Need For Renal Replacement Research Articles

Base excess is superior to creatinine in predicting haemodialysis: A multicenter study conducted Kahramanmaraş earthquake victims

PurposeThis study had two main goals: to determine which rhabdomyolysis patients need haemodialysis; and to highlight the significance of blood gas parameters, particularly base excess, as predictors of the need for haemodialysis. MethodA total of 270 patients were included in this multicentre, retrospective study. Among the patients who were transferred in from the earthquake region and developed rhabdomyolysis, those with creatine kinase (CK) values >1000 U/L were included in our study. The need for renal replacement in these patients was determined via laboratory tests, urine output monitoring and clinical follow-up. FindingsA total of 270 patients were included in our study. Univariate and multivariate regression analyses of laboratory parameters were performed to identify predictors of HD treatment. According to the univariate regression analysis, BE, HCO3, creatinine, CK, lactate, alanine transaminase (ALT) and aspartate transaminase (AST) levels were found to be significantly associated with receiving HD treatment. According to multivariate regression analysis, only BE (p = 0.003) was found to be a significant predictor of HD treatment. ROC analysis revealed that the optimal cutoff value for BE was −2.6; at this value, the sensitivity and specificity of BE for predicting HD treatment were 89% and 77.1%, respectively (AUC: 0.912; 95% CI: 0.872–0.943; p < 0.001). ConclusionBase excess is an effective predictor of the need for haemodialysis in patients with crush-related injuries that cause rhabdomyolysis and in patients who develop acute renal failure due to elevated CK.

#59 Fibroblast Growth factor 23 for prediction of outcome in community-acquired acute kidney injury: a prospective observational study

Abstract Background and Aims Serum FGF23 level has been found to be elevated in AKI through multiple previous studies. Moreover, higher FGF23 level was associated with mortality and adverse outcomes in critically ill patients and patients undergoing cardiac surgery who developed AKI suggesting that FGF23 can have a prognostic value in AKI. The current study aims to investigate the association of serum FGF23 levels with morbidity and mortality in patients with community-acquired AKI. Method A longitudinal prospective study was carried out that included 64 patients who presented with community-acquired AKI to Mansoura Nephrology and Dialysis Unit (MNDU) at Mansoura University Hospital. Serum intact FGF23 level was measured after admission. patients were followed up during hospital stay and then at 90-day after admission. The primary outcomes were hospital and 90-day mortality and renal recovery. Results In this study, nine of the studied 64 AKI patients (14.1%) died during hospital admission and 18 out of 62 AKI patients (29%) died during the 90-day follow up period including those who died during hospital admission. Hospital mortality was significantly higher in patients with shock, sepsis, hypoalbuminemia, or high FGF23 in univariate analysis (p &amp;lt; 0.05). However, when binary logistic regression was carried out, shock was the only significant independent predictor for mortality [p value = 0.015; adjusted odds ratio = 12.465], while serum FGF23 did not independently predict in-hospital [p value = 0.589; adjusted odds ratio = 1.001] or 90-day mortality [p value = 0.055; adjusted odds ratio = 1.003] when entered in the regression equation together with the other confounders. Serum FGF23 in this study was not also associated with renal recovery, need for renal replacement, or the duration from peak serum creatinine to renal recovery (p &amp;gt; 0.05). Conclusion This research showed that serum iFGF23 could not predict mortality, renal recovery, or need for renal replacement therapy in patients with community-acquired AKI.

#2770 Evaluation of the effect of IV iron therapy on eGFR and Pro-BNP in patients with chronic kidney disease and heart failure with preserved EF

Abstract Background and Aims Iron replacement in treating heart failure (HF) is an issue whose importance has been better understood in recent years. Although controversies exist, randomized controlled studies have shown that IV iron treatment reduces mortality and improves symptomatology in heart failure with low EF (HFrEF). IV iron has not dramatically affected survival in heart failure with preserved EF (HFpEF). However, there is data that it might reduce symptoms and hospitalizations. For patients with chronic kidney disease (CKD) and HF, around 60% of them have HFpEF. Major heart failure and iron studies have often been performed on patients with low EF. Furthermore, in some of these studies, GFR values were not reported, and in the others, GFR was often &amp;gt; 60 ml/minute. We planned this study to evaluate the effects of IV iron therapy on eGFR and Pro-BNP levels in non-dialysis CKD patients with HFpEF. Method This study was conducted between January 2022 and December 2023. Patients with iron deficiency anemia, stage 2-5ND chronic kidney disease, and those with Pro-BNP values of 1000 and above were selected. Two independent cardiologists evaluated them, and the diagnosis of heart failure was confirmed. Patients were given one dose of 500 or 1000 mg of FCM. Control values were obtained at the 1-month follow-up. Hospitalized or transfused patients, cases with primary hematological disease, and cases with conditions affecting ferritin levels were excluded. Patients whose RAAS blockade, SGLT-2 inhibitor, and diuretic doses were changed, were excluded from the analysis. No patients received ESA or HIF stabilizers. Demographic and clinical data of the patients were recorded. The patients' creatinine, eGFR, hemoglobin, ferritin, and pro-BNP levels were evaluated before and after iron treatment Results Seventy-four patients were recruited. Forty-seven patients were women. The average age was 68 ± 11 years. Forty-eight of the patients had diabetes (64.9%) and 47 (63.5%) had coronary artery disease. The etiology of HFpEF was diastolic heart failure in 45 patients (60%). Other patients had valve disease, HFmEF, HFimpEF, isolated right-sided HF, and mixed types of HFpEF. After IV iron treatment, an increase of 3 ± 1 ml/min in GFR and 1.1 ± 0.1 g/dL in hemoglobin was detected. ProBNP levels decreased by 46%. All findings were statistically significant. The findings are summarized in Table 1. Conclusion The decrease in ProBNP levels was similar to the HFrEF literature. No positive or negative effects of iron on GFR were observed in the REVOKE and FIND-CKD studies, which compared oral and IV iron in CKD patients. The small but significant increase in GFR in our study could be attributed to the improvement of cardiac function. However, the small number of patients and the short follow-up period make it difficult to reach a definitive conclusion on this issue. We have shown that IV iron treatment significantly reduces Pro-BNP levels in CKD patients with HFpEF. IV iron has no adverse effects on renal function in the short term, and there is little signal of potential positive effects. Longer-term studies, preferably randomized with oral iron, with appropriate sample size, are needed to evaluate how IV iron affects end-points such as HF symptom score, hospitalization, eGFR slope, need for renal replacement, and mortality in this patient group. Strengths Well-selected patient group, a high Pro-BNP cut-off point, re-evaluation of each patient by the cardiologists Limitations Relatively small cohort, short follow-up period

Intensive or liberal glucose control in intensive care units for septic patients? A meta-analysis of randomized controlled trials

ObjectiveTo compare the clinical outcomes of intensive glucose control and liberal glucose control for septic patients in intensive care unit. MethodsThe databases of PubMed, Cochrane Library, Embase and Web of Science were searched systematically from inception to November 27, 2023 to identify trials involving a randomized comparison between intensive and liberal glucose control for septic patients in intensive care unit. ResultsA total of 14 randomized controlled trials involving 6226 patients were finally included. There was no statistically significant difference observed between intensive glucose control and liberal glucose control in terms of all-cause mortality, the need for renal replacement, vasopressor-free and mechanical ventilation-free days, and length of hospital stay. However, it is noteworthy that intensive glucose control exhibited a statistically higher risk of severe hypoglycemia (RR 2.66; 95%CI 1.85 to 3.83), need for blood transfusion (RR 1.12; 95%CI 1.01 to 1.23), and statistically prolonged length of stay in the ICU (MD 1.67; 95%CI 0.22 to 3.12) compared to liberal glucose control. Nevertheless, sensitivity analysis revealed that the need for blood transfusion and length of stay in the intensive care unit were not robust. ConclusionsBoth intensive and liberal glucose control had comparable effects on improving patient outcomes, but intensive glucose control carried a higher risk of severe hypoglycemia.

Factors associated with adverse outcome among children with sickle cell disease admitted to the pediatric intensive care unit: an observational cohort

BackgroundSickle cell disease (SCD) is one of the most frequent inherited diseases in the world. Over the last decades, in high-income countries, an important decrease in mortality have been observed due to the improvement of care. However, children with SCD can become critically ill and require admission in Pediatric Intensive Care Units (PICU). The purpose of this study was to describe the epidemiology of children with SCD admitted to PICU for acute crisis and to identify factors associated with adverse outcome (AO).MethodsWe conducted a retrospective study in a Tertiary Hospital in France including all consecutive children with SCD admitted to PICU between January 1st, 2009 and December 31, 2019. We collected baseline patient’s characteristics, clinical and biological data as well as treatments and life sustaining therapies used in the PICU. Patients were defined as experiencing AO in case of death during stay and/or need for invasive mechanical ventilation (MV) and/or for non-invasive ventilation (NIV) for more than 3 days and/or need for vasopressors and/or need for renal replacement therapy.ResultsWe included 579 admissions in 395 patients, mainly of SS genotype (90%) with a median age of 9.2 years [5.5–13.4] and a median baseline hemoglobin of 8.0 g/dl (7.5–8.8). The two main reasons for admission were acute chest syndrome (ACS) (n = 331, 57%) and vaso-occlusive crisis refractory to first line therapy (n = 99, 17%). Half of patients required NIV and 47 (8%) required MV. The overall length of stay was 3 days [1–4] and seven (1%) patients died during PICU stay.There was a total of 113 (20%) admissions with AO and on multivariable analysis, baseline hemoglobin < 8 g/dL, history of bronchial obstruction and admission for ACS were associated with AO. There was no difference in the proportion of hydroxyurea treatment or exchange transfusion program between patients with AO and the other patients.ConclusionsBaseline hemoglobin < 8 g/dL, history of bronchial obstruction and admission for ACS were the strongest risk factors for severe evolution in SCD children admitted to PICU. These factors could be taken into consideration when choosing the adequate therapeutic options.

Covariates in population pharmacokinetic studies of critically ill adults receiving β-lactam antimicrobials: a systematic review and narrative synthesis.

Population pharmacokinetic studies of β-lactam antimicrobials in critically ill patients derive models that inform their dosing. In non-linear mixed-effects modelling, covariates are often used to improve model fit and explain variability. We aimed to investigate which covariates are most commonly assessed and which are found to be significant, along with global patterns of publication. We conducted a systematic review, searching MEDLINE, Embase, CENTRAL and Web of Science on 01 March 2023, including studies of critically ill adults receiving β-lactam antimicrobials who underwent blood sampling for population pharmacokinetic studies. We extracted and categorized all reported covariates and assessed reporting quality using the ClinPK checklist. Our search identified 151 studies with 6018 participants. Most studies reported observational cohorts (120 studies, 80%), with the majority conducted in high-income settings (136 studies, 90%). Of the 1083 identified covariate instances, 237 were unique; the most common categories were patient characteristics (n = 404), biomarkers (n = 206) and physiological parameters (n = 163). Only seven distinct commonly reported covariates (CLCR, weight, glomerular filtration rate, diuresis, need for renal replacement, serum albumin and C-reactive protein) were significant more than 20% of the time. Covariates are most commonly chosen based on biological plausibility, with patient characteristics and biomarkers the most frequently investigated. We developed an openly accessible database of reported covariates to aid investigators with covariate selection when designing population pharmacokinetic studies. Novel covariates, such as sepsis subphenotypes, have not been explored yet, leaving a research gap for future work.

Serial assessments of cardiac output and mixed venous oxygen saturation in comatose patients after out-of-hospital cardiac arrest

AimTo assess the association with outcomes of cardiac index (CI) and mixed venous oxygen saturation (SvO2) in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA).MethodsIn the cohort study of 789 patients included in the “BOX”-trial, 565 (77%) patients were included in this hemodynamic substudy (age 62 ± 13 years, male sex 81%). Pulmonary artery catheters were inserted shortly after ICU admission. CI and SvO2 were measured as soon as possible in the ICU and until awakening or death. The endpoints were all-cause mortality at 1 year and renal failure defined as need for renal replacement therapy.ResultsFirst measured CI was median 1.7 (1.4–2.1) l/min/m2, and first measured SvO2 was median 67 (61–73) %. CI < median with SvO2 > median was present in 222 (39%), and low SvO2 with CI < median was present in 59 (11%). Spline analysis indicated that SvO2 value < 55% was associated with poor outcome. Low CI at admission was not significantly associated with mortality in multivariable analysis (p = 0.14). SvO2 was significantly inversely associated with mortality (hazard ratioadjusted: 0.91 (0.84–0.98) per 5% increase in SvO2, p = 0.01). SvO2 was significantly inversely associated with renal failure after adjusting for confounders (ORadjusted: 0.73 [0.62–0.86] per 5% increase in SvO2, p = 0.001). The combination of lower CI and lower SvO2 was associated with higher risk of mortality (hazard ratioadjusted: 1.54 (1.06–2.23) and renal failure (ORadjusted: 5.87 [2.34–14.73].ConclusionFirst measured SvO2 after resuscitation from OHCA was inversely associated with mortality and renal failure. If SvO2 and CI were below median, the risk of poor outcomes increased significantly.RegistrationThe BOX-trial is registered at clinicaltrials.gov (NCT03141099, date 2017–30–04, retrospectively registered).Graphical abstract

#3783 INCIDENCE AND PREDICTORS OF MAJOR ADVERSE KIDNEY EVENTS IN ICU PATIENTS WITH SEPSIS: A PROSPECTIVE COHORT STUDY FROM A DEVELOPING COUNTRY

Abstract Background and Aims Acute kidney injury (AKI) occurs in 15-60% of intensive care unit (ICU) admissions and is associated with higher mortality, morbidity and increased healthcare costs. Major adverse kidney events (MAKE) is a clinically meaningful patient-centred outcome for AKI which includes mortality, need for renal replacement (RRT) and persistent kidney dysfunction. There is a paucity of data on the incidence and risk factors of MAKE, particularly from developing countries. We sought to examine the incidence of MAKE at day 30 (MAKE30) and its predictors in a cohort of critically ill patients with sepsis. Method This was a prospective cohort study conducted in the medical ICUs of a tertiary-care hospital in India. Ethical clearance was obtained from the Institutional Ethics Committee. Adult patients (≥ 18 years) admitted in the medical ICUs between 1st September, 2022 and 31st December, 2022 with sepsis (as defined by Sepsis-3 criteria) were included. Those with chronic kidney disease stage 5/5D, those requiring dialysis within 72 hours of admission and with an ICU stay of &amp;lt;72 hours were excluded. Baseline clinical and demographic data were recorded on the day of admission. AKI was defined as per KDIGO 2012 guidelines. Patients were followed up till hospital discharge or day 30 (whichever was earlier) and clinical outcomes were noted. The primary outcome measure was MAKE30 (defined as a composite of death, provision of RRT, or sustained loss of kidney function i.e., a final inpatient creatinine ≥200% of the baseline value, at hospital discharge or at 30 days, whichever comes first). Results A total of 250 patients admitted in the medical ICUs during the study period were included for analysis. The baseline characteristics are tabulated below (Table 1). Over the 30-day follow-up period, AKI was noted in 185 (74%) patients, with stage 1 AKI in 38 (15.2%), stage 2 AKI in 29 (11.6%) and stage 3 AKI in 118 (47.2%). Renal replacement therapy was initiated in 86 (34.4%) patients. Mortality occurred in 58 (23.2%). Overall, MAKE30 was seen in 102 (40.8%) patients. Serum lactate (OR 1.04, 95% CI:1.01-1.06; P = 0.010) and SOFA score (OR 1.38, 95% CI:1.27-1.56; P &amp;lt;0.001) at admission were independently associated with MAKE30 (Table 2). There was no association with age, gender, diabetes, type of resuscitation fluid or cumulative fluid balance (at 72 hours) with MAKE30. Conclusion In this cohort of critically ill patients with sepsis, MAKE30 was observed in 40.8%. Serum lactate and SOFA score at admission were independent predictors of MAKE30.

Characteristics, risk factors and outcomes of critically ill patients with active TB.

BACKGROUND: TB continues to impose a significant healthcare burden despite advancement in diagnostics and increased availability of effective antimicrobials. Recent years have seen a resurgence of the disease in association with increasing life expectancy and use of immunosuppressive therapy. Mortality remains high in TB patients requiring admission to critical care units.METHODS: We conducted a retrospective study in two public hospitals to determine factors associated with mortality in patients with TB requiring critical care admission. All patients aged ≥21 years with a diagnosis of active TB involving any organ system at the time of a critical care admission were eligible. The primary outcome measure was 30-day mortality.RESULTS: Over the study period of 4 years, 148 patients were identified. Overall 30-day mortality was 36.5%. Based on multivariate analysis, factors which independently correlated with 30-day mortality include higher APACHE II (Acute Physiology and Chronic Health Evaluation II) score, acid-fast bacilli smear positivity, initiation of anti-TB treatment prior to critical care admission and need for renal replacement therapy.CONCLUSION: TB in critically ill patients continues to be associated with significant mortality. The factors identified to be associated with poor survival outcomes in our study were largely related to greater disease burden and potential for suboptimal treatment.

COVID-19 infection in kidney transplant recipients during the first versus the second wave - Retrospective Observational study from a single center

Background: Kidney transplant recipients (KTRs) are deemed to be at a high risk of severe coronavirus disease (COVID-19). Herein, we describe the clinical, laboratory profiles, management, and outcomes of 26 KTRs who developed COVID-19 during the first and second waves of the pandemic from a tertiary care center in northern India. Methods: This retrospective observational study included KTRs detected with COVID-19 infection during the first wave (March–November 2020) and the second wave (March–July 2021). Their clinical and laboratory investigations, management aspects, and outcomes were compared, using data retrieved from clinical and telenephrology records, and the hospital information system. Results: Of the 23 KTRs, 20 were male (86%), 20 patients had fever (86%), and cough and breathlessness were seen in 19 (82%) and 12 (52%), respectively. Acute graft dysfunction was seen in 6 (26%) patients, and the need for renal replacement was seen in 4 (17%) patients. Supplemental oxygen by reservoir mask was utilized in 10 (43%) patients, high-flow nasal cannula in 3 (13%), noninvasive mechanical ventilation in 4 (17%), and invasive mechanical ventilation in 6 (26%) patients. All the KTRs with moderate and severe COVID illness and 6/7 nonsurvivors were infected during the second wave. Overall mortality in this group of patients was very high at 27%, and the mortality in the group on mechanical ventilation was 100%. Conclusions: The second wave of the COVID-19 pandemic was associated with greater severity of illness and high mortality in KTRs.

Acute Kidney Injury After Liver Transplant: Incidence, Risk Factors, and Impact on Patient Outcomes.

Acute kidney injury is a frequent complication of liver transplant. Here, we assessed the rate and contributing factors of acute kidney injury and need for renal replacement therapy in patients undergoing liver transplant at a transplant center in Tehran, Iran. We identified all patients who underwent liver transplant at the Imam Khomeini Hospital Complex from March 2018 to March 2019 and who were followed for 3 months after transplant. Acute kidney injury was defined based on the Acute Kidney Injury Network criteria. We collected demographic and pretransplant, intraoperative, and posttransplant data. Univariable and multivariable models were applied to explore independent risk factors for acute kidney injury incidence and need for renal replacement therapy. Our study included 173 deceased donor liver transplant recipients. Rates of incidence of acute kidney injury and need for renal replacement therapy were 68.2% and 14.5%, respectively. The 3-month mortality rate among those with severe and mild or moderate acute kidney injury was 44.0% (14/25) and 9.7% (9/ 93), respectively (P < .001). Multivariable analyses indicated that serum albumin (relative risk of 0.55; 95% confidence interval, 0.34-0.87; P = .021), baseline serum creatinine (relative risk of 2.11; 95% confidence interval, 1.56-2.90; P = .037), and intraoperative mean arterial pressure (relative risk of 0.76; 95% confidence interval, 0.63-0.82; P = .008) were independent factors for predicting posttransplant acute kidney injury. Independent risk factors for requiring renal replacement therapy were pretransplant serum creatinine (relative risk of 1.99; 95% confidence interval, 1.89-4.47; P = .044) and intraoperative vasopressor infusion (relative risk of 1.41; 95% confidence interval, 1.38-2.00; P = .021). We found a high incidence of acute kidney injury among liver transplant recipients in our center. There was a significant association between severity of acute kidney injury and 3-month and in-hospital mortality.

Severe Pulmonary Hemorrhage after Left Ventricular Assist Device Implantation - Gambling with Luck?

Purpose Left ventricular assist device (LVAD) implantation is an invasive treatment for advanced heart failure. Anticoagulation is required to prevent thrombotic events and subsequently bleeding complications are feared, most commonly gastrointestinal and intracranial. The aim of this analysis was to identify risk factors for severe pulmonary hemorrhage (SPH) after LVAD implantation. Methods We retrospectively analyzed our institutional database of 125 patients who underwent LVAD implantation between 2008 and 2019 and reviewed pre-/ intra-/ and postoperative variables, duration of intensive care unit (ICU) stay, ventilation time and hospital mortality. Results Nine out of 125 patients suffered SPH in their postoperative course. None of them had a known history of lung disease or bleeding disorder. No differences were noted between LVAD device manufacturers, intraoperative management including blood, plasma, platelet and coagulation factor transfusion or pulmonary vasodilator administration. Concomitant aortic valve replacement was statistically more common in the group with SPH (33.3% versus 7.0%, p = 0.034). Postoperatively, patients with SPH developed kidney failure (100% versus 36.7%, p = 0.001) with need for renal replacement more frequently (100% versus 24.7%, p Conclusion SPH is a rare but very serious complication after LVAD implantation and significantly worsens prognosis. Risk factors remain uncertain and may be related to parameters not included in our database, such as frequent suctioning or empiric bronchoscopy causing airway irritation.

Clinical Profile, Need for Dialysis and Mortality of Community Acquired versus Hospital Acquired Acute Kidney Injury

Introduction: Occurrence of Acute Kidney Injury (AKI) is high in hospitalised and critically ill patients. Most of the cases reported by the developed countries are Hospital Acquired Acute Kidney Injury (HA-AKI). AKI is a major medical complication in the developing world also and is due to predominantly community acquired causes, where the epidemiology differs from that in developed countries. Many studies have reported that Community Acquired Acute Kidney Injury (CA-AKI) and HA-AKI differ in mortality, need for renal replacement and residual renal injury. Aim: To know the difference in need for renal replacement therapy and in-hospital mortality between patients diagnosed with CA-AKI and HA-AKI using Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Materials and Methods: A prospective cohort study was conducted from January 2018-December 2018 after obtaining Institutional Ethical Clearance by comparing 50 cases of CA-AKI and 50 cases of HA-AKI admitted by the General Medicine Department as per the inclusion and exclusion criteria. Serum Creatinine (S.Cr) at admission, after 48 hours and at the time of discharge were measured. Serial urine output measurements were done. Need for dialysis was noted in both the groups. Both groups were compared based on need for dialysis, difference in mortality and residual renal injury at the time of discharge. Chi-square and student t-tests were applied respectively and p-value ≤0.05 was considered as significant. Statistical Package for Social Sciences (SPSS) version 17.0 was used for data entry and analysis. Results: the CA-AKI and HA-AKI groups were comparable in age and gender but differed in some co-morbidities. CA-AKI group had underlying hepatobiliary disorders and Non steroidal Anti-Inflammatory Drug (NSAID) abuse more often than HA- AKI group. There was a significant reduction in S.Cr over the duration of hospital stay in CA-AKI (mean S.Cr at admission was 4.85 mg/dL, at 48 hours 2.05 mg/dL and at discharge 1.20 mg/dL). S.Cr increased after 48 hours of admission from baseline and declined later in HA-AKI but did not reach baseline in many patients in comparison to CA-AKI group (mean S.Cr at admission was 1.10 mg/dL, at 48 hours 2.38 mg/dL, at discharge 1.57 mg/dL). The highest stage of AKI was stage 3 in CA-AKI group (22 vs 11 of HA-AKI). HA-AKI group had more number of patients in stage 2 AKI (26 vs 18 of CA-AKI). There was no significant difference in mortality and requirement of haemodialysis between CA-AKI and HA-AKI groups. Conclusion: There was no difference between the two groups in terms of mortality and need for renal replacement therapy but there was significant residual renal injury in HA-AKI group.

Rationale and Design of a Spanish Mulicenter Randomized Controlled Trial of Use of Preoperative Levosimendan to Reduce Low Cardiac Output Syndrome (LCOS) in Low Ejection Fraction (? 35%) Cardiac Surgery Patients Spanish Randomized Clinical Trial on Sindax (Spartans Study)

Background: Low Cardiac Output Syndrome (LCOS) is a complication that appears in approximately 20%of cardiac surgeries with extracorporeal circulation. This is associated with increased mortality, delayed recovery and prolonged hospital stay. The Spanish Randomized Clinical Trial on Sindax (SPARTANS) aims to demonstrate the effectiveness of the preoperative use of levosimendan in reducing LCOS in patients with poor Left Ventricle Ejection Fraction (LVEF) undergoing elective cardiac surgery. Methods: SPARTANS study is a multicenter, randomized triple-blind, placebo-controlled trial. 300 patients with LVEF ≤ 35%, undergoing elective cardiac surgery will be recruited from 9 Spanish hospitals and randomized into two groups: Preoperative administration of levosimendan or placebo for 24 hours. The study drug will be started as a continuous infusion (0.1 μg/kg/ min) at least 8 hours before surgery. The primary endpoint will be 30-day LCOS. It will be evaluated using any of the following criteria: 1) Postoperated cardiac index ≤ 2.0 L/min/m2, 2) Need to implant a intra-aortic balloon pump/left ventricular assist device, 3) Vasoactive inotropic scale (VIS) >5.5. The secondary end-point will be composite event rate at one year including the following events: death from any cause, need for renal replacement therapy or dialysis and LCOS. The sample size is based on the assumption that levosimendan reduces LCOS by 50%. Conclusion: The effectiveness of levosimendan has not yet been reported with a good evidence in cardiac surgery. We will test the hypothesis that levosimendan reduces LCOS in patients with compromised left ventricular function. Trial registration number: NCT04179604 (ClinicalTrials.gov). Rationale and Design of a Spanish Mulicenter Randomized Controlled Trial of Use of Preoperative Levosimendan to Reduce Low Cardiac Output Syndrome (LCOS) in Low Ejection Fraction (≤ 35%) Cardiac Surgery Patients Spanish Randomized Clinical Trial on Sindax (Spartans Study)

Effect of Deep Hypothermic Circulatory Arrest Versus Moderate Hypothermic Circulatory Arrest in Aortic Arch Surgery on Postoperative Renal Function: A Systematic Review and Meta-Analysis.

BackgroundModerate hypothermic circulatory arrest (MHCA) has been widely used in aortic arch surgery. However, the renal function after MHCA remains controversial. We performed a systematic review and meta‐analysis direct comparison of the postoperative renal function of MHCA versus deep hypothermic circulatory arrest (DHCA) in aortic arch surgery.Methods and ResultsWe searched PubMed, Embase, and the Cochrane Library for postoperative renal function after aortic arch surgery with using MHCA and DHCA, published from inception to January 31, 2020. The primary outcome was renal failure. Secondary outcomes were the need for renal therapy and other major postoperative outcomes. The random‐effects model was used for all comparisons to pool the estimates. A total of 14 observational studies with 4142 patients were included. Compared with DHCA, MHCA significantly reduced the incidence of renal failure (odds ratio [OR], 0.76; 95% CI, 0.61–0.94; P=0.011; I2=0.0%) and the need of renal replacement (OR, 0.68; 95% CI, 0.48–0.97; P=0.034; I2=0.0%). Subgroup analysis showed that when the hypothermic circulatory arrest time was <30 minutes, the incidence of renal failure in MHCA group was significantly lower than that in DHCA group (OR, 0.73; 95% CI, 0.54–0.99; P=0.040; I2=1.1%), whereas an insignificant difference between 2 groups when hypothermic circulatory arrest time was >30 minutes (OR, 0.76; 95% CI, 0.51–1.13; P=0.169; I2=17.3%).ConclusionsMHCA compared with DHCA reduces the incidence of renal failure and the need for renal replacement.RegistrationURL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42020169348.

Long-term outcome after dialysis-dependent renal failure on the intensive care unit

HintergrundDas akute dialysepflichtige Nierenversagen („dialysis-requiring acute kidney injury“ [AKI‑D]) ist eine häufige und schwerwiegende Komplikation bei intensivmedizinisch behandelten Patienten.FragestellungIm Rahmen dieser Studie sollte untersucht werden, welchen Einfluss ein AKI‑D auf die Sterblichkeit von Intensivpatienten besitzt, bei welchem Anteil der überlebenden Patienten auch bei Entlassung noch ein Nierenersatzverfahren benötigt wird und wie sich dies auf die Langzeitmortalität und die längerfristige Notwendigkeit einer Dialysetherapie auswirkt.Material und MethodenAuswertung von 118 Patientenfällen mit AKI‑D zwischen November 2016 und Dezember 2017 auf einer internistischen Intensivstation am Universitätsklinikum Tübingen. Die Dialysefreiheit zum Entlasszeitpunkt und die 1‑Jahres-Mortalität wurden als primäre Endpunkte definiert. Den sekundären Endpunkt stellte die Dialysepflichtigkeit nach 18 Monaten dar.ErgebnisseDie Krankenausmortalität der Patienten mit AKI‑D betrug 45,8 % (54/118). Von den 64 überlebenden Patienten mit AKI‑D waren 41 (64,1 %) zum Zeitpunkt der Entlassung nicht mehr auf ein Nierenersatzverfahren angewiesen. Im Vergleich dazu war die 1‑Jahres-Mortalität bei den 23 (35,9 %) Patienten, bei denen zur Krankenhausentlassung noch eine Dialysepflicht bestand, signifikant höher (24,4 % vs. 60,9 %, p = 0,004). Eine Dialysepflichtigkeit 18 Monate nach Krankenhausentlassung bestand bei 7 Patienten (10,9 %). Zu diesem Zeitpunkt waren überwiegend noch Patienten von einer Dialyse abhängig, bei denen bereits zum Entlasszeitpunkt ein Nierenersatzverfahren notwendig war (71,4 % vs. 7,1 %, p = 0,001).SchlussfolgerungenSchwere AKI-Episoden, bei denen ein Nierenersatzverfahren auf einer Intensivstation notwendig wird, sind auch 1 Jahr bzw. 18 Monate nach Entlassung mit einer erhöhten Mortalität bzw. einer anhaltenden Dialysepflichtigkeit assoziiert.

P1011ATHE SGTL-2 INHIBITORS DECREASE THE MORTALITY AND PROGRESSION OF CHRONIC KIDNEY DISEASE (CKD) IN TYPE 2 DIABETES PATIENTES. SYSTEMATIC REVIEW AND META-ANALYSIS OF THE LITERATURE

Abstract Background and Aims Diabetic nephropathy is one of the main causes of chronic kidney disease (CKD) in the world. In the past years new studies using SGLT-2 inhibitors in diabetic patients have shown benefit in both mortality and progression of CKD. However, these works show heterogeneity between studies regarding the severity of CKD of patients included. All above complicates the interpretation of the benefits of SGLT-2 inhibitors. Method We did a systematic search of the literature in PUBMED, EMBASE, Cochrane CENTRAL trials database and in references of the selected studies. Terms used for the search were Canaglifozin, Dapaglifozin, Ertuglifozin, Empaglifozin, diabetes, mortality and CKD. Search included studies in all languages. We selected only randomized and controlled studies that reported mortality and relevant renal outcomes (doubling serum creatinine or decrease in eGFR&amp;gt; 40%, need for renal replacement or renal death). We included studies until September 30, 2019. For the meta-analysis, a Mantel-Haenszel model of random effects was used. The software Review Manager, Version 5.3 The Cochrane Collaboration, 2014 was used. Results We obtained results from 142 studies, fifteen studies met the selected criteria, but only four reported mortality and renal outcomes (EMPA-REG, CANVAS, CREDENCE AND DECLARE-TIMI 58). A total of 38,721 patients (SGTL2 inhibitors n = 21,264 and control n = 17,457) were included for the analysis. The EMPA-REG study used Empaglifozin, the CANVAS and CREDENCE studies used Canaglifozin and the DECLARE-TIMI 58 used Dapaglifozin. All studies were funded by pharmaceutical laboratories.The average age range of the studies was between 62 to 67 years. The percentage of patients with eGFR &amp;lt;60ml/min were 26%, 20%, 60% and 7% for the EMPA-REG, CANVAS, CREDENCE and DECLARE-TIMI 58 studies respectively.Mortality was lower in patients who used SGTL2 inhibitors OR 0.86 (CI 0.80-0.94) Figure 1. Renal outcomes were also lower in patients who used SGTL-2 inhibitors OR 0.69 (CI 0.60-0.78) Figure 2. We assessed whether the effect was related to the severity of the CKD taking out the work with patients with more severe CKD (CREDENCE study), the effect on mortality did not change OR 0.87 (CI 0.80-0.95) as well as renal outcome OR 0.66 (CI 0.52- 0.83). Conclusion The SGTL-2 inhibitors decrease mortality and improve renal outcomes in patients with diabetic nephropathy. These benefits remain in patients with less severe CKD.

Çocuk Yoğun Bakım Ünitesinde Başvuru Trombosit Değerinin Hasta Sağkalımına Etkisi

Introduction Thrombocytopenia is a common haematological finding in critically ill patients. Studies have shown that decreased platelet counts are associated with prolonged hospitalisation, increased costs, and mortality in adult populations. However, not enough studies have investigated the incidence of thrombocytopenia and the relationship between thrombocytopenia and the prognoses of paediatric patients who require treatment in the intensive care unit. We evaluated the effects of initial platelet counts on the outcomes of.pediatric intensive care unit patients. Material and Methods We performed a retrospective analysis of the records of all patients admitted to the pediatric intensive care unit between October 2016 and December 2017. The relationship between the initial thrombocyte counts and the need of invasive mechanical ventilation and non-invasive mechanical ventilation,inotropic drug use, continuous renal replacement need, duration of hospitalization and mortality rate were investigated. Results Totally 387 patients were included in the study. Age distributions ranged from 1 month to 17 years, and the mean patient age was 3.95±4.80 years. The most frequent diagnoses of patients were respiratory disorders (144 patients; 37.2%). There was a statistically significant relationship between thrombocyte levels of the first complete blood count performed during admission and invasive mechanical ventilation, non- invasive mechanical ventilation , inotropic drug use, mortality, acute kidney injury, and continuous renal replacement therapy. Analyses of receiver-operator characteristic (ROC) curves for the thrombocyte counts showed that with a cutoff value of 102,000, mortality had 92.7% sensitivity and 53.1% specificity. The odds ratios (ORs) and relationship between prognostic factors and thrombocytopenia were calculated using logistic regression models. ORs were 4.616 for continuous renal replasman therapy, 6.682 for inotropic drug use, and 3.649 for mortality. Conclusion A low platelet count at the time of admission to the pediatric intensive care unit should be considered an independent risk factor that increases mortality and morbidity and prolongs hospitalisation. Extensive care should be provided to this group of patients.

The renoprotective effects of sodium-glucose cotransporter 2 inhibitors versus placebo in patients with type 2 diabetes with or without prevalent kidney disease: A systematic review and meta-analysis.

We undertook a systematic review and meta-analysis to assess the efficacy and safety of sodium-glucose cotransporter 2 inhibitors (SGLT2is) concerning kidney outcomes in patients with type 2 diabetes mellitus (T2DM), with or without prevalent kidney disease. PubMed, Web of science, Embase and the Cochrane Library were systematically searched for randomized controlled trials (RCTs) to assess the efficacy and safety of treatment with SGLT2is versus placebo in patients with T2DM. The weighted mean difference (WMD) and its 95% confidence interval (CI) were applied for continuous variables, and the risk ratio (RR) and corresponding 95% CI were used for dichotomous outcomes. Patients were categorized according to whether the baseline mean estimated glomerular filtration rate (eGFR) was less or was more than 60 mL/min/1.73 m2 . A total of 25 eligible studies with 43 721 participants were included. There was an initial and small decrease in eGFR during the early treatment period (WMD, -4.63; 95% CI, -6.08 to -3.19 mL/min/1.73 m2 ), which was noted at 1-6 weeks and gradually narrowed over time, with a decline in protection from eGFR in the long term (WMD, 3.82; 95% CI, 2.80-4.85 mL/min/1.73 m2 ). SGLT2is significantly delayed albuminuria progression (RR, 0.71; 95% CI, 0.66-0.76), promoted albuminuria regression (RR,1.71; 95% CI, 1.54-1.90), improved the composite of ≥40% decrease in eGFR, in the need for renal-replacement and in death from renal causes (RR, 0.57; 95% CI, 0.49-0.66), and reduced all-cause mortality (RR, 0.84; 95% CI, 0.75-0.94). At the same time, they significantly increased the risk of genital infection (RR, 3.43; 95% CI, 2.87-4.10) vs placebo in patients with T2DM. Meta-regression analyses showed that eGFR-preservation effects were not significantly associated with basic patient characteristics (age, BMI, HbA1c, eGFR level), but were influenced by drug administration (treatment duration, type, dosage of SGLT2is). Subgroup analyses showed that the relative effects on renal outcomes of SGLT2is vs placebo were similar across eGFR subgroups (P heterogeneity >0.05). SGLT2is slowed eGFR decline, lowered albuminuria progression, improved adverse renal endpoints and reduced all-cause mortality, but increased risk of genital infections vs placebo in patients with T2DM. The indication of consistent renal benefits across categories of baseline eGFR levels may allow additional individuals to benefit from SGLT2is therapy.

Prognosis and Early Prediction of Acute Kidney Injury in Critically Ill Children

Background: Acute kidney injury (AKI) is a serious clinical condition in children admitting to the pediatric intensive care unit. Beside having the risk of significant morbidity and mortality, AKI has also increased the risk for chronic kidney disease. However, there is paucity of data regarding AKI epidemiology in children. Herein, we aimed to describe the incidence, risk factors, and outcome of AKI in critically ill children. Methods: The records of patients, who were hospitalized in our pediatric intensive care unit between October 2016 and March 2018 were investigated retrospectively. The relationship between AKI and the need of invasive mechanical ventilation and non-invasive mechanical ventilation, inotropic and nephrotoxic drug use, initial laboratory findings, continuous renal replacement need, pediatric risk of mortality-III score (PRISM-III), duration of hospitalization, and mortality rate were investigated. Results: Totally, 447 patients were found to have been included in the study. The AKI developed in 111 patients. The sepsis was the most common underlying disease with 27 patients (24.3 %). There was a statistical significance between development of AKI and the need of invasive mechanical ventilation, inotropic and nephrotoxic drug use, PRISM-III score, continuous renal replacement need, plasma exchange, blood component transfusion, duration of hospitalization, and mortality. Conclusions: The AKI is associated with prolonged hospitalization and increased mortality. AKI should be considered as a medical emergency that should be diagnosed and managed accurately.