Early Renal Replacement Therapy Research Articles

Mortality among Critically Ill Acute Kidney Injury Patients Stratified with RIFLE Classification

Acute kidney injury, also referred to as AKI, is a common complication seen in critically ill patients . There has been a significant increase in the number of AKI cases over the past few decades. In order to standardize the classification of AKI, the RIFLE (Risk, Injury, Failure, Loss, End-Stage) and AKIN (AKI Network) criteria were developed.This is a prospective, observational, and longitudinal cohort study where data from all patients admitted to the hospital intensive care unit (ICU) were collected. The study duration ranged from March 2019 to September 2020. During the study period, 198 patients were admitted to the ICU. Of these, 69 were excluded while the remaining 104 patients were included in the study.About 66–67% of the total critically ill patient population admitted in the ICU suffer from some etiology related to AKI. Our study highlights the aspect in which the cases of AKI are underreported. RIFLE class R or class I is still associated with excess mortality compared with patients who maintained normal function. RIFLE is a reliable system of classification, which is well classified and indicates the immediate necessity of renal replacement therapy (RRT); the prognosis of early RRT is fairly good in critically ill patients with AKI.

Timing of renal replacement therapy initiation for acute kidney injury in critically ill patients: a systematic review of randomized clinical trials with meta-analysis and trial sequential analysis

BackgroundAcute kidney injury (AKI) is a common serious complication in critically ill patients. AKI occurs in up to 50% patients in intensive care unit (ICU), with poor clinical prognosis. Renal replacement therapy (RRT) has been widely used in critically ill patients with AKI. However, in patients without urgent indications such as acute pulmonary edema, severe acidosis, and severe hyperkalemia, the optimal timing of RRT initiation is still under debate. We conducted this systematic review of randomized clinical trials (RCTs) with meta-analysis and trial sequential analysis (TSA) to compare the effects of early RRT initiation versus delayed RRT initiation.MethodsWe searched databases (PubMed, EMBASE and Cochrane Library) from inception through to July 20, 2020, to identify eligible RCTs. The primary outcome was 28-day mortality. Two authors extracted the data independently. When the I2 values < 25%, we used fixed-effect mode. Otherwise, the random effects model was used as appropriate. TSA was performed to control the risk of random errors and assess whether the results in our meta-analysis were conclusive.ResultsEleven studies involving 5086 patients were identified. Two studies included patients with sepsis, one study included patients with shock after cardiac surgery, and eight others included mixed populations. The criteria for the initiation of RRT, the definition of AKI, and RRT modalities existed great variations among the studies. The median time of RRT initiation across studies ranged from 2 to 7.6 h in the early RRT group and 21 to 57 h in the delayed RRT group. The pooled results showed that early initiation of RRT could not decrease 28-day all-cause mortality compared with delayed RRT (RR 1.01; 95% CI 0.94–1.09; P = 0.77; I2 = 0%). TSA result showed that the required information size was 2949. The cumulative Z curve crossed the futility boundary and reached the required information size. In addition, early initiation of RRT could lead to unnecessary RRT exposure in some patients and was associated with a higher incidence of hypotension (RR 1.42; 95% CI 1.23–1.63; P < 0.00001; I2 = 8%) and RRT-associated infection events (RR 1.34; 95% CI 1.01–1.78; P = 0.04; I2 = 0%).ConclusionsThis meta-analysis suggested that early initiation of RRT was not associated with survival benefit in critically ill patients with AKI. In addition, early initiation of RRT could lead to unnecessary RRT exposure in some patients, resulting in a waste of health resources and a higher incidence of RRT-associated adverse events. Maybe, only critically ill patients with a clear and hard indication, such as severe acidosis, pulmonary edema, and hyperkalemia, could benefit from early initiation of RRT.

Frequency of Renal Dysfunction and its effects on outcomes after open heart surgery.

Objectives:In this study we determined the frequency of renal dysfunction and its outcomes in terms of morbidity and mortality in patients who underwent open heart surgery at the Aga Khan University Hospital, Karachi, Pakistan.Methods:A total of 175 patients aged between 15-80 years having open heart Surgery(OHS) were included. Preoperative and postoperative serum creatinine (SCr) was noted and the glomerular filtration rate (GFR) calculated by Cockcroft-Gault equation. Their hospital course was charted and followed-up for 30-day.Results:The mean age and mean BMI were 58.1±12.6 years and 26.4±4.3 kg/m2 respectively. Females were 18.3%, out of which 51.4% hypertensive, 46.9% diabetics, 45.1% had dyslipidemia, 2.9% had preoperative renal dysfunction and 40% had moderate ejection fraction. On follow up, 30.3% developed postoperative renal dysfunction within 30-days after OHS with mean SCr and GFR as 1.6±0.7 and 56.9±24.5, respectively. In RD group more patients showed positive outcomes i.e. prolonged inotropic requirement (75.5% vs. 18%, p-value <0.005), diuretic infusion usage (47.2% vs. 3.3%, p-value <0.005), dialysis/renal replacement therapy (17% vs. 0%, p-value <0.005), requirement for prolonged ventilation (35.8% vs. 6.6%, p-value <0.005), prolonged ICU and hospital stay (15.4% vs. 1.6%, p-value <0.005 and 41.5% vs. 17.2%, p-value <0.005), sepsis (20.8% vs. 1.6%, p-value <0.005) and death (9.4% vs. 2.5%, p-value 0.05).Conclusion:Timely recognition of renal dysfunction, early renal replacement therapy, diuretics or dialysis and proper nutritional and inotropic support to maintain adequate hemostasis shows survival benefits.

1260: Early Renal Replacement Therapy Improves Renal Function in Patients With Septic Acute Kidney Injury

Critical Care Medicine: January 2021 - Volume 49 - Issue 1 - p 635 doi: 10.1097/01.ccm.0000730928.43648.79

Contrast induced acute kidney injury prevention during angiographic procedure with early renal replacement therapy

Abstract Background and purpose Post-angiography renal replacement therapy (RRT) has shown protective effects from Ci-AKI (contrast induced acute kidney injury) in patients with pre-existing advanced renal disfunction. We analysed a series of 1095 continuative patients who undergone coronary or peripheral angiography in our center. In non-haemodialyzed patients with eGFR &amp;lt;20ml/min/1.73m2 or with poor renal reserve we performed an “early” RRT, starting during angiography procedure and applied for at least 6 h after procedure, thus diverging from previous literature data based only on post-procedure hours delayed RRT application. The RRT modality chosen was CVVHDF (continous veno-venous hemodiafiltration). Methods We considered following subjects variability: age, sex, weight, presence of hypertension, dyslipidaemia, diabetes, smoking habitude, left ventricular ejection fraction, amount of contrast media given and shock or infection occurrence during hospital stay. We evaluate statistic significative of serum creatine (SCr) variation in patients receiving RRT from pre-procedure time (T0), at 24h (T1), 48h (T2), 72h (T3) after procedure and at 3–8 weeks follow-up (T4). Quantitative data were compared with Student T test, qualitative data with Chi Square test, considering statistically significant p value &amp;lt;0.05 with two tails. Ci-AKI was defined as serum creatinine rise ≥0.3 mg/dL at 48h from contrast media administration, following KDIGO (kidney disease improving global outcomes) guidelines definition. Results 26 patients received RRT. Medium SCr at T0 was 3.37 mg/dl and showed a significative reduction (see figure) at T1 (−0.88mg/dl = −20.6%, p=0.003) and T2 (−0.96mg/dl = −18.33%, p=0.029) and a trend towards reduction at T3 (−0.78mg/dl, p=0.174) and at T4 (−0.28mg/dl, p=0.568). Between 26 pts, 6 pts (23%) developed Ci-AKI. Only contrast media amount significatively diverge between two groups (183 ml in the group with Ci-AKI vs 162 ml in pts with no Ci-AKI, p=0.03), showing also a trend towards significance for infection occurrence (83.3% pts Ci-AKI vs 40% pts no Ci-AKI, p=0.06) and shock onset (33.3%pts Ci-AKI vs 5% pts no Ci-AKI, p=0.06). Average SCr diverge at T2 (3.18mg/dl Ci-AKI vs 2.04mg/dl no Ci-AKI, p=0.01) and at T3 (3.33mg/dl CI-AKI vs 2.31mg/dl no CI-AKI, p=0.06); we also found a trend towards progressive increase of SCr for Ci-AKI pts (T0-T1: +0.17mg/dl, p=ns; T0-T2: +0.41mg/dl, p=ns; T0-T3: +0.57mg/dl, p=ns; T0-T4: +1.35mg/dl, p=ns) and a significative reduction in SCr for no Ci-AKI pts (T0-T1: −1.23mg/dl = −29.32% p=0.001; T0-T2: −1.46mg/dl = −30.78%, p=0.01; T0-T4: −0.41mg/dl = −15.5%, p=0.05). Conclusions Early RRT with CVVHDF modality results effective in 77% of patients in avoiding Ci-AKI, with a significative SCr reduction at 24 and 48h. An increased amount of contrast media is significatively related to Ci-AKI incidence. Ci-AKI development could also possibly be related to shock and infection occurrence. Figure 1 Funding Acknowledgement Type of funding source: None

Dynamics of innate immunity parameters in acute kidney injury after coronary artery bypass grafting

Acute kidney injury (AKI) developing after cardiac surgery remains unsolved issue despite the high level of surgical techniques as well as organ and tissue protection during artificial blood circulation. Various publications demonstrate that complications emerge in as many as 42% cases, whereas renal replacement therapy is required in up to 1-8% cases. Systemic inflammatory response syndrome and activation of the blood coagulation system largely underlie developing AKI finally resulting in acute renal failure. Release of large amounts of cytokines is associated with subclinical renal damage, primarily with blocking renal glomerular filtration. Measuring concentration of serum inflammatory markers that could reflect activity of inflammatory events is crucial for predicting and selecting treatment methods as well as for identifying predictors of severe course with opportunity of early onset renal replacement therapy after hospitalization. Objective of our study was to assess diagnostic and prognostic value of innate immunity parameters such as interleukin (IL) 6, 8, 10, 17, tumor necrosis factor alpha (TNFα), growth factor TGF-β1 in patients with acute kidney injury before and after CABG. Blood serum samples collected from 120 patients (males and females) with ischemic heart disease (IHD) were examined before and after CABG. It was found that patients with acute kidney injury had elevated serum level of cytokines IL-6, IL-8, IL-10, IL-17, TNFα, and TGF-β1 in all groups on day 1 and day 2 after surgery. Hence, we provided the data on more detailed investigation of immune alterations in cardiosurgical patients with AKI prepared for planned CABG.

Comparison of Standard Conservative Treatment and Early Initiation of Renal Replacement Therapy in Pregnancy-related Acute Kidney Injury: A Single-center Prospective Study.

Introduction and objectivePregnancy-related acute kidney injury (PRAKI) is one of the most important cause of maternal and fetal morbidity and mortality. Some of the reasons behind PRAKI may be due to sepsis, postpartum hemorrhage, preeclampsia, thrombotic microangiopathies (TMA), and acute fatty liver of pregnancy (AFLP). The timing of initiation of renal replacement therapy (RRT) for better patient outcome is still debatable. We conducted this study to establish whether earlier initiation of RRT in PRAKI improves fetomaternal survival compared to a more conservative approach.Materials and methodsThis is a prospective study, where patients were screened at a multispecialty tertiary care hospital in north India for 1 year. The patients were divided into two groups: early RRT and standard AKI treatment. The demographic profile and clinical characteristics of the patients in terms of age, parity access to antenatal care, fetal outcome, urine output, hematological and biochemical profiles, RRT, duration of hospitalization, recovery of renal function, and patients survival were recorded.ResultsThis prospective study conducted included 13 patients in the early RRT group and 23 patients in the standard group. Considering the fetal outcome, the number of fetal deaths in early RRT group were 14.29%, whereas for the standard group it was 85.71%. In all, 75% of early RRT group and 25% of standard group had normal term delivery. Probability test applied showed they were statistically significant. One maternal mortality was there in the standard group. The indices of maternal outcome in PRAKI patients were found to be statistically insignificant.ConclusionThe planning of RRT whether early or late does not make a difference in maternal mortality or morbidity. The fetal outcome is significantly better for patients with early RRT than conservative treatment in PRAKI.How to cite this articleBanerjee A, Mehrotra G. Comparison of Standard Conservative Treatment and Early Initiation of Renal Replacement Therapy in Pregnancy-related Acute Kidney Injury: A Single-center Prospective Study. Indian J Crit Care Med 2020;24(8):688–694.

Early versus standard renal replacement therapy after left ventricular assist device implantation.

Renal function may improve after left ventricular assist device (LVAD) implant, however, some patients develop postoperative acute kidney injury (AKI). Randomized trials showed benefit for early renal replacement therapy (RRT) in critically ill patients with AKI, but this practice has not been studied in LVAD patients. We performed a single-center, retrospective cohort study of all adults (>18 years) who underwent LVAD placement from 1/2010 to 12/2018. We collected preoperative, hemodynamic, echocardiographic, intraoperative, and postoperative data. AKI was defined according to Kidney Disease: Improving Global Outcomes definition. Early (E) RRT was considered treatment at AKI stage II or below. Standard (S) RRT was considered treatment at AKI stage III. Outcomes and Kaplan-Meier analysis were compared between groups. A total of 184 patients were included (mean age 56.10 years, 81% males, 30.4% African-American race). A total of 71 (38.6%) developed AKI and 17 (9.24%) needed RRT (11 E vs 6 S). A total of 11 remained hemodialysis-dependent at discharge (5 [45.5%] in E vs 6 [100%] in S, P = .043). There was a trend toward shorter intensive care unit stay and ventilation time in E group, and overall hospital stay was significantly less in the E group (48.18 ± 25.95 vs 94.00 ± 53.07 days, P = .028). Thirty-day mortality was similar between groups (E 18% vs S 16%, P = .9), but there was a trend toward improved overall survival in the E group. This is the first study to examine early initiation of RRT after LVAD implant. Early RRT was associated with shorter hospital stay, lower need for permanent RRT, and a trend toward improved survival. This practice may provide significant cost savings and should be examined further.

Delayed versus early initiation of renal replacement therapy for severe acute kidney injury: a systematic review and individual patient data meta-analysis of randomised clinical trials

The timing of renal replacement therapy (RRT) for severe acute kidney injury is highly debated when no life-threatening complications are present. We assessed whether a strategy of delayed versus early RRT initiation affects 28-day survival in critically ill adults with severe acute kidney injury. In this systematic review and individual patient data meta-analysis, we searched MEDLINE (via PubMed), Embase, and the Cochrane Central Register of Controlled Trials for randomised trials published from April 1, 2008, to Dec 20, 2019, that compared delayed and early RRT initiation strategies in patients with severe acute kidney injury. Trials were eligible for inclusion if they included critically ill patients aged 18 years or older with acute kidney injury (defined as a Kidney Disease: Improving Global Outcomes [KDIGO] acute kidney injury stage 2 or 3, or, where KDIGO was unavailable, a renal Sequential Organ Failure Assessment score of 3 or higher). We contacted the principal investigator of each eligible trial to request individual patient data. From the included trials, any patients without acute kidney injury or who were not randomly allocated were not included in the individual patient data meta-analysis. The primary outcome was all-cause mortality at day 28 after randomisation. This study is registered with PROSPERO (CRD42019125025). Among the 1031 studies identified, one study that met the eligibility criteria was excluded because the recruitment period was not recent enough, and ten (including 2143 patients) were included in the analysis. Individual patient data were available for nine studies (2083 patients), from which 1879 patients had severe acute kidney injury and were randomly allocated: 946 (50%) to the delayed RRT group and 933 (50%) to the early RRT group. 390 (42%) of 929 patients allocated to the delayed RRT group and who had available data did not receive RRT. The proportion of patients who died by day 28 did not significantly differ between the delayed RRT group (366 [44%] of 837) and the early RRT group (355 [43%] of 827; risk ratio 1·01 [95% CI 0·91 to 1·13], p=0·80), corresponding to an overall risk difference of 0·01 (95% CI -0·04 to 0·06). There was no heterogeneity across studies (I2=0%; τ2=0), and most studies had a low risk of bias. The timing of RRT initiation does not affect survival in critically ill patients with severe acute kidney injury in the absence of urgent indications for RRT. Delaying RRT initiation, with close patient monitoring, might lead to a reduced use of RRT, thereby saving health resources. None.

Comparison between watchful waiting strategy and early initiation of renal replacement therapy in the critically ill acute kidney injury population: an updated systematic review and meta-analysis

BackgroundThe optimal timing of renal replacement therapy (RRT) initiation is debatable. Many articles in this field enrolled trials not based on acute kidney injury. The safety of the watchful waiting strategy has not been fully discussed, and late RRT initiation criteria vary across studies. The effect of early RRT initiation in the AKI population with high plasma neutrophil gelatinase-associated lipocalin (NGAL) has not been examined yet.MethodsIn accordance with PRISMA guidelines, the PubMed, Embase, and Cochrane databases were systemically searched for randomized controlled trials (RCTs). Trials not conducted in the AKI population were excluded. Data of study characteristics, primary outcome (all-cause mortality), and related secondary outcomes [mechanical ventilation (MV) days, length of hospital stay, RRT days, and length of ICU stay] were extracted. The outcomes were compared between early and late RRT groups by estimating the pooled odds ratio (OR) for binary outcomes and the weighted mean difference for continuous outcomes. Prospective trials were also examined and analyzed using the same method.ResultsNine RCTs with 1938 patients were included. Early RRT did not provide a survival benefit (pooled OR, 0.88; 95% confidence interval [CI] 0.62–1.27). However, the early RRT group had significantly fewer MV days (pooled mean difference, − 3.98 days; 95% CI − 7.81 to − 0.15 days). Subgroup analysis showed that RCTs enrolling the surgical population (P = .001) and the AKI population with high plasma NGAL (P = .031) had favorable outcomes regarding RRT days in the early initiation group. Moreover, 6 of 9 RCTs were selected for examining the safety of the watchful waiting strategy, and no significant differences were found in primary and secondary outcomes between the early and late RRT groups.ConclusionsOverall, early RRT initiation did not provide a survival benefit, but a possible benefit of fewer MV days was detected. Early RRT might also provide the benefit of shorter MV or RRT support in the surgical population and in AKI patients with high plasma NGAL. Depending on the conventional indication for RRT initiation, the watchful waiting strategy is safe on the basis of all primary and secondary outcomes.

707 Factors Associated with Early vs. Late AKI in Burn Patients

Abstract Introduction Acute kidney injury (AKI) in burn patients is known to increase morbidity and mortality, with significant improvement after the initiation of renal replacement therapy (RRT). Our primary objective is to characterize the sub-population of burn patients with early (≤48 hours post-injury) versus late (&amp;gt;48 hours post injury) onset of AKI. We hypothesize that patients with early onset AKI versus late onset AKI have different causalities, risk factors, and outcomes. A secondary aim is to investigate the timing and use of RRT in the setting of early and late AKI with the goal of improving morbidity and mortality. Methods A retrospective cohort study was conducted on all patients admitted to a verified burn center requiring RRT for AKI from 2015 – 2019. Patients were stratified by age, gender, percent total body surface area (TBSA), race, time of onset of AKI, timing of RRT initiation, hospital LOS, pre-admission co-morbidities, admission toxicology, and mortality. Results In total, 1537 burn patients were reviewed and 1.3% (n=20) required RRT for AKI. Out of this cohort, 70% developed early AKI and 30% developed late AKI. Early versus late AKI patients had the same median age (57). Patients with larger TBSA developed early AKI (median TBSA 51%) versus late AKI (median TBSA 21%). Half of the patients who developed late AKI presented with positive alcohol toxicology screens, while 86% of patients with early AKI tested negative. The patient mortality rate in early AKI was 57%, and the mortality rate in late AKI was 17%. Only 14% of early AKI patients required dialysis at discharge, while 33% of late AKI patients required dialysis at discharge. The majority of patients started on early RRT (&amp;lt; 48 hours post injury) did not develop sepsis (43% developed sepsis), while the majority of patients started on late RRT (&amp;gt;48 hours post injury) did develop sepsis (85%). Conclusions Positivity for alcohol on admission may be a predictor for development of late AKI, while larger TBSA may predict early AKI. Mortality is higher for patients with early AKI; however, the need for dialysis at discharge is higher in patients with late AKI. Our data further suggests that early initiation of RRT is negatively correlated with the development of sepsis. Applicability of Research to Practice A deeper understanding of associations and causality of early vs late onset AKI in burn patients will help guide further management and improve outcomes.

Timing of renal replacement therapy for patients with acute kidney injury: A systematic review and meta-analysis.

Acute kidney injury is associated with high mortality, and the optimal time to start renal replacement therapy for acute kidney injury is unknown despite several randomised controlled trials on the subject. We performed a systematic review and meta-analysis to assess the effect of earlier initiation of renal replacement therapy for acute kidney injury on mortality and reported secondary outcomes. All literature in databases EMBASE, MEDLINE and CENTRAL was searched from January 1970 to March 2019 using terms related to renal replacement therapy, timing and randomised controlled trials. All randomised controlled trials with 25 or more adult participants suffering from acute kidney injury comparing timing of renal replacement therapy were included. The results of the selected studies were pooled and expressed in terms of risk ratios (RR) and 95% confidence intervals (95% CI) using a random effects model. A total of 7008 records were identified; 94 were selected for full text review of which 10 were included in the final meta-analysis. The 10 studies comprised 1956 participants (989 'early' group; 967 'late' group) with 918 total deaths; the analysis demonstrated no significant differences between the 'early' and 'late' renal replacement therapy groups (RR = 0.98 (95% CI = 0.84, 1.15)) for mortality. No significant differences between groups were evident for period-wise mortality; dialysis dependence; recovery of renal function; length of intensive care unit or hospital stay; or number of renal replacement therapies, mechanical ventilation and vasopressor-free days. Current evidence does not support the use of early renal replacement therapy for patients with acute kidney injury. Data from ongoing and future randomised controlled trials are required to strengthen the evidence base in the area.

Delayed versus Early Renal Replacement Therapy for Severe Acute Kidney Injury: A Systematic Review and Individual Patient Data Meta-Analysis of Randomised Clinical Trials

Background: The timing of renal replacement therapy (RRT) for severe acute kidney injury (AKI) is highly debated when no life-threatening complication is present. We assessed whether a strategy of delayed versus early RRT initiation affects 28-day survival in critically-ill adults with severe AKI. Methods: In this systematic review and individual-patient data (IPD) meta-analysis, we searched MEDLINE via PubMed, EMBASE and the Cochrane Central Register of Controlled Trials for randomised trials published from April 2008 to December 2019 comparing delayed and early RRT initiation strategies in critically-ill patients with severe AKI. We contacted the principal investigator of each eligible trial to request IPD. The primary outcome was 28-day all-cause mortality. Findings: Of 1031 studies identified, 10 were eligible. We obtained IPD for 9/10 trials (2083/2143 patients). Among patients with severe AKI (n=1879), there were 946 [50·3%] in the delayed strategy and 933 [49·6%] in the early strategy. Mortality at 28-days did not significantly differ (366/837 [43·7%] in the delayed strategy vs 355/827[42·9%] in the early strategy;risk ratio 1·01 [95%CI, 0·91-1·13], p=0·798) with no heterogeneity across studies (phet=0.80, I2=0%; τ2=0). Mortality did not significantly differ at day-60, day-90 or at hospital discharge. Among patients allocated to the delayed strategy 390/929 (42%) did not receive RRT. Other secondary outcomes including RRT free-days and complication rates did not significantly differ between groups. Interpretation: RRT initiation strategy did not affect survival in critically ill patients with severe AKI who had no urgent indications for RRT. Delaying RRT initiation with close patient monitoring led to a reduced use of RRT which may allow for resource saving. Funding Statement: The authors stated there was no funding source. Declaration of Interests: NB is the recipient of a grant from the Societe Francophone de Nephrologie, Dialyse et Transplantation for the submitted work. SMB is supported by a Canada Research Chair in Critical Care Nephrology. SMB reports receiving grant support from Baxter Healthcare Corp and speaker fees from Baxter Healthcare Corp and CAN Diagnostic Inc. RW reports receiving grant support from Baxter Healthcare Corp and speaker fees from Baxter Healthcare Corp. SG, DH, KC, SB, AC, NL, NS, TJ, GG, AD, JPQ, DD declare no competing interests. Ethics Approval Statement: This study was approved by Assistance Publique Hopitaux de Paris.

Timing of initiation of renal replacement therapy in acute kidney injury: an updated meta-analysis of randomized controlled trials

Purpose The results from randomized controlled trials (RCTs) concerning the timing of initiation of renal replacement therapy (RRT) for patients with acute kidney injury (AKI) are still inconsistent. Materials and methods We searched for RCTs, as well as relevant references, focusing on the timing of RRT for AKI patients in the Medline, Embase, Cochrane Library, Google Scholar and Chinese databases from their inception to December 2018. Results We included 18 RCTs from 1997 to 2018 involving 2856 patients. Pooled analyses of all RCTs showed no significant difference in mortality between early initiation and delayed initiation of RRT (RR 0.98, 95% CI: 0.89 to 1.08, p = .7) (I 2 = 2%), and similar results were found in critically ill and community-acquired AKI patients, as well as in a subgroup of patients with sepsis and in cardiac surgery recipients. There was also no difference in the incidence of dialysis independence (RR 0.75, 95% CI: 0.47 to 1.2, p = .2) (I 2 = 0). However, an early RRT strategy was associated with a significantly higher incidence of the need for RRT for AKI patients (RR 1.24, 95% CI: 1.13 to 1.36, p < .01) (I 2 = 34%). Conclusions As no life-threatening complications occurred, there was no evidence to show any benefit of an early RRT strategy for critically ill or community-acquired AKI patients; in contrast, a delayed strategy might avert the need for RRT.

Peripheral arterial disease diagnosed by ankle–brachial index: Predictor for early renal replacement therapy in chronic kidney disease

Our study aimed to investigate the relationship between ankle-brachial index (ABI) and need for early renal replacement therapy (RRT) in predialysis patients with chronic kidney disease (CKD). A total of 112 patients (62% men) with pre-dialysis CKD, seen in the outpatient clinic, were included, and ABI was obtained as per standard protocol. Peripheral arterial disease (PAD) was defined as ABI <0.9 or >1.3 in either leg. The clinical data were analyzed, and the risk factors for early RRT were determined by multivariate logistic regression analysis. The prevalence of PAD was 44% in predialysis CKD patients. Over three years' follow- up, 14.2% required RRT; 11.3% developed major cardiovascular event (myocardial infarction, stroke, or death). A total of 26 events occurred. The incidence of all events was significantly higher in patients with abnormal ABI than in those with normal ABI (34.7% vs. 12.7%; log rank P = 0.02). PAD was associated with all events [hazard ratio (HR): 2.72; 95% CI: 1.04-7.17; P = 0.042] as also the need for RRT (HR 3.2; 95% Cl: 1.005-10.23; P = 0.049), on univariate cox proportional hazard analysis. Multivariate logistic regression analysis adjusted for other risk factors identified that PAD remained an independent predictor for the need for early RRT (HR: 12.2; 95%Cl: 2.2-66.5; P = 0.004) and all events (HR: 3.5; 95% Cl: 0.9-13.5; P = 0.032). PAD was an independent predictor for RRT requirement in predialysis CKD.

Clinical characteristics and risk factors for severe burns complicated by early acute kidney injury.

Early acute kidney injury (AKI) is a frequent fatal complication of severely burned patients. Although significant progress has been made in fluid resuscitation, intensive care, and renal replacement therapy (RRT) technology in recent years, the incidence and mortality rate in severely burned patients with AKI remains considerable. This study aims to provide theoretical evidence for prevention and treatment by investigating the clinical characteristics and risk factors influencing the incidence and severity of early AKI in severely burned patients. This 3-year retrospective, single-center study was conducted in critically ill burned patients admitted to the Burn ICU at Guangzhou Red Cross Hospital of Jinan University. Patients whose age is older than 18 years with ≥30% burned total body surface area (TBSA) were enrolled in this study. Those patients who arrived at our burn ICU>72h after injury or died within 48h from arrival were excluded. Data of 128 patients were studied in the final. Demographic and injury details were recorded. KDIGO criteria were used to assess the incidence and severity of early AKI. Factors influencing early AKI were determined using univariate and multiple logistic regression analysis. Between January 2016 and December 2018, Data from 128 critically ill burned patients were available for analysis. The median age was 44.9±16.8 years; 68.8% of the patients were male. The median TBSA% was 60 (IQR, 41.3-80%). According to the KDIGO criteria, 36 patients (28.3%) developed early AKI, as follows: stage 1 AKI, 69.4% (25/36); stage 2 AKI, 13.9% (5/36); and stage 3 AKI, 16.7% (6/36). The incidence of early AKI was associated with TBSA%, full-thickness TBSA%, abbreviated burn severity index on admission (ABSI), inhalation injury, mechanical ventilation, cardiovascular complications, and rhabdomyolysis. Multiple logistic regression analysis indicate that TBSA% (OR=0.224, p=0.007), full-thickness TBSA% (OR=0.254, p=0.014), ABSI (OR=18.326, p=0.009), and rhabdomyolysis (OR=24.036, p=0.000) were independent risk factors for the occurrence of early AKI. Significant factors influencing the severity of early AKI included full-thickness body surface area burns, electrical burns, and rhabdomyolysis. Full-thickness TBSA% (OR=1.437, p=0.041) and rhabdomyolysis (OR=5.401, p=0.035) are associated with mortality. The risk of death due to the occurrence of AKI was 5.407 in the Cox model adjusted for TBSA%, full-thickness body surface area burns, ABSI and rhabdomyolysis. Three patients died, all of whom had stage 3 AKI, accounting for 8.3% (3/36) of AKI patients. The death rate of stage 3 AKI who did and did not receive early RRT was 33.3% and 66.7%, respectively. Rhabdomyolysis is an independent risk factor for early AKI and closely related to the severity of early AKI in critically ill burned patients. Although with a high incidence of early AKI in severely burned patients, most of them are mild. Early adequate fluid resuscitation, timely and effective escharotomy, reducing the incidence and severity of rhabdomyolysis, most of them can achieve a relatively good prognosis.

Severe leptospirosis in tropical Australia: Optimising intensive care unit management to reduce mortality.

Severe leptospirosis can have a case-fatality rate of over 50%, even with intensive care unit (ICU) support. Multiple strategies-including protective ventilation and early renal replacement therapy (RRT)-have been recommended to improve outcomes. However, management guidelines vary widely around the world and there is no consensus on the optimal approach. All cases of leptospirosis admitted to the ICU of Cairns Hospital in tropical Australia between 1998 and 2018 were retrospectively reviewed. The patients' demographics, presentation, management and clinical course were examined. The 55 patients' median (interquartile range (IQR)) age was 47 (32-62) years and their median (IQR) APACHE III score was 67 (48-105). All 55 received appropriate antibiotic therapy, 45 (82%) within the first 6 hours. Acute kidney injury was present in 48/55 (87%), 18/55 (33%) required RRT, although this was usually not administered until traditional criteria for initiation were met. Moderate to severe acute respiratory distress syndrome developed in 37/55 (67%), 32/55 (58%) had pulmonary haemorrhage, and mechanical ventilation was required in 27/55 (49%). Vasopressor support was necessary in 34/55 (62%). Corticosteroids were prescribed in 20/55 (36%). The median (IQR) fluid balance in the initial three days of ICU care was +1493 (175-3567) ml. Only 2/55 (4%) died, both were elderly men with multiple comorbidities. In patients with severe leptospirosis in tropical Australia, prompt ICU support that includes early antibiotics, protective ventilation strategies, conservative fluid resuscitation, traditional thresholds for RRT initiation and corticosteroid therapy is associated with a very low case-fatality rate. Prospective studies are required to establish the relative contributions of each of these interventions to optimal patient outcomes.

Effects of early dialysis on the outcomes of critically ill patients with acute kidney injury: a systematic review and meta-analysis of randomized controlled trials

The appropriate timing for initiating renal replacement therapy (RRT) in critically ill patients with acute kidney injury (AKI) remains unknown. This meta-analysis aims to assess the efficacy of early initiation of RRT in critically ill patients with AKI. The Pubmed, Embase and Cochrane databases were searched up to August 13, 2019. Only randomized controlled trials (RCTs) comparing the effects of early and late RRT on AKI patients were included. The primary outcome was 28-day mortality. Eleven RCTs including 1131 and 1111 AKI patients assigned to early and late RRT strategies, respectively, were enrolled in this meta-analysis. The pooled 28-day mortality was 38.1% (431/1131) and 40.7% (453/1111) in the patients assigned to early and late RRT, respectively, with no significant difference between groups (risk ratio (RR), 0.95; 95% CI, 0.78–1.15, I2 = 63%). No significant difference was found between groups in terms of RRT dependence in survivors on day 28 (RR, 0.90; 95% CI, 0.67–1.25, I2 = 0%), and recovery of renal function (RR, 1.03; 95% CI, 0.89–1.19, I2 = 56%). The early RRT group had higher risks of catheter-related infection (RR, 1.7, 95% CI, 1.01–2.97, I2 = 0%) and hypophosphatemia (RR, 2.5, 95% CI, 1.25–4.99, I2 = 77%) than the late RRT group. In conclusion, an early RRT strategy does not improve survival, RRT dependence, or renal function recovery in critically ill patients with AKI in comparison with a late RRT strategy. However, clinicians should be vigilant because early RRT can carry higher risks of catheter-related infection and hypophosphatemia during dialysis than late RRT.

Cardiopulmonary Bypass and AKI: AKI Is Bad, So Let's Get Beyond the Diagnosis.

It is now well-established that AKI is a serious and common complication following cardiopulmonary bypass (CPB) in both children and adults, adverse outcomes may occur in the short term as well as long term, with higher incidence of chronic kidney disease, increased healthcare utilization and higher frequency of cardiovascular events in patients who develop post-CPB AKI. Despite the advances in our understanding of the pathogenesis of the disease and the improvement in diagnostic tools, our therapeutic options have remained suboptimal. There are multiple challenges in designing a clinical therapeutic AKI trial, including a multi-factorial etiology, difficulties with accurate diagnosis of AKI, achievement of adequate study power, and determination of appropriate outcomes. We are often left with “supportive” care. Studies have shown some benefit to AKI bundles, but adherence to bundle guidelines may be suboptimal. Current best practices should include maintenance of adequate renal perfusion pressure and avoidance of fluid overload, with consideration of early renal replacement therapy. Finally, multi-center trials of AKI therapies are crucial to finding treatment for this devastating complication of CPB.

Efficacy of Early Goal-Directed Renal Replacement Therapy for the Treatment of Acute Kidney Injury After Heart Transplantation: A Single-Center 10-Year Experience

Acute kidney injury (AKI) after heart transplantation is a common and serious complication. The present study aimed to evaluate the efficacy of early goal-directed renal replacement therapy (GDRRT) for the treatment of AKI after heart transplantation. Retrospective, observational study. Grade A tertiary hospital that performs more than 4,000 cardiac surgery procedures per year. Patients who underwent heart transplantation with postoperative AKI and received renal replacement therapy from January 2008 to June 2018. Patients were divided into a late GDRRT group (LGDRRT) (January 2008-September 2012) or an early GDRRT group (EGDRRT) (October 2012-June 2018). The LGDRRT group comprised 30 patients, and the EGDRRT group comprised 46 patients. Duration between surgery to renal replacement therapy (RRT) initiation in the EGDRRT group was significantly shorter than in the LGDRRT group (1 [1-3] d v 2 [2-3] d; p = 0.020). The in-hospital mortality in the EGDRRT group was significantly lower than that of the LGDRRT group (39.1% v 63.3%; p = 0.039). After multivariate adjustment for confounding factors, the hazard ratio for death in the LGDRRT group relative to the EGDRRT group was 2.028 (95% confidence interval 1.072-3.655; p = 0.048). Length of intensive care unit and hospital stays in the EGDRRT group was significantly shorter than that of the LGDRRT group (26 ± 18 d v 38 ± 20 d; p = 0.008 and 38 ± 33 d v 64 ± 45 d; p = 0.005, respectively). The complete renal recovery rate was much greater in the EGDRRT group than that of the LGDRRT group (50.0% v 20.0%; p < 0.001). Serum creatinine at discharge was significantly less in the EGDRRT group than that of the LGDRRT group (134.8 ± 97.3 μmol/L v 220.7 ± 113.6 μmol/L; p < 0.001). Cost of RRT in the EGDRRT group was significantly less than that of the LGDRRT group (0.54 ± 0.10 v. 0.63 ± 0.11 ten thousand USD; p < 0.001). For heart transplantation recipients with AKI, EGDRRT can reduce the in-hospital mortality and the length of intensive care unit and hospital stays, improve the complete renal recovery rate, and reduce the cost of RRT.