Early Initiation Of Continuous Renal Replacement Therapy Research Articles

The benefits of early continuous renal replacement therapy in critically ill patients with acute kidney injury at high-altitude areas: a retrospective multi-center cohort study

Severe hypoxia would aggravate the acute kidney injury (AKI) in high-altitude areas and continuous renal replacement therapy (CRRT) has been used to treat critically ill patients with AKI. However, the characteristics and outcomes of CRRT in critically ill patients at AKI in high altitudes and the optimal timing of CRRT initiation remain unclear. 1124 patients were diagnosed with AKI and treated with CRRT in the ICU, comprising a high-altitude group (n = 648) and low-altitude group (n = 476). Compared with the low-altitude group, patients with AKI at high altitude showed longer CRRT (4.8 vs. 3.7, P = 0.036) and more rapid progression of AKI stages (P < 0.01), but without any significant minor or major bleeding episodes (P > 0.05). Referring to the analysis of survival and kidney recovery curves, a higher mortality but a lower possibility of renal recovery was observed in the high-altitude group (P < 0.001). However, in the high-altitude group, the survival rate of early CRRT initiation was significantly higher than that of delayed CRRT initiation (P < 0.001). The findings showed poorer clinical outcomes in patients undergoing CRRT for AKI at high altitudes. CRRT at high altitudes was unlikely to increase the adverse events. Moreover, early CRRT initiation might reduce the mortality and promote renal recovery in high-altitude patients.

Early initiation of continuous renal replacement therapy for metformin-associated lactic acidosis

Introduction. Rapid diagnosis of metformin-associated lactic acidosis (MALA) and initiation of continuous renal replacement therapy (CRRT) in diabetic patient successfully corrects a severe metabolic disorder of a patient with acute renal failure. Case outline. A 58-year-old male patient with a medical history of type 2 diabetes and alcohol abuse was admitted to the Emergency Department because of vomiting, diarrhea, and altered mental status. Initial arterial blood gas analysis revealed severe metabolic acidosis (pH: 6.8, PaCO2: 12 mmHg, HCO3: 3.2 mmol/l), but the lactate level was too high to measure. MALA was suspected based on progressive lactic acidosis and past intake of metformin. Renal replacement therapy was initiated ? continuous veno?venous hemodiafiltration, and as a result a significant improvement of the clinical status, with both blood pH and lactate level showing normalization, was achieved after finishing CRRT. Conclusion. MALA carries an ominous prognosis. This case suggests early initiation of CRRT in hemodynamically unstable diabetic patients with MALA.

Clinical outcomes of severe sepsis and septic shock patients with left ventricular dysfunction undergoing continuous renal replacement therapy

Baseline left ventricular (LV) dysfunction is associated with subsequent risks of acute kidney injury (AKI) and mortality in patients with sepsis. This study investigated the therapeutic effects of continuous renal replacement therapy (CRRT) in hemodynamically unstable patients with severe sepsis and septic shock combined with LV dysfunction. In this multicenter retrospective study, severe sepsis and septic shock patients with LV dysfunction were classified into one of two groups according to the timing of CRRT: the early group (before AKI was detected) or the control group (patients with AKI). Patients from the control group received an accelerated strategy or a standard strategy of CRRT. The primary outcome was all-cause intensive care unit (ICU) mortality. Patients were weighted by stabilized inverse probability of treatment weights (sIPTW) to overcome differences in baseline characteristics. After sIPTW analysis, the ICU mortality was significantly lower in the early group than the control group (27.7% vs. 63.5%, p < 0.001). Weighted multivariable analysis showed that early CRRT initiation was a protective factor for the risk of ICU mortality (OR 0.149; 95% CI 0.051–0.434; p < 0.001). The ICU mortality was not different between the accelerated- and standard-strategy group (52.5% vs. 52.9%, p = 0.970). Early CRRT in the absence of AKI is suggested for hemodynamically unstable patients with severe sepsis and septic shock combined with LV dysfunction since it benefits survival outcomes.

3 Continuous Renal Replacement Therapy for the Treatment of Burn Shock: A Post Hoc Analysis

IntroductionBurn shock is a consequence of burns that cover ≥20% TBSA and may be complicated by acute kidney injury, which is commonly treated with continuous renal replacement therapy (CRRT). However, early initiation of CRRT has not been clinically evaluated for the treatment of burn shock.MethodsData were obtained from the Renal Replacement Therapy in Severe Burns: A Multicenter Observational Study. In that study, baseline (t0) measurements were taken at the time of CRRT initiation and ~24 (t1) and ~48 (t2) hours thereafter. Patients were included in this analysis if they had ≥20% TBSA and began CRRT within 2 days of injury. Patients were categorized as Group A (began CRRT on same day as injury), Group B (began CRRT on day 1 postburn), and Group C (began CRRT on day 2 postburn). Outcomes measured at t0, t1, and t2 and hospital and ICU length of stay (LOS) were analyzed using generalized linear mixed models. Cox proportional hazards models were used to assess survival to hospital discharge (HD). All models were adjusted, e.g. for age, % full thickness, etc. Burn center was included as a random effect.ResultsMore than half of the 48 patients included were treated at just 2 burn centers. Timing of CRRT initiation varied by center, with all patients at one center starting CRRT on either the day of injury or the day after injury. Nearly 96% of patients had AKI at CRRT start and, of those, 22 were at stage 1 or 2. Patients generally had severe burns; Group A had more inhalation injuries and higher %TBSA, % full thickness, and Baux scores than Groups B and C. Shock index (SI) was persistently elevated across all 3 time points and did not vary by timing of CRRT initiation (p=0.37). Vasopressor dependency index (VDI) was also not associated with timing of CRRT initiation (p >0.99), although mean VDI for Groups B and C declined over time. For all 3 groups, fluid balance decreased from t0, but there were no differences among the groups (all p >0.30). Survival to HD was better for patients with lower TBSA (i.e. 20-49%) compared to those with TBSA ≥50% (hazard ratio=0.37; 95% CI=0.15-0.91). In contrast, timing of CRRT initiation was not associated with survival (p=0.73). Among patients that survived to HD, the mean hospital LOS was shorter for Groups A (13 days; p=0.01) and B (39 days; p=0.03) compared to Group C (131 days). Mean ICU LOS was also shorter for Groups A (13 days; p=0.01) and B (52 days; p=0.03) than for Group C (168 days).ConclusionsIn this analysis, earlier initiation of CRRT did not improve survival to hospital discharge. Nonetheless, starting patients on CRRT early may be advantageous for reducing ICU and hospital LOS for those patients that do survive.

LEGIONNAIRES' DISEASE: A FATAL FORM OF COMMUNITY-ACQUIRED PNEUMONIA

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Legionella pneumophila is gram-negative bacilli known to cause community-acquired pneumonia (CAP), also termed Legionnaires' disease. While pneumonia is the most common manifestation, extrapulmonary infections include renal injury and rhabdomyolysis. Age, immunosuppression and multi-system infection increase mortality, even with early initiation of therapy. CASE PRESENTATION: A 30-year-old male with history of bipolar disease, alcohol and tobacco abuse presented with diarrhea, fever and confusion for three days. He was found to be febrile, tachycardic, encephalopathic and hypoxic requiring high-flow nasal cannula. Initial evaluation revealed leukocytosis, acute liver injury, acute renal injury, respiratory alkalosis, lactic acidosis, and elevated troponin and creatine kinase levels. Chest x-ray (CXR) showed a dense left upper lobe consolidation. Sepsis was worked up and he was given intravenous fluids and antibiotics (Vancomycin, Cefepime, Metronidazole, Azithromycin). Over several hours, he became oliguric, tachypnic and hypotensive requiring vasopressors, continuous renal replacement therapy (CRRT) and mechanical ventilation. Urinary legionella antigen returned positive so Levofloxacin was added. Despite antibiotics and CRRT, his shock worsened and he ultimately had pulseless electrical activity arrest with demise. DISCUSSION: The presence of acute renal injury in Legionnaires' disease increases mortality up to 51% so early diagnosis is crucial to guide management. The urinary antigen test for L. pneumophila only identifies serogroup 1, which is the most common type. When prevalence is high, specificity of this test is >99%. Severe cases of CAP should be tested for Legionella as half of patients with Legionnaires' disease will require intensive care. Rhabdomyolysis occurs due to direct toxin invasion and renal injury occurs subsequently or due to sepsis. Levofloxacin or Azithromycin are the antibiotics of choice as they are bactericidal and reach high intracellular concentrations. There are twenty-two known cases of Legionnaires' disease with rhabdomyolysis and acute renal injury. Nearly all patients with this triad survived and of those who did, all received antibiotics and about half required hemodialysis (HD). To our knowledge, there is only one other case where the outcome was death despite several days of HD. In comparison, presentation to death occurred in less than twenty-four hours in our case. Cause of death was refractory hyperkalemia due to rhabdomyolysis-induced renal injury despite CRRT. CONCLUSIONS: Even with timely diagnosis and treatment of Legionnaires' disease, renal involvement portends a high mortality rate. At the earliest evidence of renal injury in Legionnaires' disease complicated by rhabdomyolysis, immediate placement of central venous catheters and early initiation of CRRT is mandatory and may be life saving. REFERENCE #1: Soni AJ, Peter A. Established association of legionella with rhabdomyolysis and renal failure: A review of the literature. Respir Med Case Rep. 2019 Oct 28;28:100962. REFERENCE #2: Mercante, J. W., & Winchell, J. M. (2015). Current and emerging Legionella diagnostics for laboratory and outbreak investigations. Clinical microbiology reviews, 28(1), 95–133. REFERENCE #3: Straus W.L., Plouffe J.F., File T.M. Risk factors for domestic acquisition of Legionnaires' disease. Ohio Legionnaires Disease group. Arch. Intern. Med. 1996;156(15):1685–1692. DISCLOSURES: No relevant relationships by Allen Roberts, source=Web Response No relevant relationships by Jigna Solanki, source=Web Response

Timing of continuous renal replacement therapy in severe acute kidney injury patients with fluid overload: A retrospective cohort study

We aimed to evaluate the association of early versus late initiation of Continuous renal replacement therapy (CRRT) with mortality in patients with fluid overload. This was a retrospective cohort study of patients with fluid overload (FO) treated with CRRT due to severe acute kidney injury (AKI) between January 2015 and December 2017 in a mixed medical intensive care unit of a teaching hospital in Beijing, China. Patients were divided into early (≤15 h) and late (>15 h) groups based on the median time from ICU admission to CRRT initiation. The primary outcome was all-cause mortality at day 60. Multivariable Cox model analysis was used for analysis. The study patients were male predominant (84/150) with a mean age of 64.8 ± 16.7 years. The median FO value before CRRT initiation was 10.1% [6.2-16.1%]. The 60-day mortality rates in the early vs the late CRRT groups were 53.9% and 73%, respectively. On multivariable Cox modelling, the late initiation of CRRT was independently associated with an increased risk of death at 60 days (HR 1.75, 95% CI 1.11-2.74, p = 0.015). Early initiation of CRRT was independently associated with survival benefits in severe AKI patients with fluid overload.

Evaluation of the timing of initiating continuous renal replacement therapy in community-acquired septic patients with acute kidney injury.

Acute kidney injury (AKI) in community-acquired septic patients is often associated with relatively high mortality rate. However, the appropriate timing for continuous renal replacement therapy (CRRT) initiation remains controversial. In the present study, we retrospectively analyzed 123 community-acquired septic patients with AKI admitted to the medical intensive care unit (ICU). The baseline patient characteristics and renal function parameters were compared between survivors and non-survivors. Then, we used the Cox proportional hazard analysis to identify the risk factors for ICU mortality. Moreover, we employed the area under the receiver operating characteristic curve analysis to determine the cutoff time for CRRT initiation. Finally, we used the cutoff time to separate the patients into early (treatment initiated earlier than the cutoff time) and late (treatment initiated later than the cutoff time) CRRT groups and performed the Kaplan-Meier survival analysis to assess the overall mortalities. At the time of ICU release, the mortality rate of the 123 patients was 48.8% (n = 60). We identified several baseline characteristics and renal function parameters that were significantly different between the survivors and the non-survivors. All of them were also identified as the risk factors for community-acquired sepsis. Importantly, the cutoff time point to distinguish the early and late CRRT initiation groups was determined to be 16 h after AKI onset. Based on such grouping, the mortality rate was significantly lower in the early CRRT initiation group at 30, 60 and 90 days. Our data suggest that initiating CRRT within 16 h may help improve the mortality rate of community-acquired septic patients.

Optimal timing of initiating CRRT in patients with acute kidney injury after liver transplantation.

BackgroundAcute kidney injury (AKI) is a frequent complication after liver transplantation (LT), and is associated with high mortality. Continuous renal replacement therapy (CRRT) is an important treatment for AKI, but the optimal time for initiation is still controversial. The purpose of this study was to investigate the prognostic effect of initial CRRT treatment time.MethodsWe retrospectively reviewed the clinical data of 173 recipients undergoing LT from January 2018 to March 2019. AKI was defined according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria. All patients receiving CRRT were divided into early and late group according to urine output. Prognosis was compared between the two groups.ResultsA total of 48 (27.8%) patients were identified with AKI, 23 (13.3%) of whom received CRRT. According to urine output, 13 (56.5%) patients were in early group and 10 (43.5%) patients in late group. AKI was associated with longer intensive care unit (ICU) and hospital stay, increased post-operative 90-day mortality and the incidence of early allograft dysfunction (EAD). Patients in late CRRT group had a longer ICU stay {median, IQR, 183.5 [92.25–336.75] vs. 139 [94–240] hours, P=0.043} and hospital stay {median, IQR, 38.5 [17.5–62.75] vs. 35 [17–38] days, P=0.019} than patients in early CRRT group, respectively. The rate of severe infection was significantly higher in the late CRRT group than in the early CRRT group (80.0% vs. 30.8%, P=0.026).ConclusionsAKI was associated with longer length of ICU and hospital stay, poor short-term mortality and functional recovery of transplanted organ. Early initiation of CRRT could reduce the severe infection and length of ICU and hospital stay.

Extracorporeal Life Support Organization (ELSO): Guidelines for Neonatal Respiratory Failure.

Extracorporeal Life Support Organization (ELSO): Guidelines for Neonatal Respiratory Failure.

Timing of continuous renal replacement therapy in patients with septic AKI: A systematic review and meta-analysis.

Background:The effects of early continuous renal replacement therapy (CRRT) on mortality in patients with septic acute kidney injury (AKI) remain controversial. A systematic review and meta-analysis was performed to investigate the impact of timing of CRRT on clinical outcomes in patients with septic AKI.Methods:The PubMed, Cochrane, and Embase databases were searched from inception to the 31st of March 2019, to identify trials that assessed the timing of initiation of CRRT in patients with septic AKI.Results:Five trials including 900 patients were included. The results of this meta-analysis showed that there was no significant difference between 28-day mortality (odds ratio = 0.76;95% CI, 0.58–1.00; P = .05) and 90-day mortality(odds ratio = 0.79;95% CI, 0.59–1.06; P = .12)of early and late initiation of CRRT group. In addition, compared with late initiation strategy, early initiation showed no significant advantage in length of stay in ICU (Mean difference = −0.9;95% CI, −2.37 to 0.57; P = .23) and length of stay in hospital (Mean difference = −1.43;95% CI, −5.28 to 2.41; P = .47).Conclusion:Our meta-analysis revealed that early initiation of CRRT could not reduce mortality in patients with septic AKI. The study also showed no significant difference in ICU length of stay or hospital length of stay between early and late CRRT group. To achieve optimal timing of CRRT for septic AKI, large multicenter randomized trials with better design are still needed.

Continuous renal replacement therapy: individualization of the prescription.

Continuous renal replacement therapy (CRRT) is now the mainstay of renal organ support in the critically ill. As our understanding of CRRT delivery and its impact on patient outcomes improves there is a focus on researching the potential benefits of tailored, patient-specific treatments to meet dynamic needs. The most up-to-date studies investigating aspects of CRRT prescription that can be individualized: CRRT dose, timing, fluid management, membrane selection, anticoagulation and vascular access are reviewed. The use of different doses of CRRT lack conventional high-quality evidence and importantly studies reveal variation in assessment of dose delivery. Research reveals conflicting evidence for clinicians in distinguishing which patients will benefit from 'watchful waiting' vs. early initiation of CRRT. Both dynamic CRRT dosing and precision fluid management using CRRT are difficult to investigate and currently only observational data supports individualization of prescriptions. Similarly, individualization of membrane choice is largely experimental. Clinicians have limited evidence to individualize the prescription of CRRT. To develop this, we need to understand the requirements for renal support for individual patients, such as electrolyte imbalance, fluid overload or clearance of systemic inflammatory mediators to allow us to target these abnormalities in appropriately designed randomized trials.

Early Continuous Renal Replacement Therapy Improves Nutrition Delivery in Neonates During Extracorporeal Life Support

Optimizing nutrition in neonatal patients as soon as possible after extracorporeal life support (ECLS) initiation is imperative as malnutrition can worsen both short- and long-term outcomes. Fluid restriction, used to manage the fluid overload that commonly complicates neonatal ECLS, severely impairs nutrition delivery. Continuous renal replacement therapy (CRRT) can be used to help manage fluid overload. We hypothesize that early CRRT utilization ameliorates the need for fluid restriction and allows providers to prescribe higher parenteral nutrition (PN) volumes leading to better nutrition delivery. The design of the study was a retrospective chart review, and the setting was a single, level III neonatal intensive care unit. Neonatal patients (n=42) treated with ECLS between January 1, 2008, and December 31,2013. Comparisons were made between 2 groups: neonates who received ECLS without early CRRT initiation (group 1; n=23) and with early CRRT initiation (group 2; n=19). The main outcome measures were goal total fluid intake, prescribed PN volume, protein, glucose infusion rate, intralipid, and kilocalories. Infants who received early CRRT were prescribed higher mean total fluid intake goals (group 1: 99mL/kg/day vs. group 2: 119mL/kg/day, P<.001) and higher mean volumes of PN (group 1: 61mL/kg/day vs. group 2: 81mL/kg/day, P<.001) over the first 72hours of ECLS compared with infants who did not receive early CRRT. Early CRRT receivers also were prescribed greater mean amounts of protein during the first 72hours of ECLS (group 1: 2.7g/kg/day vs. group 2: 3g/kg/day, P=0.03). There were no significant changes noted in prescribed glucose infusion rates, intralipid, or total kilocalories. Institution of early CRRT in neonates on ECLS allows for administration of greater volumes of PN with improved protein delivery. This study characterizes one benefit of early CRRT initiation in neonates on ECLS and suggests these patients could experience improved nutritional outcomes.

Early initiation of continuous renal replacement therapy improves survival of elderly patients with acute kidney injury: a multicenter prospective cohort study

BackgroundContinuous renal replacement therapy (CRRT) is essential in the management of critically ill patients with acute kidney injury (AKI). However, the optimal timing for initiating CRRT remains controversial, especially in elderly patients. Therefore, we investigated the outcomes of early CRRT initiation in elderly patients with AKI.MethodsA total of 607 patients ≥65 years of age who started CRRT due to AKI between August 2009 and December 2013 were prospectively enrolled. They were divided into two groups based on the median 6-hour urine output immediately before CRRT initiation. Propensity score matching was used to compare the overall survival rate, CRRT duration, and hospitalization duration.ResultsThe median age of both groups was 73.0 years, and 60 % of the patients were male. The most common cause of AKI was sepsis. In the early CRRT group, the mean arterial pressure was higher, but the prothrombin time and total bilirubin, aspartate aminotransferase, and alanine aminotransferase levels were lower. The overall cumulative survival rate was higher in the early CRRT group (log-rank P < 0.01). Late CRRT initiation was associated with a higher mortality rate than early initiation after adjusting for age, sex, the Charlson comorbidity index, systolic arterial pressure, prothrombin time, the total bilirubin, aspartate aminotransferase, and alanine aminotransferase levels, cumulative fluid balance and diuretic use (hazard ratio, 1.35; 95 % confidence interval 1.06, 1.71, P = 0.02). Following propensity score matching, patient survival was significantly better in the early CRRT group than in the late CRRT group (P < 0.01). The total duration of hospitalization from the start of CRRT was shorter among the survivors when CRRT was started earlier (26.7 versus 39.1 days, P = 0.04).ConclusionA better prognosis can be expected if CRRT is applied early in the course of AKI in critically ill, elderly patients.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1437-8) contains supplementary material, which is available to authorized users.

Fluid overload and outcomes in neonates receiving continuous renal replacement therapy.

Continuous renal replacement therapy (CRRT) has emerged as the modality of choice for the management of high-risk neonates with acute kidney injury (AKI), inborn errors of metabolism and multi-organ dysfunction. The aim of this study was to evaluate fluid overload (FO) and investigate the factors associated with outcomes in neonates undergoing CRRT. We retrospectively reviewed the medical records of 34 neonates with AKI who were admitted to the neonatal intensive care unit (NICU) of Samsung Medical Center, Seoul, Republic of Korea between January 2007 and December 2014 where they underwent at least 24 h of CRRT. The survival rates of patients with an FO of ≥30% at the time of CRRT initiation were lower than those of patients with an FO of <30% at the same time-point. Univariate Cox regression analysis revealed that a higher percentage FO at CRRT initiation and decreased urine output at the end of CRRT were associated with mortality, and multivariate Cox regression analysis indicated that mortality was associated with decreased urine output at the end of CRRT. Univariate linear regression analysis revealed that the length of hospital stay was associated with higher levels of serum creatinine at CRRT initiation, longer stay in the NICU prior to initiation of CRRT, longer duration of CRRT and lower body weight at the time of NICU admission. Neonates with a higher percentage FO and higher levels of serum creatinine at CRRT initiation showed poor outcomes. Early initiation of CRRT before the development of severe FO or azotemia might improve the outcomes of neonates requiring CRRT.

Effect of early initiation of continuous renal replacement therapy based on the KDIGO classification on the prognosis of critically ill patients with acute kidney injury

To investigate the impact of early initiation of continuous renal replacement therapy (CRRT) based on "Kidney Disease: Improving Global Outcomes (KDIGO)" classification on the prognosis of critically ill patients with acute kidney injury (AKI). A retrospective analysis of clinical data of patients diagnosed as AKI in Department of Critical Care Medicine of Zhejiang Provincial People's Hospital from January 2011 to January 2015 was conducted. All patients included should be 18 years old or older, having stayed in intensive care unit (ICU) for more than 48 hours, and received CRRT. All subjects were divided into three groups according to their renal function before CRRT according to the KDIGO-AKI guideline: AKI-stage 1 group, AKI-stage 2 group and AKI-stage 3 group. The general condition, original disease, severity of disease, duration of mechanical ventilation, the length of ICU or hospital stay, 28-day survival rate and in-hospital mortality rate were compared among these three groups. Additionally, risk factors for the 28-day survival rate and hospital mortality of critically ill patients with AKI were screened by logistic regression analysis. A total of 258 critically ill patients with AKI were enrolled, with 64 cases in AKI-stage 1 group, 62 cases in AKI-stage 2 group, and 132 cases in AKI-stage 3 group. 116 patients survived with 28-day survival rate of 44.96%. 154 patients died with hospital mortality 59.69%. The precipitating factors of AKI in all three groups (stage 1, stage 2, and stage 3) were similar, with sepsis, heart failure and poisoning (drugs or poison) being the main triggers for AKI, accounting for 35.66%, 19.38% and 13.18%, respectively. There were significant differences in the rate of vasoactive agent usage (31.25%, 41.94%, 50.00%, χ2 = 6.241, P = 0.044), acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score (20.87±7.37, 17.19±7.02, 22.58±7.95, F = 5.292, P = 0.006) and sequential organ failure assessment (SOFA) score (8.41±3.46, 6.22±2.43, 9.58±3.71, F = 10.328, P = 0.000), while there was no significant difference in gender, age, primary disease, time from ICU admission to the beginning of CRRT, mean arterial pressure (MAP), lactate level or 24-hour lactate clearance rate (LCR), mechanical ventilation time, the length of ICU or hospital stay, 28-day survival rate or hospital mortality among these three groups (all P > 0.05). According to the logistic regression analysis, time from ICU admission to start of CRRT and lactate level were the independent risk factors for 28-day survival rate or hospital mortality of critically ill patients with AKI [odds ratio (OR) for 28-day survival rate was 0.850 and 0.774, 95% confidence interval (95%CI) was 0.752-0.960 and 0.638-0.940, P value was 0.009 and 0.010, respectively; OR for hospital mortality was 0.884 and 0.756, 95%CI was 0.781-1.000 and 0.610-0.939, P value was 0.049 and 0.011, respectively]. Early initiation of CRRT based on KDIGO-AKI classification could not improve the prognosis of critically ill patients with AKI, the optimal timing of RRT for such patients remains to be further explored.

Early Initiation of Continuous Renal Replacement Therapy Improves Clinical Outcomes in Patients With Acute Respiratory Distress Syndrome

BackgroundThe acute respiratory distress syndrome (ARDS) is a common devastating syndrome in intensive care unit in critically ill patients. Continuous renal replacement therapy (CRRT) has been shown beneficial effects on oxygenation and survival in patients with ARDS. However, it is still controversial about the timing of initiation of CRRT. MethodsFifty-three patients with ARDS admitted to intensive care unit in Zhejiang Provincial People’s Hospital, China from 2009 to 2013 were enrolled in the study. The authors compared ventilation parameter, including PaO2/FIO2, A-a gradient, positive end-expiratory pressure, plateau pressure, dynamic compliance and hemodynamic parameters, including central venous pressure, mean arterial pressure, cardiac index, extravascular lung water index, fluid balance between early initiation (within 12 hours after ARDS onset) and late initiation of CRRT (48 hours after ARDS onset) groups. The authors further investigated transforming growth factor (TGF)-β1 level changes in serum and bronchoalveolar lavage fluid (BALF) by enzyme-linked immunosorbent assay during 7 days of follow-up. ResultsSignificant improvement of oxygenation and shorter duration of mechanical ventilation were observed in early CRRT group during 7-day followup. In addition, TGF-β1 concentrations in serum and BALF were significantly decreased in patients with early initiation of CRRT compared to those with late initiation of CRRT on day 2 and day 7. Furthermore, patients who died of ARDS had higher levels of TGF-β1 in BALF than survivors. ConclusionsOur findings showed that early initiation of CRRT is associated with favorable clinical outcomes in ARDS patients, which might be due to the reduced serum and BALF TGF-β1 levels through CRRT. However, large multi-center studies are needed to make further recommendations as to the optimal use of CRRT in ARDS patient populations.

Acute Renal Failure as Part of Multi-Organ Failure: How Long We Should Wait before We Intervene? A Dissection of Studies

Mortality rate in multisystem organ failure (MOF) is very high. Acute renal failure is an important part of MOF. In this special feature article I have aimed to streamline the achievements of different studies on continuous renal replacement therapy (CRRT) for a fruitful outcome. For this I have gone for retrospective evaluation of the studies reached through PubMed, internet alert system of different journals, proceedings of conferences on CRRT and personal communication with the experts in this field. I have evaluated the outcome of studies to explore the causes of failure to achieve a positive result and to identify the positive gains of studies. Finally, I have compiled the positive gains to outline a new strategy for future study and greater achievement. The findings of evaluation led to the conclusion that while planning for initiation of CRRT, multiple strategies should be targeted. The strategy should involve early initiation of CRRT guided by new markers of acute kidney injury (AKI), continuous venovenous hemofiltration (CVVH) modality, optimum intensity (intensity should be adequate enough to improve hemodynamics within a targeted period), selection of an effective filter membrane. Elderly patients should be studied in a different group. Cardiac patients with AKI should not be studied in the same group along with the patients with sepsis DOI: http://dx.doi.org/10.3329/jemc.v5i1.21496 J Enam Med Col 2015; 5(1): 39-43

Continuous renal replacement therapy in children with severe sepsis and multiorgan dysfunction - A pilot study on timing of initiation.

Objective:Scanty literature is available regarding continuous renal replacement therapy (CRRT) utility in severe sepsis with multiorgan dysfunction syndrome (MODS) from developing countries. Author unit's experience in pediatric CRRT is described and outcome of early initiation of CRRT with sepsis and MODS is assessed.Materials and Methods:Children aged <16 years with sepsis and MODS who required CRRT from September 2010 to February 2015 were analyzed on demographic factors, timing of initiation of CRRT, mode of CRRT, effect of CRRT onhemodynamics, oxygenation parameters, and outcome.Results:Twenty-seven children required CRRT (male - 16). The median age was 11 years (range 1.1–16). Twenty-one had severe sepsis with MODS. Eighteen patients were given CRRT within 48 h of admission to Intensive Care Unit (ICU). Statistically significant improvement in the P/F ratio, decrement in plateau pressure and vasoactive-inotropic score were noted in survivor group compared to nonsurvivor group (P = 0.022, 0.00, and 0.03, respectively). There was no statistically significant difference in duration of ICU stay, fluid overload, CRRT duration, PRISM score at 12 and 24 h, percentage of decrease in inotrope score, plateau pressure, and percentage of increase in P/F ratio in relation to timing of CRRT initiation. However, the survival rate was 61.1% (11/18) who received CRRT within 48 h of ICU admission compared to 33.3% (3/9) who received after 48 h (P = 0.0001).Conclusion:Our study emphasizes the CRRT role in improving the oxygenation status and hemodynamics. Survival benefit may be expected in those children who receive CRRT early in the course of sepsis. However, multicenter RCTs are required to prove mortality benefit.

Acute Kidney Injury – An Underestimated Problem In Pediatric Intensive Care / Akûts Nieru Bojâjums — Nenovçrtçta Problçma Bçrnu Intensîvajâ Terapijâ

Abstract Acute kidney injury (AKI) frequently occurs in critically ill children and adults, with 5-20% of patients experiencing an episode during their stay in an intensive care unit. AKI rarely is an isolated event and is associated with a broader spectrum of diseases, including sepsis and respiratory insufficiency, and often progresses into multiorgan dysfunction syndrome. Despite recent advancements in renal replacement therapy (RRT), mortality among patients who sustain AKI complicated by multiorgan dysfunction appears to have remained unchanged and is estimated at approximately 50%. Recent clinical evidence suggests that AKI is not only an indicator for severity of illness, but that it also leads to earlier onset of multiorgan dysfunction with profound effects on mortality rates. The aim of this paper is to inform medical professionals involved in the paediatric intensive care of recent advances in AKI diagnosis and management. Studies were identified from MEDLINE (OVID), PubMed, and the Cochrane Library for topics relevant to AKI. There is limited evidence in paediatrics regarding effective therapy for acute kidney injury, a significant problem in the paediatric intensive care unit that extends length of stay, duration of mechanical ventilation, and overall mortality. Sublethal kidney injury may be contributing to overall morbidity. Prospective clinical trials are needed to evaluate specific diagnostic aids, such as biomarkers, and therapeutic strategies like early initiation of continuous RRT in children with fluid overload

Timing for Initiation of Continuous Renal Replacement Therapy in Patients With Septic Shock and Acute Kidney Injury

The optimal timing for renal replacement therapy initiation in septic acute kidney injury (AKI) remains controversial. This study investigates the impact of early versus late initiation of continuous renal replacement therapy (CRRT) on organ dysfunction among patients with septic shock and AKI. Patients were dichotomized into "early" (simplified RIFLE Risk) or "late" (simplified RIFLE Injury or Failure) CRRT initiation. Patients with chronic kidney disease stage 5 or those on long-term dialysis were excluded. Organ dysfunction was quantified by Sequential Organ Failure Assessment (SOFA) score. From January 2008 to June 2011, 120 patients fulfilled the inclusion criteria. Thirty-one (26%) underwent "early" while 89 (74%) had "late" CRRT. No significant difference was noted between groups on improvement of total SOFA/non-renal SOFA score or noradrenaline equivalent in the first 24 and 48 h after CRRT initiation. Dialysis requirement and mortality (at 28 days, 3 months and 6 months) did not differ. In conclusion, improvement of non-renal SOFA score 48 h after CRRT correlated with SOFA score on CRRT initiation (P = 0.040) and APACHE IV risk of death (P = 0.000), but not estimated glomerular filtration rate on CRRT initiation (P = 0.377). Improvement of non-renal SOFA score correlated with SOFA score on CRRT initiation and APACHE IV risk of death. However, this retrospective review cannot identify any significant clinical benefit of early CRRT initiation in patients presenting with septic shock and AKI.