Frequency Of Renal Replacement Therapy Research Articles

Influence of smoking on disease activity and prognosis of antineutrophil cytoplasmic antibody-associated vasculitis: a retrospective cohort study.

Antineutrophil cytoplasmic antibody-associated vasculitides (AAV) are a group of autoimmune diseases characterized by inflammation of small blood vessels. Smoking is a potential trigger for such diseases, however, its link with AAV remains controversial. The aim of this study was to analyze the link between AAV and smoking based on clinical characteristics, disease activity, and mortality. This retrospective study included 223 AAV patients. Their smoking status was assessed at diagnosis and they were classified as ever smokers (ESs), including current or past smokers, and never smokers (NSs). Information regarding clinical presentation, the disease activity, immunosuppressive therapy, and survival was collected. The ESs had similar organ involvement to the NSs, except for significantly greater frequency of renal replacement therapy (31% vs 14%; P = 0.003). Median (interquartile range [IQR]) time from symptom onset to diagnosis was significantly shorter in the ESs than the NSs (4 [2-9.5] vs 6 [3-13] months; P = 0.03), with significantly higher mean (SD) value of the Birmingham Vasculitis Activity Score version 3 (19.5 [7.93] vs 17.25 [8.05]; P = 0.04). The ESs were more likely to receive cyclophosphamide therapy (P = 0.03), and had significantly higher morality than the NSs (hazard ratio, 2.89; 95% CI, 1.47-5.72; P = 0.002). There were no significant differences between the current and past smokers. The multivariable Cox proportional regression analysis found ever smoking and male sex to be independent predictors of mortality in AAV patients. Ever smoking is associated with increased AAV activity and more frequent renal replacement therapy and immunosuppressive treatment, resulting in a poorer survival prognosis in AAV patients. Future multicenter studies are required to further characterize the clinical, biological, and prognostic impact of smoking on AAV.

Renal Protection and Hemodynamic Improvement by Impella® Microaxial Pump in Patients with Cardiogenic Shock.

Acute kidney injury is one of the most frequent and prognostically relevant complications in cardiogenic shock. The purpose of this study was to evaluate the potential effect of the Impella® pump on hemodynamics and renal organ perfusion in patients with myocardial infarction complicating cardiogenic shock. Between January 2020 and February 2022 patients with infarct-related cardiogenic shock supported with the Impella® pump were included in this single-center prospective short-term study. Changes in hemodynamics on different levels of Impella® support were documented with invasive pulmonal arterial catheter. As far as renal function is concerned, renal perfusion was assessed by determining the renal resistive index (RRI) using Doppler sonography. A total of 50 patients were included in the analysis. The increase in the Impella® output by a mean of 1.0 L/min improved the cardiac index (2.7 ± 0.86 to 3.3 ± 1.1 p < 0.001) and increased central venous oxygen saturation (62.6 ± 11.8% to 67.4 ± 10.5% p < 0.001). On the other side, the systemic vascular resistance (1035 ± 514 N·s/m5 to 902 ± 371 N·s/m5p = 0.012) and the RRI were significantly reduced (0.736 ± 0.07 to 0.62 ± 0.07 p < 0.001). Furthermore, in the overall cohort, a baseline RRI ≥ 0.8 was associated with a higher frequency of renal replacement therapy (71% vs. 39% p = 0.04), whereas the consequent reduction of the RRI below 0.7 during Impella® support improved the glomerular filtration rate (GFR) during hospital stay (15 ± 3 days; 53 ± 16 mL/min to 83 ± 16 mL/min p = 0.04). Impella® support in patients with cardiogenic shock seems to improve hemodynamics and renal organ perfusion. The RRI, a well-known parameter for the early detection of acute kidney injury, can be directly influenced by the Impella® flow rate. Thus, a targeted control of the RRI by the Impella® pump could mediate renal organ protection.

Intermediate (One-Year) Outcomes of Cardiogenic Shock Patients Supported by ECMO Due to Decompensated Heart Failure and Acute Myocardial Infarction

<h3>Purpose</h3> Cardiogenic shock patients who are supported by ECMO have high mortality and morbidity. We evaluated the 1-year outcomes in ECMO supported patients with decompensated heart failure (DHF) or acute myocardial infarction (AMI), including death, heart transplantation (HT), left ventricular assist device (LVAD) implantation as well as dependency on hemodialysis or ventilation. <h3>Methods</h3> Patients supported by ECMO due to DHF or AMI registered in the Spectrum Health ECMO registry were included in this study. Clinical, echocardiographic, laboratory and hemodynamic characteristics were obtained in all patients. Survival analysis using Kaplan-Meier curves for the combined outcome of death, heart transplantation (HT) and LVAD implantation were developed. These outcomes were compared between DHF and AMI patients. The frequency of renal replacement therapy or ventilator dependency on 1-year survivors was calculated. <h3>Results</h3> A total of 283 patients received ECMO, 228 due to DHF and 55 due to AMI. Of these, 22 patients received LVAD, and 1patient received HT. A total of 174 patients died (including 6 LVAD patients and 1 HT patient) within 1 year of ECMO. Patients with AMI had higher troponin (2.5 ng/dL (0.49 - 7.85) vs. 1.4 ng/dL (0.15 - 4.6), p=0.013), lower total bilirubin 0.65 mg/dL (0.4 - 1.12) vs. 0.8 mg/dL (0.5 - 1.6), p=0.025), higher ALT (117 IU (61- 225) vs. 48 IU (29 - 171), p = 0.003), lower creatinine (1.35 mg/dL ± 0.75 vs. 1.6 mg/dL ± 1.17, p=0.006), lower inotropic score (7 (1 - 18) vs. 9 (4 - 20), p=0.022). The combined endpoint survival free of HT or LVAD implantation at 1-month was 45.5% vs. 38.6% for AMI and DHF, respectively. There was a small but continued decrease in the survival of combined outcome at 1 year (36.4% vs. 32%, p=0.607, Figure 1). The 1-year survival probability free of the combined outcome for those patients who survived 30 days was 81.4% vs. 81.7% for AMI and DHF, respectively. Of the 92 patients who were alive at one year, 5 (5.4%) had end stage renal disease and were receiving hemodialysis and 3 (3.2%) were dependent on a ventilator. <h3>Conclusion</h3> The 1-year survival free of HT or LVAD in AMI or DHF patients requiring ECMO is low. This is predominantly driven by the outcome on the first 30 days after ECMO implantation. A small proportion of 1-year survivors have end stage renal disease or are dependent on mechanical ventilation.

Noonan Syndrome-Associated Post-Transplant Capillary Leak Syndrome

<h3>Introduction</h3> Noonan syndrome (NS) is a genetic disorder associating congenital heart disease (CHD), mainly pulmonary stenosis (PS). Clinical course after heart transplantation (HT) in NS is not well described in the literature. Capillary leak syndrome (CLS) is a rare disorder after heart transplantation characterized by leakage of plasma due to endothelial hyperpermeability, resulting in hypovolemia and kidney failure. Case series of HT due to NS and associated CHD in a single centre. Demographic characteristics, HT outcomes and complications were analysed. <h3>Case Report</h3> Two patients with genetic diagnosis of NS were transplanted in our centre in 2020. Clinical characteristics are shown in table 1. Severe PS was present in both patients requiring surgery during childhood and later reintervention, associating restrictive physiology. CLS was developed after HT in both patients, defined as pleural effusion and ascites with intravascular depletion, worsening after steroid-dose reduction. Case 1 developed acute kidney failure secondary to diuretic treatment, requiring continuous venovenous hemofiltration. Colchicine was started reducing third space and decreasing the frequency of renal replacement therapy. Case 2 presented with acute kidney failure due to diuretic treatment, requiring high doses initially, which could be decreased after starting colchicine, associating kidney function improvement. After withdrawing colchicine, an increase in extravasation occurred in both patients, improving after restarting treatment. Hospital discharge in both patients was possible with intermediate doses of steroids and colchicine, requiring chronic renal replacement therapy in case 1. <h3>Summary</h3> Post-transplant CLS is a rare disorder which may be associated with NS resulting in kidney failure. Post-transplant CLS treatment requires higher doses of steroids as well as colchicine, decreasing plasma leakage and improving kidney function.

The influence of multidisciplinary team clinic on the prognosis of patients with chronic kidney disease.

Chronic kidney disease (CKD) seriously affects the quality of life and survival time of patients, and even affects social and national economic development. In China, how to effectively control the disease process of CKD outpatients has not been determined. A retrospective analysis was made to 100 patients with CKD. Fifty patients treated with traditional clinical treatment were in the control group, and the other fifty patients treated with multidisciplinary team (MDT) clinical treatment were in the MDT group. The prognosis of the two groups after treatment was compared, including glomerular filtration rate (GFR), number of renal replacement treatments, and mortality, to evaluate the actual effect of MDT clinic. CKD patients in the MDT group received the MDT clinic for 24 months. There was no significant difference between GFR and serum creatinine level before treatment, and the quality of life was significantly higher than before. In the control group, the GFR declined more dramatically, the serum creatinine level was higher, and the quality of life was lower than before (P < 0.05). The frequency of renal replacement therapy and mortality in the MDT group were significantly lower than those in the control group (P < 0.05). MDT clinic can effectively improve the prognosis of patients with CKD, delay kidney disease progression, and reduce mortality.

AKI Epidemiology and Outcomes: A Retrospective Cohort Study from the Prenephrology Era.

Background Acute kidney injury substantially worsens the prognosis of hospitalized patients. The Brandenburg Medical School was founded in 2014, and a nephrology section was opened in summer 2017. The aim of the study was to analyze AKI epidemiology and outcomes in one of two university hospitals belonging to the medical school. The period of interest dated from January to December 2015. Methods The investigation was designed as a single-center, retrospective cohort study at the Brandenburg Hospital of the Brandenburg Medical School. All in-hospital patients treated between January and the end of December 2015 were included. AKI was defined as specified in the 2012 published KDIGO criteria (criteria 1 and 2). Four parameters were evaluated in particular: AKI incidence, in-hospital mortality, frequency of renal replacement therapy, and renal recovery during the stay at the hospital. Results A total number of 5,300 patients were included in the analysis. AKI was diagnosed in 490 subjects (10.1%). The in-hospital mortality was 26%. The following conditions/parameters significantly differed between survivors (s) and nonsurviving (ns) subjects: duration of in-hospital treatment (s > ns), AKI onset (outpatient vs. in-hospital) (outpatient in s > ns), dialysis due to AKI (s < ns), vasopressor administration (s < ns), and invasive ventilation (s < ns). 5.6% received dialysis therapy, and renal recovery occurred in 31% of all surviving AKI subjects. Conclusion Both, the AKI incidence and the frequency of dialysis were lower than reported in the literature. However, fewer subjects recovered from AKI. These discrepant findings possibly result from the lack of prehospitalization creatinine values, the lack of follow-up data, and a generally lower awareness for the need to perform renal replacement therapy in AKI.

Particulars of the perioperative management of patients with end stage renal disease during hip and knee replacement arthroplasty

The world prevalence of chronic kidney disease (CKD) stages 1 to 5 ranges from 11.7 to 15.1%. Incidence of fractures in patients with CKD stage 5 is 5-fold higher than that in the general population, which is related to mineral metabolism disorders, secondary hyperparathyroidism, and osteoporosis. By damaging multiple organs and systems, CKD triggers a whole pathological cascade. There are hematopoietic abnormalities, cell lineages, direct toxic effect on blood cell elements, with simultaneously increased risk of bleeding and a high and extremely high risk of thrombi formation and thromboembolic complications. Calcium and phosphorus metabolism disorders lead to calcification and mineralization of vasculature, myocardium and heart valves; progressive renal dysfunction affects the course of heart and vessel diseases, aggravating their clinical manifestations. Cardiovascular disorders become the main cause of death of such patients, and the development of pulmonary hypertension is associated with increased morbidity and mortality. At the same time, protein and energy deficiencies do occur, with disturbance of the acid-base balance, water and electrolyte balance; uremic toxins exert unhealthy effects on the gastrointestinal tract. Various extra-renal pathologies, specific pharmacokinetics, regimen and frequency of renal replacement therapy needed to maintain an adequate volume status make it necessary to thoroughly prepare the patients for surgery and define special requirement to perioperative management in arthroplasty. Currently, there are no guidelines on the perioperative management of this patient category. In this review article we consider specifics and particulars of preoperative, intraoperative and postoperative management of the end stage CKD patients during knee and hip replacement arthroplasties.

Impact of intraoperative cytokine adsorption on outcome of patients undergoing orthotopic heart transplantation-an observational study.

The aim of this study was to assess the influence of intraoperative cytokine adsorption on the perioperative vasoplegia, inflammatory response and outcome during orthotopic heart transplantation (OHT). Eighty-four OHT patients were separated into the cytokine adsorption (CA)-treated group or controls. Vasopressor demand, inflammatory response described by procalcitonin and C-reactive protein, and postoperative outcome were assessed performing propensity score matching. In the 16 matched pairs, the median noradrenaline requirement was significantly less in the CA-treated patients than in the controls on the first and second postoperative days (0.14 vs 0.3μg*kg-1 *min-1 , P=.039 and 0.06 vs 0.32μg*kg-1 *min-1 , P=.047). The inflammatory responses were similar in the two groups. There was a trend toward shorter length of mechanical ventilation and intensive care unit (ICU) stay in the CA-treated group compared to the controls. No difference in adverse events was observed between the two groups. The frequency of renal replacement therapy was less in the CA‐treated patients than in the controls. Intraoperative CA treatment was associated with reduced vasopressor demand with a favorable tendency in length of mechanical ventilation, ICU stay and renal replacement therapy. CA treatment was not linked to higher rates of adverse events.

Portal hypertension in polycystic liver disease patients does not affect wait-list or immediate post-liver transplantation outcomes.

AIMTo establish the impact of portal hypertension (PH) on wait-list/post-transplant outcomes in patients with polycystic liver disease (PCLD) listed for liver transplantation.METHODSA retrospective single-centre case controlled study of consecutive patients listed for liver transplantation over 12 years was performed from our centre. PH in the PCLD cohort was defined by the one or more of following parameters: (1) presence of radiological or endoscopic documented varices from our own centre or the referral centre; (2) splenomegaly (> 11 cm) on radiology in absence of splenic cysts accounting for increased imaging size; (3) thrombocytopenia (platelets < 150 × 109/L); or (4) ascites without radiological evidence of hepatic venous outflow obstruction from a single cyst.RESULTSForty-seven PCLD patients (F: M = 42: 5) were listed for liver transplantation (LT) (single organ, n = 35; combined liver-kidney transplantation, n = 12) with 19 patients (40.4%) having PH. When comparing the PH group with non-PH group, the mean listing age (PH group, 50.6 (6.4); non-PH group, 47.1 (7.4) years; P = 0.101), median listing MELD (PH group, 12; non-PH group, 11; P = 0.422) median listing UKELD score (PH group, 48; non-PH group, 46; P = 0.344) and need for renal replacement therapy (P = 0.317) were similar. In the patients who underwent LT alone, there was no difference in the duration of ICU stay (PH, 3 d; non-PH, 2 d; P = 0.188), hospital stay length (PH, 9 d; non-PH, 10 d; P = 0.973), or frequency of renal replacement therapy (PH, 2/8; non-PH, 1/14; P = 0.121) in the immediate post-transplantation period.CONCLUSIONClinically apparent portal hypertension in patients with PCLD listed for liver transplantation does not appear to have a major impact on wait-list or peri-transplant morbidity.

Split liver transplant recipients do not have an increased frequency of acute kidney injury.

Small series have suggested that split liver transplantation (SLT) has an increased frequency of peri-operative acute kidney injury (AKI). However, the optimal donor selection in this setting could have a favourable impact on renal outcomes. This was a retrospective single-centre study of 76 adults who underwent SLT (right extended lobe) and 301 adults who underwent elective full-size donation after brain death liver transplantation (FSLT). SLT recipients were less likely than unmatched FSLT recipients to develop AKI (≥stage 1 KDIGO criteria) (40.3% vs. 56.1%, P=0.016) and had a reduced frequency of renal replacement therapy (11.8% vs. 21.9%, P=0.049). In 72 pairs of SLT patients and propensity risk score-matched FSLT controls the incidence of AKI was not significantly different (40.3% vs. 47.2%, P=0.473). However, SLT patients were less likely to require renal replacement therapy (11.1% vs. 23.6%, P=0.078; adjusted OR 0.32; 95% CI 0.11-0.87, P=0.026). There was no association between SLT and the development of chronic kidney disease (eGFR<60ml/min/1.73m(2) , log rank P=0.534). In conclusion, SLT is not associated with an increased frequency of AKI. These observations support the postulation that the optimal donor status of SLT may result in less graft injury with renal sparing effects.

Tricuspid Regurgitation on Echocardiography May Not Be a Predictor of Patient Survival After Liver Transplantation

To the Editor: We read with interest the report by Kia et al 1 in a recent issue of American Journal of Transplantation. In this study, tricuspid regurgitation (TR) on pretransplant transthoracic echocardiography (TTE) was an independent predictor of reduced survival after liver transplantation. The authors hypothesized that back pressure with hepatic congestion, or poor cardiac reserve, could explain the association between TR and worse outcome. However, the increased mortality of the TR group was primarily beyond the perioperative period making it difficult to link TR with the causes of death. Furthermore, only 20% of TR was graded as being more severe than mild. Mild TR is common in the general population where it has not been linked with mortality 2, 3. In the hyperdynamic state of cirrhosis, a relatively high prevalence of mild but functionally insignificant TR might be expected 4. TTE is performed routinely in our unit during the transplant assessment process. An elevated estimated pulmonary artery systolic pressure or right ventricle dilatation precipitates further investigation with right heart catheterization. To validate Kia et al's 1 findings, we repeated their study in 236 patients transplanted for chronic liver disease between January 2007 and March 2010. Exclusion criteria were combined liver–kidney transplant, regraft and diagnosis of hepatopulmonary syndrome or portopulmonary hypertension. Data were obtained from a prospectively collected database and retrospective case-note review. Sixty-eight patients (28.8%) had TR (mild, 65 patients; moderate, 3 patients). Baseline characteristics are shown in Table 1. During the immediate postoperative period, TR and non-TR patients had a comparable frequency of renal replacement therapy (TR, 23.5%; non-TR, 19.0%, p = 0.439), length of stay in intensive care (TR, 3 days; non-TR, 2 days, median, p = 0.404) and hospital (TR, 13 days; non-TR, 11 days, median, p = 0.190). The estimated 1- and 3-year posttransplant survival was 91.9% and 85.1%, respectively for TR patients, and 88.3% and 82.0% for non-TR patients (log-rank, p = 0.509). No patient with moderate TR died during follow-up. The causes of death within 1 year of transplantation were sepsis (n = 8), hepatic artery thrombosis (n = 4), primary nonfunction (n = 2), cardiac (n = 2), hepatocellular carcinoma (n = 2) and others (n = 6). Five patients with TR (7.4%) and 19 patients without TR (11.3%) died by 1 year posttransplant (p = 0.362). After adjusting for age, Model for End-State Liver Disease (MELD) and donor risk index, there was no association between TR and 1-year mortality (odds ratio [OR] 0.61; 95% confidence interval [CI] 0.21–1.72, p = 0.349). Similarly, there was no association between TR and 1-year graft loss (death/retransplantation) (adjusted OR 0.95; 95% CI 0.40–2.28, p = 0.905). The pretransplant characteristics of our cohort differ from those reported by Kia et al (Table 2). It is possible that TR has greater prognostic relevance in patients with a higher MELD and more hyperdynamic state. Kia et al 1 did not report the impact of grade of TR on outcome, and moderate-to-severe TR may be more significant than mild. Moreover, their inclusion of patients with mild portopulmonary hypertension may be of importance. We conclude that in patients with a lower MELD score and without portopulmonary hypertension, mild TR on TTE may not be a useful indicator of worse outcome after liver transplantation. The observations of Kia et al 1 should be interpreted with caution. J. A. Leithead1,2*, K. Kandiah1, H. Steed1, B. K. Gunson1,2, R. P. Steeds3, and J. W. Ferguson1 1Liver Unit, Queen Elizabeth Hospital, Birmingham, UK 2NIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK 3Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK *Corresponding author: Joanna Agnes Leithead, j.a.leithead@bham.ac.uk The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

Die akute Nierenschädigung

Acute kidney injury plays a pivotal role in intensive care medicine and exerts crucial adverse effects on the course of the disease and overall prognosis of the critically ill patient. Intensive renal support, including initiation of earlier dialysis or maximal uremic toxin removal by higher dosage and frequency of renal replacement therapy, and individualized selection of modality were not able to decrease excessive mortality in this population. Systemic acute inflammation, mediated, at least in part, by cytokines, and not secondary uremic side effects, seems to have a major impact on nonrenal organ damage. Assessment of short-term outcome in critically ill patients who develop acute kidney injury may underestimate the true burden of disease. The overall survival at 5 years in patients discharged alive after severe acute kidney injury necessitating renal replacement therapy is only 20-30%, comparable to cancer patients. In addition, acute renal damage was identified as an independent risk factor for progression of chronic renal insufficiency. Current research focuses on strategies for the prevention of acute kidney injury and on the establishment of effective biomarkers for the early recognition and accurate diagnosis of subclinical renal damage.

Secular trends in severe renal failure associated with the use of new antimicrobial agents in critically ill surgical patients

Randomized controlled trials conducted since 2000 have shown that new antibacterial and antifungal agents may reduce the frequency of kidney injury in selected groups of critically ill patients, yet it is unclear whether these benefits translate to the clinical setting. The aim of the present study was to evaluate longitudinally the successive routine implementation of new antimicrobial agents (caspofungin, voriconazole, linezolid) after February 2002 and the association of these agents with the frequency of mechanical renal replacement therapy in postsurgical critically ill patients at risk of severe kidney failure. A retrospective, observational cohort study was performed using data collected prospectively from 1 March 1993 through 28 February 2005. A cohort of 2,123 consecutive cases who required intensive care therapy for more than 2 days was analysed. A statistically significant decrease in the frequency of renal replacement therapy was observed in the later years of the study. After adjustment for relevant covariates, treatment with new antimicrobial agents after February 2002 was identified as an independent factor linked with a reduced risk of severe kidney failure (odds ratio 0.244; 95% confidence interval 0.136-0.439). Thus, the implementation of new antimicrobial agents with reduced or no nephrotoxicity into routine care of critically ill surgical patients is associated with a reduced need for renal replacement therapy.