Indications For Renal Replacement Therapy Research Articles

Acute kidney injury in acute liver failure: A narrative review.

Acute kidney injury (AKI) is a frequent complication of acute liver failure (ALF) and it worsens the already worse prognoses of ALF. ALF is an uncommon disease, with varying etiologies and varying definitions in different parts of the world. There is limited literature on the impact of AKI on the outcome of ALF with or without transplantation. The multifaceted etiology of AKI in ALF encompasses factors such as hemodynamic instability, systemic inflammation, sepsis and direct nephrotoxicity. Indications of renal replacement therapy (RRT) for AKI in ALF patients extend beyond the conventional criteria for dialysis and continuous renal replacement therapy (CRRT) may have a role in transplant-free survival or bridge to liver transplantation (LT). LT is a life-saving option for ALF, so despite somewhat lower survival rates of LT in ALF patients with AKI, LT is not usually deferred. In this review, we will discuss the guidelines' recommended definition and classification of AKI in ALF, the impact of AKI in ALF, the pathophysiology of AKI and the role of CRRT and LT in ALF patients with AKI.

#6665 NON TRAUMATIC RHABDOMYOLYSIS AND ACUTE RENAL FAILURE: WHICH INDICATIONS OF RENAL REPLACEMENT THERAPY?

Abstract Background and Aims The aim of our study is to identify the causes of non-traumatic rhabdomyolysis in our context, to study the clinical and biological presentation of patients and the indications of renal replacement therapy in the management of this entity. Method Our study is a monocentric retrospective study conducted at the universitary hospital Mohamed VI of Marrakech including 14 patients who presented rhabdomyolysis complicated by acute kidney inury (AKI) with no traumatic context. Those patients were followed up at intensive care unit and nephrology department over a period of 10 months from March to December 2022. Results The age of our patients varied between 24 and 64 years for an average of 42 years. The male sex was predominant (78.57%) 11 men versus 3 women with no history of previous kidney disease. The average hospital stay was 20 days [12-42 days]. The most common clinical signs were oligo-anuria (85.7%), abdominal pain (57.1%), nausea and vomiting (42.8%), flank pain (42.8%) and muscle pain (14.2%), hypertension in 5 patients (35.7%), while 4 were hypotensive. The average creatinine on admission was 22mg/l [14-42.3], the average CPK level was 6240UI/L [2225-12570], the myoglobin was assayed in a single patient which returned positive at 6230 mg/l. The mean serum potassium was 5.6mmol/l [4.2-8.1], serum phosphorus was 45mg/l [32-72mg/l], serum calcium 81.2mg/l [68- 91] and bicarbonate 12 mmol/l [4-22]. The etiologies of rhabdmyolysis in our series were as follows: In 3 cases rhabdomyolysis was related to prolonged immobilization, in 3 cases it occurred in a postoperative context (post-vascular surgery of femoro-popliteal bypass and ilio-popliteal bypass in 2 cases and orthopedic surgery for a bone tumor of the tibia in one case), in 3 patients rhabdomyolysis was related to severe sepsis. In 2 cases, it was a status epilepticus, in 2 cases a neuroleptic malignant syndrome and in one case it occurred post-IdM. Management was based on hemodynamic and respiratory support through the restoration of blood volume by intravenous (100% of patients) and oral (83.3%) rehydration, the use of vasoactive drugs (35.7%), the correction of metabolic disorders essentially hyperkalaemia and acidosis and the etiological treatment of the causal condition. RRT (Renal replacement therapy) was indicated in a total of 5 patients: In 3 patients with anuria > 24 hours and in 2 with threatening hyperkalaemia. The modalities were as follows: The technique used was daily IHD (intermittent hemodialysis) lasting from 1h30 to 4h. The average number of hemodialysis sessions was 3.6 (minimum of 3 sessions maximum of 5). The evolution of the patients was as follows: Among the 9 patients not on dialysis, 6 recovered normal renal function, 2 maintained an IR at discharge (creatinine at 13 and 19 mg/l respectively) and one patient died of septic shock. Among the 5 patients on dialysis, two recovered good renal function with recovery of diuresis, 2 remained on kidney failure, and one patient died due to multiple organ failure. Conclusion The management of non traumatic rhabdomyolysis is based above all on rehydration in order to establish blood volume and eliminate the myoglobin pigment. The use of RRT is necesseray in some cases such as sever acute renal failure, threatening hyperkalaemia, acidosis or persistent anuria. Several studies suggest the benefit of its early initiation, which still remains to be demonstrated.

Annals for Educators - January 2023.

Annals for Educators - January 2023.

Renal Replacement Therapy in Abdominal Blunt Trauma with Uncompromised Hemodynamics: A Case Report

Background: Severe kidney injury after blunt trauma poses a diagnostic and therapeutic challenge to a multidisciplinary team, especially regarding the urgency between operative and nonoperative approaches. In patients with severe acute kidney injury (AKI) but no urgent indication for renal replacement therapy (RRT), the optimal timing of initiation of RRT is controversial. This study aimed to present a case of hemodynamically stable blunt abdominal trauma treated with renal replacement therapy and supportive therapy to control complications in the intensive care unit of Dr. Moewardi General Hospital with a multidisciplinary team approach.
 Case presentation: A 34-year-old woman with grade V, AKIN-III, and hemodynamically stable renal laceration caused by blunt abdominal trauma, treated with nonoperative conservative therapy for 14 days in the ICU of a tertiary hospital. 
 Conclusion: Nonoperative management can be applied without the risk of increased morbidity and mortality in patients. Significant kidney-related complications, in this case, included electrolyte balance disturbances, pulmonary edema to sepsis but were successfully treated with additional interventions. Hemodynamically stable patients with grade V renal injury can be safely managed supportively and non-operatively.

Effect of Hemadsorption Therapy in Critically Ill Patients with COVID-19 (CYTOCOV-19): A Prospective Randomized Controlled Pilot Trial

Introduction: Immunomodulatory therapies have shown beneficial effects in patients with severe COVID-19. Patients with hypercytokinemia might benefit from the removal of inflammatory mediators via hemadsorption. Methods: Single-center prospective randomized trial at the University Medical Center Hamburg-Eppendorf (Germany). Patients with confirmed COVID-19, refractory shock (norepinephrine ≥0.2 µg/kg/min to maintain a mean arterial pressure ≥65 mm Hg), interleukin-6 (IL-6) ≥500 ng/L, and an indication for renal replacement therapy or extracorporeal membrane oxygenation were included. Patients received either hemadsorption therapy (HT) or standard medical therapy (SMT). For HT, a CytoSorb® adsorber was used for up to 5 days and was replaced every 18–24 h. The primary endpoint was sustained hemodynamic improvement (norepinephrine ≤0.05 µg/kg/min ≥24 h). Results: Of 242 screened patients, 24 were randomized and assigned to either HT (N = 12) or SMT (N = 12). Both groups had similar severity as assessed by SAPS II (median 75 points HT group vs. 79 SMT group, p = 0.590) and SOFA (17 vs. 16, p = 0.551). Median IL-6 levels were 2,269 (IQR 948–3,679) and 3,747 (1,301–5,415) ng/L in the HT and SMT groups at baseline, respectively (p = 0.378). Shock resolution (primary endpoint) was reached in 33% (4/12) versus 17% (2/12) in the HT and SMT groups, respectively (p = 0.640). Twenty-eight-day mortality was 58% (7/12) in the HT compared to 67% (8/12) in the SMT group (p = 1.0). During the treatment period of 5 days, 6/12 (50%) of the SMT patients died, in contrast to 1/12 (8%) in the HT group. Conclusion: HT was associated with a non-significant trend toward clinical improvement within the intervention period. In selected patients, HT might be an option for stabilization before transfer and further therapeutic decisions. This finding warrants further investigation in larger trials.

Effect of first session dialysis on acid

Background: MA results from the inability of the kidneys to eliminate acid load, leading to HCO3- depletion and accumulation of H+, the more deterioration of renal function the more severity of acidosis, In AKI, acidosis is a traditional and typical complication, and refractory acidosis is an indication for renal replacement therapy. Aim: to study the effect of first dialysis session on acidosis correction. Methods: an interventional study included 33 patients with renal failure presented for 1st time dialysis, we calculated the change in their pH, HCO3-, BD, AG and Cl- to Na+ ratio caused by dialysis, and studied whether or not this change is related to URR. Results: dialysis had significant effect on pH, HCO3- and BD, and there was positive correlation between URR and HCO3- difference and negative correlation between both BD difference with HCO3- difference, and BD difference with HCO3- difference. Conclusion: 1st dialysis session has significant effect on acidosis correction without affecting electroneutrality of the blood.

Chronic kidney disease in cancer patients, the analysis of a large oncology database from Eastern Europe.

IntroductionKidney dysfunction is prevalent in oncology patients and has an impact on their treatment and quality of life. The aim of our study was to analyze the prevalence of CKD in a large cohort of several types of cancer patients in an East European Region.Material and methodsWe conducted an observational retrospective cohort study on 5831 consecutive, biopsy-diagnosed cancer patients between January 2019 –December 2020 in the largest oncology hospital and outpatient clinic in Western Romania. 4342 subjects were included in the statistical analysis.Results and discussionFrom the 24 cancer types, the most prevalent cancers were represented by: breast (22.02%), lung (10.18%) and colonic cancer (9.51%). The prevalence of CKD (G3 –G5) was 12.27% after the first year of follow-up and 13.42 after the second year. The prevalence of CKD was higher in patients with renal (50%), urinary tract (33.6%) and pancreatic cancers (19.6%) and lower in patients with colonic cancers (5.3%) and brain tumors (2.5%). At the end of our 2-year survey period, 0,7% of the CKD cases had an eGFR around 6 ml/min/1.73m2 –an indication for renal replacement therapy.ConclusionOncology patients have a significantly higher prevalence of CKD compared to the general population, dependent of the age of the patients and the type of cancer. The prevalence of advanced CKD was surprisingly high (stages G4-G5 Pre-Dialysis 22.15%) one third of the CKD- G5 patients having indication for initiation of renal replacement therapy. An onco- nephrology team should be needed for the best medical care of these patients.

Influence of Advanced Organ Support (ADVOS) on Cytokine Levels in Patients with Acute-on-Chronic Liver Failure (ACLF).

Background: ADVanced Organ Support (ADVOS) is a novel type of extracorporeal albumin dialysis that supports multiorgan function in patients with acute-on-chronic liver failure (ACLF). No data exist on whether ADVOS affects inflammatory cytokine levels, which play a relevant role in ACLF. Aim: Our aim was to quantify cytokine levels both before and after a single ADVOS treatment in patients with ACLF at a regular dialysis ward. Methods and results: In this prospective study, 15 patients (60% men) with ACLF and an indication for renal replacement therapy were included. Patient liver function was severely compromised, reflected by a median CLIF-consortium ACLF score of 38 (IQR 35; 40). Blood samples were directly taken before and after ADVOS dialysis. The concentration of cytokines for IL-1β, IFN-α2, IFN-γ, TNF-α, MCP-1, IL-6, IL-8, IL-10, IL-12p70, IL-17A, IL-18, IL-23, IL-33 were quantified via a cytometric bead array. We found no significant (p > 0.05) change in cytokine levels, even when patients were stratified for dialysis time (<480 min versus ≥480 min). The relevance of the assessed cytokines in contributing to systemic inflammation in ACLF was demonstrated by Ingenuity pathway analysis®. Conclusion: Concentrations of pathomechanistically relevant cytokines remained unchanged both before and after ADVOS treatment in patients with ACLF.

Acute Kidney Injury in Patients with the New Coronavirus Infection

Estimations of the frequency of acute kidney injury in SARS-CoV-2 (COVID-19) coronavirus disease are very diverse. The literature data is highly inconsistent and shows AKI ranging from 0.5 to 80%.The objective: to analyze the incidence of renal dysfunction in COVID-19 patients and assess the significance of systemic inflammation for its development.Subjects and methods: The analysis was performed basing on data of 3,806 patients with COVID-19 treated at the Pavlov State Medical University, 395 of them were admitted to the intensive care units (ICU). The criterion for establishing renal dysfunction (RD) is the increase in blood creatinine level above the upper limit of reference values (0.115 mmol/l). Patients with end-stage chronic kidney disease who needed to continue routine long-term dialysis were not included in the study. We analyzed the incidence of renal dysfunction, changes in blood levels of creatinine, urea, and electrolytes during 8 days. In addition, glomerular filtration rate, diuresis volume, levels of hematocrit, hemoglobin, LDH, CRP, ferritin, and procalcitonin were evaluated.Results. The frequency of RD among all patients was 19.0%, among patients in the ICU – 41.0%. In 79% and 81%, respectively, it was detected on the first day of hospitalization. The increase in the number of patients with RD and the aggravation of the existing dysfunction occurred after 6 days. At the initial stage of the disease, the manifestations of RD in most cases were not expressed even in those with an unfavorable course of the disease but the level of creatinine showed a weak but significant (p &lt; 0.5) correlation with changes in CRP (r = 0.110), ferritin (r = 0.137), and procalcitonin (PCT, r = 0.418). The difference in the level of creatinine in patients with PСT level above and below 0.5 ng/ml was observed on the first day only; the value of this parameter returned to normal faster in the subgroup of patients whose procalcitonin level did not exceed 0.5 ng/ml.Conclusion. In case of the signs indicative of RD, it is advisable to distinguish between primary and secondary injury. In the first case, it is primarily due to systemic inflammation, in the second case it is caused by additional impact of other aggressive factors. This will make it possible to clarify the renal and non-renal indications for renal replacement therapy (RRT) in patients with COVID-19, and to evaluate the results adequately since the effectiveness of RRT at different stages of the disease cannot be the same.

Continuous renal replacement therapy in patients treated with extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) is a life‐saving therapy utilized for patients with severe life‐threatening cardiorespiratory failure. Patients treated with ECMO are among the most severely ill encountered in critical care and are at high‐risk of developing multiple organ dysfunction, including acute kidney injury (AKI) and fluid overload. Continuous renal replacement therapy (CRRT) is increasingly utilized inpatients on ECMO to manage AKI and treat fluid overload. The indications for renal replacement therapy for patients on ECMO are similar to those of other critically ill populations; however, there is wide practice variation in how renal supportive therapies are utilized during ECMO. For patients requiring both CRRT and ECMO, CRRT may be connected directly to the ECMO circuit, or CRRT and ECMO may be performed independently. This review will summarize current knowledge of the epidemiology of AKI, indications and timing of CRRT, delivery of CRRT, and the outcomes of patients requiring CRRT with ECMO.

Renal Dysfunction in Cirrhosis: Critical Care Management.

Cirrhotic patients with manifestations of the end-stage liver disease have a high risk for developing renal dysfunction even with minor insults. The development of renal dysfunction increases the morbidity and mortality of these patients. Causes of renal dysfunction in cirrhotics can be due to hepatorenal syndrome (HRS) or acute kidney injury (AKI) resulting from prerenal, renal, and postrenal causes. Development of pretransplant renal dysfunction has been shown to affect post-liver transplantation outcomes. Early detection and aggressive strategies for the prevention of further progression of renal dysfunction seem to decrease the morbidity and improve survival in this group of patients. This article aims to outline the pathogenesis of renal dysfunction in cirrhosis, etiological factors, and evaluation of renal dysfunction, strategies for aggressive therapy for renal dysfunction, the indications of renal replacement therapy (RRT) in this group of patients, and the various modalities of RRT with their merits and demerits. A thorough understanding of the pathogenesis, early detection, and aggressive corrective measures for AKI can prevent further progression. In conclusion, a good knowledge of treatment modalities available for renal dysfunction in cirrhosis and institution of timely interventions can significantly improve survival in this group of patients.Key messagesDevelopment of renal dysfunction in cirrhotics increases the morbidity and mortality of these patients and results in poor outcomes after liver transplantation. Early detection and aggressive strategies for the prevention of further progression of renal dysfunction seem to decrease the morbidity and improve survival in this group of patients.How to cite this articleRajakumar A, Appuswamy E, Kaliamoorthy I, Rela M. Renal Dysfunction in Cirrhosis: Critical Care Management. Indian J Crit Care Med 2021;25(2):207–214.

The Characteristics and Clinical Course of Patients with Scrub Typhus and Queensland Tick Typhus Infection Requiring Intensive Care Unit Admission: A 23-year Case Series from Queensland, Tropical Australia.

Scrub typhus and Queensland tick typhus (QTT)-rickettsial infections endemic to tropical Australia-can cause life-threatening disease. This retrospective study examined the clinical course of all patients with laboratory-confirmed scrub typhus or QTT admitted to the intensive care unit (ICU) of a tertiary referral hospital in tropical Australia between 1997 and 2019. Of the 22 patients, 13 had scrub typhus and nine had QTT. The patients' median (interquartile range [IQR]) age was 50 (38-67) years; 14/22 (64%) had no comorbidity. Patients presented a median (IQR) of seven (5-10) days after symptom onset. Median (IQR) Acute Physiology and Chronic Health Evaluation II scores were 13 (9-17) for scrub typhus and 13 (10-15) for QTT cases (P = 0.61). Following hospital admission, the median (IQR) time to ICU admission was five (2-19) hours. The median (IQR, range) length of ICU stay was 4.4 (2.9-15.9, 0.8-33.8) days. Multi-organ support was required in 11/22 (50%), 5/22 (22%) required only vasopressor support, 2/22 (9%) required only invasive ventilation, and 4/22 (18%) were admitted for monitoring. Patients were ventilated using protective lung strategies, and fluid management was conservative. Standard vasopressors were used, indications for renal replacement therapy were conventional, and blood product usage was restrictive; 9/22 (41%) received corticosteroids. One patient with QTT died, and two (8%) additional patients with QTT developed purpura fulminans requiring digital amputation. Death or permanent disability occurred in 3/9 (33%) QTT and 0/13 scrub typhus cases (P = 0.055). Queensland tick typhus and scrub typhus can cause multi-organ failure requiring ICU care in otherwise well individuals. Queensland tick typhus appears to have a more severe clinical phenotype than previously believed.

A Continuous Renal Replacement Therapy Protocol for Patients with Acute Kidney Injury in Intensive Care Unit with COVID-19.

COVID-19 often leads to acute respiratory distress syndrome complicated by acute kidney injury (AKI). The indications for renal replacement therapy for these patients are those commonly accepted to treat AKI. We describe a continuous veno-venous haemodialysis (CVVHD) protocol for AKI, which aims to provide the best treatment according to the particular patient’s and medical personnels’ needs in biohazard settings with limited human and technological resources. We designed a CVVHD protocol with a high cut-off (HCO) filter in regional citrate anticoagulation (RCA). The HCO filter in diffusion determines the enhanced cytokines clearance with less filter clotting due to a lower filtration fraction. In our hospital, at the beginning of the pandemic outbreak, we treated seven COVID-19 patients with AKI stage 2 and 3 and recorded the circuit lifespan and the number of interventions on monitors. CVVHD in RCA appears to be safe, effective and easy to be performed in a biohazard scenario using lower blood flows and less bag changes with fluid savings, a biohazard reduction and sparing of resources. Although the data come from a very small cohort, our protocol seems related to a low mortality.

Hemodiafiltración intermitente en línea como terapia de reemplazo renal en paciente crítico: Experiencia en un centro de diálisis de agudo

In critical patients with acute renal failure, intermittent diffusive renal replacement techniques cause hemodynamic problems due to their high depurative efficiency. This situation is avoided using continuous low efficiency therapies, which are expensive, prevent patient mobilization and add hemorrhagic risk due to systemic anticoagulation. Intermittent and prolonged hemodiafiltration (HDF) has the depurative benefits of diffusion, plus the positive attributes of convection in a less expensive therapy. To report our experience with intermittent and prolonged on-line HDF in critically ill patients. During 2016, HDF therapies performed on critical patients with indication of renal replacement therapy were characterized. The hemodynamic profile was evaluated (doses of noradrenaline, blood pressure, heart rate and perfusion parameters). Fifty-one therapies were performed in 25 critical patients, aged 58 ± 11 years (28% women), with an APACHE II score of 22.1 ±10. The average time of the therapies was 4.15 hours (range 3-8 hours), the replacement volume was 75 ± 18 mL/kg/h and ultrafiltration rate was 226 ± 207 mL/h. The mean initial, maximum and final noradrenaline doses were 0.07 ± 0.1, 0.13 ±0.18 and 0.09 ±0.16 μg/kg/min respectively. No differences between patients with low, medium and high doses of noradrenaline or dose increases during therapy, were observed. The greatest decrease in mean arterial pressure was 15.3% and the maximum increase in heart rate was 12.8%. Anticoagulation was not required in 88% of therapies. High-volume intermittent or prolonged HDF is an effective therapy in critical patients, with good hemodynamic tolerability, lower costs and avoidance of systemic anticoagulation risks.

Acute kidney injury in cancer patients: A nationwide survey in China

Cancer patients have a high risk for acute kidney injury (AKI); however, the incidence, severity, and risk factors of malignancy-related AKI (MR-AKI) are unclear. This study aimed to assess MR-AKI risk factors and provide reliable data for AKI prevention, diagnosis, and management in China. This cross-sectional study analysed data from 44 academic and local hospitals in China. AKI patients were identified based on 2 screening criteria: the 2012 Kidney Disease: Improving Global Outcomes-AKI definition and the expanded screening criteria for patients with no repeated serum creatinine (SCr) test within 7 days and those who recovered from AKI. Patients whose SCr level increased or decreased by 50% during hospitalization, compared with that at admission, were considered to have AKI according to the expanded criteria. A total of 7,604 AKI patients were enrolled (1,418 with MR-AKI). Patient characteristics were compared between the MR-AKI and non-MR-AKI groups. Multivariate logistic models were used to statistically assess risk factors. The proportions of MR-AKI patients in academic and local hospitals were 20.2% and 14.1%, respectively. The incidence of MR-AKI was higher in mid-China (the affluent region), elderly patients, and groups with higher per capita gross domestic product. Among MR-AKI cases, gastrointestinal cancer (50.1%) was the most common malignancy, followed by cancers of the reproductive (15.3%), haematological (13.1%), respiratory (11.8%), and other systems (8.3%), and cancers of unknown classification (1.4%). Of 268 hospital deaths, respiratory, haematological, gastrointestinal, reproductive, other system, and unknown classification cancers accounted for 29.3%, 18.8%, 18.6%, 12.9%, 16.9%, and 20.0%, respectively. Increased age, advanced AKI stage at peak, level of per capita gross domestic product, geographic region, and renal replacement therapy indication were risk factors for hospital mortality in patients with gastrointestinal MR-AKI, whereas cardiovascular disease history, AKI stage at peak, and geographic region were risk factors for mortality in patients with reproductive MR-AKI. The incidence and mortality of MR-AKI vary by hospital, economic level, age, geographic region, and malignancy type. High MR-AKI incidence was associated with gastrointestinal cancers and higher level of medical care provided by academic hospitals in affluent regions such as Beijing, Shanghai, and other provincial-level cities. Elderly patients with advanced gastrointestinal cancer in mid-China showed the highest incidence of MR-AKI and in-hospital mortality, and thus require special attention.

Psychoactive Medications

Psychoactive medications are defined as medications that affect the central nervous system neurotransmitter pathways with the intention to modulate mood or consciousness. This broad category of medications includes sedative-hypnotic agents such as benzodiazepines and barbiturates, antidepressants, neuroleptics, and mood stabilizers. The principal source of exposure for these medications is through prescription drug use and misuse. This review discusses the principles of toxicity, immediate stabilization, diagnosis and definitive therapy, and disposition and outcomes related to sedative-hypnotics, antidepressants, neuroleptics, and lithium. Tables include common benzodiazepine and barbiturate compounds, dosing instructions for multidose activated charcoal, flumazenil dosing recommendations, commonly available tricyclic and atypical (noncyclic) antidepressants, dosing recommendations for sodium bicarbonate in serum alkalinization, benzodiazepine dosing recommendations in serotonin syndrome, dosing recommendations for cyproheptadine, signs and symptoms that differentiate neuroleptic malignant syndrome from serotonin syndrome, and indications for renal replacement therapy based on lithium concentration and clinical setting. Figures show action potentials in the His-Purkinje syndrome, an electrocardiogram tracing demonstrating a terminal R wave, and a QT interval nomogram. This review contains 2 highly rendered figures, 9 tables, and 101 references.

Heterogeneity of Cause, Care, and Prognosis in Severe Acute Kidney Injury in Hospitalized Patients: A Prospective Observational Study.

Background:KDIGO (Kidney Disease: Improving Global Outcomes) defines acute kidney injury (AKI) solely by serum creatinine (SCr) and urine output variation. Severe AKI is a syndrome covering various clinical situations.Objective:To describe severe AKI heterogeneity by department of hospitalization.Design:This is a prospective observational single-center study.Setting:Adult patients hospitalized in a French tertiary hospital from August 2016 to December 2017.Patients:All adults with severe AKI, defined by dialysis for AKI or an increase in SCr above 354 μmol/L.Measurements:Patient characteristics, clinical and laboratory presentation, AKI cause, medical indication for renal replacement therapy (RRT), planned palliative care, and vital status 30 days after severe AKI.Methods:A global description of patient characteristics, care, and prognosis and comparison by department of hospitalization: intensive care unit (ICU), nephrology, and others.Results:The study included 480 patients (73% men, median age: 72 years, range: 64-83), with medical histories including cardiovascular disease, diabetes, cancer, and chronic kidney disease. Principal causes were sepsis (104; 22%), hypovolemia (98; 20%), obstructive AKI (84; 18%), acute tubular necrosis (ATN; 74; 15%), and cardiorenal syndrome (51; 11%). Severe AKI was diagnosed in the ICU for 188 (39%) patients, the nephrology department for 130 (27%), and in other wards for 162 (34%). Patient characteristics differed by department for age, comorbidity, cause, and RRT use and indications. Palliative care was planned for 72 (15%) patients, most frequently in other wards.Limitations:We studied a subgroup of stage 3 KDIGO AKI patients in a single center without cardiac surgery.Conclusion:Patients hospitalized for severe AKI have frequent and various comorbidities, different clinical presentations, care, hospitalization in various departments, and different prognosis. The heterogeneity of this severe AKI implies the need for personalized care, which requires prognostic tools that include information besides SCr and diuresis.

Effect of timing of renal replacement therapy on outcomes of critically ill patients in the intensive care unit.

Currently, indications for renal replacement therapy (RRT) remain controversial. Whether early RRT can improve the prognosis of critically ill patients in the ICU is unclear. This study aimed to assess the relationship between timing of RRT initiation and short-term prognosis of patients in the ICU. This was a retrospective study of data obtained from 28 hospitals in Beijing. The subjects received RRT treatment in the ICU from March 2012 to August 2012. A total of 9049 cases were reviewed, and 281 patients who underwent RRT were enrolled and divided into the non-survival (n = 144) and survival (n = 137) groups, according to their outcome at 28 days from ICU admission. Median RRT initiation times were 1 (0-25) and 1 (0-21) days in the non-survival and survival groups, respectively (P = 0.001) and oliguria/anuria frequency at RRT initiation were 76.6% and 65.3% (P = 0.036), respectively. The mortality of patients administered RRT within 24 h of ICU admission was lower than that of those treated after 24 h (P = 0.014). In patients with oliguria/anuria at RRT initiation, the 28-day mortality rate was 52.8%, which was higher than 39.0% obtained for those with no oliguria/anuria at RRT initiation (P = 0.036). Multivariate logistic analysis showed that late initiation of RRT was an independent risk factor for 28-day mortality (HR = 1.139, 95%CI 1.046-1.242, P = 0.003). Timing of RRT is associated with 28-day mortality of ICU treated patients. Early RRT might improve patient survival.

Successful peritoneal dialysis using a percutaneous tube for peritoneal drainage in an extremely low birth weight infant: a case report

BackgroundPeritoneal dialysis (PD) for acute kidney injury (AKI) of newborns has been performed safely. AKI occurs in 8 to 24% of extremely low birth weight (ELBW) infants. Although PD has only been used occasionally in ELBW infants, prognosis is poor for ELBW infants with AKI. Several reports have described successful PD in these infants, but no guideline-based evidence concerning indications for renal replacement therapy in ELBW infants are currently available. Here, we report on our experience with PD in an ELBW infant with AKI resulting from septic shock.Case presentationA male was born at 24 weeks and 3 days gestation weighing 264 g by emergency cesarean section due to complications of pregnancy in a patient with hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. On day of life (DOL) 15, the inability to ventilate, along with cardiovascular dysfunction, acute kidney injury, and ascites under tension led to the tentative diagnosis of abdominal compartment syndrome (ACS). On DOL 17, placement of a percutaneous drainage tube immediately released compression of the tense abdomen. Although intra-abdominal pressure reduction with percutaneous drainage temporarily improved respiratory status, circulatory impairment persisted and infections were not well controlled. Finally, the patient developed anuria. On DOL 21, peritoneal dialysis (PD) was started by initially inserting a drainage tube. Although the patient had catheter-associated peritonitis, urine output improved by DOL 44 and PD was discontinued on DOL 53. On DOL 75, extubation was conducted without circulatory dysfunction. The patient was discharged on DOL 224.ConclusionsWe emphasize that starting PD treatment before the onset of anuria is important in ELBW infants with AKI. Although the catheter used in our case was initially inserted for drainage of ascites, this type of catheter is sufficiently useful for PD in ELBW infants, and PD using a drainage tube may represent a safe, effective, and minimally invasive treatment for ELBW infants. To our knowledge, this is the first report to describe the use of a percutaneous tube to conduct successful PD for peritoneal drainage in an ELBW infant. This is the lowest-weight ELBW infant with successful PD reported to date.

Assessment of Knowledge of Acute Kidney Injury among Non-Nephrology Doctors in Two Government Hospitals in Ondo City, Southwest, Nigeria.

Adequate knowledge of acute kidney injury (AKI) among doctors is essential for its prevention, early diagnosis and management. Assessing knowledge of AKI among doctors is necessary to identify areas of deficiencies and key areas to be emphasized when organizing educational programs aimed at improving AKI care. This study determined the knowledge of AKI among non-nephrology doctors in Ondo City, Southwest Nigeria. This was a cross-sectional descriptive study carried out in two government hospitals in Ondo City using a self-administered pretested questionnaire that assessed knowledge of AKI among non-nephrology doctors. P-value of < 0.05 was taken as significant. Eighty-one doctors participated in the study with a median post-graduation experience of 5.5 years. Sixty-one (78.2%) were in surgical specialty while the remaining worked in medical specialty. Only 1(1.2%) of the respondents had good knowledge of AKI, 56(69.2%) had fair knowledge while the remaining 24 (29.6%) had poor knowledge of AKI. Identified areas of deficiencies in knowledge of AKI were in mode of presentation, risk factors, potentially nephrotoxic medications, criteria for AKI definition and staging, newer AKI biomarkers and indications for renal replacement therapy. There was no significant association between knowledge of AKI and specialty (p=0.593) or year of practice (p=0.312). There were significant deficiencies in the knowledge of AKI amongst most non-nephrology doctors in Ondo city. We therefore recommend regular in-service training on AKI for practicing doctors.