Duration Of Renal Replacement Therapy Research Articles

Prediction of successful weaning from renal replacement therapy in critically ill patients based on machine learning

Background Predicting the successful weaning of acute kidney injury (AKI) patients from renal replacement therapy (RRT) has emerged as a research focus, and we successfully built predictive models for RRT withdrawal in patients with severe AKI by machine learning. Methods This retrospective single-center study utilized data from our general intensive care unit (ICU) Database, focusing on patients diagnosed with severe AKI who underwent RRT. We evaluated RRT weaning success based on patients being free of RRT in the subsequent week and their overall survival. Multiple logistic regression (MLR) and machine learning algorithms were adopted to construct the prediction models. Results A total of 976 patients were included, with 349 patients successfully weaned off RRT. Longer RRT duration (7.0 vs. 9.6 d, p = 0.002, OR = 0.94), higher serum cystatin C levels (1.2 vs. 3.2 mg/L, p < 0.001, OR = 0.46), and the presence of septic shock (28.1% vs. 41.5%, p < 0.001, OR = 0.63) were associated with reduced likelihood of RRT weaning. Conversely, a positive furosemide stress test (FST) (60.2% vs. 40.7%, p < 0.001, OR = 2.75) and higher total urine volume 3 d before RRT withdrawal (755 vs. 125 mL/d, p < 0.001, OR = 2.12) were associated with an increased likelihood of successful weaning from RRT. Next, we demonstrated that machine learning models, especially Random Forest and XGBoost, achieving an AUROC of 0.95. The XGBoost model exhibited superior accuracy, yielding an AUROC of 0.849. Conclusion High-risk factors for unsuccessful RRT weaning in severe AKI patients include prolonged RRT duration. Machine learning prediction models, when compared to models based on multivariate logistic regression using these indicators, offer distinct advantages in predictive accuracy.

Prognosis of critically ill patients with extreme acidosis: A retrospective study

ObjectiveThis study aims to assess the impact of different subtypes of extreme acidosis on the mortality of critically ill patients. MethodsThis retrospective cohort study included critically ill patients who were admitted to the intensive care unit (ICU) with a pH level <7. Clinical data and blood gas analyses were collected from electronic medical records. The primary outcome was in-hospital mortality. The use of vasopressors, mechanical ventilation (MV), and renal replacement therapy (RRT), the duration of MV and RRT, and the length of ICU and hospital stay were secondary outcomes. The simplified Stewart approach to acid-base disorders was used to analyze the causes of acidosis. ResultsA total of 231 patients with 371 arterial blood gas analyses with pH < 7 were admitted from January 2012 to December 2021 and 222 were included in the study. Out of the 222 patients analyzed, respiratory acidosis was the primary disorder in 11.3% of patients (n = 25), metabolic acidosis in 33.8% (n = 75), and mixed acidosis in 55% (n = 122). Overall mortality was 42.8% (n = 95). No significant difference was observed in mortality among patients with respiratory, metabolic, or mixed acidosis (28%, 42.7%, and 45.9%, respectively; p = 0.26). The primary disorder affected the use of vasopressors and MV, the duration of MV, and the length of ICU and hospital stay. Patients with extreme acidosis due to unmeasured anions with lactate levels of 4 mmol/L or higher had higher mortality compared with patients with lactate levels <4 mmol/L (55.6% and 27.7%, respectively; p = 0.007). ConclusionAmong critically ill patients with extreme acidosis, the primary disorder is not associated with mortality, but it is associated with the use of vasopressors and MV, the duration of MV, and the length of ICU and hospital stay. Additionally, hyperlactatemia is a predictor of poor prognosis in patients with extreme acidosis.

#6760 EFFICACY OF HEMOSORPTION IN REMOVAL OF HIGH MOLECULAR WEIGHT UREMIC TOXINS IN CHRONIC HEMODIALYSIS PATIENTS

Abstract Background and Aims Symptoms associated with the accumulation of large uremic toxins (the development of chronic inflammation, accelerated progression of cardiovascular diseases and an increase in the incidence of protein-energy malnutrition) are common for patients who get chronic hemodialysis (HD) for a long time. HD effectively removes small and medium molecules (up to 15 kDa), while convection techniques, which are not always available, are used to remove substances of higher molecular weight. An alternative strategy for removing uremic toxins, especially large medium molecules, is the use of sorption techniques. The aim of the study was to compare the removal efficiency of substances with a molecular weight from 11.8 to 45 kDa using HD on a high-flux membrane and a combination of a high-flux membrane with hemosorption. Method The study included patients with a duration of hemodialysis therapy for more than 5 years. Blood sampling was carried out before and after the procedures, in the average RRT session per week. The following indicators were determined: β-2-microglobulin, leptin, free light chains (FLC) κ and λ, Il-6. The first HD session was performed on a Fresenius Fx-80 high-flux membrane. The second procedure (one week after) was carried out using the same filter, but with the connection of a Jafron HA130 sorption column (HD+HP). The duration of the both procedures was 4 hours. Blood flow did not exceed 300 ml/min. Results Total 10 patients were included in the study. Mean duration of renal replacement therapy was 12±5 years. The ratio of men and women was equal. Mean age 54±12 years. All patients used AV fistulas as vascular access. When determining and comparing the concentrations of β-2-microglobulin, leptin, Il-6, a comparable significant decrease in concentrations was noted after both procedures without significant statistical differences between the methods. At the same time, the efficiency of FLC removal on HD and HD+GP was convincingly different: - average kappa-FLC concentration change after HD was +1.8±9.1 mcg/ml, after HD+GP: -9.4±7.5 mcg/ml, p = 0.04. - average lambda -FLC concentration change after HD/HD+GP was +3.2±16.3 and -12.9±4.4 mcg/ml, respectively. p = 0.02. Conclusion The use of sorption techniques as an adjunct to standard HD therapy can increase the excretion of medium-large molecular substances, such as FLC kappa/lambda, which may help reduce the severity of symptoms associated with the accumulation of these uremic toxins. Additional studies are required to evaluate the clinical effectiveness of the new sorption method in chronic HD.

#4543 EFFECT OF COMORBIDITIES ON HEALTHCARE EXPENDITURES FOR PATIENTS ON KIDNEY REPLACEMENT THERAPY IN A FRENCH COHORT

Abstract Background and Aims End stage kidney disease (ESKD) is associated with a substantial economic burden. In France, the cost of care for such patients represents 2.5% of the total French healthcare expenditures, but serves less than 1% of the population. These patients’ healthcare expenditures are high because of the specialized and complex treatment needed as well as the presence of multiple comorbidities. This study aims to describe and assess the effect of comorbidities on healthcare expenditures (direct medical cost and non-medical costs including transportation and compensatory allowances) for patients with ESKD in France, while considering the modality and duration of renal replacement therapy (RRT). Method This retrospective observational study included adults who started RRT for the first time between 2012 and 2014 in France and were followed for 5 years. Linear models were built to predict mean monthly cost (MMC) by integrating first the time duration in the cohort, then patient characteristics and finally the duration of use of each treatment modalities. A complementary analysis stratified on age group was also performed. The variables included in this analyses were: body mass index, age, sex, RRT modality, time in the cohort, coronary artery disease, heart failure, chronic respiratory disease, active cancer, diabetes, lower-limb arterial disease, HIV/AIDS, abdominal aneurism, rhythm disorders, stroke or transient ischemic attack, liver disease, mobility limitations. All RRT modalities available in France were also included: renal transplant (RT), hemodialysis (HD) in center, HD in self-care unit, HD in out-center, HD at home, assisted continuous ambulatory peritoneal dialysis (aCAPD), non-assisted continuous ambulatory dialysis (naCAPD), assisted automated peritoneal dialysis (aAPD), non-assisted automated peritoneal dialysis (naAPD). Results A total of 22,506 patients were included in the study. The mean MMC was 6,391€ (95% CI 6,345-6,438 €). The comorbidities with the highest effect on MMC were inability to walk +1,434€ (95% CI 1,434-1,434€), lower-limb arterial disease stage III-IV 777€ (95% CI 777-777€), active cancer +594€ (95% CI 594-594€), HIV positivity +507€ (95% CI 507-507€), and diabetes +395€ (95% CI 395-395€). Other comorbidities were also positively associated with MMC. KT and naAPD were negatively associated with the MMC by -161€ (95% CI -161 - -161€) and -2€ (95% CI -2 - -2€). The remaining RRT modalities were positively associated with the MMC. Hemodialysis in center had the highest effect on the MMC, adding 291€ (95% CI 291-291€). An age-stratified analysis showed an interaction between age groups and comorbidities. The presence of diabetes, cancer and respiratory disease had a great impact on MMC in younger patients. Conclusion This study confirms the importance of considering patient characteristics, comorbidities and type of RRT when assessing healthcare expenditures for patients with ESKD. Better care of comorbidities prior to RRT could reduce cost for individual patients as well as potentially reduce the incidence of patients in ESKD. Even though the Euro value is specific to France, other countries might benefit from evaluating and anticipating healthcare costs for patients in RRT by assessing patient comorbidities.

Factors affecting continuous renal replacement therapy duration in critically ill patients: A retrospective study.

This study aimed to analyze the factors affecting continuous renal replacement therapy (CRRT) duration in critically ill patients and provide a reference for clinical treatment. We divided patients into regional citrate anti-coagulation (RCA) and low-molecular-weight-heparin (LMWH) groups according to the anti-coagulation method and collected the relevant data, to analyze the factors associated with CRRT time. Compared with the LMWH group, the RCA group had a longer mean treatment time (55.36 ± 22.57 vs. 37.65 ± 27.09 h, p < 0.001), lower transmembrane pressure, and lower filter pressure, regardless of vascular access site. Multivariable linear regression analysis showed a significant correlation between anti-coagulation patterns, filter pressure at CRRT discontinuation, nurses' level of intensive care unit experience, pre-machine fibrinogen level, and CRRT time. Anti-coagulation is the most important factor affecting CRRT duration. Filter pressure, nurses' level of intensive care unit experience, and fibrinogen level also affecting CRRT duration.

The role of interleukin-6 in the pathogenesis of protein-energy malnutrition in patients treated with haemodialysis

BACKGROUND. Protein-energy malnutrition (PEM) often develops in patients receiving long-term treatment with programmed haemodialysis (HD). Its main causes are decreased intake of basic nutrients, increased losses, disorders inherent to the terminal renal failure itself (including chronic inflammation), as well as the influence of factors associated with the HD procedure. THE AIM: to clarify the role of interleukin-6 (IL-6 ) in the pathogenesis of BEN in patients treated with programmed haemodialysis. PATIENTS AND METHODS. We examined 645 patients receiving HD treatment, including 300 men and 345 women aged 56.8±12.8 years, the duration of renal replacement therapy was 8.4±5.3 years. Nutritional status was assessed according to International Society of Renal Nutrition and Metabolism (ISRNM) recommendations. Serum IL-6 levels were determined by a three-step "sandwich" version of a solid phase enzyme immunoassay using mono- and polyclonal antibodies to IL-6 using a commercial kit "Interleukin-6-IFA-BEST" from Vector-Best, Russia, under the manufacturer's instructions. The reference values for IL-6 are 0-7 pg/ml. RESULTS. The prevalence of BEN was 24.9 % (160 patients). Mean IL-6 concentration was 6.47±2.64 pg/ml in patients without evidence of BEN, and 23.20±10.40 pg/ml in patients with BEN, p&lt;0.001. Elevated IL-6 levels revealed statistically significantly lower levels of total protein, albumin, prealbumin, total cholesterol, transferrin and blood lymphocyte counts. Patients with elevated IL-6 levels were also characterized by statistically significantly lower values of body mass index, skeletal muscle mass index and skeletal muscle mass index. CONCLUSION. The results of this study suggest that the high prevalence of PEM in patients treated with HD is closely related to an imbalance of pro- and anti-inflammatory cytokines. An increase in the duration of renal replacement therapy is accompanied by an increase in serum IL-6 levels. Therefore, this cytokine can be considered as a therapeutic target for prevention and treatment of sarcopenia in dialysis patients.

Effect of comorbidities on healthcare expenditures for patients on kidney replacement therapy considering the treatment modality and duration in a French cohort.

End-stage kidney disease (ESKD) is associated with a substantial economic burden. In France, the cost of care for such patients represents 2.5% of the total French healthcare expenditures but serves less than 1% of the population. These patients' healthcare expenditures are high because of the specialized and complex treatment needed as well as the presence of multiple comorbidities. This study aims to describe and assess the effect of comorbidities on healthcare expenditures (direct medical cost and non-medical costs including transportation and compensatory allowances) for patients with ESKD in France while considering the modality and duration of renal replacement therapy (RRT). This study included adults who started RRT for the first time between 2012 and 2014 in France and were followed for 5years. Generalized linear models were built to predict mean monthly cost (MMC) by integrating first the time duration in the cohort, then patient characteristics and finally the duration of use of each treatment modalities. Comorbidities with the highest effect on MMC were inability to walk (+ 1435€), active cancer (+ 593€), HIV positivity (+ 507€) and diabetes (+ 396€). These effects vary according to age or treatment modalities. This study confirms the importance of considering patient characteristics, comorbidities and type of RRT when assessing healthcare expenditures for patients with ESKD.

Densitometric justification of the diagnosis of osteoporosis in patients with chronic kidney disease stage 5D

BACKGROUND. Chronic kidney disease leads to increased bone fragility and fractures. Assessing the risk of fractures is a direct way to prevent them. THE AIM: to assess the possibility of using DXA to predict fracture risk in patients with stage 5D CKD. PATIENTS AND METHODS. The prospective cohort study included 359 patients (166 men, 193 women). BMD was evaluated by DRA. Some markers of mineral and bone metabolism were also analyzed. All fractures in patients were recorded from the moment of inclusion in the study. RESULTS. All patients with fractures had lower BMD and received longer-term renal replacement therapy (RRT). The absolute risk of fractures increased as BMD decreased. Patients with fractures had higher levels of parathyroid hormone and alkaline phosphatase. Stepwise multivariate regression analysis showed that the combination of BMD scores of the forearm, hip, lumbar vertebrae and the duration of RRT best predicts the risk of fractures. The presence of previous fractures also increases risk for the future. Risk of fractures in man and women did not differ. CONCLUSION. The risk of fractures in patients with CKD 5 st. on maintenance hemodialysis increases with a decrease in BMD, an increase in the duration of RRT and the presence of previous fractures, but does not significantly depends on the gender of the patients. It is also can be concluded that it is possible to use criteria reflecting the state of BMD, taking into account their sensitivity and specificity, in assessing the risk of fractures in patients with CKD 5D st.

Biomarker-guided intervention to prevent acute kidney injury after major surgery (BigpAK-2 trial): study protocol for an international, prospective, randomised controlled multicentre trial

IntroductionPrevious studies demonstrated that the implementation of the Kidney Disease Improving Global Outcomes (KDIGO) guideline-based bundle, consisting of different supportive measures in patients at high risk for acute kidney injury...

Factors associated with low-compliance bladder in end-stage renal disease patients and development of a clinical prediction model for urodynamic evaluation: the DUDi score.

To investigate factors associated with low-compliance bladders (LCB) in pretransplant patients with end-stage renal disease (ESRD) and develop a clinical prediction model for urodynamic studies. This study was a prospective cohort study. Patients with ESRD on the renal transplantation waiting list were recruited and underwent the urodynamic study. Demographics data, predictor factors related to the bladder compliance such as underlying disease of the lower urinary tract disease (LUTD), duration of urine < 250mL/day, type and duration of renal replacement therapy (RRT), urine volume per day and urodynamic study information were collected. Univariable and multivariable logistic regression models were used to assess the independence of explanatory factors, then we developed the clinical prediction model. One hundred fifty-two patients participated in the study: 94 patients in the normal bladder group and 58 patients in LCB group. Demographic data were not significantly different between the two groups, except diabetes. Cystometric capacity, detrusor pressure, compliance were significantly different. From the univariate analysis, DM status, duration of RRT, and passing < 100mL of urine per day were related to LCB. We named the prediction model, the DUDi score based on the predictors (Duration of RRT, Urine volume/day, Diabetes). Higher scores predicted a higher risk of low-compliance bladder [P value = 0.464 according to the Hosmer-Lemeshow test, and the AUC was 0.87 (95% CI 0.81-0.92)]. Our clinical prediction model is easy to use and provides a high predictive value that is appropriate for patients who have no known LUTD to identify low-compliance bladder. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION FOR PROSPECTIVELY REGISTERED TRIALS: This study was approved by the Thai Clinical Trials Registry Committee on 09 February 2021. TheTCTRidentification number is TCTR20210209006.

Mitochondria and vascular calcification in chronic kidney disease: Lessons learned from the past to improve future therapy.

Chronic kidney disease-mineral and bone disorders (CKD-MBD) is a common complication of CKD Stages 3-5. Hyperphosphatemia is one of the major metabolic components of CKD-MBD, frequently resulting in vascular calcification (VC) in advanced-stage patients. Also, a long duration of renal replacement therapy can cause the worsening of VC, leading to increased cardiovascular morbidity and mortality. Vascular smooth muscle cells play an important role in the development of VC through osteochondrogenic transformation and the apoptotic process. It has been shown that mitochondrial dysfunction is involved with CKD progression, and excessive oxidative stress can aggravate osteoblastic transformation and VC. Currently, novel interventions targeting mitochondrial function and dynamics, in addition to mitochondrial antioxidants, have been studied with the aim of attenuating VC. This review aims to comprehensively summarize and discuss the experimental and clinical reports concerning mitochondrial studies, along with the purpose of interventions that can improve the outcomes of VC among CKD patients.

Comparison of lactate/albumin ratio to lactate and lactate clearance for predicting outcomes in patients with septic shock admitted to intensive care unit: an observational study

The aim of this study was to evaluate the prognostic value of the Lactate to Albumin (L/A) ratio compared to that of lactate and lactate clearance in predicting outcomes in patients with septic shock. This was a multi-center observational study of adult patients with septic shock, who admitted to intensive care units (ICUs) at Shohada and Imam Reza Hospitals, Tabriz, Iran, between Sept 2018 and Jan 2021. The area under the curve (AUC) of receiver operating characteristic (ROC) curve and multivariate logistic regression analyses were used to explore associations of the L/A ratio, lactate and lactate clearance on the primary (mortality) and secondary outcomes [ICU length of stay (LOS), duration of mechanical ventilation (MV), need of renal replacement therapy (RRT) and duration of using vasopressors] at baseline, 6 h and 24 h of septic shock recognition. Best performing predictive value for mortality were related to lactate clearance at 24 h, L/A ratio at 6 h and lactate levels at 24 h with (AUC 0.963, 95% CI 0.918–0.987, P < 0.001), (AUC 0.917, 95% CI 0.861–0.956, P < 0.001), and (AUC 0.904, 95% CI 0.845–0.946, P < 0.001), respectively. Generally, the lactate clearance at 24 h had better prognostic performance for mortality and duration of using vasopressor. However, the L/A ratio had better prognostic performance than serum lactate and lactate clearance for RRT, ICU LOS and MV duration.

A predictive risk score to diagnose hypocalcemia after parathyroidectomy in patients with secondary hyperparathyroidism: a 22-year retrospective cohort study

Hypocalcemia is a common complication found in patients with secondary hyperparathyroidism (SHPT) who undergo parathyroidectomy. This study aimed to construct a predictive risk score for the occurrence of hypocalcemia after parathyroidectomy in patients with SHPT who underwent chronic renal replacement therapy (RRT). This 22-year retrospective cohort study enrolled 179 patients with SHPT who had their first parathyroidectomy. Eighty-two percent of patients developed hypocalcemia within 16.9 (95% CI 14.5–19.5) h after parathyroidectomy. This study demonstrated four factors as independent risk factors for post-parathyroidectomy hypocalcemia, including duration of RRT, preoperative serum phosphate, preoperative serum alkaline phosphatase (ALP) and mean difference of serum intact parathyroid hormone (iPTH). By using logistic regression analysis, this study demonstrated cut-off points for these four risk factors for the diagnosis of hypocalcemia after parathyroidectomy: 5 years for the duration of RRT, 5 mg/dL for serum phosphate, 387 U/L for serum ALP, and 97% for the mean difference of serum iPTH. Finally, the predictive risk score was constructed by assigning a score of one to each factor. With a total score of at least 2, the proposed predictive risk score has an AuROC of 0.755 with a sensitivity of 78.2%, a specificity of 71.4%, and an accuracy of 76.9%.

Early versus delayed initiation of renal replacement therapy in cardiac-surgery associated acute kidney injury: an economic perspective.

Timing for renal replacement therapy (RRT) initiation for cardiac-surgery associated acute kidney surgery (CSA-AKI) is subject to debate. Evidence suggests earlier initiation leads to shorter length of stay (LoS). We investigated differences in healthcare costs associated with timing of RRT initiation in CSA-AKI. A cost-consequences model compared costs of Early (<24 h) vs. Delayed (>24 h) RRT initiation. Data were from the ELAIN trial in Germany, and the HiDenIC database, a US multi-hospital database. Resource utilization was determined by RRT duration, ICU, and hospital LoS. All resources were costed from a US healthcare perspective. Extensive sensitivity analyses (SA) were conducted, notably regarding the proportion of patients not initiated on RRT with the Delayed strategy. Early RRT initiation exhibited cost savings compared to Delayed RRT initiation. With ELAIN data, savings reached -$122,188 (ranging from -$157,707 to -$74,763 in the SA). Findings were confirmed with HiDenIC data; Early RRT initiation showed savings of -$77,303 (ranging from -$108,971 to -$47,012 in the SA). Our costing model indicates that Early RRT initiation for CSA-AKI may result in appreciable cost savings. Delaying RRT, in the setting of CSA-AKI, may lead to longer LoS and increased healthcare costs.

Association Between Glycemic Gap and Mortality in Critically Ill Patients with Diabetes.

Dysglycemia is associated with poor outcomes in critically ill patients,which is uncertain in patients with diabetes regarding to the situation of glucose control before hospitalization. This study was aimed to investigate the effect of the difference between the level of blood glucose during ICU stay and before admission to ICU upon the outcomes of critically ill patients with diabetes. Patients with diabetes expected to stay for more than 24hs were enrolled, HbA1c was converted to A1C-derived average glucose (ADAG) by the equation: ADAG = [ (HbA1c * 28.7) - 46.7 ] * 18-1, blood glucose were measured four times a day during the first 7 days after admission, the mean glucose level(MGL) and SOFA (within 3, 5, and 7days) were calculated for each person, GAPadm and GAPmean was calculated as admission blood glucose and MGL minus ADAG, the incidence of moderate hypoglycemia(MH), severe hypoglycemia (SH), total dosage of glucocorticoids and average daily dosage of insulin, duration of renal replacement therapy(RRT), ventilator-free hours, and non-ICU days were also collected. Patients were divided into survival group and nonsurvival group according to survival or not at 28-day, the relationship between GAP and mortality were analyzed. 431 patients were divided into survival group and nonsurvival group. The two groups had a comparable level of HbA1c, the nonsurvivors had greater APACHE II, SOFA, GAPadm, GAPmean-3, GAPmean-5, GAPmean-7 and higher MH and SH incidences. Less duration of ventilator-free, non-ICU stay and longer duration of RRT were recorded in the nonsurvival group. GAPmean-5 had the greatest predictive power with an AUC of 0.807(95%CI: 0.762-0.851), the cut-off value was 3.6 mmol/L (sensitivity 77.7% and specificity 76.6%). The AUC was increased to 0.852(95%CI: 0.814-0.889) incorporated with SOFA5 (NRI = 11.34%). Glycemic GAP between the MGL within 5 days and ADAG was independently associated with 28-day mortality of critically ill patients with diabetes. The predictive power was optimized with addition of SOFA5.

MO956: Sarcopenia Predicts Mortality in Renal Transplant Candidates

Abstract BACKGROUND AND AIMS Sarcopenia is common in chronic kidney disease (CKD) and is associated with increased mortality and morbidity. Sarcopenia in CKD can be defined as a decreased muscle mass, mainly due to the catabolic state caused by the uremic environment. Malnutrition and inflammation are also common in sarcopenic patients. In this study, we aimed to investigate the prevalence of sarcopenia defined as low muscle mass determined by Psoas Muscle Index (PMI) in waitlisted end-stage renal disease (ESRD) patients and its association between ‘Prognostic Nutritional Index (PNI)’, ‘C-reactive protein (CRP) to Albumin Ratio (CAR)’ and mortality. METHOD ESRD patients registered to national kidney transplant waiting list and had abdomen CT at admission were included in the study. Kidney donor candidates were constituted as healthy controls. PMI ​​(cm2/m2) were calculated by proportioning the psoas muscle area detected in the abdomen CT with the square of the height. The PMI of the controls at the fifth percentile according to gender was accepted as the limit value for sarcopenia. PNI and CAR were calculated using albumin, CRP and absolute lymphocyte count. The associations between PMI, PNI, CAR and all-cause mortality were investigated. RESULTS A total of 162 ESRD patients and 87 age matched healthy controls were included in the study. The mean age of the patients was 44.7 ± 14.2 years and follow-up time was 3.37 (0.35–9.60) years. The mean PMI were similar between the groups (5.24 ± 1.71 versus 5.48 ± 1.87 cm2/m2 P = 0.302). While prevalence of sarcopenia (16.7% versus 3.4%, P = 0.002) and CAR [1.47 (0.12–37.10) versus 0.74 (0.21–10.20), P &amp;lt; 0.001] was higher; PNI [40 (20.4–52.2) versus 44 (36.1–53.0), P &amp;lt; 0.001] was lower in ESRD patients than controls. When ESRD patients compared according to sarcopenia PMI [3.45 ± 0.9 versus 5.59 ± 1.6, P &amp;lt; 0.001] and PNI [39 (20.4–51) versus 41 (23–52.2), P = 0.005] was significantly lower and CAR [2.03 (0.28–34.65) versus 1.28 (0.12–37.1), P = 0.041] was higher in sarcopenic ESRD group than non-sarcopenic ESRD group (Table 1). In the correlation analysis, PMI was positively correlated with PNI ​​(r = 0.246, P = 0.002), no correlated with CAR (r = −0.061, P = 0.445). In the follow-up, 67 waitlisted patients had been transplanted. In the five-year survival analysis, the non-sarcopenic transplant group [95% CI: 4.612–5.123 versus 95% CI: 2.721–5.413, P = 0.001] had better survival than sarcopenic transplant group (Figure 1). Mortality rates were similar in both sarcopenic transplant group and non-sarcopenic-non-transplant group. Multivariate regression analysis showed that sarcopenia (HR: 10.277, 95% CI: 3.912–27.000, P &amp;lt; 0.001), not having a transplant (HR: 3.949, 95% CI: 1.301–11.993, P = 0.015), low PNI (HR: 3.532, 95% CI: 1.303–9.574, P = 0.013) and duration of renal replacement therapy (HR: 1.009, 95% CI: 1.002–1.015, P = 0.008) were independent risk factors for mortality in all ESRD group. CONCLUSION In this study we observed that sarcopenia, as defined by low muscle mass, is almost seen five times more frequent in ESRD patients than controls and positively correlated with PNI. Sarcopenia is an independent risk factor for mortality in waitlisted patients.

Predicting the risk of fractures in kidney transplant recipients

BACKGROUND. Chronic kidney disease leads to a significant increase in the risk of fractures, which increases even more after kidney transplantation. THE AIM. The goal of this study was to develop simple, accessible criteria for predicting the risk of fracture in patients with a functioning kidney transplant. PATIENTS AND METHODS. The prospective study included 131 kidney transplant recipients (men-55, women-76) (average age 39.7±11.7 years). The duration of follow-up was 40.7±21.2 months. Bone mineral density was assessed using dual-energy x-ray absorptiometry. To determine the prognostic significance of variables, we used stepwise regression (Cox model) analysis. p &lt; 0.05 was considered statistically significant. RESULTS. During the follow-up period, fractures were registered in 47 patients (35.9 %). Fractures were detected more often in women (42 %) than in men (27.3 %). All patients with fractures had lower bone mineral density and longer-term renal replacement therapy. Stepwise multivariate regression analysis showed that the combination of bone mineral density scores of lumbar vertebra and duration of renal replacement therapy best predicts the overall fracture risk. Adding the other variables to the analysis did not increase significantly their predictive value. A comparative analysis of the cumulative proportion of males and females with fractures confirmed a greater susceptibility of female transplant recipients to fractures. CONCLUSIONS. The combination of bone mineral density scores of the lumbar vertebra with the duration of renal replacement therapy best predict the risk of fracture in patients with kidney transplants and can be used in the choice of prevention measures.

Analysis of Prognostic Factors for Patients Undergoing Renal Replacement Therapy With Acute Kidney Injury Prior to Living Donor Liver Transplantation

Acute kidney injury (AKI) is a common complication in patients undergoing liver transplantation (LT) for end-stage liver disease (ESLD), and renal replacement therapy (RRT) is required in many cases. This study was performed to identify the prognostic factors for patients undergoing RRT owing to AKI before living donor liver transplantation (LDLT). From January 2010 to December 2018, LDLT was performed in 464 adult patients in our center. We reviewed 33 patients who underwent RRT before LDLT among 464 consecutive cases. Patients who continued to RRT after LDLT or who underwent subsequent kidney transplantation were considered to have not recovered from renal impairment. Among 33 patients, there were 23 patients in the recovery group and 10 patients in the nonrecovery group. The preoperative duration of RRT was shorter in the recovery group, but it was not statistically significant. In the nonrecovery group, diabetes mellitus was found to have a higher prevalence and ischemic time was longer. Other perioperative factors were not significantly different between the 2 groups. After LDLT, the peak total bilirubin level was higher, and the intensive care unit stay was longer in the nonrecovery group. The overall survival rate was higher in the recovery group. Liver transplant recipients who maintain RRT after LDLT have poor outcome. It is necessary to know the risk factors and manage them well, perioperatively.

Incidence of Atrial Fibrillation in Haemodialysis Patients

Abstract Background Chronic kidney disease patients usually experience several comorbid conditions including cardiovascular disorders and at final end-stage renal disease (ESRD) stage, cardiovascular mortality accounts for about 50% of total mortality. End-stage renal disease (ESRD) patients commonly have a higher risk of developing cardiovascular diseases than general population. Chronic kidney disease is an independent risk factor for atrial fibrillation (AF); however, little is known about the AF risk among ESRD patients with various modalities of renal replacement therapy. Aim of the Work To detect the incidence of AF in hemodialysis patients during six months. Patients and Methods The study was a prospective cohort study for six months included 250 adult patients with end stage renal diseases on regular hemodialysis sessions in National Institute of Urology and Nephrology in CAIRO, EGYPT for at least six months with no past history suggestive of any arrhythmias and normal holter ECG at the start of the study. Results The study includes 250 patients from whom 37 patients refuse follow up after 6 months and 18 patients was died before our follow up holter ECG so mortality rate 14.4% .1n our study population there were 102 male patients (52.3%) and 93 female patients (47.7%) with mean age 54.39 ± 9.98 (19:73) and BMI 29.01±1.28 (24.5:34). In study population 96 patients were diabetic (49.2%), 84 patients were hypertensive (43.1%), 100patients were with ischemic heart diseases (51.3%) with median renal replacement duration 4 (3 — 6) with range (1 — 13). The main etiological causes of dialysis were diabetes mellitus, hypertension and analgesic nephropathy and other different causes of dialysis 35 patients (45%).The study showed association between incidence of AF in hemodialysis patients and different factors as increased BMI (0.006), prolonged duration of renal replacement therapy (0.017), diabetes mellitus (0.005), hypertension (0.000), ischemic heart diseases (0.02) and left atrium dilation (0.000). Conclusion The incidence of AF in patients with ESRD is 16.4%. The risk factors for increased incidence of AF in hemodialysis are; increased BMI, increased duration of renal replacement therapy, hypertension, diabetes mellitus, ischemic heart diseases and left atrium dilation by echocardiography.

The Effect of Long-Term Duration Renal Replacement Therapy on Outcomes of Critically Ill Patients with Acute Kidney Injury: A Retrospective Cohort Study.

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.