Dialysis-requiring Acute Kidney Injury Research Articles

The value of the ACEF II score in Chinese patients with elective and non-elective cardiac surgery

ObjectiveTo evaluate the value of the ACEF II score in predicting postoperative hospital death and acute kidney injury requiring dialysis (AKI-D) in Chinese patients.MethodsThis retrospective study included adult patients who underwent cardiopulmonary bypass open heart surgery between January 2010 and December 2015 at Guangdong Provincial People’s Hospital. ACEF II was evaluated to predict in-hospital death and AKI-D using the Hosmer–Lemeshow goodness of fit test for calibration and area under the receiver operating characteristic (ROC) curve for discrimination in non-elective and elective cardiac surgery.ResultsA total of 9748 patients were included. Among them, 1080 underwent non-elective surgery, and 8615 underwent elective surgery. Mortality was 1.8% (177/9748). In elective surgery, the area under the ROC (AUC) of the ACEF II score was 0.704 (95% CI: 0.648–0.759), similar to the ACEF score of 0.709 (95% CI: 0.654–0.763). In non-elective surgery, the AUC of the ACEF II score was 0.725 (95% CI: 0.663–0.787), higher than the ACEF score (AUC = 0.625, 95% CI: 0.553–0.697). The incidence of AKI-D was 3.5% (345/9748). The AUC of the ACEF II score was 0.718 (95% CI: 0.687–0.749), higher than the ACEF score (AUC = 0.626, 95% CI: 0.594–0.658).ConclusionACEF and ACEF II have poor discrimination ability in predicting AKI-D in non-elective surgery. The ACEF II and ACEF scores have the same ability to predict in-hospital death in elective cardiac surgery, and the ACEF II score is better in non-elective surgery. The ACEF II score can be used to assess the risk of AKI-D in elective surgery in Chinese adults.

Strategies for post-cardiac surgery acute kidney injury prevention: A network meta-analysis of randomized controlled trials.

ObjectsCardiac surgery is associated with acute kidney injury (AKI). However, the effects of various pharmacological and non-pharmacological strategies for AKI prevention have not been thoroughly investigated, and their effectiveness in preventing AKI-related adverse outcomes has not been systematically evaluated.MethodsStudies from PubMed, Embase, and Medline and registered trials from published through December 2021 that evaluated strategies for preventing post–cardiac surgery AKI were identified. The effectiveness of these strategies was assessed through a network meta-analysis (NMA). The secondary outcomes were prevention of dialysis-requiring AKI, mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS. The interventions were ranked using the P-score method. Confidence in the results of the NMA was assessed using the Confidence in NMA (CINeMA) framework.ResultsA total of 161 trials (involving 46,619 participants) and 53 strategies were identified. Eight pharmacological strategies {natriuretic peptides [odds ratio (OR): 0.30, 95% confidence interval (CI): 0.19–0.47], nitroprusside [OR: 0.29, 95% CI: 0.12–0.68], fenoldopam [OR: 0.36, 95% CI: 0.17–0.76], tolvaptan [OR: 0.35, 95% CI: 0.14–0.90], N-acetyl cysteine with carvedilol [OR: 0.37, 95% CI: 0.16–0.85], dexmedetomidine [OR: 0.49, 95% CI: 0.32–0.76;], levosimendan [OR: 0.56, 95% CI: 0.37–0.84], and erythropoietin [OR: 0.62, 95% CI: 0.41–0.94]} and one non-pharmacological intervention (remote ischemic preconditioning, OR: 0.76, 95% CI: 0.63–0.92) were associated with a lower incidence of post–cardiac surgery AKI with moderate to low confidence. Among these nine strategies, five (fenoldopam, erythropoietin, natriuretic peptides, levosimendan, and remote ischemic preconditioning) were associated with a shorter ICU LOS, and two (natriuretic peptides [OR: 0.30, 95% CI: 0.15–0.60] and levosimendan [OR: 0.68, 95% CI: 0.49–0.95]) were associated with a lower incidence of dialysis-requiring AKI. Natriuretic peptides were also associated with a lower risk of mortality (OR: 0.50, 95% CI: 0.29–0.86). The results of a sensitivity analysis support the robustness and effectiveness of natriuretic peptides and dexmedetomidine.ConclusionNine potentially effective strategies were identified. Natriuretic peptide therapy was the most effective pharmacological strategy, and remote ischemic preconditioning was the only effective non-pharmacological strategy. Preventive strategies might also help prevent AKI-related adverse outcomes. Additional studies are required to explore the optimal dosages and protocols for potentially effective AKI prevention strategies.

A real-world prospective study on dialysis-requiring acute kidney injury.

BackgroundCurrent information about acute kidney injury (AKI) epidemiology in developing nations derives mainly from isolated centers, with few quality multicentric epidemiological studies. Our objective was to describe a large cohort of patients with dialysis-requiring AKI derived from ordinary clinical practice within a large metropolitan area of an emerging country, assessing the impact of age and several clinical predictors on patient survival across the spectrum of human life.MethodsWe analyzed registries drawn from 170 hospitals and medical facilities in Rio de Janeiro, Brazil, in an eleven-year period (2002–2012). The study cohort was comprised of 17,158 pediatric and adult patients. Data were analyzed through hierarchical logistic regression models and mixed-effects Cox regression for survival comparison across age strata.ResultsSevere AKI was mainly hospital-acquired (72.6%), occurred predominantly in the intensive care unit (ICU) (84.9%), and was associated with multiple organ failure (median SOFA score, 11; IQR, 6–13). The median age was 75 years (IQR, 59–83; range, 0–106 years). Community-acquired pneumonia was the most frequent admission diagnosis (23.8%), and sepsis was the overwhelming precipitating cause (72.1%). Mortality was 71.6% and was higher at the age extremes. Poor outcomes were driven by age, mechanical ventilation, vasopressor support, liver dysfunction, type 1 cardiorenal syndrome, the number of failing organs, sepsis at admission, later sepsis, the Charlson score, and ICU admission. Community-acquired AKI, male gender, and pre-existing chronic kidney disease were associated with better outcomes.ConclusionsOur study adds robust information about the real-world epidemiology of dialysis-requiring AKI with considerable clinical detail. AKI is a heterogeneous syndrome with variable clinical presentations and outcomes, including differences in the age of presentation, comorbidities, frailty state, precipitation causes, and associated diseases. In the cohort studied, AKI characteristics bore more similarities to upper-income countries as opposed to the pattern traditionally associated with resource-limited economies.

Early Comprehensive Kidney Care in Dialysis-Requiring Acute Kidney Injury Survivors: A Populational Study.

BackgroundFor patients with Acute Kidney Injury (AKI), a strong and graded relationship exists between AKI severity and mortality. One of the most severe entities of AKI is Dialysis-Requiring Acute Kidney Injury (D-AKI), which is associated with high rates of mortality and end-stage renal disease (ESRD). For this high-risk population group, there is a lack of evidence regarding optimal post-AKI care. We propose that post-AKI care through the combined efforts of the nephrologist and the multidisciplinary care team may improve outcomes. Our aim here is to study for survivors of dialysis-requiring acute kidney injury, the effects of implementing early comprehensive kidney care.MethodsThis is a retrospective longitudinal cohort study of Taiwanese through analyzing the National Health Insurance Research Database (NHIRD). We included patients with acute dialysis during hospitalization from January 1, 2015 to December 31, 2018. Propensity match was done at 1:1, including estimated glomerular filtration rate (eGFR) based on CKD-EPI which was performed due to large initial disparities between these two cohorts.ResultsAfter the propensity match, each cohort had 4,988 patients. The mean eGFR based on CKD-EPI was 27.5 ml/min/1.73 m2, and the mean follow-up period was 1.4 years.The hazard ratio for chronic dialysis or ESRD was 0.55 (95% CI, 0.49–0.62; p < 0.001). The hazard ratio for all-cause mortality was 0.79 (95% CI, 0.57–0.88; p < 0.001). Both outcomes favored early comprehensive kidney care.ConclusionsFor survivors of dialysis-requiring acute kidney injury, early comprehensive kidney care significantly lowered risks of chronic dialysis and all-cause mortality.

Angiotensin II Receptor Blocker Associated With Less Outcome Risk in Patients With Acute Kidney Disease.

Objective: The aim of this study was to explore the respective use of angiotensin-converting-enzyme inhibitors (ACEis) or angiotensin receptor blockers (ARBs) on the outcomes of patients who could be weaned from dialysis-requiring acute kidney injury (AKI-D). Methods: This case–control study enrolled 41,731 patients who were weaned from AKI-D for at least 7 days from Taiwan’s National Health Insurance Administration. We further grouped AKI-D patients according to ACEi and ARB use to evaluate subsequent risks of all-cause mortality and re-dialysis. The outcomes included the all-cause mortality and new-onset of end-stage kidney disease (ESKD; re-dialysis) following withdraw from AKI-D. Results: A total of 17,141 (41.1%) patients surviving AKI-D could be weaned from dialysis for at least 7 days. The overall events of mortality were 366 (48.9%) in ACEi users, 659 (52.1%) in ARB users, and 6,261 (41.3%) in ACEi/ARB nonusers, during a mean follow-up period of 1.01 years after weaning from AKI-D. In regard to all-cause of mortality, pre-dialysis ARB users had lower incidence than ACEi users [hazard ratio (HR 0.82), p = 0.017]. Compared with ACEi/ARB nonusers, continuing ARB users had a significantly low risk of long-term all-cause mortality (adjusted hazard ratio 0.51, p = 0.013) after propensity score matching. However, new users of ACEi at the acute kidney disease (AKD) period had a higher risk of re-dialysis after weaning than ACEi/ARB nonusers (aHR 1.82, p < 0.001), whereas neither ACEi nor ARB users confronted significantly increased risks of hyperkalemia after weaning. Conclusions: Compared with patients without ACEi/ARB, those continuing to use ARB before the event and after weaning had low all-cause mortality, while new users of ACEi at AKD had increased risk of re-dialysis. AKI-D patients continuing to use ACEi or ARB did not have higher risk of hyperkalemia. Future prospective randomized trials are expected to confirm these findings.

"Double whammy" to the kidneys: an unusual etiology of acute kidney disease

Severe rhabdomyolysis could lead to myoglobinuria and acute kidney injury (AKI). Acute interstitial nephritis (AIN) is commonly caused by drugs. AIN per se can cause ‘severe’ AKI. Renal recovery is delayed when several factors are involved in the pathogenesis of AKI. Survivors of AKI require long-term follow-up. Here, we report a case where both severe rhabdomyolysis and drug-induced AIN contributed to ‘severe’ dialysis-requiring AKI. Renal biopsy was diagnostic and showed characteristic features. Steroid therapy for AIN resulted in partial recovery.

Management of acute kidney injury in frail patients with biopsy-proven cast nephropathy: a combined approach with chemotherapy plus Supra-hemodiafiltration with post-adsorption endogenous reinfusion.

Patients with multiple myeloma often have kidney involvement with acute kidney injury which is frequently due to cast nephropathy. Hemodiafiltration with endogenous reinfusion (HFR) allows removal from the circulation of significant amounts of free light chains (FLCs) responsible for tubular damage. Between 2014 and 2018, 13 patients affected bymultiple myeloma (64% λ chain and 36% k), including 10 caseswith biopsy-proven cast nephropathy, were treated with this technique. Each patient had high free light chains levelsat diagnosis: median 8586mg/l for λ and 4200mg/l for k, and stage III acute kidney injury (median serum creatinine 7.5mg/dl). We initially performed daily HFR-Supra sessions and then modulated them based on renal response (mean 10 sessions/patient). At the same time, the patients also received various chemotherapy regimens, depending on their hematological criteria. Forty-six percentof patients showed at least partialrenal functionrecovery within the third month, thus allowing dialysis discontinuation; 38% remained on dialysis. Two patients died. The mean reduction rate offree light chains at the end of the HFR-Supra cycle was 85% (k) and 40% (λ), respectively. Serum albumin remained stable during the whole treatment. In our experience, the synergistic effect of chemotherapy and HFR-Supra led to a recovery of renal function in 6 out of 13 patients presenting with severe dialysis-requiringacute kidney injury. HFR-Supraallowedstable albumin levels, withhigh free light chains removal rate, at arelatively low costs.

Hyponatremia, Inflammation at Admission, and Mortality in Hospitalized COVID-19 Patients: A Prospective Cohort Study.

Background: Systemic inflammation has been associated with severe coronavirus disease 2019 (COVID-19) disease and mortality. Hyponatremia can result from inflammation due to non-osmotic stimuli for vasopressin production.Methods: We prospectively studied 799 patients hospitalized with COVID-19 between March 7 and November 7, 2020, at Hospital Posadas in Buenos Aires, Argentina in order to evaluate the association between hyponatremia, inflammation, and its impact on clinical outcomes. Admission biochemistries, high-sensitivity C-reactive protein (hsCRP), ferritin, patient demographics, and outcome data were recorded. Outcomes (within 30 days after symptoms) evaluated included ICU admission, mechanical ventilation, dialysis-requiring acute kidney injury (AKI), and in-hospital mortality. Length of hospital stay (in days) were evaluated using comprehensive data from the EHR.Results: Hyponatremia (median Na = 133 mmol/L) was present on admission in 366 (45.8%). Hyponatremic patients had higher hsCRP (median 10.3 [IR 4.8–18.4] mg/dl vs. 6.6 [IR 1.6–14.0] mg/dl, p < 0.01) and ferritin levels (median 649 [IQR 492–1,168] ng/dl vs. 393 [IQR 156–1,440] ng/dl, p = 0.02) than normonatremic patients. Hyponatremia was associated with higher odds of an abnormal hsCRP (unadjusted OR 5.03, 95%CI: 2.52–10.03), and remained significant after adjustment for potential confounders (adjusted OR 4.70 [95%CI: 2.33–9.49], p < 0.01). Hyponatremic patients had increased mortality on unadjusted (HR 3.05, 95%CI: 2.14–4.34) and adjusted (HR 2.76, 95%CI:1.88–4.06) in Cox proportional hazard models. Crude 30-day survival was lower for patients with hyponatremia at admission (mean [SD] survival 22.1 [0.70] days) compared with patients who were normonatremic (mean [SD] survival 27.2 [0.40] days, p < 0.01).Conclusion: Mild hyponatremia on admission is common, is associated with systemic inflammation and is an independent risk factor for hospital mortality.Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT04493268.

Acute Kidney Injury in Extracorporeal Membrane Oxygenation Patients: National Analysis of Impact of Age

Background: The aim of this study was to determine epidemiology and outcomes of acute kidney injury (AKI) in patients on extracorporeal membrane oxygenation (ECMO) and to assess if age modifies the effect of AKI on mortality. Methods: Using National (Nationwide) Inpatient Sample Database for hospitalizations in the USA from 2003 to 2014, we identified adult patients on ECMO support. Using International Classification of Diseases 9th Revision, we assessed the rates of AKI and AKI requiring dialysis (AKI-D) among them and associated survival. We used a multivariable logistic regression to identify risk factors of and differential effect of age on mortality from AKI. Results: AKI was seen in 63.9% of 17,942 ECMO hospitalizations: 21.9% of those with AKI required dialysis. The percentage of those with AKI increased steadily. Mortality was higher in those with AKI, with highest in those with AKI-D (70.8% vs. 61.7%; p < 0.001). While both age and AKI were independent predictors of mortality, age was neither a risk factor for AKI nor did it modify the effect of AKI on mortality. Conclusions: AKI is common and is increasing among patients on ECMO support. Patients on ECMO have high mortality and AKI is an independent predictor of mortality. Though age is also an independent predictor of mortality in patients on ECMO, it is neither a predictor of AKI nor does not modify the relationship between AKI and mortality.

Kidney Recovery in Patients With Acute Kidney Injury Treated in Outpatient Hemodialysis or Rehabilitation Facilities

Rationale & ObjectiveSince January 2017, patients with acute kidney injury requiring dialysis (AKI-D) can be discharged to outpatient dialysis centers for continued hemodialysis (HD) support. We aimed to examine the rate of kidney recovery, time to recovery, and hospitalization-related clinical parameters associated with kidney recovery in patients with AKI-D.Study DesignSingle-center prospective cohort study.Setting & Participants111 adult patients who were admitted to the University of Kentucky Hospital, experienced AKI-D, and were discharged with need of outpatient HD.ExposureHospitalization-related clinical parameters were evaluated.OutcomeKidney recovery as a composite of being alive and no longer requiring HD or other form of kidney replacement therapy.Analytical ApproachDiscrete-time survival analysis and logistic regression were used to determine adjusted probabilities of kidney recovery at prespecified time points and to evaluate clinical parameters associated with recovery.Results45 (41%) patients recovered kidney function, 25 (55.5%) within the first 30 days following discharge, 16 (35.5%) within 30 to 60 days, and 4 (9%) within 60 to 90 days. Adjusted probabilities of recovery were 36.7%, 27.4%, and 6.3%, respectively. Of the remaining patients, 49 (44%) developed kidney failure requiring chronic kidney replacement therapy and 17 (15%) died or went to hospice. Patients who did not recover kidney function were older, had more comorbid conditions, had lower estimated glomerular filtration rates at baseline, and received more blood transfusions during hospitalization when compared with those who recovered kidney function.LimitationsSelection bias given that patients included in the study were all eligible for AKI management with outpatient HD as part of Medicare/Medicaid services.ConclusionsAt least one-third of AKI-D survivors discharged from an acute care hospital dependent on HD recovered kidney function within the first 90 days of discharge, more commonly in the first 30 days postdischarge. Future studies should elucidate clinical parameters that can inform risk classification and interventions to promote kidney recovery in this vulnerable and growing population.

IN-HOSPITAL MORTALITY OF ACUTE KIDNEY INJURY: AN EXPERIENCE FROM SOUTH RAJASTHAN.

INTRODUCTION: There are few studies on in-hospital mortality among medical intensive care unit (MICU) patients with acute kidney injury (AKI). We assessed the clinical characteristics of AKI at MICU admission, its impact on mortality during the current hospitalization, and whether the inuence of AKI varied in subgroups of AKI patients. METHODS: We identied all adult aged 12 years and above having medical etiology related community acquired AKI who were admitted to MICU at Pacic Medical College and Hospital, Udaipur, India; from 2015 to 2019. AKI was dened based on the Kidney Disease Improving Global Outcomes (KDIGO) criteria; based on serum creatinine (SCr). Dialysis requiring AKI (D-AKI) was dened as needing acute dialysis at or after MICU admission. Among 2440 MICU patients; 516 patients (21.1%) had AKI. We analyzed in-hospital mortality for subgroups of AKI: stage1, stage2 and stage3: with different etiology, comorbidity levels, acute risk factors, primary hospital diagnosis, and treatment with mechanical ventilation, vasopressors and dialysis. RESULTS: Maximum number of AKI patients (57.8%) were in KDIGO Stage3, while stage1 and stage2 had 17.8% and 24.4% respectively. 51.4% patients were male, median age was 54.81 years and average length of ICU stay was 11.73 days. The most common primary diagnosis and etiology was sepsis (31.4%), the most common acute risk factor was hypovolemia (18.8%), the common chronic comorbidity were diabetes (17.0%) and hypertension (10.0%). The most common presenting symptoms was oliguria (43.8 %), while commonest sign on admission was edema (28.1%). Common indications for dialysis were oliguria (75%), hyperkalemia (38.2%), refractory uid overload (36.2%) and metabolic acidosis (35.2%). Overall common critical care treatment required in AKI patients were acute dialysis (58.9%), vasopressor support (16.5%) and ventilator support (14%). The requirement of dialysis was 0.0%, 4.8% and 100%; among stage1, stage2 and stage3 respectively. The overall AKI mortality was 9.9% (95% condence interval (CI) 7% to 12% ). The associations between AKI and mortality were 10.87% (95% CI 5% to 17%) for the AKI-stage1, 13.49% (95% CI 8% to 19% ) for the AKI-stage2 and 8.05% (95% CI 5% to 11%) for the AKI-stage3. The mortality in D-AKI group was 8.6% (95% CI 5 % to 12 %) compared to the mortality in ND-AKI group 11.8% (95% CI 7 % to 16 %). The association between AKI and in-hospital mortality was evident in all subgroups of AKI; association was more pronounced in stage2 AKI, mostly due to worsening of complications which suggests that KDIGO stage2 AKI is a transition zone among D-AKI and ND-AKI groups. Further, it may be needed to lower the threshold for dialysis criteria in AKI. CONCLUSIONS: Any degree of AKI was associated with increased mortality. Timely and early initiation of dialysis in AKI was an important prognostic factor for the reduction of in-hospital mortality.

The Association of COVID-19 With Acute Kidney Injury Independent of Severity of Illness: A Multicenter Cohort Study

Rationale & ObjectiveAlthough coronavirus disease 2019 (COVID-19) has been associated with acute kidney injury (AKI), it is unclear whether this association is independent of traditional risk factors such as hypotension, nephrotoxin exposure, and inflammation. We tested the independent association of COVID-19 with AKI.Study DesignMulticenter, observational, cohort study.Setting & ParticipantsPatients admitted to 1 of 6 hospitals within the Yale New Haven Health System between March 10, 2020, and August 31, 2020, with results for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing via polymerase chain reaction of a nasopharyngeal sample.ExposurePositive test for SARS-CoV-2.OutcomeAKI by KDIGO (Kidney Disease: Improving Global Outcomes) criteria.Analytical ApproachEvaluated the association of COVID-19 with AKI after controlling for time-invariant factors at admission (eg, demographic characteristics, comorbidities) and time-varying factors updated continuously during hospitalization (eg, vital signs, medications, laboratory results, respiratory failure) using time-updated Cox proportional hazard models.ResultsOf the 22,122 patients hospitalized, 2,600 tested positive and 19,522 tested negative for SARS-CoV-2. Compared with patients who tested negative, patients with COVID-19 had more AKI (30.6% vs 18.2%; absolute risk difference, 12.5% [95% CI, 10.6%-14.3%]) and dialysis-requiring AKI (8.5% vs 3.6%) and lower rates of recovery from AKI (58% vs 69.8%). Compared with patients without COVID-19, patients with COVID-19 had higher inflammatory marker levels (C-reactive protein, ferritin) and greater use of vasopressors and diuretic agents. Compared with patients without COVID-19, patients with COVID-19 had a higher rate of AKI in univariable analysis (hazard ratio, 1.84 [95% CI, 1.73-1.95]). In a fully adjusted model controlling for demographic variables, comorbidities, vital signs, medications, and laboratory results, COVID-19 remained associated with a high rate of AKI (adjusted hazard ratio, 1.40 [95% CI, 1.29-1.53]).LimitationsPossibility of residual confounding.ConclusionsCOVID-19 is associated with high rates of AKI not fully explained by adjustment for known risk factors. This suggests the presence of mechanisms of AKI not accounted for in this analysis, which may include a direct effect of COVID-19 on the kidney or other unmeasured mediators. Future studies should evaluate the possible unique pathways by which COVID-19 may cause AKI.

Association of dialysis-requiring acute kidney injury with 90-day prognosis in patients with coronary artery disease and advanced kidney disease after coronary angiography.

BackgroundDialysis-requiring acute kidney injury (AKI-D) is a potentially serious complication associated with high in-hospital mortality among patients with coronary artery disease (CAD) after coronary angiography (CAG). Patients with existing advanced kidney disease (AKD) have an increased risk of developing AKI-D. However, few studies have investigated the prognosis of AKI-D in patients with both CAD and AKD.MethodsIn this observational study, 603 CAD patients with AKD (estimated glomerular filtration rate, eGFR <30 mL/min/1.73 m2) were enrolled. AKI-D was defined as acute or worsening renal failure requiring the initiation of renal dialysis. The primary endpoint was 90-day all-cause mortality. Kaplan-Meier and Cox regression analyses were used to assess the association of AKI-D and 90-day all-cause mortality among CAD patients complicated with AKD.ResultsOverall, among 603 CAD patients complicated with AKD, 83 patients (13.8%) required AKI-D. Patients underwent AKI-D had a significantly higher rate of 90-day mortality than those who did not (13.3% vs. 6.5%, log rank P=0.028), with an unadjusted hazard ratio (HR) of 1.28 [95% confidence interval (CI): 1.02–1.61, P=0.032]. After adjustment for cardiac and renal impairment, however, AKI-D was no longer associated with 90-day mortality (HR: 1.08, 95% CI: 0.84–1.39, P=0.559). The attenuation analysis showed that after adjustment for cardiac and renal function, the residual effect of 90-day mortality was as low as 30% of the unadjusted effect.ConclusionsThe incidence of AKI-D is high among patients with CAD complicated by AKD. The high 90-day mortality rate of patients undergoing AKI-D is mainly attributable to cardio-renal impairment.

Intermittent hemodiafiltration as a down-step transition therapy in patients with acute kidney injury admitted to intensive care unit who initially underwent continuous venovenous hemodiafiltration.

Continuous renal replacement therapies (CRRT) are initially employed in patients with acute kidney injury (AKI) in ICU setting. After the period of serious illness, hemodialysis is usually used as a mode of transition from CRRT. Intermittent hemodiafiltration (HDF) is not commonly applied in this scenario. To evaluate the feasibility of using HDF as transition therapy after CVVHDF in critically patients with AKI. An observational and prospective pilot study was conducted in ICU patients with dialysis-requiring AKI. Patients were initially treated with CVVHDF and, after medical improvement, those who still needed renal replacement therapy were switched to HDF treatment. Ten Patients underwent 53 HDF sessions (mean of 5.3 sessions/patient). The main cause of renal dysfunction was sepsis (N = 7; 70%). The APACHE II mean score was 27.6 ± 6.9. During HDF treatment, the urea reduction ratio was 64.5 ± 7.5%, for β-2 microglobulin serum levels the percentage of decrease was 42.0 ± 7.8%, and for Cystatin C was 36.2 ± 6.9%. Five episodes of arterial hypotension occurred (9.4% of sessions). There were 20 episodes of electrolytic disturbance (37.7% of sessions), mainly hypophosphatemia. No pyrogenic or suggestive episode of bacteremia was observed. Hemodiafiltration was safe and efficient to treat critically ill patients with acute kidney injury during the transition phase from continuous to intermittent dialysis modality. Special attention should be paid regarding the occurrence of electrolytic disturbance, mainly hypophosphatemia.

Association between regional economic status and renal recovery of dialysis-requiring acute kidney injury among critically ill patients

The association between regional economic status and the probability of renal recovery among patients with dialysis-requiring AKI (AKI-D) is unknown. The nationwide prospective multicenter study enrolled critically ill adult patients with AKI-D in four sampled months (October 2014, along with January, April, and July 2015) in Taiwan. The regional economic status was defined by annual disposable income per capita (ADIPC) of the cities the hospitals located. Among the 1,322 enrolled patients (67.1 ± 15.5 years, 36.2% female), 833 patients (63.1%) died, and 306 (23.1%) experienced renal recovery within 90 days following discharge. We categorized all patients into high (n = 992) and low economic status groups (n = 330) by the best cut-point of ADIPC determined by the generalized additive model plot. By using the Fine and Gray competing risk regression model with mortality as a competing risk factor, we found that the independent association between regional economic status and renal recovery persisted from model 1 (no adjustment), model 2 (adjustment to basic variables), to model 3 (adjustment to basic and clinical variables; subdistribution hazard ratio, 1.422; 95% confidence interval, 1.022–1.977; p = 0.037). In conclusion, high regional economic status was an independent factor for renal recovery among critically ill patients with AKI-D.

Exploring reasons for state-level variation in incidence of dialysis-requiring acute kidney injury (AKI-D) in the United States

BackgroundThere is considerable state-level variation in the incidence of dialysis-requiring acute kidney injury (AKI-D). However, little is known about reasons for this geographic variation.MethodsNational cross-sectional state-level ecological study based on State Inpatient Databases (SID) and the Behavioral Risk Factor Surveillance System (BRFSS) in 2011. We analyzed 18 states and six chronic health conditions (diabetes mellitus [diabetes], hypertension, chronic kidney disease [CKD], arteriosclerotic heart disease [ASHD], cancer (excluding skin cancer), and chronic obstructive pulmonary disease [COPD]). Associations between each of the chronic health conditions and AKI-D incidence was assessed using Pearson correlation and multiple regression adjusting for mean age, the proportion of males, and the proportion of non-Hispanic whites in each state.ResultsThe state-level AKI-D incidence ranged from 190 to 1139 per million population. State-level differences in rates of hospitalization with chronic health conditions (mostly < 3-fold difference in range) were larger than the state-level differences in prevalence for each chronic health condition (mostly < 2.5-fold difference in range). A significant correlation was shown between AKI-D incidence and prevalence of diabetes, ASHD, and COPD, as well as between AKI-D incidence and rate of hospitalization with hypertension. In regression models, after adjusting for age, sex, and race, AKI-D incidence was associated with prevalence of and rates of hospitalization with five chronic health conditions--diabetes, hypertension, CKD, ASHD and COPD--and rates of hospitalization with cancer.ConclusionsResults from this ecological analysis suggest that state-level variation in AKI-D incidence may be influenced by state-level variations in prevalence of and rates of hospitalization with several chronic health conditions. For most of the explored chronic conditions, AKI-D correlated stronger with rates of hospitalizations with the health conditions rather than with their prevalences, suggesting that better disease management strategies that prevent hospitalizations may translate into lower incidence of AKI-D.

Outcome of Dialysis-Requiring Acute Kidney Injury in Patients With Infective Endocarditis: A Nationwide Study.

Infective endocarditis (IE) may be complicated by acute kidney injury, yet data on the use of dialysis and subsequent reversibility are sparse. Using Danish nationwide registries, we identified patients with first-time IE from 2000 to 2017. Dialysis-naïve patients were grouped into: those with and those without dialysis during admission with IE. Continuation of dialysis was followed 1 year postdischarge. Multivariable adjusted Cox proportional hazard analysis was used to examine 1-year mortality for patients surviving IE according to use of dialysis. We included 7307 patients with IE; 416 patients (5.7%) initiated dialysis treatment during admission with IE and these were younger, had more comorbidities and more often underwent cardiac valve surgery compared with nondialysis patients (47.4% vs 20.9%). In patients with both cardiac valve surgery and dialysis treatment (n = 197), 153 (77.7%) initiated dialysis on or after the date of surgery. The in-hospital mortality was 40.4% and 19.0% for patients with and without dialysis, respectively (P < .0001). Of those who started dialysis and survived hospitalization, 21.6% continued dialysis treatment within 1 year after discharge. In multivariable adjusted analysis, dialysis during admission with IE was associated with an increased 1-year mortality from IE discharge, hazard ratio = 1.64 (95% confidence interval, 1.21-2.23). In dialysis-naïve patients with IE, approximately 1 in 20 patients initiated dialysis treatment during admission with IE. Dialysis identified a high-risk group with an in-hospital mortality of 40% and an approximate 20% risk of continued dialysis. Those with dialysis during admission with IE showed worse long-term outcomes than those without.

Neutrophil Gelatinase-Associated Lipocalin Measured on Clinical Laboratory Platforms for the Prediction of Acute Kidney Injury and the Associated Need for Dialysis Therapy: A Systematic Review and Meta-analysis

The usefulness of measures of neutrophil gelatinase-associated lipocalin (NGAL) in urine or plasma obtained on clinical laboratory platforms for predicting acute kidney injury (AKI) and AKI requiring dialysis (AKI-D) has not been fully evaluated. We sought to quantitatively summarize published data to evaluate the value of urinary and plasma NGAL for kidney risk prediction. Literature-based meta-analysis and individual-study-data meta-analysis of diagnostic studies following PRISMA-IPD guidelines. Studies of adults investigating AKI, severe AKI, and AKI-D in the setting of cardiac surgery, intensive care, or emergency department care using either urinary or plasma NGAL measured on clinical laboratory platforms. PubMed, Web of Science, Cochrane Library, Scopus, and congress abstracts ever published through February 2020 reporting diagnostic test studies of NGAL measured on clinical laboratory platforms to predict AKI. Individual-study-data meta-analysis was accomplished by giving authors data specifications tailored to their studies and requesting standardized patient-level data analysis. Individual-study-data meta-analysis used a bivariate time-to-event model for interval-censored data from which discriminative ability (AUC) was characterized. NGAL cutoff concentrations at 95% sensitivity, 95% specificity, and optimal sensitivity and specificity were also estimated. Models incorporated as confounders the clinical setting and use versus nonuse of urine output as a criterion for AKI. A literature-based meta-analysis was also performed for all published studies including those for which the authors were unable to provide individual-study data analyses. We included 52 observational studies involving 13,040 patients. We analyzed 30 data sets for the individual-study-data meta-analysis. For AKI, severe AKI, and AKI-D, numbers of events were 837, 304, and 103 for analyses of urinary NGAL, respectively; these values were 705, 271, and 178 for analyses of plasma NGAL. Discriminative performance was similar in both meta-analyses. Individual-study-data meta-analysis AUCs for urinary NGAL were 0.75 (95% CI, 0.73-0.76) and 0.80 (95% CI, 0.79-0.81) for severe AKI and AKI-D, respectively; for plasma NGAL, the corresponding AUCs were 0.80 (95% CI, 0.79-0.81) and 0.86 (95% CI, 0.84-0.86). Cutoff concentrations at 95% specificity for urinary NGAL were>580ng/mL with 27% sensitivity for severe AKI and>589ng/mL with 24% sensitivity for AKI-D. Corresponding cutoffs for plasma NGAL were>364ng/mL with 44% sensitivity and>546ng/mL with 26% sensitivity, respectively. Practice variability in initiation of dialysis. Imperfect harmonization of data across studies. Urinary and plasma NGAL concentrations may identify patients at high risk for AKI in clinical research and practice. The cutoff concentrations reported in this study require prospective evaluation.

Survival and renal recovery after acute kidney injury requiring dialysis outside of intensive care units

The incidence of acute kidney injury requiring dialysis (AKI-D) is increasing globally and it is usually associated to chronic kidney disease (CKD) and high mortality. Literature is lacking in short- and intermediate-term data on recovery of renal function after acute kidney injury (AKI). The objective was to evaluate the overall survival and renal recovery after an episode of AKI requiring dialysis out of intensive care units (ICUs). Retrospective study including patients admitted in two nephrology units along a period of 2years. Patients admitted to ICUs and renal transplant patients were excluded. Baseline renal function, mortality and glomerular filtration rate (GFR) improvement were evaluated. 151 consecutive adult patients with AKI requiring renal replacement therapy (RRT) were included. Mean age was 70.5 ± 15.2years, 60.3% were males. Median baseline creatinine (bCr) and baseline GFR (bGFR) were 1.4mg/dL and 46mL/min/1.73m2, respectively. After 1year of follow-up, we completed the monitoring of 94 patients: 64.9% had died, 10.6% were alive on dialysis and 24.5% were alive without need for RRT. Patients with bGFR > 60mL/min/1.73m2 prior to AKI episode had a slower but sustained GFR improvement through the follow-up in comparison with patients with bGFR < 60mL/min/1.73m2 whose recovery was incomplete. Patients with AKI requiring RRT have high short- and intermediate-term mortality and some require maintenance dialysis. Patients with GFR > 60mL/min/1.73m2 prior to AKI had a renal recovery closer to the basal renal function than in patients with a previously diminished GFR.

Clinical characteristics and short-term outcome of dialysis-requiring acute kidney injury in critically ill patients

Amac: Diyaliz gerektiren akut bobrek hasari yogun bakim unitelerinde yuksek mortalite ve diyalize bagimli kronik bobrek hastaligi gibi olumsuz sonuclari ile iliskilidir. Bu retrospektif calisma gunumuz yogun bakim pratiginde diyaliz gerektiren akut bobrek hasarinin klinik ozelliklerini ve renal replasman tedavi yontemlerini tanimlamayi amaclamistir. Yontemler: Bu retrospektif kohort calisma, bir universite hastanesinin 20 yatakli ucuncu basamak yogun bakim unitesinde 2011-2017 arasinda gerceklestirilmistir. Toplamda, renal replasman tedavisi uygulanan 145 diyaliz gerektiren akut bobrek hasari hastasi tanimlanmistir. Diyaliz gerektiren akut bobrek hasari hastalarinin hastane kayitlari demografi, tibbi oyku, klinik ozellikler, renal replasman tedavisi detaylari ve isa donemli sonuclar icin retrospektif olarak analiz edilmistir. Bulgular: Incelenen 1689 hastanin 145’inde diyaliz gerektiren akut bobrek hasari mevcuttu. Dahil edilen hastalarin ortanca yasi 73 idi. septik etiyoloji, diyaliz gerektiren akut bobrek hasari gelisiminde en sik suphelenilen nedendi. Elli iki hasta (%35,9) surekli renal replasman tedavisi hastaya uygulanmisken 93 hastaya (%64,1) aralikli hemodiyaliz uygulanmistir. Surekli renal replasman tedavisi uygulanan hastalarda mekanik ventilasyon ve inotrop destegi daha sik kullanilmistir (P=0,03). Toplamda, hastane ici mortalite orani %73,1 iken taburculukta diyaliz bagimli kronik bobrek hastaligi orani %6,2 idi. mortalite orani surekli renal replasman tedavisi uygulanan hastalarda anlamli olarak daha yuksekti (%84,6’ya karsilik %66,7, P=0,019). Sonuc: Calismamizin bulgulari yogun bakim hastalarinda diyaliz gerektiren akut bobrek hasarinin en onemli nedeninin sepsis oldugunu gostermektedir. Diyaliz gerektiren akut bobrek hasari yasli hastalarda daha fazla gorulmustur ve kisa donemli mortalite riskinde artis ile iliskilidir.