Association Between a Chloride-Liberal vs Chloride-Restrictive Intravenous Fluid Administration Strategy and Kidney Injury in Critically Ill Adults

Use of Relative Blood Volume Monitoring to Reduce Intradialytic Hypotension in Hospitalized Patients Receiving Dialysis

Perioperative Acute Kidney Injury

Progression From Acute Kidney Injury to Chronic Kidney Disease: A Pediatric Perspective

Intravenous fluid therapy is one of the most frequent interventions provided to patients in the intensive care unit; however, the type of fluid (i.e., crystalloid or colloid) used for resuscitation remains controversial. The most common type of colloid administered to resuscitate critically ill patients is hydroxyethyl starch (HES); however, its safety and efficacy have not been rigorously evaluated in large pragmatic randomized trials, and emerging data have accumulated to question its potential for toxic adverse effects. To evaluate the efficacy and safety of HES for fluid resuscitation in critically ill patients with a focus on survival and kidney function. Multicentre (32 sites in Australia and New Zealand) blinded randomized controlled parallel-group trial. Seven thousand eligible adult patients (age - ≥ 18 yr) admitted to an intensive care unit and judged by their treating clinician to require fluid resuscitation were included in the study. Study treatment allocation used encrypted Web-based randomization stratified by site and an admission diagnosis of trauma. Randomized patients were assigned to receive either 6% HES with a molecular weight of 130 kD and molar substitution ratio of 0.4 (130/0.4; Voluven(®), Fresenius Kabi) in 0.9% sodium chloride or 0.9% sodium chloride (saline) in indistinguishable Free flex 500 mL bags until intensive care unit (ICU) discharge, death, or 90 days after randomization. According to registration guidelines, the study fluid was administered to a maximum dose of 50 mL kg(-1) body weight per day and followed, if necessary, by open-label saline during the remaining 24-hr period. The primary efficacy outcome was death within 90 days after randomization. The key secondary outcomes were incidence of acute kidney injury (AKI), defined by the RIFLE (Risk, Injury, Failure, Loss, Endstage) criteria; treatment with renal replacement therapy(RRT); development of new organ dysfunction, defined by the sequential organ failure assessment score; duration of mechanical ventilation; duration of RRT; cause-specific mortality; and adverse events. Tertiary outcomes were ICU and hospital lengths of stay and ICU and hospital mortality. The primary outcome was evaluated across six a prior idefined subgroups: urine output criteria for AKI; presence of sepsis; presence of trauma, with or without traumatic brain injury; acute physiology and chronic health evaluation (APACHE) score C ≥ 25; and receipt of HES prior to randomization. The HES and saline groups had similar characteristics at baseline. The average age was 63 yr, 60.4% of patients were male, and 42.7% were admitted to the ICU after surgery (54.7% after elective surgery). The median [interquartile range] APACHE II score was 17[12.0-23.0] with a score C ≥ 25 in 18.2%. Sepsis and trauma were primary diagnoses in 28.8% and 7.9% of patients, respectively. Mechanical ventilation was received by 64.5% of patients, vasopressor therapy by 45.8%, and HES fluid prior to randomization by 15.1%. Enrolment occurred approximately 11 hr after ICU admission. During the first four days after randomization, the mean (standard deviation) study fluid received by the HES group was less when compared with the saline group [526 (425) mL day(-1) vs 616 (488) mL day(-1), respectively; P < 0.001]. Mortality at 90 days was 18.0% in patients receiving HES (597/3,315) and 17.0% in those receiving saline (566/3,336) (relative risk [RR] for HES, 1.06; 95% confidence interval (CI), 0.96 to 1.18; P = 0.26). There was no significant difference in 90-day mortality across the six a priori defined subgroups. Renal replacement therapy was received in 7.0% of patients in the HES group (235/3,352) and 5.8% of patients in the saline group (196/3,376) (RR for HES, 1.21; 95% CI, 1.00 to 1.45; P = 0.04). In the HES and saline groups, RIFLE - Injury occurred in 34.6% and 38.0% of patients,respectively (P = 0.005), and RIFLE - Failure occurred in 10.4% and 9.2% of patients, respectively (P = 0.12). There were no differences in mortality in ICU, in hospital, or at 28 days. Hydroxyethyl starch was associated with a decrease in new cardiovascular organ failure compared with saline (36.5% vs 39.9%, respectively; RR 0.91; 95% CI, 0.84 to 0.99; P = 0.03) and an increase in new hepatic organ failure compared with saline (1.9% vs 1.2%, respectively; RR 15.6; 95% CI, 1.03 to 2.36; P = 0.03). There were no differences between HES and saline for days in ICU or hospital or for duration of mechanical ventilation or RRT. Hydroxyethyl starch was associated with more adverse events compared with saline (5.3% vs 2.8%, respectively; RR 1.86; 95% CI, 1.46 to 2.38; P < 0.001). Adverse events were predominantly accounted for by pruritis and skin rash. In critically ill patients receiving fluid resuscitation, there was no significant difference in 90-day mortality between 6% HES (130/0.4) or saline. Even so, more patients who received resuscitation with HES were treated with RRT and experienced adverse events.

Propofol may help to protect against ischaemic acute kidney injury (AKI); however, research on this topic is sparse. The current study aimed to investigate whether there were differences in the incidence of postoperative AKI after lung resection surgery between patients who received propofol-based total intravenous anaesthesia (TIVA) and those who received sevoflurane-based inhalational anaesthesia. A retrospective observational study. A single tertiary care hospital. Medical records of patients aged 19 years or older who underwent curative lung resection surgery for nonsmall cell lung cancer between January 2005 and February 2018 were examined. After propensity score matching, the incidence of AKI in the first 3 postoperative days was compared between patients who received propofol and those who received sevoflurane. Logistic regression analyses were also used to investigate whether propofol-based TIVA lowered the risk of postoperative AKI. The analysis included 2872 patients (1477 in the sevoflurane group and 1395 in the propofol group). After propensity score matching, 661 patients were included in each group; 24 (3.6%) of the 661 patients in the sevoflurane group developed AKI compared with 23 (3.5%) of the 661 patients in the propofol group (95% confidence intervals of difference in incidence -0.019 to 0.022, P = 0.882). The logistic regression analyses revealed that the incidence of AKI was not different in the two groups (odds ratio 0.96, 95% confidence interval 0.53 to 1.71, P = 0.882). In this retrospective study, no significant difference was found in the incidence of postoperative AKI after lung resection surgery between patients who received propofol-based TIVA and those who received sevoflurane-based inhalational anaesthesia. Considering the methodological limitation of this retrospective study, further studies are required to confirm these results.

World Kidney Day 2013: Acute Kidney Injury—Global Health Alert

Intravenous Fluid Therapy: Saline Versus Mixed Electrolyte and Organic Anion Solutions

S1001 Anti-High Mobility Group Box Chromosomal Protein 1 Antibodies Improve Survival of Rats with Fulminant Hepatic Failure

Background Normal saline (0.9% NS) is a common intravenous fluid used worldwide. Recent studies have shown that NS use is associated with increased incidence of acute kidney injury (AKI) and a need for renal replacement therapy (RRT). The practice is changing toward using balanced solutions to prevent AKI. Postcardiac surgery patients are more prone to develop AKI after cardiopulmonary bypass (CPB). We aim to study the type of fluid administrated, incidence of AKI, need for RRT, and overall outcome of these patients. Methods This prospective observational study was conducted in the cardiothoracic intensive care unit (cardiothoracic and vascular surgery intensive care unit) in a cohort of 197 adult patients who underwent on pump cardiac surgery in our hospital from July 2021 to October 2021 as a pilot study. Data was analyzed using SPSS 20.0 (IBM, Chicago, Illinois, United States). A p-value &lt; 0.05 was considered significant. Results In our study, 58 (29.34%) patients developed AKI in the first three postoperative days and 16 (8.12%) patients required RRT. Incidence of AKI was found to be higher in patients who received NS only, as fluid of choice was 34.48% compared with other intravenous fluids. Patients with AKI had higher positive fluid balance (p &lt; 0.001), longer CPB (p &lt; 0.001), and aortic cross clamp (p = 0.006) times. Intensive care unit and hospital stay and mortality rates were higher in AKI patients than those without AKI (p &lt; 0.001). Conclusion Our study demonstrated that NS was the commonly used crystalloid in our patients and was associated with increased incidence of AKI and RRT when compared with other balanced salts solutions.

Do Children With Acute Kidney Injury Require Long-term Evaluation for CKD?

Acute Kidney Injury Within 72 Hours After Lung Transplantation: Incidence and Perioperative Risk Factors

Long-Term Outcomes of Acute Kidney Injury

Acute kidney injury is independently associated with mortality and resource use after emergency general surgery operations

Knowledge about the epidemiology, diagnosis, and management of coronavirus disease 2019 (COVID-19) is rapidly evolving. More evidence is accumulating that COVID-19 is a systemic disease with more extra-pulmonary manifestations than initially thought.1–3 We describe here the incidence, predictors, and prognosis of acute kidney injury (AKI) in critically-ill patients with COVID-19. Data were collected prospectively for all patients with severe COVID-19 admitted to all intensive care units (ICUs) at the Massachusetts General Hospital, Boston, MA, USA between March 13th and April 22nd, 2020. COVID-19 infection was confirmed in all patients via reverse-transcriptase-polymerase-chain-reaction testing. AKI with or without the need for renal replacement therapy (RRT) was defined using the Kidney Disease: Improving Global Outcomes criteria.4 In our institution, the decision to start RRT is made by the nephrology team together with the critical care team. Univariate and multivariable analyses were performed to identify independent predictors for AKI and the need for RRT. A total of 206 consecutive patients were included. The median [interquartile ranges (IQR)] age was 60 years (47, 71), and 134 patients (65.1%) were males; 89 patients (43.2%) had diabetes mellitus, 27 (13.1%) had a history of chronic kidney disease, and 7 (3.4%) were dialysis-dependent before hospital admission. The median (IQR) Sequential Organ Failure Assessment score at the time of ICU admission was 5 (3, 7.5), and 87% of patients were intubated and mechanically ventilated. Of 206 patients, 148 (71.8%) developed AKI. Table S1 in the Supplementary Appendix, https://links.lww.com/SLA/C440 shows the univariate analyses comparing the demographics, comorbidities, and clinical presentation of AKI and non-AKI patients. In the AKI patient population, 62 (41.9%) had significant hyperkalemia (K+ > 5.5 mmol/L), 37 (25.0%) had oliguria/anuria (urine output < 100 mL/d), and 103 (69.6%) developed metabolic acidosis (pH < 7.30). The mean highest creatinine and blood urea nitrogen of patients that developed AKI were 3.80 mg/dL and 77 mg/dL, respectively. Forty-three percent of patients were diagnosed with AKI on hospital admission, whereas 89.2% of the patients developed AKI by hospital day 6 (Fig. 1 in the Supplementary Appendix, https://links.lww.com/SLA/C443). Almost half of the patients (70 patients, 47.3%) with AKI had a severe stage 3 disease, and of those, 46 (65.7%) progressed to require RRT; 24 patients were started and maintained on accelerated veno-venous hemofiltration or continuous veno-venous hemofiltration, 4 patients on hemodialysis, and 18 patients were started on accelerated veno-venous hemofiltration/continuous veno-venous hemofiltration but later transitioned to hemodialysis. The median (IQR) duration of RRT in our patient population was 14.5 (3, 22) days; the median (IQR) duration of RRT in the surviving cohort of patients was 18 (15, 32) days. At the time of this report, out of the 46 patients requiring RRT, 27 (58.7%) are alive; 7 are still in the hospital (5 have recovered renal function and 2 remain RRT dependent) and 20 patients have been discharged (15 have recovered renal function and 5 patients were discharged on RRT). Clotting in the dialysis circuit was encountered in 33 (73.3%) patients undergoing RRT. On multivariable analyses, older age, male gender, and higher body mass index (BMI) were identified as independent predictors for the development of AKI (Table S2 in the Supplementary Appendix, https://links.lww.com/SLA/C441). Similarly, male sex, higher BMI, and hypertension were identified as independent predictors of the need for RRT among AKI patients (Table S3 in the Supplementary Appendix, https://links.lww.com/SLA/C442). To date, both ICU and hospital mortality are significantly higher in the AKI vs. non-AKI patients (27.7% vs 5.2%, P-value < 0.001 and 33.1% vs 8.6%, P-value < 0.001, respectively). At the time of this report, 8 (3.9%) patients are still hospitalized. In this series of critically-ill COVID-19 patients, we report an extremely high incidence of AKI; almost a third of the patients required RRT. This might be secondary to kidney hypoperfusion or medication adverse effects; however, COVID-19 related pathophysiologic mechanisms, including cytokine storm and cell-mediated renal injury, could have played a role and thus warrant further investigation.5,6 Male gender and higher BMI were identified as independent predictors for the development of AKI and the requirement of RRT among critically-ill COVID-19 patients. The rate of AKI reported herein is significantly higher than the one reported by Hirsch et al (71.8% vs 36.6%).7 In their study the identified risk factors for AKI included older age, diabetes mellitus, cardiovascular disease, black race, hypertension, ventilation requirement, and administration of vasopressors.7 The hospital mortality rate of AKI patients was nearly 4 times that of non-AKI patients. Front line clinicians should be aware of these renal morbidities and should monitor closely patients’ renal function with prompt early intervention when possible.

Rationale: Acute Kidney Injury (AKI) is common in critically ill patients. Patients in the intensive care unit (ICU) who develop AKI and multi organ failure face a high mortality rate and in those progressing to renal replacement therapy (RRT) mortality rates may exceed 50%. Coronavirus disease 2019 (COVID-19) is a global pandemic caused by severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2). Severe COVID-19 often results in multi system involvement and may particularly affect the kidneys. The incidence of AKI in this setting is unclear and has varied widely in reports based on population evaluated. There is limited data on the incidence and outcomes of severe AKI necessitating RRT in COVID-19 patients who progress to respiratory failure requiring mechanical ventilation (MV). We conducted a retrospective study in order to determine the incidence and outcomes associated with need for RRT in patients with COVID-19 that progressed to need MV. Methods: We reviewed the records of all COVID-19 patients who were intubated for respiratory failure in our hospital between March and May 2020. Our primary endpoint was the incidence of RRT while outcomes in these subjects (e.g. hospital mortality, length of stay and recovery of renal function) served as secondary endpoints. We examined the relationship between our endpoints and baseline demographics, pre-existing co-morbidities, severity of illness identified by vasopressor requirement, PaO2/FiO2 ratio, plateau pressure, fluid balance in the first three days, and treatment with full strength anticoagulation and/or tocilizumab. Results: Our final cohort consisted of 135 patients of which 46 (34.0%) required RRT. Patients who required RRT had similar baseline characteristics to those who did not. Patients treated with RRT had a higher fluid balance in the first 72 hours (+4761 vs +3076, p=0.040). The mortality rate was higher in those requiring RRT (69.6% vs 39.3%, p=0.001), while the median ICU and hospital stay was lower in this subgroup. Amongst hospital survivors evaluated by the end of our study, 43.0% continued to require RRT, 7.0% no longer required RRT but still had some degree of renal dysfunction, and 50.0% had complete recovery of renal function. Conclusion: There is high incidence of AKI in patients with COVID-19 who require MV and one third of these patients develop renal failure requiring RRT. The mortality in these patients is high and exceeds that reported in patients with Acute Respiratory Distress Syndrome from other causes who need RRT. Complete renal function recovery often occurs in survivors.