Hemodialysis For Acute Kidney Injury Research Articles

Does lung ultrasound-guided ultrafiltration lead to better outcomes in acute kidney injury requiring intermittent hemodialysis: A randomized control trial.

Optimization of ultrafiltration during hemodialysis is a critical parameter in achieving therapeutic efficacy and ensuring hemodynamic stability. While various modalities such as blood volume monitoring, inferior vena cava diameter assessment, natriuretic peptide levels, bioimpedance assay, and lung ultrasound have been widely explored in the context of maintenance hemodialysis, the concept of volume-guided ultrafiltration in dialysis patients with acute kidney injury remains unexplored. Adult patients with acute kidney injury requiring dialysis, who were hemodynamically stable and not on ventilator support, without underlying lung pathology or cardiac failure, were randomized into two groups. All patients underwent 28-zone lung ultrasound before dialysis. The ultrafiltration was decided based on the treating physician's clinical judgment in controls. In the intervention group, the ultrafiltration orders prescribed by the treating physician were modified, based on the Kerley B line scores obtained by lung ultrasound. The rest of the dialysis prescriptions were similar. A postdialysis lung ultrasound was done in both groups to assess the postdialysis volume status 30 min after the dialysis session. A total of 74 patients undergoing hemodialysis for acute kidney injury were randomized. The baseline characteristics were comparable except for higher baseline B line score scores in the intervention arm. All patients received similar dialysis prescriptions. The lung ultrasound-guided ultrafiltration arm had a higher change in B line scores (BLS) from baseline (4 [0-9.5] vs. 0 [0-4]; p value 0.004) during the first dialysis session. The predialysis BLS indexed to ultrafiltration (mL/kbw/h) were significantly lower in controls, reflecting a relatively higher rate of ultrafiltration in controls compared with intervention (p = 0.006). The total number of dialysis sessions done in the control and intervention arm were 61 and 59, respectively. Among controls, 23/61 sessions (37.7%) had intradialytic adverse events, whereas, in the intervention arm, only 4/59 sessions (6.7) had any adverse intradialytic events (p < 0.01). Lung ultrasound-guided ultrafiltration was associated with a better safety profile, as demonstrated by reduced intradialytic events.

Hemodialysis: The Life Boat for AKI Patients in the COVID Cytokine Storm

Abstract Introduction: Interleukin-6 (IL-6), a biomarker of hyperinflammatory immune response, can be used to determine the severity of coronavirus disease 2019 (COVID-19) in patients with multi-organ involvement requiring critical care. The aim of our study is to understand the utility of hemodialysis, not only in terms of reducing renal burden, but also improving the outcome by tackling the COVID cytokine storm syndrome. Materials and Methods: In this prospective, observational study, 126 patients admitted to the COVID intensive care unit (ICU) wards were treated with hemodialysis for acute kidney injury (AKI). Patients’ routine baseline blood parameters were evaluated. IL-6 was measured predialysis in all patients and on the day of discharge in the patients who survived. Results: Out of total 126 patients, 79 were survivors and 47 were nonsurvivors. Among nonsurvivors, majority were older (P = 0.009). Both the groups had a higher percentage of males (78.72% and 55.69% in survivors and nonsurvivors, respectively). Mean neutrophil lymphocyte ratio (NLR) and D-dimer level were significantly higher in nonsurvivors compared to survivors (P &lt; 0.001). Mean serum urea, creatinine, and IL-6 levels were significantly greater in nonsurvivors (P &lt; 0.001). Mean number of hemodialysis sessions received by survivors was higher. The curve between delta IL-6 and delta serum creatinine for survivors showed a significant positive association (r = 0.819, P &lt; 0.001). Conclusion: Our study establishes IL-6 as a poor outcome predictor in COVID ICU patients with AKI. It also emphasizes the use of hemodialysis as a cost-effective lifesaving therapeutic interventional modality to not only improve the renal outcome, but also curb the cytokine storm by reducing IL-6 levels.

HBA1C, AN OUTCOME PREDICTOR FOR PATIENTS ADMITTED IN COVID ICU TREATED WITH HAEMODIALYSIS FOR ACUTE KIDNEY INJURY

Context: COVID-19, initially identied as a respiratory illness, was soon found to cause manifestations of almost every organ system in patients of different proles. Thus, there is a need to understand possible predictors in various patient settings to improve the outcome. Aims: To study HbA1c as an outcome predictor for patients admitted in COVID ICU with acute kidney injury undergoing haemodialysis as a treatment modality. Methods and Material: From July 2020 to January 2022, data of COVID patients who underwent haemodialysis for acute kidney injury were collected. Baseline parameters and outcomes were recorded and comparison between diabetics and non-diabetics of similar COVID severity were compared. Survival analysis as per HbA1c was also performed. Results: Total 126 patients were included in this study out of which 25, 21 and 26 non-diabetics had mild, moderate and severe disease respectively, classied as per Computed Tomography Severity Index. 14, 16 and 24 diabetics had mild, moderate and severe disease respectively. The number of survivors in each severity class was signicantly higher in non-diabetics as compared to diabetics. Furthermore, in diabetics, the survival curve was signicantly better in patients with an HbA1c of 6.5-9% as compared to those with an HbA1c of &gt;9%. Conclusions: This study reveals that intervening COVID ICU patients with haemodialysis for AKI can signicantly reduce the mortality provided they have a better pre-infection glycemic control as predicted by HbA1c levels. Also, there is a need to lower the dialysis-initiation threshold in COVID positive patients with AKI.

Uremic Pruritus In End-Stage Renal Disease Patients Receiving Three Times Weekly Hemodialysis a Multi-Center Study

Objective: To quantify the prevalence of uremic pruritus in ESRD patients receiving maintenance hemodialysis three times per week. Study Design: Analytical cross-sectional research Place and Duration of Study: Institute of kidney diseases Peshawar from May 1, 2021, to April 25, 2022. Methodology: A total of 32 adult patients receiving hemodialysis for a period more significant than three months were included in the study, while those receiving hemodialysis for acute kidney injury for less than three months or displaying clinical or laboratory signs of other conditions, such as chronic skin disease, cholestasis, and malignancies, were excluded. Results: There were 9 (28.1%) females and 23 (71.9%) men, with a mean age of 45, 13.29 years. The patients' average BMI was 23.73 kg/m2. 15 (46.9%) of the participants had diabetes, whereas 17 (53.1%) did not. 27 (84.4%) were discovered to have hypertension, while 3 (9%) were normotensive, 2 (6.2%) were taking HD for six months to a year, while 9 (28.1%), 23 (71.9%), and &gt;3 years were the appropriate HD treatment durations. Conclusion: Uremic pruritis affects 23.1% of individuals receiving thrice-weekly MHD in our study. Keywords: End-stage renal disease, uremic pruritis, and hemodialysis

Frequency of Sleep Pattern Abnormalities among End Stage Renal Disease Patients on Maintenance Hemodialysis

Background: End-stage renal disease patients getting hemodialysis (HD) frequently report sleep problems. There are various sorts of sleep disorders, generally classified into different categories depending upon initiation of sleep, duration, and continuity of sleep, calmness during sleep, respiration pattern during sleep, and daytime alertness. Sleep abnormalities have a significant and well-documented effect on daily routine activities thereby reducing the quality of life. Objective: To determine the frequency of sleep pattern abnormalities in patients with chronic kidney disease on maintenance hemodialysis. Study Design: Cross-sectional study Place and Duration of Study: Department of Nephrology, Sir Ganga Ram Hospital, Lahore from 24th January 2019 to 24th July 2019. Methodology: Ninety one cases ages between 14-70 years of either gender, having ESRD, and are on maintenance HD for at least 3 months were included. All those patients who were having HD for acute kidney injury were excluded. Sleeping disorders were evaluated using Pittsburgh Sleep Quality Index by a single interviewer. Results: Fifty five (60.4%) were males and 36 (39.6%) were females. The mean age was 51.1±12.1 years, mean BMI was 25.1±5.2, and mean duration of dialysis was 5.1±2.8 years, 74(81.3%) patients had sleep disorders. Among patients having sleep disorders, 38(41.8%) had Insomnia, Narcolepsy in 41(51.6%), Sleep Apnoea Syndrome in 38(41.8%), restless leg syndrome in 35(38.5%) and parasomnia in 17(18.7%) patients. Conclusion: Sleep disorders are common in regular hemodialysis patients affecting 81.3% of individuals. Key words: Chronic kidney disease, Haemodialysis, Sleep disorders

Is Missing Haemodialysis Associated with Short Term Morbidity and Mortality in End Stage Renal Disease?

Objective: To determine the effect of missed haemodialysis sessions. Methods: This cohort study was carried out from July to October 2019. Patients on maintenance haemodialysis were selected by consecutive sampling technique. Exclusion criteria included patients admitted to hospital during first month of study, haemodialysis for acute kidney injury, haemodialysis from multiple dialysis units, haemodialysis less than two times a week and unwilling patients. Data on haemodialysis sessions carried out during July 2019 was recorded to document attendance patterns. Patients were followed up for all-cause mortality, hospital admissions and need for haemodialysis in emergency over next three months. Results: Appointments were given to 84 patients, aged 59.27± 14.09 years, for 700 sessions during July. Amongst them, 24 (28.57%) missed 34 (4.86%) haemodialysis sessions. At least one haemodialysis session was missed by 14 (26.92%) males as compared to 10 (31.25%) females (p=0.670). During follow up period, 12 (14.29%) patients died. Five of 24 patients missing dialysis died, as compared to seven out of 60 patients with good compliance (p=0.310; relative risk: 1.992). Eight out of 24 patients missing dialysis required hospital admissions, as compared to 19 out of 60 patients with good compliance (p=0.883; relative risk: 1.079). Seven out of 24 patients missing dialysis required emergency haemodialysis, as compared to 12 out of 60 patients with good compliance (p=0.364; relative risk: 1.647). Conclusion: There was a statistically insignificant greater trend towards mortality and need for emergency haemodialysis amongst poorly compliant patients.

The predictors of catheter-related bloodstream infections in patients undergoing hemodialysis: A single center experience.

Here we aimed to investigate the predictors of catheter-related bloodstream infections (CRBSI) in patients with acute kidney injury or chronic kidney disease who required renal replacement therapy through a non-tunneled hemodialysis catheter. A total of 111 patients who received non-tunneled hemodialysis catheters were retrospectively evaluated. Patients were divided into two groups; those who developed CRBSI and those who did not. Patient's demographic data, laboratory results at admission, information regarding catheter infections, and culture results were obtained from electronic medical records. The mean age of the patients was 64 ± 16 years, and 51 of them were male. CRBSI occurred in 14 patients (12.6%). Admission serum albumin level (OR: 0.119, 95% CI: 0.019-0.756, p = 0.024), admission mean platelet volume (OR: 2.207, 95% CI: 1.188-4.100, p = 0.012) and catheter duration (OR: 1.580, 95% CI: 1.210-2.064, p = 0.001) were independent predictors for the CRBSI development. ROC curve analysis demonstrated that a catheter duration of 22 days was predictive for presence of CRBSI (78% sensitivity, 76% specificity, AUC: 0.825, 95% CI: 0.724-0.925, p < 0.001). Prolonged catheter duration, low serum albumin, and high mean platelet volume independently predict the development of CRBSI in patients undergoing hemodialysis for acute kidney injury or chronic kidney disease.

Late thrombotic complications after SARS-CoV-2 infection in hemodialysis patients.

IntroductionThere is an increased risk of thrombotic complications in patients with COVID‐19. Hemodialysis patients are already at an increased risk for thromboembolic events such as stroke and pulmonary embolism. The aim of our study was to determine the incidence of late thrombotic complications (deep vein thrombosis, pulmonary embolism, stroke, new‐onset vascular access thrombosis) in maintenance hemodialysis patients after recovery from COVID‐19.MethodsWe performed a retrospective cohort study of 200 prevalent hemodialysis patients in our center at the start of the pandemic. We excluded incident patients after the cohort entry date and those who required hemodialysis for acute kidney injury, and excluded patients with less than 1 month follow‐up due to kidney transplantation or death from non‐thrombotic causes.FindingsOne‐hundred and eighty five prevalent hemodialysis patients finally met the inclusion criteria; 37 patients (17.6%) had SARS‐CoV‐2 infection, out of which 10 (27%) died during the acute phase of disease without evidence of thrombotic events. There was an increased risk of thrombotic events in COVID‐19 survivors compared to the non‐infected cohort (18.5% vs. 1.9%, p = 0.002) after a median follow‐up of 7 months. Multivariate regression analysis showed that COVID‐19 infection increased risk for late thrombotic events adjusted for age, sex, hypertension, diabetes, antithrombotic treatment, and previous thrombotic events (Odds Ratio (OR) 26.4, 95% confidence interval 2.5–280.6, p = 0.01). Clinical and laboratory markers did not predict thrombotic events.ConclusionsThere is an increased risk of late thrombotic complications in hemodialysis patients after infection with COVID‐19. Further studies should evaluate the benefit of prolonged prophylactic anticoagulation in hemodialysis patients after recovery from COVID‐19.

MO721THROMBOTIC EVENTS AFTER COVID-19 INFECTION IN HEMODIALYSIS PATIENTS*

Background and AimsThere is an increased risk of thrombotic complications in patients with COVID-19. Hemodialysis patients are already at an increased risk for thromboembolic events such as stroke and pulmonary embolism. The aim of our study was to determine the incidence of late thrombotic complications (deep vein thrombosis, pulmonary embolism, stroke, new-onset vascular access thrombosis) in maintenance hemodialysis patients after recovery from COVID-19.MethodWe performed a retrospective cohort study of 200 prevalent hemodialysis patients in our center at the start of the pandemic. We excluded incident patients after the cohort entry date and those who required hemodialysis for acute kidney injury, and excluded patients with less than 1 month follow-up due to kidney transplantation or death from non-thrombotic causes.Results185 prevalent hemodialysis patients finally met the inclusion criteria; 37 patients (17.6%) had SARS-CoV-2 infection, out of which 10 (27%) died during the acute phase of disease without evidence of thrombotic events. There was an increased risk of thrombotic events in COVID-19 survivors compared to the non-infected cohort (18.5% vs 1.9%, p=0.002) after a median follow-up of 7 months. Stroke incidence was 38.9 episodes/1000 patient-years in patients infected with SARS-CoV-2, compared to an incidence of 2.8 episodes/1000 patient-years in non-infected patients during the follow-up period. The median time from diagnosis of SARS-CoV-2 to the first thrombotic event was 62 days (interquartile range 5-118 days). Survival analysis with Kaplan-Meier curves revealed an increase in the rate of thrombotic events after SARS-CoV-2 compared to non-infected patients (see Figure 1). Mean survival from thrombotic event was 6.1±0.4 months in the COVID-infected group, compared to 6.97±0.04 months in the non-infected group (p<0.001). Multivariate regression analysis showed that COVID-19 infection increased risk for late thrombotic events adjusted for age, sex, hypertension, diabetes, antithrombotic treatment and previous thrombotic events (OR 26.4, 95% CI 2.5-280.6, p=0.01). Clinical and laboratory markers did not predict thrombotic events.MO721 Figure 1:Kaplan-Meier survival curves for freedom from thrombotic events, stratified by COVID-19 infection statusConclusionThere is an increased risk of late thrombotic complications in hemodialysis patients after infection with COVID-19. Further studies should evaluate the benefit of prolonged prophylactic anticoagulation in hemodialysis patients after recovery from COVID-19.

Peritoneal dialysis with a lower dosage versus conventional intermittent hemodialysis in acute kidney injury: A propensity-matched study.

Literature regarding the outcomes of lower dosage peritoneal dialysis (PD) in treating acute kidney injury (AKI) among resource-limited setting is sparse. This study aims to compare the risk of mortality in patients with AKI receiving lower PD dosage and conventional intermittent hemodialysis (IHD) in Thailand. In a tertiary center in Thailand, a matched case-control study using propensity scores in patients with AKI was conducted to compare the outcomes between lower PD dosage (18 L per day for first two sessions, weekly Kt/V 2.2) and IHD (three times a week) from February 2015 to January 2016. The primary outcome was a 30-day in-hospital mortality rate. Secondary outcomes included dialysis dependence at 90 days. Eighty-four patients were included (28 PD and 56 IHD). Patient characteristics were comparable between two treatment groups. Overall, the mean age was 58 years. Most of the patients were critically ill (87% need mechanical ventilator; mean acute physiological and chronic health evaluation (APACHE II) score: 25). The 30-day in-hospital mortality rate was similar between the PD and IHD patients (57% vs. 46%, p = 0.36). The dialysis dependence rate was also comparable at 90 days. The risk of death among AKI patients was higher in those with respiratory failure, higher APACHE II score, and starting dialysis with blood urea nitrogen greater than 70 mg dL-1. Clinical outcomes, including risk of mortality and 90-day dialysis dependence among patients with AKI, appear to be comparable between lower dosage PD and IHD.

Efficacy of 5%, 10% Trisodium Citrate and Heparin as Catheter-Locking Solution for Central Venous Hemodialysis Catheters: A Prospective Randomized Controlled Study

Background: The use of central venous catheter (CVC) is inevitable for hemodialysis in acute kidney injury (AKI) and in end-stage renal disease patients when arteriovenous fistula (AVF) is ineligible. The catheter-locking anticoagulant (CLA) is mandatory for maintaining the patency of CVCs. Trisodium citrate (TSC) is an alternative CLA to unfractionated heparin (UFH). However, the optimal concentration of TSC that yield the best efficacy and safety remains questionable. Objective: To evaluate the efficacy of 5%, 10% TSC and UFH as CLA for CVCs. Materials and Methods: The present study was a randomized controlled study of patients with non-tunneled cuffed catheters (NTCC) and tunneled cuffed catheters (TCC). Patients were stratified according to types of CVCs and randomized to receive UFH, 5%, and 10% TSC as a CLA for three months. The primary outcome was the development of catheter dysfunction (CD), defined as a persistent inability to obtain blood flow rate of 250 mL or more per minute despite flushing and repositioning the patient, or the use of recombinant tissue plasminogen activator. The secondary outcomes are the rates of catheter-related bloodstream infection (CRBSI), exit-site infection (ESI), bleeding, and all-cause death. Results: Three hundred forty patients were randomized, and 249 were analyzed. One hundred thirty-four patients were in the NTCC group , and 115 were in the TCC group. There were 83, 79, and 87 patients in UFH, 5%, and 10% TSC group. The CD rates were 2.2, 1.6, and 1.2 per 1,000 catheter-day in UFH, 5% and 10% TSC groups. Compared to UFH group, the incidence rate ratio (IRR) of CD in 5% and 10% TSC group were 0.74 (p=0.55) and 0.55 (p=0.24). The IRR for CRBSI, ESI, and all-cause death were not significantly different to UFH group in both types of TSC. There was no serious adverse events and major bleeding episodes. Conclusion: The efficacy and safety of UFH, 5% TSC, and 10% TSC as CLA were not significantly different. Keywords: Catheter-locking anticoagulant, Citrate, Hemodialysis

Adequacy of hemodialysis in acute kidney injury: Real-time monitoring of dialysate ultraviolet absorbance vs. blood-based Kt/Vurea.

Current guidelines recommend monitoring the adequacy of hemodialysis (HD) treatments in patients with acute kidney injury (AKI). Blood-based methods for calculating urea such as reduction ratio (URR) and single-pool Kt/Vurea (spKt/Vurea) require pre- and post-HD blood urea nitrogen (BUN) measurements. This study aims to compare real-time monitoring of urea clearance using dialysate ultraviolet absorbance (UV) with laboratory-measured spKt/Vurea. We conducted a single-center, retrospective study among hospitalized patients with AKI, who required intermittent hemodialysis (IHD). Those patients whose dialysis dose was simultaneously monitored by spKt/Vurea and UV-absorbance (UV-spKt/Vurea) were included in the study. The statistical correlation between both methods was assessed by means of the Pearson moment product correlation, Mann-Whitney U-test and Bland-Altman analysis of agreement. Thirty patients with AKI were evaluated. There was no statistical difference between the mean spKt/Vurea calculated by traditional methods and the mean UV-spKt/Vurea. (1.37 ± 0.37 vs. 1.28 ± 0.36, P = 0.12, CI: 95%). A Pearson moment correlation analysis revealed a close agreement between both methods (r = 0.79, P < 0.001). Furthermore, Bland-Altman analysis showed that >95% of the data points were confined within the upper and lower levels of agreement. In this pilot study of patients with AKI, UV-spKt/Vurea correlated with standard blood-based spKt/Vurea and may be a useful tool to monitor dialysis adequacy. Larger studies evaluating multiple UV and blood-based measurements per patient and a more diverse AKI population are needed to confirm this initial observation.

LOCULATED PERICARDIAL EFFUSION CAUSING FUNCTIONAL TRICUSPID VALVE STENOSIS

Loculated pericardial effusions (LPE) are often underestimated on transthoracic echocardiography (TTE) and can compress cardiac chambers leading to hemodynamic compromise. A 62-year-old male was admitted for anasarca and dyspnea. He was started on hemodialysis for acute kidney injury and failure to

Trends, Outcomes and Readmissions among Left Ventricular Assist Device Recipients with Acute Kidney Injury Requiring Hemodialysis: An Insight from the National Readmissions Database 2012-2014

Purpose Although renal function may improve after left ventricular assist devices (LVAD) implantation, acute kidney injury (AKI) requiring hemodialysis (HD) therapy can occur post-operatively. We sought to investigate in-hospital outcomes and readmissions among patients who developed AKI requiring HD during index admission for LVAD implantation. Methods We utilized data from the National Readmissions Database and the US Census Bureau to calculate annual national rates of in-hospital mortality, stroke, post-operative bleeding, length of stay, hospital cost and readmissions among patients who underwent implantation and developed acute kidney injury(AKI) requiring hemodialysis (HD) for years 2012 to 2014. Results We identified 208 patients with AKI on HD after LVAD implantation (weighted = 536). Among these patients, 68.5% had chronic kidney disease and 45.8% diabetes before LVAD implantation. Rates of in-hospital mortality (from 55.53% in 2012 to 34.67 % in 2014, p=0.025), length of stay (from 66.8 days in 2012 to 52.1 days in 2014, p Conclusion In-hospital mortality and length of stay are decreasing in patients requiring HD for AKI after LVAD implantation but remain higher than LVAD recipients without AKI on HD. A significant percentage of these patients who survive hospital discharge require maintenance hemodialysis.

High cutoff versus high-flux haemodialysis for myeloma cast nephropathy in patients receiving bortezomib-based chemotherapy (EuLITE): a phase 2 randomised controlled trial

In multiple myeloma, severe acute kidney injury due to myeloma cast nephropathy is caused by pathogenic free light chain immunoglobulin in serum. High cutoff haemodialysis (HCO-HD) can remove large quantities of free light chain immunoglobulin from serum, but its effect on clinical outcomes is uncertain. We therefore aimed to assess whether HCO-HD could increase the frequency of renal recovery in patients with de novo multiple myeloma, severe acute kidney injury, and myeloma cast nephropathy relative to treatment with standard high-flux haemodialysis (HF-HD). In this open-label, phase 2, multicentre, randomised controlled trial (EuLITE), we recruited patients with newly diagnosed multiple myeloma, biopsy-confirmed cast nephropathy, and acute kidney injury that required dialysis from renal services in 16 hospitals in the UK and Germany. Patients were randomly assigned (1:1) by random number generation to receive intensive HCO-HD (in sessions lasting 6-8 h) or standard HF-HD and they were stratified by age and centre. Patients and the medical staff treating them were not masked to treatment allocation. Patients received bortezomib, doxorubicin, and dexamethasone chemotherapy, and were then followed up for 2 years. The primary outcome was independence from dialysis at 90 days after random allocation to groups, which was assessed in an intention-to-treat population. The trial has completed follow-up, and is registered at the ISRCTN registry, number ISRCTN45967602. Between June 7, 2008, and Sept 18, 2013, we recruited 90 patients, of whom 43 (48%) were randomly assigned to receive HCO-HD and 47 (52%) were randomly assigned to receive HF-HD. All 90 patients were included in the analysis of the primary outcome. One (2%) patient from the HF-HD group withdrew consent before receiving treatment. During treatment, nine (21%) patients from the HCO-HD group and two (4%) patients in the HF-HD group discontinued trial treatment. After 90 days, 24 (56%) patients in the HCO-HD group and 24 (51%) patients in the HF-HD group were independent from dialysis (relative risk 1·09, 95% CI 0·74-1·61; p=0·81). During the 2-year follow-up, 98 serious adverse events were reported in the HCO-HD group and 82 serious adverse events were reported in the HF-HD group. The most common serious adverse events were infections and adverse events related to the cardiovascular and thrombotic and musculoskeletal systems. During the first 90 days, 26 infections were reported in the HCO-HD group and 13 infections were reported in the HF-HD group, including 14 lung infections in the HCO-HD group and three lung infections in the HF-HD group. In this phase 2 study, HCO-HD did not improve clinical outcomes for patients with de novo multiple myeloma and myeloma cast nephropathy who required haemodialysis for acute kidney injury and who received a bortezomib-based chemotherapy regimen relative to those receiving HF-HD. These results do not support proceeding to a phase 3 study for HCO-HD in these patients. Gambro, Janssen, and Binding Site.

Characteristics and Outcomes of Patients With Cardiogenic Shock Utilizing Hemodialysis for Acute Kidney Injury

In the setting of cardiogenic shock (CS), impaired biventricular function can cause acute decrease in renal function via reduced renal perfusion and increased renal venous pressure. We sought to analyze the characteristics and outcomes of patients hospitalized with CS who utilized renal replacement therapy (hemodialysis) for acute kidney injury (AKI-HD). We utilized data from the National Inpatient Sample to calculate national rates of in-hospital mortality, use of temporary mechanical support, vascular injury requiring surgery, length of stay (LOS) and hospitalization cost from 2010 to September 2015. We compared the in-hospital outcomes between CS with AKI-HD and a propensity score-matched group without AKI-HD. We identified 6,076 hospitalizations (weighted n = 24,272) with CS and AKI-HD and 76,878 (weighted n = 378,553) with CS not AKI-HD. Among these cases 48.1% (n = 39,403, weighted n = 193,746) had ST elevation myocardial infarction as the cause of CS. Patients with CS and AKI-HD had higher comorbidity burden and they were also more likely to receive mechanical circulatory support device (absolute standardized difference >10% for all comparisons) compared with CS patients without AKI-HD. After matching 4,457 cases for patient-level and hospital-level characteristics, CS with AKI-HD was associated with significantly higher in-hospital mortality (75.74% vs 51.58%, p <0.001), use of temporary mechanical support (24.0% vs 19.3%, p <0.001), LOS (21.4 vs14.4 days, p <0.001) and cost ($80,406 vs $52,833, p <0.0001). AKI-HD occurred in approximately 6% of patients with CS in years 2010 to 2015 and was associated with significantly increased in-hospital morbidity and mortality, LOS, and cost.

Urea reduction ratio may be a simpler approach for measurement of adequacy of intermittent hemodialysis in acute kidney injury

BackgroundAssessment of adequacy of intermittent hemodialysis (IHD) is conventionally based upon urea kinetic models for calculation of single pool Kt/Vurea (Kt/V), with 1.2 accepted as minimum adequate clearance for thrice weekly IHD. In the Acute Renal Failure Trial Network (ATN) Study, adequacy of IHD in patients with acute kidney injury (AKI) was assessed using Kt/V. However, equations for Kt/V require volume of distribution of urea, which is highly variable in AKI. Therefore, simpler methods are needed to assess adequacy of IHD in AKI. We assessed correlation of urea reduction ratio (URR) with Kt/V and determined URR thresholds corresponding to Kt/V values to determine if URR could be a simpler means to assess the delivered dose of IHD.MethodsUsing patients who received IHD for 2.5–6 h and with pre-dialysis BUN ≥20 mg/dL, we plotted URR against Kt/V. We determined URR thresholds (0.60 to 0.75) corresponding to Kt/V ≥ 1.2, 1.3, and 1.4. We generated receiver operating characteristic (ROC) curves for increasing URR values for each level of Kt/V to identify the corresponding thresholds of URR.ResultsThere was strong correlation between URR and Kt/V. ROC curves comparing URR with Kt/V ≥ 1.2, 1.3, and 1.4 had area under the curves (AUC) of 0.99. Sensitivity and specificity of URR ≥0.67 for corresponding values of Kt/V ≥ 1.2 were 0.769 (95% CI: 0.745 to 0.793) and 0.999 (95% CI: 0.997 to 1.000), respectively and the sensitivity and specificity of URR ≥0.67 for corresponding values of Kt/V ≥ 1.4 were 0.998 (95% CI: 0.995 to 1.000) and 0.791 (95% CI: 0.771 to 0.811), respectively.ConclusionsTargeting a URR ≥0.67 provides a simplified means of assessing adequacy of IHD in patients with AKI. Use of URR will enhance ability to assess delivery of small solute clearance and improve adherence with clinical practice guidelines in AKI.

Safety Lapses Prior to Initiation of Hemodialysis for Acute Kidney Injury in Hospitalized Patients: A Patient Safety Initiative.

Background: Safety lapses in hospitalized patients with acute kidney injury (AKI) may lead to hemodialysis (HD) being required before renal recovery might have otherwise occurred. We sought to identify safety lapses that, if prevented, could reduce the need for unnecessary HD after AKI; Methods: We conducted a retrospective observational study that included consecutive patients treated with HD for AKI at a large, tertiary academic center between 1 September 2015 and 31 August 2016. Exposures of interest were pre-specified iatrogenic processes that could contribute to the need for HD after AKI, such as nephrotoxic medication or potassium supplement administration. Other outcomes included time from AKI diagnosis to initial management steps, including Nephrology referral; Results: After screening 344 charts, 80 patients were included for full chart review, and 264 were excluded because they required HD within 72 h of admission, were deemed to have progression to end-stage kidney disease (ESKD), or required other renal replacement therapy (RRT) modalities in critical care settings such as continuous renal replacement therapy (CRRT) or sustained low efficiency dialysis (SLED). Multiple safety lapses were identified. Sixteen patients (20%) received an angiotensin converting enzyme inhibitor or angiotensin receptor blocker after AKI onset. Of 35 patients with an eventual diagnosis of pre-renal AKI due to hypovolemia, only 29 (83%) received a fluid bolus within 24 h. For 28 patients with hyperkalemia as an indication for starting HD, six (21%) had received a medication associated with hyperkalemia and 13 (46%) did not have a low potassium diet ordered. Nephrology consultation occurred after a median (IQR) time after AKI onset of 3.0 (1.0–5.7) days; Conclusions: Although the majority of patients had multiple indications for the initiation of HD for AKI, we identified many safety lapses related to the diagnosis and management of patients with AKI. We cannot conclude that HD initiation was avoidable, but, improving safety lapses may delay the need for HD initiation, thereby allowing more time for renal recovery. Thus, development of automated processes not only to identify AKI at an early stage but also to guide appropriate AKI management may improve renal recovery rates.

One- and three-year outcomes in patients treated with intermittent hemodialysis for acute kidney injury: prospective observational multicenter post-hoc FINNAKI study.

Studies reporting renal and overall survival after acute kidney injury (AKI) treated exclusively with intermittent modalities of renal replacement therapy (IRRT) are rare. This study focused on outcomes of AKI patients treated with IRRT both in intensive care units (ICUs) and non-ICU dialysis units. This prospective observational study was carried on during a 5-month period in 17 ICUs and 17 non-ICUs. ICU and non-ICU patients (total n=138; 65 ICU, 73 non-ICU) requiring RRT for AKI and chosen to receive IRRT were included. Patient and RRT characteristics as well as outcomes at 90days, 1year, and 3years were registered. Characteristics of ICU and non-ICU patients differed markedly. Pre-existing chronic kidney disease (CKD) and chronic heart failure were significantly more common among non-ICU patients. At 1year, RRT dependence was significantly more common in the non-ICU group. At 3years, there was no significant difference between the groups either in RRT dependence or mortality. Outcome of AKI patients treated with IRRT is dismal with regard to 3-year kidney function and mortality. Although pre-existing CKD emerged as a major risk factor for end-stage renal disease after AKI, the poor kidney survival was also seen in patients without prior CKD.

Blood pressure variation and its correlates among patients undergoing hemodialysis for renal failure in Benin City, Nigeria.

Background:Blood pressure (BP) variation is commonly encountered during hemodialysis (HD) procedure. Both intradialysis hypotension and hypertension have implications for outcome of treatment and overall morbidity and mortality of the patients.Methodology:A retrospective study was carried out in the dialysis unit of a tertiary health institution in Benin City among patients who had HD for acute kidney injury (AKI) or chronic kidney disease (CKD) over a 3-year period. Data retrieved included age, gender, type of kidney disease, cause of kidney disease, systolic BP at onset of dialysis and at end of dialysis, and diastolic BP (DBP) at onset of and at end of dialysis.Results:Complete data were available for 217 patients. One hundred and seven patients (49.3%) had no significant change in BP; 30.9% had intradialytic hypertension (IDHT) while 19.8% had intradialytic hypotension (IDH). IDH was more prevalent among patients with diabetic kidney disease while IDHT was more common among patients with hypertensive nephropathy (P = 0.002). Female patients had higher mean BP parameters compared to male patients pre- and post-dialysis, but only changes in DBP were statistically significant (P = 0.029). Patients with CKD had higher mean BP parameters pre- and post-dialysis compared to patients with acute AKI and the differences were statistically significant.Conclusion:Females had higher mean BP parameters than males. Patients with CKD had higher mean BP parameters compared with AKI patients. IDHT is a significant problem among patients on HD in our center. Measures to curtail this trend should be instituted with the goal of reducing morbidity and mortality.