proportion of patients with a 6-h plasma concentration exceeding the maximum plasma concentration was high. BMI and APACHE II scores were important factors affecting the pharmacokinetics of polymyxin B. In patients undergoing CRRT, the plasma concentration of polymyxin B was significantly reduced, suggesting that in patients with severe disease, plasma concentration monitoring played an important role in drug efficacy and patient safety. In patients treated with CRRT, the dose of polymyxin B may need to be increased.

Prognostic Value of the Red Blood Cell Distribution Width-to-Albumin Ratio in Critically Ill Older Patients with Acute Kidney Injury: A Retrospective Database Study

Background. There is no evidence suggesting that red blood cell distribution width-to-albumin ratio (RA) predicts outcomes in severely ill older individuals with acute kidney injury (AKI). We hypothesized that RA is associated with all-cause mortality in critically ill older patients with AKI. Methods. We recorded demographics, laboratory tests, comorbidities, vital signs, and other clinical information from the MIMIC-III V1.4 dataset. The primary endpoint was 90-day all-cause mortality, and the secondary endpoints were 30-day mortality, one-year mortality, renal replacement treatment (RRT), duration of stay in the intensive care unit (ICU), sepsis, and septic shock. We generated Cox proportional hazards and logistic regression models to determine RA’s prognostic values and subgroup analyses to determine the subgroups’ mortality. We conducted a Pearson correlation analysis on RA and C-reactive protein (CRP) in the cohort of patients from the Second Affiliated Hospital of Wenzhou Medical University. Results. A total of 6,361 patients were extracted from MIMIC-III based on the inclusion and exclusion criteria. RA levels directly and linearly correlated with 90-day all-cause mortality. After controlling for ethnicity, gender, age, and other confounding variables in multivariate analysis, higher RA was significantly associated with an increased risk of 30-day, 90-day, and one-year all-cause mortality as opposed to the reduced levels of RA (tertile 3 vs. tertile 1: hazard ratios (HRs), 95% confidence intervals (CIs): 1.70, 1.43–2.01; 1.90, 1.64–2.19; and 1.95, 1.72–2.20, respectively). These results suggested that elevated levels of RA were linked to an elevated risk of 30-day, 90-day, and one-year all-cause death. There was a similar trend between RA and the use of RRT, length of stay in ICUs, sepsis, and septic shock. The subgroup analysis did not reveal any considerable interplay among strata. When areas under the curve were compared, RA was a weaker predictor than the SAPS II score but a stronger predictor than red blood cell distribution width (RDW) or albumin alone ( $P<0.001$ ); RA combined with SAPS II has better predictive power than SAPS II alone ( $P<0.001$ ). The Second Affiliated Hospital of Wenzhou Medical University cohort showed that CRP positively correlated with RA, with a coefficient of 0.2607 ( $P<0.001$ ). Conclusions. RA was an independent prognostic predictor in critically ill older patients with AKI, and greater RA was linked to a higher probability of death. The risk of AKI is complicated when RRT occurs; sepsis and septic shock increase with RA levels.

Analysis of the extracorporeal anticoagulation effect of modified citrate infusion during continuous renal replacement therapy in critically ill patients

INTRODUCTION

To analyze the anticoagulation effect of different local infusion methods of citrate underwent continuous renal replacement therapy (CRRT) in critically ill patients.

METHODS

The study adopted a single-centre retrospective design. Critically ill patients were divided into conventional group and modified group based on the infusion methods of citrate.

RESULTS

The modified group had a longer mean treatment time (67.67 ± 18.69  hours vs. 52.11 ± 24.26 hours, p = 0.007), a lower transmembrane pressure (147.77 ± 66.85 cm H₂ O vs. 200.63 ± 118.66 cm H₂ O, p = 0.038), fewer citrate bag replacements (1.43 ± 0.50 times vs. 10.60 ± 3.19 times, p < 0.001), and more steady ionized calcium at the venous end (0.35 ± 0.06 mmol/L vs. 0.40 ± 0.05 mmol/L, p = 0.006) compared to the conventional group patients, with statistically significant differences. The incidences of citrate accumulation and tubing coagulation were marginally lower in the modified group.

CONCLUSION

The modified local citrate infusion method can prolong treatment time, while reducing both the nursing workload and the occurrence of citrate accumulation.

[Research advances on the prevention and treatment of burn infection in the elderly]

Infection is a common complication after burns and the major cause of death in patients suffering severe burn injury. The infection of the elderly after burns is more serious due to their decreased immune function that is complicated with factors such as multiple chronic diseases and dysfunction of various organs. In addition, the burn infection in the elderly lacks the specific symptoms and signs, which brings great challenges to its diagnosis and treatment. To effectively prevent and control infection is very important for the treatment of elderly burn patients. Combined the clinical characteristics of burn infection in the elderly, this paper summarized the research advances of prevention and treatment for burn infection in the elderly from fluid resuscitation, wound treatment, antibiotic using, organ protection, nutritional support, and infection prevention, aiming to provide reference for clinical practice.

Continuous Renal Replacement Therapy for Hypertension Complicated by Refractory Heart Failure: An Analysis of Safety and Nursing Highlights

Objective

This research is aimed at analyzing the safety profile and nursing highlights of continuous renal replacement therapy (CRRT) for hypertension (HT) complicated by refractory heart failure (RHF).

Methods

Sixty-six HT + RHF patients admitted between March 2018 and December 2021 were enrolled and assigned to two groups: a CRRT group with 33 cases treated with CRRT and a control group with 33 cases intervened by routine treatment. The therapeutic effect and alterations of cardiac function (CF) indexes were observed in both cohorts. Besides, statistics were made in terms of serum B-type natriuretic peptide (BNP), C-reactive protein (CRP) and mean arterial pressure (MAP) concentrations, time of asthma relief, heart rate recovery (HRR), edema resolution, and hospitalization, as well as incidence of adverse reactions (ARs). Finally, pre- and posttreatment psychological quality and pain of both cohorts of subjects were assessed using the self-rating anxiety and depression scale (SAS and SDS) and visual analogue scale (VAS), respectively.

Results

CRRT group exhibited higher overall response rate and better CF than control group (P < 0.05), with lower BNP, CRP, and MAP levels, and shorter time of asthma relief, HRR, edema resolution, and hospitalization (P < 0.05); the incidence of ARs was similar (P > 0.05); for both groups, the scores of SAS, SDS, and VAS reduced statistically after treatment (P < 0.05).

Conclusion

CRRT can effectively improve the therapeutic effect and CF of patients with HT complicated by RHF, to protect the health and safety of patients.

Inhibition of Homeobox D10 Alleviates Acute Kidney Injury by Upregulating PI3K/AKT Signaling Proteins

Purpose. To observe the protective effect of homeobox D10 (HOXD10) on acute kidney injury (AKI) by regulating PI3K/AKT signaling pathway is the purpose of this study.Methods. 30 rats were randomly divided into three groups: blank control group, model group, and HOXD10 interference group. The kidney function indexes, HOXD10 protein expression, histopathological features, tubulointerstitial injury, and PI3K and AKT protein expression levels of the three groups were analyzed. Results. Compared with the blank control group, the kidney weight, BUN and SCr in model group increased significantly, and TIL score was higher ( $P>0.05$ ). The expression of HOXD10 in model group and HOXD10 interference group were higher than blank control group, and the expression of HOXD10 in HOXD10 interference group was lower than model group ( $P<0.05$ ). After we administered HOXD10 blocker to AKI rats, pathological sections by HE staining showed that the kidney tissue damage was significantly reduced compared with the model group, and the expression levels of BUN and SCr in kidney tissue decreased, and the TIL score decreased. The expression of p-PI3K and p-AKT decreased after kidney injury. Compared with the model group, the phosphorylation levels of PI3K and AKT in HOXD10 interference group were significantly increased ( $P<0.05$ ). Conclusion. Downregulation of HOXD10 can play a protective role on AKI by activating PI3K/AKT signaling pathway, which can reduce tubulointerstitial injury and improve kidney function.

Role of T cells in ischemic acute kidney injury and repair

Ischemic acute kidney injury (AKI) is a common medical problem with significant mortality and morbidity, affecting a large number of patients globally. Ischemic AKI is associated with intrarenal inflammation as well as systemic inflammation; thus, the innate and adaptive immune systems are implicated in the pathogenesis of ischemic AKI. Among various intrarenal immune cells, T cells play major roles in the injury process and in the repair mechanism affecting AKI to chronic kidney disease transition. Importantly, T cells also participate in distant organ crosstalk during AKI, which affects the overall outcomes. Therefore, targeting T cell-mediated pathways and T cell-based therapies have therapeutic promise for ischemic AKI. Here, we review the major populations of kidney T cells and their roles in ischemic AKI.

Mortality predictors in critically ill patients with acute kidney injury requiring continuous renal replacement therapy

Background

Because of high cost of continuous renal replacement therapy (CRRT) and the high mortality rate among severe acute kidney injury patients, careful identification of patients who will benefit from CRRT is warranted. This study determined factors associated with mortality among critically ill patients requiring CRRT.

Methods

This was a retrospective observational study of 414 patients admitted to the intensive care unit of four hospitals in South Korea who received CRRT from June 2017 to September 2018. Patients were divided according to degree of fluid overload (FO) and disease severity. The Cox proportional hazards model was used to explore the effect of relevant variables on mortality.

Results

In-hospital mortality rate was 57.2%. Ninety-day mortality rate was 58.5%. Lower creatinine and blood pH were significant predictors of mortality. A one-unit increase in the Sequential Organ Failure Assessment (SOFA) score was associated with increased risk of and 90-day mortality (hazard ratio [HR], 1.07; p < 0.001). The risk of 90-day mortality in FO patients was 57.2% (p < 0.001) higher than in those without FO. High SOFA score was associated with increased risk for 90-day mortality (HR, 1.79; p = 0.03 and HR, 3.05; p = 0.001) in patients without FO and with FO ≤ 10%, respectively. The highest mortality rates were in patients with FO > 10%, independent of disease severity.

Conclusion

FO increases the risk of mortality independent of other factors, including severity of acute illness. Prevention of FO should be a priority, especially when managing the critically ill.

Immortalized canine adipose-derived mesenchymal stem cells alleviate gentamicin-induced acute kidney injury by inhibiting endoplasmic reticulum stress in mice and dogs

Adipose-derived mesenchymal stem cells have been used to treat acute kidney injury (AKI). The role of endoplasmic reticulum (ER) stress in AKI treatment with canine adipose-derived mesenchymal stem cells (cADSCs) remains unknown. This study intended to investigate the therapeutic effects of cADSCs cultured in different media on AKI in mice and dogs and reveal the role of ER stress in this process. The mice were divided into two branches: a control group and a gentamicin induced group (this group treated with low-serum ADSC or high-serum ADSC or 4-phenylbutyric acid (4-PBA)). The dogs were divided into control, model, and cell-injected groups. To suppress ER stress, mice were simultaneously treated with 4-PBA. The results showed there were improvements in renal function and tissue damage and a corresponding decrease in ER stress in the kidneys of the mice that received cell injection. However, the cells cultured with 2% FBS showed a better growth state and resulted in lower ER stress levels in treated kidneys. In the 4-PBA-treated group, ER stress was suppressed, and there was corresponding kidney injury recovery. Similarly, both kidney damage and ER stress were alleviated after AKI dogs were injected with the cells. Our findings reveal that both allogeneic and xenogeneic cADSCs were effective treatments for AKI by inhibiting ER stress. These results also provide evidence for a new clinical therapy for acute renal disease in pets.