Resource management and clinical outcomes during a national intravenous fluid shortage.

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

Towards Consensus in Timing of Kidney Replacement Therapy for Acute Kidney Injury?

Dialysis Dosing in Critically Ill Patients With Acute Kidney Injury

Background Renal replacement therapy (RRT), as a cornerstone of supportive treatment, has long been performed in critically ill patients with acute kidney injury (AKI). However, the majority of studies may have neglected the effect of the duration of RRT on the outcome of AKI patients. This paper is aiming to explore the effect of the long duration of RRT on the outcome of critically ill patients with AKI. Methods This retrospective study was conducted by using the Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC-II) database. The primary outcome measure of this study was the mortality at 28 days, 60 days, and 90 days in the long-duration RRT group and the non-long-duration RRT group. The secondary outcomes assessed the difference in clinical outcome in these two groups. Lastly, the effect of the duration of RRT on mortality in AKI patients was determined as the third outcome. Results We selected 1,020 patients in total who received RRT according to the MIMIC-II database. According to the inclusion and exclusion criteria, we finally selected 506 patients with AKI: 286 AKI patients in the non-long-duration RRT group and 220 in the long-duration RRT group. After 28 days, there was a significant difference in all-cause mortality between the long-duration RRT group and the non-long-duration RRT group (P=0.001). However, the difference disappeared after 60 days and 90 days (P=0.803 and P=0.925, respectively). The length of ICU stay, length of hospital stay, and duration of mechanical ventilation were significantly longer in the long-duration RRT group than those in the non-long-duration RRT group. Considering 28-day mortality, the longer duration of RRT was shown to be a protective factor (HR = 0.995, 95% CI 0.993–0.997, P < 0.0001), while 60-day and 90-day mortality were not correlated with improved protection. Conclusions The long duration of RRT can improve the short-term prognosis of AKI patients, but it does not affect the long-term prognosis of these patients. Prognosis is determined by the severity of the illness itself. This suggests that RRT can protect AKI patients through the most critical time; however, the final outcome cannot be altered.

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

To analyze the incidence of acute kidney injury (AKI) in elderly patients with sepsis, compare the clinical characteristics and prognosis between AKI and non-AKI elderly patients with sepsis, and to investigate the impact of classification of AKI and renal replacement therapy (RRT) on the outcome of elderly patients with sepsis. The clinical data of 490 septic patients over 65 years old, admitted to intensive care unit (ICU) of Tianjin First Center Hospital from April 1st, 2016 to December 31st, 2018 were retrospectively analyzed. The patients were divided into two groups according to those with or without AKI. The clinical characteristics of patients were compared, and subgroup analysis of elderly septic patients with AKI was performed according to Kidney Disease: Improving Global Outcomes (KDIGO) staging criteria and whether RRT was performed, to observe the effects of AKI staging and RRT on the prognosis of elderly septic patients with AKI. Multivariate Cox regression analysis was used to screen the risk factors of death in elderly patients with sepsis associated AKI. (1) A total of 490 septic elderly patients were enrolled, including 249 patients with AKI and 241 patients without AKI, with the AKI incidence of 50.8%. Compared with non-AKI group, the patients in AKI group were older (years old: 72.0±7.2 vs. 68.8±5.1), acute physiology and chronic health evaluation II (APACHE II) score and sequential organ failure assessment (SOFA) score were evidently higher (23.1±6.1 vs. 22.0±3.7, 9.4±3.8 vs. 6.1±3.5); the duration of mechanical ventilation [days: 7.0 (5.0, 10.0) vs. 6.0 (3.0, 9.0)], length of ICU stay [days: 12.0 (7.0, 15.0) vs. 7.0 (4.0, 13.0)] and total length of hospital stay [days: 15.0 (10.0, 21.5) vs. 12.0 (7.0, 15.0)] were longer, and ICU mortality and 28-day mortality were evidently higher [22.9% (57/249) vs. 14.1% (34/241), 36.1% (90/249) vs. 24.5% (59/241), all P < 0.05]. (2) According to KDIGO staging, 93 patients were in stage 1, 70 in stage 2 and 86 in stage 3 of AKI. The rate of RRT was increased with increase in KDIGO staging [14.0% (13/93), 30.0% (21/70), 88.4% (76/86)], the duration without mechanical ventilation within 28 days was shortened [days: 20.0 (0, 23.0), 8.0 (0, 20.5), 8.0 (0, 13.0)], the rate of kidney recovery was decreased [71.0% (66/93), 51.4% (36/70), 37.2% (32/86)], meanwhile, the ICU and 28-day mortality was increased [12.9% (12/93), 38.6% (27/70), 20.9% (18/86), and 26.9% (25/93), 35.7% (25/70), 46.5% (40/86), all P < 0.05]. (3) 110 elderly septic patients with AKI were treated with RRT, and 139 without RRT. Compared with non-RRT group, the ratio of mechanical ventilation in RRT group was lowered [46.4% (51/110) vs. 68.3% (95/139)], the duration without mechanical ventilation within 28 days [days: 18.0 (0, 23.0) vs. 10.0 (0, 13.0)], the length of ICU stay [days: 13.0 (12.0, 17.9) vs. 10.0 (6.0, 14.0)] and the total length of hospital stay [days: 22.5 (15.0, 46.0) vs. 16.0 (12.0, 23.0)] were prolonged, and the 28-day mortality was evidently increased [50.0% (55/110) vs. 25.2% (35/139), all P < 0.01], however, no significant difference in ICU mortality was found [27.3% (30/110) vs. 19.4% (27/139), P > 0.05]. (4) Cox regression analysis showed that SOFA score [relative risk (RR) = 1.214, 95% confidence interval (95%CI) = 1.117-1.319], KDIGO stage (RR = 4.077, 95%CI = 1.850-8.982), vasoactive substance usage (RR = 2.896, 95%CI = 1.502-5.584), and mechanical ventilation (RR = 5.787, 95%CI = 1.512-22.156) were the risk factors of 28-day mortality in elderly septic patients with AKI (all P < 0.05). The incidence of AKI for elderly septic patients with AKI was about 50%, who had a worse prognosis as compared with non-septic AKI patients. The higher the stage of KDIGO, the higher the mortality in elderly septic patients with AKI was. RRT can decrease the rate of mechanical ventilation, whereas, it may not improve the prognosis of elderly septic patients with AKI.

Determining the timing of renal replacement therapy (RRT) in patients with acute kidney injury (AKI) and heart failure (HF) can optimize the clinical management strategy. We compared the impact of "early" and "delayed" timing of RRT on the prognosis of patients with AKI and HF. Clinical data from September 2012 to September 2022 were retrospectively analyzed. Patients with AKI complicated by HF and undergoing RRT in the intensive care unit (ICU) were enrolled. Patients with stage 3 AKI and fluid overload present (FOP) or who met the emergency indications for RRT were assigned to the delayed RRT group. Patients with stage 1 AKI or stage 2 AKI and without urgent indications for RRT and patients with stage 3 AKI without FOP and without urgent indications for RRT were enrolled in the Early RRT group. At 90-day follow-up after initiation of RRT, the mortality was compared between the two groups. Logistic regression analysis was performed to adjust for confounding factors affecting 90-day mortality. A total of 151 patients were enrolled, including 77 in the early RRT group and 74 in the delayed RRT group. For baseline characteristics, patients in the early RRT group had significantly lower acute physiology and chronic health evaluation-II (APACHE-II) score, sequential organ failure assessment (SOFA), serum creatinine (Scr) values and blood urea nitrogen (BUN) values on the day of ICU admission than those in the delayed RRT group (both P values <0.05), there were no significant differences in other baseline characteristics. The number of RRT-free days in the ICU was significantly longer in the early RRT group than in the delayed RRT group [1.69 (0.35-10.87) vs. 0.88 (0.20-4.55) days; P=0.046]. However, clinical outcomes (except for the number of RRT-free days) and complications showed no significant differences between these 2 groups (all P values >0.05). Multivariate binary logistic regression analysis showed early initiation of RRT was not an independent risk factor for increased 90-day mortality [odds ratio (OR): 0.671; 95% confidence interval (CI): 0.314-1.434; P=0.303]. Early initiation of RRT is not recommended to reduce mortality in AKI patients with HF.

Acute kidney injury (AKI) is a widespread problem in the intensive care unit (ICU) that heralds increased morbidity, mortality, and ICU length and cost of stay, independent of other factors (1–3). Unfortunately, there are few, if any, specific interventions proven to prevent or treat AKI. Renal replacement therapy is a reactionary, supportive therapy that almost by definition is started long after the inciting process and well into the pathophysiologic cascade of AKI. Although renal replacement therapy is effective at treating the sequelae of AKI such as electrolyte, fluid, and acid-base disorders, it does not address the underlying disease and is rather a bridge to hoped-for spontaneous renal recovery. Although many interventions have been studied to treat AKI and prevent its progression (4), nothing has been clearly beneficial, and we are left with the obvious yet nonspecific interventions: Maintain renal perfusion, avoid nephrotoxic drugs, and correct the underlying process (sepsis, hypovolemia). Many have suggested that at least one reason for the futility of interventions for AKI is late disease detection using conventional markers of renal function (4–7). That is, by the time azotemia and its sequelae are detected, renal injury is well established and may be outside the window for mitigation by an intervention (8). Part of the problem is that in contrast to many other acute disease states in which patients present with acute symptoms, patients with AKI are relatively asymptomatic until the disease is advanced. For example, in the case of acute myocardial infarction, patients typically present with symptoms of disease (chest pain, …

Introduction: In September 2024, Hurricane Helene disrupted U.S. pharmaceutical manufacturing, causing an intravenous (IV) fluid shortage. Hospitals responded by limiting IV use to essential cases, avoiding maintenance fluids, and substituting types based on availability. At Emory Healthcare, this shortage occurred from Oct-Dec 2024. This analysis examined the impact of compelled changes in IV fluid use on patient outcomes, specifically hospital-onset acute kidney injury (HA-AKI). Methods: A retrospective cohort study was conducted among adults admitted from the emergency department during the same seasonal period in different years: pre-shortage (Oct–Dec 2023; n = 12,657) and shortage (Oct–Dec 2024; n = 13,658). Fluid usage was compared using t-tests. Multivariable models assessed differences in HA-AKI, vasopressor use, and 30-day mortality, adjusting for demographics, comorbidities, and IV fluids given in the first 24 hours. HA-AKI, selected to reflect the potential impact of fluid management on kidney function, was defined as creatinine ≥1.5× baseline between 48 hours and 7 days post-admission. Results: Demographics and comorbidities were similar across cohorts (53% female, 56–57% Black, mean age 61, 33% heart failure, 74% hypertension, 26% liver disease). The shortage cohort received 28% less IV fluid in the first 24 hours and 26% less overall. During the shortage, unadjusted rates of HA-AKI were higher (5.4% vs. 4.8%), 30-day mortality lower (4.7% vs. 5.6%), and vasopressor use stable. After adjustment, odds of HA-AKI increased by 20% (p=0.002) vasopressor use increased by 10% (p=0.024), and 30-day mortality decreased by 10% (p=0.045). Conclusions: Reduced IV fluid use during the shortage was associated with modest but clinically meaningful outcome changes. Despite adjusting for fluid volume, the shortage period was linked to higher HA-AKI and vasopressor use, but lower mortality. The mortality effect may be attributed to limited power, unmeasured cohort heterogeneity, differences in fluid type or timing, decreased total fluid volume, or other shifts in clinical practice. These results underscore the complexity of clinical care during supply shortages and highlight the need for further data-driven research to guide fluid stewardship in both crisis and routine settings.

Renal replacement therapy (RRT) during acute kidney injury (AKI) in critically ill patients used to be started early for long. Recent trials supporting a conservative approach with delayed RRT initiation may have influenced clinical practice. We aim to assess temporal trends in the use of RRT among intensive care unit (ICU) patients with AKI over a 12-year period. We conducted a retrospective cohort study using data from the CUB-Réa database, including ICU patients with AKI who required invasive mechanical ventilation and/or catecholamine infusion between 2008 and 2019. Patients were grouped into three periods based on the calendar year of ICU stay: 2008-2011, 2012-2015, and 2016-2019. The primary outcome was the temporal trend in RRT utilization. Secondary outcomes included annual crude RRT rates per 1000 ICU stays and trends in RRT modality. Multivariable logistic regression was used to adjust for confounders. We used a monthly interrupted time series (ITS) over 2008-2019 with a prespecified breakpoint at July 2016 (AKIKI trial publication). Among 45,242 eligible ICU stays, 16,999 (37.6%) required RRT. The use of RRT decreased over the study period, from 39.7% in 2008-2011 to 37.4% in 2012-2015, and to 35.9% in 2016-2019 (p < 0.0001). Adjusted analyses confirmed this trend, with an odds ratio (OR) of 0.91 (95% CI 0.87-0.96) for 2012-2015 and 0.80 (95% CI 0.76-0.84) for 2016-2019, compared to the baseline period. In the adjusted ITS analysis, only the post-intervention monthly trend reached statistical significance (RR per year = 0.97; 95% CI 0.94-0.99). The annual crude rate of RRT use declined from 441 per 1000 ICU stays at baseline to 339 in 2019 (relative reduction: 20.8%). Use of intermittent RRT declined, while continuous modestly increased. Among critically ill patients with AKI, RRT use decreased in the past decade. This suggests a progressive shift toward more conservative RRT initiation strategies.

Michael R. Charlton, William J. Wall, Akinlolu O. Ojo, Pere Gines, Stephen Textor, Fuad S. Shihab, Paul Marotta, Marcelo Cantarovich, James D. Eason, Russell H. Wiesner, Michael A. Ramsay, Juan C. Garcia-Valdecasas, James M. Neuberger, Sandy Feng, Connie L. Davis, Thomas A. Gonwa, and the International Liver Transplantation Society Expert Panel Mayo Clinic, Rochester MN; Department of General Surgery, London Health Science Center, London, Ontario, Canada; Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI; Liver Unit, Hospital Clinic, University of Barcelona School of Medicine, Barcelona, Spain; Department of Nephrology, University of Utah School of Medicine, Salt Lake City, UT; Medical School, University of Western Ontario, London, Ontario, Canada; Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada; Transplant Institute, University of Tennessee, Memphis, TN; Baylor University Medical Center, Dallas, TX; Hospital Clinic I Provincial, Barcelona, Spain; Queen Elizabeth Hospital, Birmingham, England; Department of Transplant Surgery, University of California San Francisco Medical Center, San Francisco, CA; Department of Medicine, University of Washington Medical Center, Seattle, WA; and Mayo Clinic, Jacksonville, FL

Characteristics and Outcomes of Survivors of Critical Illness and Acute Kidney Injury Followed in a Pilot Acute Kidney Injury Clinic

The optimal time to initiate renal replacement therapy in critically ill patients with acute kidney injury is controversial. We investigated the effect of such earlier versus later initiation of renal replacement therapy on the primary outcome of 28-day mortality and other patient-centered secondary outcomes. We searched MEDLINE (via PubMed), EMBASE, and Cochrane databases to July 17, 2020, and included randomized controlled trials comparing earlier versus later renal replacement therapy. Multiple centers involved in eight trials. Total of 4,588 trial participants. Two independents investigators screened and extracted data using a predefined form. We selected randomized controlled trials in critically ill adult patients with acute kidney injury and compared of earlier versus later initiation of renal replacement therapy regardless of modality. Overall, 28-day mortality was similar between earlier and later renal replacement therapy initiation (38.43% vs 38.06%, respectively; risk ratio, 1.01; [95% CI, 0.94-1.09]; I2 = 0%). Earlier renal replacement therapy, however, shortened hospital length of stay (mean difference, -2.14 d; [95% CI, -4.13 to -0.14]) and ICU length of stay (mean difference, -1.18 d; [95% CI, -1.95 to -0.42]). In contrast, later renal replacement therapy decreased the use of renal replacement therapy (relative risk, 0.69; [95% CI, 0.58-0.82]) and lowered the risk of catheter-related blood stream infection (risk ratio, 0.50, [95% CI, 0.29-0.86). Among survivors, renal replacement therapy dependence at day 28 was similar between earlier and later renal replacement therapy initiation (risk ratio, 0.98; [95% CI, 0.66-1.40]). Earlier or later initiation of renal replacement therapy did not affect mortality. However, earlier renal replacement therapy was associated with significantly shorter ICU and hospital length of stay, whereas later renal replacement therapy was associated with decreased use of renal replacement therapy and decreased risk of catheter-related blood stream infection. These findings can be used to guide the management of critically ill patients with acute kidney injury.

Renal Support for Acute Kidney Injury in the Developing World

To systemically review the effects of timing of initiation of renal replacement therapy (RRT) on prognosis in septic patients with acute kidney injury (AKI). A systematic search for randomized controlled trials (RCTs) and other clinical studies focused on comparing varied timing of initiation of RRT in septic AKI patients was performed in English or Chinese from PubMed, Web of Science, EMBASE, CNKI, Wanfang data, VIP from January 2000 to July 2014. Data screened were extracted with Cochrane systemically review method, and enrolled literature was collected for Meta analysis with RevMan 5.2 software. Total mortality, 28-day mortality, the total length of hospital stay and intensive care unit (ICU) stay in septic AKI patients with early or late initiation of RRT was analyzed. Funnel plots were drawn to detect publication bias. Five retrospective comparative studies with a total of 885 patients were enrolled. Random effect model in Meta analysis showed that there was no significant difference in total mortality between early RRT group and late RRT group [65.7% (226/344) vs. 68.7% (239/348), odds ratio (OR) = 0.71, 95% confidence interval (95%CI) = 0.38-1.31, P = 0.27]. The funnel plot demonstrated publication bias. Fixed effect model showed that there was significant difference in 28-day mortality between early RRT group and late RRT group [43.4% (66/152) vs. 55.3% (94/170), OR = 0.59, 95% CI = 0.36-0.94, P = 0.03 ]. The funnel plot demonstrated publication bias too. The data of total length of hospital stay and ICU stay could not be Meta-analyzed because of different data distribution, but no differences in total length of hospital stay and ICU stay between early and late RRT groups for septic AKI patients were found. Early RRT could reduce the 28-day mortality in patients with septic AKI compared with late RRT, but it did not lower the total mortality.