BEdside ultraSound-guided ulTrafiltration for Acute Kidney Injury patients receiving CRRT: protocol for a randomised controlled trial (the BEST-AKI study)

Clinical practice guidelines for the provision of renal service in Hong Kong: General Nephrology.

Objective To investigate the relationship between fluid overload(FO) and prognosis of critically ill patients with acute kidney injury (AKI) receiving continuous renal replacement therapy (CRRT), so as to provide a basis for the reasonable optimization of fluid management and improve the prognosis of critically ill patients with AKI. Methods We enrolled 261 adult AKI patients receiving CRRT who were admitted in ICU Department of the First Hospital of Jinlin University from January 2012 to June 2017. We retrospectively analyzed the clinical data of all enrolled patients and compared the clinical data between the survival group (n=149) and the death group (n=112). We screened and analyzed the risk factors of 30-day mortality after entering ICU of AKI critically ill patients receiving CRRT through multiple Logistic regression analysis. The Kaplan-Meier survival curve was used to compare the difference of 30-day mortality after entering ICU between the subgroups of fluid overload and non-fluid overload patients. Results ①The 30 day mortality was significantly higher in AKI patients receiving CRRT when the following situation existed: %FO total≥10%(OR=1.30, 95%CI:1.13-2.05, P=0.01), ventilator dependency(OR=1.65, 95%CI:1.01-2.55, P=0.03), oliguria(OR=1.55, 95%CI:1.13-2.15), SOFA≥13(OR=1.15, 95%CI:1.01-1.20, P 3 days (OR=1.03, 95%CI:1.01-1.13, P=0.04) and mean arterial pressure group 2> group 3> group > 4 (P<0.01).④The 30 day survival rate was significantly different between fluid overload patients(n=62) and non-fluid overload patients (n=92) in the septic group (P<0.01), while in the non-septic group the 30-day survival rate had no significant difference between fluid overload patients (n=31) and non-fluid overload patients (n=76) (P=0.291). The 30-day survival rate was significant different between fluid overload patients (n=57) and non-fluid overload patients (n=78) in the SOFA≥13 group (P=0.026), while in the SOFA<13 group the 30-day survival rate had no significant difference between fluid overload patients (n=35) and non-fluid overload patients (n=91) (P=0.074). Conclusions Fluid overload is closely associated with poor prognosis of critical ill patients with AKI. The removal of too much fluid through CRRT appears to reduce the mortality of severe AKI patients. The adverse effect of fluid overload on survival is more evident in AKI patients with sepsis or with more severe illness (SOFA≥13). Key words: Fluid overload; Acute kidney injury; Continuous renal replacement therapy; Prognosis

Acute Kidney Injury in Alcohol-Associated Hepatitis: More than a Bystander

Severe Intraabdominal Hypertension in Critically Ill COVID-19 Patients With Acute Kidney Injury

OBJECTIVES:Acute kidney injury (AKI) and fluid overload (FO) are among the top reasons to initiate intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT). Prior research suggests CRRT provides more precise volume control, but whether CRRT is cost-effective remains unclear. We assessed the cost-effectiveness of CRRT for volume control compared with IHD from a U.S. healthcare payer perspective.DESIGN:Decision analytical model comparing health outcomes and healthcare costs of CRRT versus IHD initiation for AKI patients with FO. The model had an inpatient phase (over 90-d) followed by post-discharge phase (over lifetime). The 90-day phase had three health states: FO, fluid control, and death. After 90 days, surviving patients entered the lifetime phase with four health states: dialysis independent (DI), dialysis dependent (DD), renal transplantation, and death. Model parameters were informed by current literature. Sensitivity analyses were performed to evaluate results robustness to parametric uncertainty.SETTING:ICU.PATIENTS OR SUBJECTS:AKI patients with FO.INTERVENTIONS:IHD or CRRT.MEASUREMENTS AND MAIN RESULTS:The 90-day horizon revealed better outcomes for patients initiated on CRRT (survival: CRRT 59.2% vs IHD 57.5% and DD rate among survivors: CRRT 5.5% vs IHD 6.9%). Healthcare cost was 2.7% (+$2,836) higher for CRRT. Over lifetime, initial CRRT was associated with +0.313 life years (LYs) and +0.187 quality-adjusted life years (QALYs) compared with initial IHD. Even though important savings were observed for initial CRRT with a lower rate of DD among survivors (–$13,437), it did not fully offset the incremental cost of CRRT (+$1,956) and DI survival (+$12,830). The incremental cost-per-QALY gained with CRRT over IRRT was +$10,429/QALY. Results were robust to sensitivity analyses.CONCLUSIONS:Our analysis provides an economic rationale for CRRT as the initial modality of choice in AKI patients with FO who require renal replacement therapy. Our finding needs to be confirmed in future research.

Previous investigations showed inconsistent results for comparison in renal recovery, in-hospital, and in-intensive care unit (ICU) mortalities between acute kidney injury (AKI) patients treated with continuous renal replacement therapy (CRRT) and some kinds of intermittent renal replacement therapies (IRRTs). We systematically searched for articles published in the databases (PubMed, Web of Science, EMBASE, Medline, and Google Scholar) until June 2019. We made all statistical analysis using STATA 12.0 software. In the present meta-analysis, relative risks with 95% confidence intervals were calculated for binary outcomes (renal recovery status or mortality). The present study indicated no significant differences in renal recovery, in-hospital mortality, and in-ICU mortality between AKI patients given CRRT and those given sustained low-efficiency dialysis (SLED). Additionally, the study showed no significant difference in in-hospital mortality between AKI patients given CRRT and those given intermittent hemodialysis (IHD), whereas elevated in-ICU mortality was detected in AKI patients given CRRT, compared to those given IHD. The three modalities (CRRT, IHD, and SLED) have their own advantages and disadvantages. More rigorous trials design with large cohort should be made to explore the differences in renal recovery, in-hospital, and in-ICU mortalities between different kinds of RRTs.

Renal Support for Acute Kidney Injury in the Developing World

Background/Aims:Little is known regarding the incidence rate of and factors associated with developing chronic kidney disease after continuous renal replacement therapy (CRRT) in acute kidney injury (AKI) patients. We investigated renal outcomes and the factors associated with incomplete renal recovery in AKI patients who received CRRT.Methods:Between January 2011 and November 2013, 408 patients received CRRT in our intensive care unit. Of them, patients who had normal renal function before AKI and were discharged without maintenance renal replacement therapy (RRT) were included in this study. We examined the incidence of incomplete renal recovery with an estimated glomerular filtration rate < 60 mL/min/1.73 m2 and factors that increased the risk of incomplete renal recovery after AKI.Results:In total, 56 AKI patients were discharged without further RRT and were followed for a mean of 8 months. Incomplete recovery of renal function was observed in 20 of the patients (35.7%). Multivariate analysis revealed old age and long duration of anuria as independent risk factors for incomplete renal recovery (odds ratio [OR], 1.231; 95% confidence interval [CI], 1.041 to 1.457; p = 0.015 and OR, 1.064; 95% CI, 1.001 to 1.131; p = 0.047, respectively). In a receiver operating characteristic curve analysis, a cut-off anuria duration of 24 hours could predict incomplete renal recovery after AKI with a sensitivity of 85.0% and a specificity of 66.7%.Conclusions:The renal outcome of severe AKI requiring CRRT was poor even in patients without further RRT. Long-term monitoring of renal function is needed, especially in severe AKI patients who are old and have a long duration of anuria.

Objective To investigate the predictive value of nutritional and fluid status measured by bioelectrical impedance methods for the prognosis of acute kidney injury (AKI) patients undergoing continuous renal replacement therapy (CRRT). Methods Patients with severe AKI received CRRT in the First Affiliated Hospital of Nanjing Medical University from September 2016 to September 2018 were enrolled, and divided into death group and survival group according to 28-day survival. Cox regression was used to analyze the association between 28-day survival and lean tissue index (LTI), fat tissue index (FTI), the ratio of extracellular water (ECW) and body cell mass (BCM) (ECW/BCM), and overhydration (OH), respectively. Results A total of 156 patients were included, including 101 males and 55 females. The age was (62.7±15.4) years, with sequential organ failure assessment (SOFA) score of 9.9±3.9. The 28-day mortality rate was 46.2%. The pre-CRRT OH values in the 28-day survival group and death group were 2.95(1.80, 5.50) L and 4.20(2.95, 5.70) L(P=0.016), and ECW/BCM values were 1.00(0.76, 1.18) and 1.07(0.88, 1.25) (P=0.033), respectively. Univariate Cox regression analysis showed that pre-CRRT high OH values (HR=1.08, 95%CI 1.00-1.17, P=0.040) and high ECW/BCM values (HR=3.02, 95%CI 1.46-6.22, P=0.003) were associated with 28-day death. The changes of OH values (HR=0.83, 95% CI 0.72-0.95, P=0.008) and ECW/BCM values (HR=6.79, 95% CI 1.72-26.82, P=0.006) between pre-CRRT and the 7th day after CRRT initiation were significantly associated with 28-day mortality in patients who survived 7 days after CRRT initiation. After adjusting for age, gender, and SOFA scores, multivariate Cox regression analysis showed that the high OH value (HR=1.16, 95%CI 1.06-1.27, P=0.002) and the high ECW/BCM value (HR=2.80, 95% CI 1.30-6.06, P=0.003) before CRRT, the change of OH value (HR=0.82, 95%CI 0.72-0.95, P=0.008) and ECW/BCM value (HR=2.79, 95% CI 1.30-5.98, P=0.009) between the 7th day after CRRT initiation and pre-CRRT, were independently associated with 28-day death, while LTI (HR=0.93, 95% CI 0.86-1.02, P=0.113) and FTI (HR=0.98, 95% CI 0.92-1.04, P=0.475) before CRRT were uncorrelated with 28-day death. Conclusions In bioelectrical impedance analysis, the high OH value and high ECW/BCM value before CRRT are associated with 28-day mortality in patients with AKI, while the nutritional indicators LTI and FTI before CRRT are not significantly related. The correction of fluid overload by CRRT within 7 days may reduce the risk of 28-day mortality. Key words: Acute kidney injury; Renal replacement therapy; Body composition; Electric impedance; Nutritional status; Organism hydration status; Prognosis

Objective: The aim of this study was to investigate the clinical characteristics of sepsis-induced acute kidney injury (AKI) in patients undergoing continuous renal replacement therapy (CRRT). Methods: From 2011 to 2015, we enrolled 340 patients who were treated with CRRT for sepsis at the Presbyterian Medical Center. In all patients, CRRT was performed using the PRISMA platform. We divided these patients into two groups (survivors and non-survivors) according to the 28-day all-cause mortality. We compared clinical characteristics and analyzed the predictors of mortality. Results: The 28-day all-cause mortality was 62%. Survivors were younger than non-survivors and had higher platelet counts (178 ± 101 × 103/mL vs. 134 ± 84 × 103/mL, p < .01) and serum creatinine levels (4.2 ± 2.8 vs. 3.3 ± 2.7, p < .01). However, survivors had lower red blood cell distribution width (RDW) scores (14.9 ± 2.1 vs. 16.1 ± 3.3, p < .01) and APACHE II scores (24.5 ± 5.8 vs. 26.9 ± 5.7, p < .01) than non-survivors. Furthermore, survivors were more likely than non-survivors to have a urine output of >0.05 mL/kg/h (66% vs. 86%, p = .001) in the first day. In a multivariate logistic regression analysis, age, platelet count, RDW score, APACHE II score, serum creatinine level, and a urine output of <0.05 mL/kg/h the first day were prognostic factors for the 28-day all-cause mortality. Conclusion: Age, platelet count, APACHE II score, RDW score, serum creatinine level, and urine output the first day are useful predictors for the 28-day all-cause mortality in sepsis patients requiring CRRT.

To explore the effect of goal-directed therapy bundle based on pulse-indicated continuous cardiac output (PiCCO) parameters to the prevention and treatment of acute kidney injury (AKI) in patients after cardiopulmonary bypass cardiac operation. A prospective observational study was conducted. The adult patients with selective cardiopulmonary bypass cardiac operation admitted to the Third People's Hospital of Chengdu from December 2015 to January 2018 were enrolled. All patients were divided into two groups based on informed consent for PiCCO monitor at the time of admission to the intensive care unit (ICU): regular monitoring and treatment group (group A) and goal-directed therapy group based on PiCCO parameters (group B). In group A, the restrictive capacity management strategy was implemented to maintain the mean arterial pressure (MAP) > 65 mmHg (1 mmHg = 0.133 kPa) and the central venous pressure (CVP) between 8 mmHg and 10 mmHg. In group B, volume and hemodynamic status were optimized depending on PiCCO parameters to a goal of cardiac index (CI) > 41.68 mL×s-1×m-2, global end diastolic volume index (GEDVI) > 700 mL/m2 or intrathoracic blood volume index (ITBVI) > 850 mL/m2, extravascular lung water index (EVLWI) < 10 mL/kg, and MAP > 65 mmHg. Then the changes in hemodynamics and different prognosis of the patients in two groups were observed. Risk factors affecting the AKI were analyzed by Logistic regression. 171 cases were included, with 68 in group A and 103 in group B. There were no significant differences in gender, age, pre-operative scores by European system for cardiac operative risk evaluation (EuroScore), operation ways, operation time, cardiopulmonary bypass time, intraoperative dominant liquid equilibrium quantity, the use of intra-aortic balloon counterpulsation (IABP) during operation, and serum creatinine (SCr) level at the time of admission to ICU between the two groups. There were no significant differences in CVP within 24 hours after admission to ICU between the two groups. MAP in group B was significantly higher than that in group A at 8 hours and 16 hours after ICU admission (mmHg: 68.9±6.3 vs. 66.7±5.1, 69.0±4.9 vs. 67.0±5.3, both P < 0.05). Sequential organ failure assessment (SOFA) score in group B was significantly lower than that in group A at 24 hours after ICU admission (5.7±2.2 vs. 6.9±2.8, P < 0.05). Dominant liquid equilibrium quantity in group B was significant higher than that in group A at 24 hours after ICU admission (mL/kg: 7.1±6.2 vs. -0.1±8.2, P < 0.01), but there was no significant difference of that between groups at 48 hours and 72 hours after ICU admission. Compared with group A, incidence of combination with AKI during 72 hours after ICU admission was significantly decreased in group B [48.5% vs. 69.1%; odds ratio (OR) = 0.422, 95% confidence interval (95%CI) = 0.222-0.802, P < 0.05], and incidence of moderate to severe AKI was also significantly decreased in group B (19.4% vs. 35.3%; OR = 0.442, 95%CI = 0.220-0.887, P < 0.05). There was no significant difference in usage of continuous renal replacement therapy (CRRT) after ICU admission between both groups (group A was 4.4%, group B was 4.9%, P > 0.05). It was shown by correlation analysis that only MAP and CI at 8 hours after ICU admission were significantly negatively correlated with AKI (MAP and AKI: r = -0.697, P = 0.000; CI and AKI: r = -0.664, P = 0.000). It was shown by Logistic regressive analysis that the MAP and CI at 8 hours after ICU admission were independent risk factors that influence the incidence of AKI at 72 hours after ICU admission (MAP: OR = 0.736, 95%CI = 0.636-0.851, P = 0.000; CI: OR = 0.006, 95%CI = 0.001-0.063, P = 0.000). There were no significant differences in the duration of mechanical ventilation, the length of ICU stay, the post-operation complications (except AKI), 7-day and 28-day mortality between the two groups. Goal-directed therapy bundle based on PiCCO parameters reduced the incidence of AKI in patients after cardiopulmonary bypass cardiac operation and improved the severity of systemic disease. However, it did not reduce the duration of mechanical ventilation, length of ICU stay, the incidence of complications (except AKI), short-term mortality. The MAP and CI at 8 hours after ICU admission were independent risk factors that influence the incidence of AKI in patients after cardiopulmonary bypass cardiac operation.

Background and Aims Critically ill acute kidney injury (AKI) patients may require treatment by extracorporeal carbon dioxide removal (ECCO2R) devices to allow protective or ultraprotective mechanical ventilation and avoid hypercapnic acidosis. Continuous venovenous hemofiltration (CVVH) and ECCO2R devices can be arranged in series to form a single extracorporeal circuit; such a circuit has been proposed to be optimal, based carbon dioxide removal efficacy, if the ECCO2R device is placed proximal to the CVVH device (Allardet-Servent et al, Crit Care Med 43:2570-2581, 2015). Method We developed a mathematical model of whole-body, acid-base balance during extracorporeal therapy using in-series ECCO2R and CVVH devices for treatment of mechanically ventilated AKI patients. Equilibrium acid-base chemistry in blood was assumed as reported previously (Rees and Andreassen, Crit Rev Biomed Eng 33:209-264, 2005). Published clinical data from Allardet-Servent et al of mechanically ventilated (6 mL/kg predicted body weight or PBW) AKI patients treated by CVVH without ECCO2R were used to adjust model parameters to fit plasma levels of arterial partial pressure of carbon dioxide (PaCO2) and arterial plasma bicarbonate concentration ([HCO3]). The effects of applying ECCO2R at an unchanged tidal volume and a reduced tidal volume (4 mL/kg PBW) on PaCO2 and [HCO3] were then simulated assuming carbon dioxide removal rates from the ECCO2R device measured in the clinical study (91 mL of CO2/min when ECCO2R was proximal and 72 mL of CO2/min when CVVH was proximal). Results Agreement of model predictions with the clinical data was good, and model predictions were relatively independent of the in-series position of the devices (see Table). Total carbon dioxide removal from the CVVH device via ultrafiltration predicted by the model was lower after applying ECCO2R at both the unchanged tidal volume (25 mL of CO2/min when ECCO2R was proximal and 39 mL of CO2/min when CVVH was proximal) and the reduced tidal volume (30 mL of CO2/min when ECCO2R was proximal and 44 mL of CO2/min when CVVH was proximal). The reduced removal of total carbon dioxide via ultrafiltration when ECCO2R was proximal resulted from the lower total carbon dioxide concentration in blood entering the CVVH device. Thus, independent of the in-series position of the devices, the magnitude of this difference in total carbon dioxide removal by the CVVH device (14 mL of CO2/min) approximately cancels out the relative greater efficacy of the ECCO2R device (19 mL of CO2/min). Conclusion The described mathematical model has quantitative accuracy. It suggests that overall acid-base balance when using ECCO2R and CVVH devices in a single, combined extracorporeal circuit will be similar, independent of their in-series position.

Hemostasis in patients with acute kidney injury secondary to acute liver failure

BackgroundThe triglyceride glucose (TyG) index is a novel and reliable alternative marker for insulin resistance. Previous studies have shown that TyG index is closely associated with cardiovascular outcomes in cardiovascular diseases and coronary revascularization. However, the relationship between TyG index and renal outcomes of coronary revascularization is unclear. The purpose of this study was to investigate the correlation between TyG index and the risk of acute kidney injury (AKI) in patients with coronary revascularization.MethodsA retrospective cohort study was conducted to select eligible patients with coronary revascularization admitted to ICU in the medical information mart for intensive care IV (MIMIC-IV). According to the TyG index quartile, these patients were divided into four groups (Q1-Q4). The primary endpoint was the incidence of AKI, and secondary endpoints included 28-day mortality and the rate of renal replacement therapy (RRT) use in the AKI population. Multivariate Cox regression analysis and restricted cubic splines (RCS) were used to analyze TyG index association with AKI risk. Kaplan-Meier survival analysis was performed to assess the incidence of endpoints in the four groups.ResultsIn this study, 790 patients who underwent coronary revascularization surgery were included, and the incidence of AKI was 30.13%. Kaplan-Meier analysis showed that patients with a high TyG index had a significantly increased incidence of AKI (Log-rank P = 0.0045). Multivariate Cox regression analysis showed that whether TyG index was a continuous variable (HR 1.42, 95% CI 1.06–1.92, P = 0.018) or a categorical variable (Q4: HR 1.89, 95% CI 1.12–3.17, P = 0.017), and there was an independent association between TyG index and AKI in patients with coronary revascularization. The RCS curve showed a linear relationship between higher TyG index and AKI in this particular population (P = 0.078). In addition, Kaplan-Meier analysis showed a significantly increased risk of RRT application in a subset of AKI patients based on quartiles of TyG index (P = 0.029).ConclusionTyG index was significantly associated with increased risk of AKI and adverse renal outcomes in patients with coronary revascularization. This finding suggests that the TyG index may be useful in identifying people at high risk for AKI and poor renal outcomes in patients with coronary revascularization.

A potential independent association was recently demonstrated between high red blood cell distribution width (RDW) and the risk of all-cause mortality in patients with cardiovascular disease, although the mechanism remains unclear. However, there have been no reports on the relationship between RDW and mortality in acute kidney injury (AKI) patients treated with continuous renal replacement therapy (CRRT). In this study, we assessed whether RDW was associated with mortality in AKI patients on CRRT treatment in the intensive care unit (ICU). We enrolled 470 patients with AKI who were treated with CRRT at the Yonsei University Medical Center ICU from August 2007 to September 2009 in this study. We performed a retrospective analysis of demographic, biochemical parameters and patient outcomes. Following CRRT treatment, 28-day all-cause mortality was evaluated. At the initiation of CRRT treatment, RDW level was significantly correlated with white blood cell count, hemoglobin (Hb) and total cholesterol. Patients with high RDW levels exhibited significantly higher 28-day mortality rates than patients with low RDW levels (P < 0.01). Baseline RDW level, Sequential Organ Failure Assessment (SOFA) score, low mean arterial pressure (MAP) and low cholesterol levels were independent risk factors for mortality. In multivariate Cox proportional hazard analyses, RDW at CRRT initiation was an independent predictor for 28-day all-cause mortality after adjusting for age, gender, MAP, Hb, albumin, total cholesterol, C-reactive protein and SOFA score. Our study demonstrates that RDW could be an additive predictor for all-cause mortality in AKI patients on CRRT treatment in the ICU.