Receiving Renal Replacement Therapy Research Articles

P0626THE RISK FACTORS OF ACUTE KIDNEY INJURY CAUSED BY HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS

Abstract Background and Aims Hemophagocytic lymphohistiocytosis (HLH) is a syndrome caused by uncontrolled natural killer (NK) cell and cytotoxic T cell activation, resulting in the overproduction of proinflammatory cytokines and hemophagocytosis. Acute kidney injury (AKI) characterized by rapid loss of renal excretion function is the most common complication of HLH in the kidney. In this retrospective study, we aimed to find the risk factors of AKI in patients with HLH. Method This study included adult patients with HLH admitted in West China Hospital of Sichuan University from January 2009 to June 2019. Patients with HLH were excluded from the study if they had a functioning kidney transplant, received renal replacement therapy (RRT) in the past month, suffered from end-stage renal disease (ESRD) or had the renal malignant tumor. The diagnosis of HLH was based on the HLH diagnostic criteria revised by the Histocyte Society in 2004 and AKI was defined according to the 2012 KDIGO (Kidney Disease: Improving Global Outcomes) guideline. We collected basic information, clinical manifestations and laboratory data of patients from electronic medical records. Results We analyzed 294 patients this time, of whom 95 (32.3%) developed AKI. The patients were divided into two groups according to the occurrence of AKI. The mortality rate in the AKI group was significantly higher than that in the non-AKI group (40.0% VS 12.6%; p<0.001). The risk factors of AKI in patients with HLH were hyperphosphatemia [Odds Ratio (OR) 3.825; 95% Confidence Interval (CI) 1.647-8.886; p=0.002] ,heart failure (OR 2.972; 95% CI 1.029-8.584; p=0.044), increased heart rate (OR 1.025; 95% CI 1.008-1.043; p=0.004), prolonged prothrombin time (OR 1.025; 95% CI 1.001-1.049; p=0.041), elevated total bilirubin level (OR 1.003; 95% CI 1.000-1.007; p=0.030), and hypoproteinemia (OR 0.915; 95% CI 0.842-0.994; p=0.035). Conclusion The incidence of AKI in HLH patients is frequent, and the risk of death in HLH patients with AKI is significantly higher. The occurrence of AKI in patients with HLH is related to hyperphosphatemia, heart failure, increased heart rate, prolonged prothrombin time, elevated total bilirubin level, and hypoproteinemia.

Serum N-terminal Pro-B-type Natriuretic Peptide Predicts Mortality in Cardiac Surgery Patients Receiving Renal Replacement Therapy.

Background: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a useful cardiac biomarker that is associated with acute kidney injury (AKI) and mortality after cardiac surgery. However, its prognostic value in cardiac surgical patients receiving renal replacement therapy (RRT) remains unclear.Objectives: Our study aimed to assess the prognostic value of NT-proBNP in patients with established AKI receiving RRT after cardiac surgery.Methods: A total of 163 cardiac surgical patients with AKI requiring RRT were enrolled in this study. Baseline characteristics, hemodynamic variables at RRT initiation, and NT-proBNP level before surgery, at RRT initiation, and on the first day after RRT were collected. The primary outcome was 28-day mortality after RRT initiation.Results: Serum NT-proBNP levels in non-survivors was markedly higher than survivors before surgery (median: 4,096 [IQR, 962.0–9583.8] vs. 1,339 [IQR, 446–5,173] pg/mL; P < 0.01), at RRT initiation (median: 10,366 [IQR, 5,668–20,646] vs. 3,779 [IQR, 1,799–11,256] pg/mL; P < 0.001), and on the first day after RRT (median: 9,055.0 [IQR, 4,392–24,348] vs. 5,255 [IQR, 2,134–9,175] pg/mL; P < 0.001). The area under the receiver operating characteristic curve of NT-proBNP before surgery, at RRT initiation, and on the first day after RRT for predicting 28-day mortality was 0.64 (95% CI, 0.55–0.73), 0.71 (95% CI, 0.63–0.79), and 0.68 (95% CI, 0.60–0.76), respectively. Consistently, Cox regression revealed that NT-proBNP levels before surgery (HR: 1.27, 95% CI, 1.06–1.52), at RRT initiation (HR: 1.11, 95% CI, 1.06–1.17), and on the first day after RRT (HR: 1.17, 95% CI, 1.11–1.23) were independently associated with 28-day mortality.Conclusions: Serum NT-proBNP was an independent predictor of 28-day mortality in cardiac surgical patients with AKI requiring RRT. The prognostic role of NT-proBNP needs to be confirmed in the future.

Transplanting the Elderly: Mandatory Age- and Minimal Histocompatibility Matching.

Worldwide over 40% of patients receiving renal replacement therapy (RRT) are aged 65 years or older, a number that is still increasing. Renal transplantation is the preferred RRT, providing substantial survival benefit over those remaining on dialysis, including the elderly. Only 3% of patients aged 65 years or older accepted on the waiting list actually received a kidney transplant offer within the Eurotransplant allocation region. To increase the chance for elderly to receive a timely kidney transplant, the Eurotransplant Senior Program was introduced. The ESP supports local allocation of older kidneys to older donors in order to decrease cold ischemia time, while disregarding former exchange principles based on matching for HLA antigens. As a consequence, more elderly received a kidney transplant and a relative higher incidence of acute rejection resulted in additional courses of high steroids and/or depleting antibody therapy. Since death with a functioning graft due to infections is the dominant reason of graft loss in elderly, more intense clinical immunosuppression to prevent or treat acute rejection is not a very attractive option. Therefore in elderly kidney transplant candidates, we advocate reintroduction of minimal histocompatibility criteria (i.e., HLA-DR matching) followed by age-matching with mandatory local/regional allocation to also facilitate short cold ischemia.

The Effect of Renal Replacement Therapy and Antibiotic Dose on Antibiotic Concentrations in Critically Ill Patients: Data From the Multinational Sampling Antibiotics in Renal Replacement Therapy Study.

The optimal dosing of antibiotics in critically ill patients receiving renal replacement therapy (RRT) remains unclear. In this study, we describe the variability in RRT techniques and antibiotic dosing in critically ill patients receiving RRT and relate observed trough antibiotic concentrations to optimal targets. We performed a prospective, observational, multinational, pharmacokinetic study in 29 intensive care units from 14 countries. We collected demographic, clinical, and RRT data. We measured trough antibiotic concentrations of meropenem, piperacillin-tazobactam, and vancomycin and related them to high- and low-target trough concentrations. We studied 381 patients and obtained 508 trough antibiotic concentrations. There was wide variability (4-8-fold) in antibiotic dosing regimens, RRT prescription, and estimated endogenous renal function. The overall median estimated total renal clearance (eTRCL) was 50 mL/minute (interquartile range [IQR], 35-65) and higher eTRCL was associated with lower trough concentrations for all antibiotics (P < .05). The median (IQR) trough concentration for meropenem was 12.1 mg/L (7.9-18.8), piperacillin was 78.6 mg/L (49.5-127.3), tazobactam was 9.5 mg/L (6.3-14.2), and vancomycin was 14.3 mg/L (11.6-21.8). Trough concentrations failed to meet optimal higher limits in 26%, 36%, and 72% and optimal lower limits in 4%, 4%, and 55% of patients for meropenem, piperacillin, and vancomycin, respectively. In critically ill patients treated with RRT, antibiotic dosing regimens, RRT prescription, and eTRCL varied markedly and resulted in highly variable antibiotic concentrations that failed to meet therapeutic targets in many patients.

Dyspnoea Assessment In Adults With End-Stage Kidney Disease: A Systematic Review.

Dyspnoea is a common, disabling symptom of people living with end-stage kidney disease (ESKD), which may persist despite optimal management. Dyspnoea assessments can be grouped according to the instruments that assess domains related to: sensory-perception (intensity, sensory quality), affective distress (unpleasantness) and impact/burden (function, quality of life). To describe dyspnoea assessment in adults with ESKD receiving renal replacement therapy (RRT). Systematic review. Five databases were searched. Primary studies reporting an assessment of dyspnoea in adults with ESKD receiving RRT were included. Studies were excluded where participants with ESKD had received palliative/conservative treatment (no dialysis) or renal transplant. Conference abstracts, protocols, commentaries and/or images were excluded. Two independent reviewers screened and extracted the data. Descriptive analysis summarised the (1) number and type of instruments used to assess dyspnoea; (2) which dyspnoea domains to be assessed and (3) rationale and context for dyspnoea assessment. From 2,234 records screened, 28 studies were eligible for inclusion (observational n = 22 and experimental n = 6). Across studies, 12 different instruments were identified (dyspnoea-specific n = 3, subscale of a comprehensive instrument n = 9). Most instruments (n = 11, 92%) assessed a single domain (intensity n = 6, unpleasantness n = 6 and impact/burden n = 5). Studies reported a rationale for measuring dyspnoea (n = 26) as either a characteristic of the participant cohort (n = 14) or as an outcome (n = 14). Surprisingly, a few primary studies reported assessment of dyspnoea in people with ESKD receiving RRT. When assessed, there was a predominance of unidimensional instruments. As dyspnoea is associated with adverse clinical outcomes, routine dyspnoea assessment may improve management and relieve suffering.

Relationship between the serum levels of Vitamin D and inflammatory markers in ESRD patients.

Background and aim:In patients with End-stage renal disease (ESRD), 25-(OH)-Vitamin D3 deficiency is a common problem and also the inflammatory responses increase in these patients. The present study aims to evaluate the relation of 25-(OH)-Vitamin D3 with the indirect inflammatory markers in patients on hemodialysis (HD) and peritoneal dialysis (PD).Methods:This study was done by cross-sectional method on 85 ESRD patients receiving renal replacement therapy (RRT), from one geographical area. 64 patients on HD and 21 patients on PD who were matched for age and sex were studied. Serum level of 25-(OH) Vitamin D3 was measured in each patient. ESR, CRP and the other routine blood tests were measured as well.Results:The level of 25-OH Vitamin D3 was significantly lower in PD group in comparison to HD group (P: 0/0012, 2/70±0/10 vs 2/05±0/14). Platelet (195/40±7/6 vs 265/52±15/6, P: 0/001) and ESR (46/80±6/89 vs 23/53±1/96, P: 0/003) were significantly higher in PD group. Considering total population of the study (PD and HD), there was a significant association between ESR and serum level of 25-(OH)-Vitamin D3 (r: 0.26, P: 0.036) but no correlation was seen between 25-(OH)-Vitamin D3 and hemoglobin (Hb) or duration of dialysis. On the other hand, in patients on HD, multiple regression analysis revealed a significant relationship between duration of dialysis (P: 0.02), Hb (P: 0.01) and ESR (P: 0.001) with 25-(OH)-Vitamin D3 level. Moreover, there was a relationship between vitamin D3 levels and inflammatory markers as well.Conclusions:The deficiency of 25-(OH)-Vitamin D3 was followed with increase of ESR as an inflammatory marker in patients on HD. (www.actabiomedica.it)

I]Clostridioides difficile[/i] infection in patients with end stage renal disease. Is it preventable?

[i]Clostridioides difficile[/i] infection (CDI) is a leading cause of a healthcare-associated diarrhea worldwide. Recently, an increased number of new cases and growing mortality due to CDI have been observed. Patients suffering from end-stage renal disease (ESRD) are most exposed to CDI. It has been proven that CDI in patients receiving renal replacement therapy (RRT) significantly increases mortality, prolongs hospitalization and increases the cost of treatment. Important risk factors of CDI in ERSD patients include hospitalization or stay in an intensive care unit in the last 90 days, HIV infection, bacteremia, prolonged antibiotic therapy and hypoalbuminemia. Cirrhosis, age over 65 years, hypoalbuminemia, longer hospitalization time and use of antibiotics are significant risk factors of death. Effective methods of preventing CDI include hand hygiene with soap and water, isolation of infected patients in a private room with a dedicated toilet, the use of masks, gloves, disinfection of the environment and systematic education and control of medical personnel, as well as rational antibiotic policy. In addition, it is important to avoid antibiotics with a proven risk of CDI, caution use of proton pump inhibitors (PPI) and H2 receptor antagonists. It is also important in the prevention of CDI in people with ERSD, to apply a fast diagnostic since the onset of the first symptoms. The use of probiotics and bile acids in the primary prevention of CDI requires further research. It seems that knowledge of these factors and methods of prevention will significantly reduce morbidity and mortality due to CDI.

Metabolic acidosis in patients with kidney disease.

The number of people receiving renal replacement therapy (RRT), through either dialysis or renal transplantation, exceeds 2.5 million worldwide and its prevalence is expected to rise sharply over the next decades. The predicted growth in prevalence of end-stage kidney disease (ESKD) demonstrates a need for initiatives that will slow the progression to ESKD in Chronic Kidney Disease (CKD) and preserve quality and quantity of life from those on dialysis. For more than a century, metabolic acidosis has been recognized as [...]

Long-term all-cause mortality and cardiovascular outcomes in Scottish children after initiation of renal replacement therapy: a national cohort study

BackgroundData on long-term outcomes in children who have received renal replacement therapy (RRT) for end-stage renal disease are limited.MethodsWe studied long-term survival and incidence of fatal and nonfatal cardiovascular disease (CVD) events and determinants of these outcomes in children who initiated RRT between 1961 and 2013 using data from the Scottish Renal Registry (SRR). Linkage to morbidity records was available from 1981.ResultsA total of 477 children of whom 55% were boys, almost 50% had congenital urinary tract disease (CAKUT), 10% received a transplant as the first mode of RRT and almost 60% were over 11 years of age at start of RRT were followed for a median of 17.8 years (interquartile range (IQR) 8.7–26.6 years). Survival was 87.3% (95% confidence interval (CI) 84.0–90.1) at 10 years and 77.6% (95% CI 73.3–81.7) at 20 years. During a median follow-up of 14.96 years (IQR 7.1–22.9), 20.9% of the 381 patients with morbidity data available had an incident of CVD event. Age < 2 years at start of RRT, receiving dialysis rather than a kidney transplant and primary renal disease (PRD) other than CAKUT or glomerulonephritis (GN), were associated with a higher risk of all-cause mortality. Male sex, receiving dialysis rather than a kidney transplant and PRD other than CAKUT or GN, was associated with a higher risk of CVD incidence.ConclusionsMortality and CVD incidence among children receiving RRT are high. PRD and RRT modality were associated with increased risk of both all-cause mortality and CVD incidence.

P.61Continuous renal replacement therapy in children with mitochondrial diseases

Mitochondrial diseases with defective oxidative phosphorylation and resultant decreased energy production put the patients at risk for metabolic decompensation or critically ill condition such as septic shock or renal failure with intercurrent illness. We aimed to review our experience of pediatric patients with mitochondrial diseases who received renal replacement therapy (RRT) via continuous veno-venous hemofiltration (CVVHF). Clinical history and laboratory data were retrospectively reviewed. We recruited total 11 patients, 3 male and 8 female who received total 15 RRT courses, at age 7.3±6.2 years with mean duration of 11±10.3 days. 2 mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes patients, 3 Leigh syndrome, 6 mitochondrial respiratory enzyme 1 deficiency and 1 unspecified mitochondrial disease patient were included. Reasons for RRT were severe uncontrolled lactic acidosis in 6/15 (40%), acute renal failure for various reasons in 6/15 (40%) and aggravation of known end stage renal disease (ESRD) in 3/15 (20%). 8/11 (72.7%) expired during the RRT courses, all from multiorgan failure. Only 3/11 (27.3%) survived, but 1 died later due to separate respiratory failure event. 1 Leigh syndrome patient received RRT at age 6.2 months, due to severe lactic acidosis 2 days after starting ketogenic diet to treat intractable seizures, was relieved with 1 day RRT and currently alive at age 6.7 years. Other survivor was unspecified mitochondrial disease patient who received 3 courses of RRT at age 4.0, 4.4 and 5.9 years, due to 2 times of known ESRD aggravation and 1 panperitonitis event, and currently alive at age 12.4 years on intermittent hemodialysis. Even though mortality rate was high and RRT via CVVHF is an invasive procedure with risk, considering fast progression of critically ill condition in these patients not compensated by routine treatment, CVVHF could be used as a treatment option and possibly benefit some mitochondrial disease patients.

Vessel wall stiffness parameters and left ventricle remodeling in patients receiving renal replacement therapy

Aim. To perform a comparative assessment of vessel wall stiffness parameters and left ventricle (LV) remodeling in groups of patients with arterial hypertension (AH) receiving renal replacement therapy (RRT) and patients with hypertensive heart disease. Material and methods. One hundred fifty eight people were examined: 32 patients on program hemodialysis (PG), 37 — after kidney transplantation (KT), 69 — with essential hypertension and 20 healthy volunteers. All patients underwent 24-hour blood pressure (BP) monitoring with an assessment of the parameters of daily vessel wall stiffness, aortic pressure and Mand B-mode echocardiography. Results. In groups of patients with PG and after KT, the central and peripheral blood pressure did not differ significantly. When comparing with the group of essential hypertension in RRT patients, with similar values of office systolic and diastolic BP, higher average values of peripheral and central BP were determined. An increase in the values of the pulse wave velocity in the aorta of more than 10 m/s was observed only in RRT patient groups. In all groups of patients with AH, BP and vessel wall Conclusion. Patients receiving RRT have higher values of the average daily pulse wave velocity in the aorta, central BP and a longer period of an increase in the pulse wave velocity in the aorta during the day, higher vessel wall stiffness values, and less pronounced LV spherification than in patients with hypertensive heart disease and comparable values of office BP.

Extracorporeal Cardiopulmonary Resuscitation (ECPR) in Infants and Children: A Single-Center Retrospective Study

Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly used to rescue patients with cardiac arrest refractory to conventional therapy, necessitating evaluation of factors that may affect outcomes. A single-center retrospective review of pediatric patients (<21 years old) who underwent ECPR from January 2010 to November 2017. Comparisons between nonsurvivors and survivors, to decannulation and discharge, were made. Factors associated with survival and rate of complications were examined. Seventy patients were supported with ECPR. Forty-nine (70%) patients survived to decannulation and 38 (54%) patients to discharge. There was no statistical difference between baseline characteristics of survivors and nonsurvivors, including age at cannulation, weight (kg), time to cannulation (minutes), and total time on extracorporeal membrane oxygenation (hours). Survivors to discharge had significantly higher pH prior to cannulation compared to nonsurvivors (7.11 ± 0.24 vs 6.97 ± 0.21, P = .01). Of all, 23.2% of patients received renal replacement therapy (RRT), 39.4% had significant bleeding, 22.5% had thrombotic complications, and 68.8% had neurologic injury on imaging studies. A greater number of nonsurvivors received RRT compared to survivors to discharge (35.5% vs 10.8%, P = .02). There were no differences in bleeding or thrombotic complications or radiographically established neurologic injury. Although ECPR effectively increases overall survival, a better characterization of long-term outcomes is needed.

Toward Portable Artificial Kidneys: The Role of Advanced Microfluidics and Membrane Technologies in Implantable Systems.

Globally, around 2.6 million people receive renal replacement therapy (RRT), and a further 4.9-9.7 million people need, but do not have access to, RRT [1]. The next generation RRT devices will certainly be in demand due to the increasing occurrence of diabetes, atherosclerosis and the growing population of older citizens. This review provides a comprehensive, yet concise overview of the cleared and remaining hurdles in the development of artificial kidneys to move beyond traditional dialysis technology-the current baseline of renal failure treatment. It compares and contrasts the state-of-the-art in 'cell-based' and 'non-cell-based' approaches. Based on this study, a new engineering perspective on the future of artificial kidneys is described. This review suggests that stem-cell-based artificial kidneys represent a long-term, complete solution but it can take years of development due to the limitations of current cell seeding technology, viability and complicated behaviour control. Alternatively, there is much potential for near- and medium- term solutions with the development of non-cell-based wearable and implantable devices to support current therapies. Based on recent fundamental advances in microfluidics, membranes and related research, it may be possible to integrate these technologies to enable implantable artificial kidneys (iAK) in the near future.

Procalcitonin and N-Terminal Pro-B-Type Natriuretic Peptide for Prognosis in Septic Acute Kidney Injury Patients Receiving Renal Replacement Therapy

Background: Sepsis is a complex clinical syndrome leading to severe sepsis and septic shock. It is very common in the intensive care unit with high mortality. Thus, judging its prognosis is extremely important. Procalcitonin (PCT) and ­N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels are commonly elevated in sepsis patients, but only a few are discussed in the septic acute kidney injury patients (AKI) who received renal replacement therapy (RRT). Our study is aimed at investigating the prognostic value of PCT and NT-proBNP in septic AKI patients who received RRT. Methods: This was a retrospective study of septic AKI patients who underwent RRT in a Chinese university hospital. All enrolled patients tested PCT and NT-proBNP at RRT initiation. PCT and NT-proBNP levels were compared between the survivors and non-survivors. Receiver operating characteristic (ROC) curves of the 2 biomarkers were performed for predicting in-hospital mortality. According to the median value of PCT (16.2 ng/mL) and NT-proBNP (10,271 pg/mL), patients were divided into 4 groups (low PCT and low NT-proBNP; high PCT and low NT-proBNP; low PCT and high NT-proBNP; high PCT and high NT-proBNP). The Kaplan-Meier survival curves were used to analyze the 28-day survival rate in the 4 groups. Results: A total of 81 patients were enrolled in the study. Of which, 48 (59.3%) patients died during hospitalization. The median of NT-proBNP in non-survivors was significantly higher than in survivors (p = 0.001), while PCT had no significant difference (p = 0.412). The area under the ROC curve of PCT and NT-proBNP for predicting in-hospital mortality was 0.561 (95% CI 0.426–0.695) and 0.729 (95% CI 0.604–0.854). Kaplan-Meier survival curve analysis showed that increased NT-proBNP level was associated with 28-day mortality while combined with PCT there was no statistical difference in 4 different level groups. Conclusion: NT-proBNP has a certain predictive value for the prognosis in septic AKI patients who received RRT. It seems that the initial PCT value for prognosis is limited. The combination of PCT and ­NT-proBNP to evaluate the prognosis in these critically ill patients is currently unclear.

Temporal change in characteristics and outcomes of acute kidney injury on renal replacement therapy in intensive care units: analysis of a nationwide administrative database in Japan, 2007\u20132016

BackgroundWe aimed to examine recent trends in patient characteristics and mortality in patients with acute kidney injury (AKI) receiving renal replacement therapy (RRT), including continuous RRT (CRRT) and intermittent RRT (IRRT), in intensive care units (ICUs).MethodsFrom the Diagnosis Procedure Combination database in Japan during 6 months (July–December) from 2007 to 2016, we identified patients with AKI who received RRT in ICUs. We restricted the study participants to those admitted to hospitals (in which both CRRT and IRRT were available) that participated in the Diagnosis Procedure Combination database for all 10 years. We examined the trends in patient characteristics and mortality overall, by RRT modality, and by main diagnosis category subgroup. Logistic regression was used to adjust for patient characteristics.ResultsWe identified 51,758 patients starting RRT in 287 hospitals, including 39,471 (76.3%) and 12,287 (23.7%) patients starting CRRT and IRRT. The crude in-hospital mortality declined from 44.9 to 36.1% (P for trend < 0.001). Compared with 2007, the adjusted odds ratio (aOR) for in-hospital mortality was 0.66 (95% confidence interval (CI) 0.60–0.72) in 2016, and the decreasing trend was observed in both patients starting CRRT (aOR 0.67, 95% CI 0.61–0.75) and IRRT (0.58, 0.45–0.74), and in all subgroups except for coronary artery disease: sepsis aOR 0.68 (95% CI 0.57–0.81); cardiovascular surgery 0.58 (0.45–0.76); coronary artery disease 0.84 (0.60–1.19); non-coronary heart disease 0.78 (0.64–0.94); central nervous system disorders 0.42 (0.28–0.62); trauma 0.39 (0.21–0.72); and other 0.64 (0.50–0.82).ConclusionsThis nationwide study confirmed a consistent decline in mortality among patients with AKI on RRT in ICUs. The adjusted mortality also declined during the study period; however, physiological variables were not measured in this study and it is possible that RRT may have been indicated for patients with less severe AKI in more recent years.

Ethylene glycol poisoning requiring critical care: Three case reports

Rapid diagnosis and treatment of ethylene glycol poisoning can be challenging and is critical for reducing the morbidity and the mortality of this intoxication. Cases from our center were retrospectively reviewed. From the 12 cases of ethylene glycol poisoning found since 2007, we present here three with significant toxicity and requiring critical care. Case 1 was an accidental intoxication in a 67 year-old male presenting dysarthria and altered level of consciousness. The patient mistakenly drank a bottle of beer containing a blue liquid 15 h before admission. Case 2 was a voluntary intoxication in a 56 year-old male with coma. The patient was found unconscious under a bridge with 9 wine bottles near him. An open bottle of car antifreeze was found at his home. Case 3 was a voluntary intoxication in a 46 year-old female presenting dyspnea. Ingestion amount was around 3 L of antifreeze 2 days before. Ethylene glycol plasma level was measured using liquid chromatography with ultraviolet detection after benzoyl chloride derivatization. At admission, case 1 showed metabolic acidosis (pH = 7.01) with very high serum lactate (> 20 mmol/L, acute renal failure (serum creatinine = 141 μmol/mL) and acute respiratory failure. The patient was transferred to an intensive care unit (ICU) where he was intubated and received renal replacement therapy (RRT). Ethylene glycol plasma level was 614 mg/L. Fomepizole was started 10 hours after admission. The patient was hospitalized for 35 days. Evolution was favorable but marked with an acute coronary syndrome. Cardiac function was recovered afterward. At admission in the ICU, case 2 was in a coma (Glasgow coma scale 3), and presented dyspnea, metabolic acidosis (pH = 6.90) with very high serum lactate (> 20 mmol/L), acute renal failure (serum creatinine = 141 μmol/mL) and hyperkaliemia (6.6 mmol/L). The patient was intubated and received RRT. Ethylene glycol plasma level was 402 mg/L. Fomepizole was started 18 h after admission. The patient was hospitalized for 21 days. Evolution was favorable except for a lower lip pressure ulcer and chronic kidney injury. Follow up at 2 months showed a partial recovery of renal function. Case 3 presented at admission metabolic acidosis (pH = 7.14) with high serum lactate (8.1 mmol/L), acute respiratory failure and acute renal failure (serum creatinine = 114 μmol/L). After transfer to the ICU, the patient was intubated and received RRT. Ethylene glycol plasma level was 607 mg/L. Fomepizole was started about 4 h after admission. The patient was hospitalized for 23 days. Evolution was marked by a ventilator-associated pneumonia but was favorable otherwise. These 3 cases have in common a severe acidosis associated with an acute renal failure and respiratory disorders. High serum lactate has to be interpreted with caution due to analytical interference [1] . Neurological toxicity was characterized for case 1 and 2. The long hospitalization duration (21 to 35 days) reflects the severity of the intoxications. Fomepizole antidote treatment must be started as soon as possible. Ethylene glycol plasma concentration should be obtained to confirm the diagnosis if available. Even though ethylene glycol poisoning is well known, cases are rare but nonetheless can currently be life-threatening. They require fast diagnostic and treatment to avoid morbidity [2] .

Experience with the HeartMate II Left Ventricular Assist Device in Patients Older than 60 Years.

Advanced age is a relative contraindication for heart transplantation, but no age cutoff has been defined for patients receiving mechanical circulatory support. Between November 1, 2003 and November 1, 2012, we implanted the HeartMate II (HMII) left ventricular assist device (LVAD) in 319 patients. One hundred seven patients (89 men, 18 women) were over 60 years old (mean, 66 ± 4 years, range, 61-78 years) and received the HMII as a bridge to transplantation (n = 45) or as destination therapy (n = 62). We evaluated their experience by performing a retrospective analysis. Seventy-two patients had ischemic cardiomyopathy, and 34 had idiopathic cardiomyopathy. Three patients (2.8%) already had a HeartMate XVE LVAD, 54 (50.5%) were receiving intra-aortic balloon pump support, 52 (48.6%) had undergone a previous cardiac procedure, and 9 (8.4%) had received renal replacement therapy (RRT) (continuous venovenous hemofiltration, hemodialysis, or both) before HMII implantation. The median duration of HMII support was 313 days (range, 1-3339 days). After device implantation, 36 patients (33.6%) had gastrointestinal bleeding, 24 (23%) required RRT, 18 (17.5%) had ventricular arrhythmias, and 24 (22.4%) had LVAD-related infections, and 9 (8.4%) had right ventricular failure requiring mechanical support, and 28 (26.2%) had neurologic complications. The actual survival rate was 69% at 6 months, 63% at 1 year, and 54% at 2 years. Eighty-one patients died, 9 are still receiving HMII support, and 17 are alive after heart transplantation. Older patients can benefit from LVAD therapy, and advanced age should not preclude LVAD implantation.

Balanced crystalloids versus normal saline for fluid resuscitation in critically ill patients: A systematic review and meta-analysis with trial sequential analysis

IntroductionFluid resuscitation is a fundamental component of the management of critically ill patients, but whether choice of crystalloid affects patient outcomes remains controversial. Therefore, we performed this meta-analysis to compare the efficacy and safety of balanced crystalloids with normal saline. MethodsWe searched the MEDLINE, Cochrane Central and EMBASE up to October 2018 to identify randomized controlled trials (RCTs) that compared balanced crystalloids versus normal saline in critically ill patients. The primary outcome was mortality. The secondary results were the incidence of acute kidney injury (AKI) and risk of receiving renal replacement therapy (RRT). Two authors independently screened articles based on the inclusion and exclusion criteria. The meta-analysis was conducted using Revman 5.3, trial sequential analysis (TSA) 0.9 and STATA 12.0. ResultsNine RCTs were identified. The pooled analyses showed that there were no significant differences in mortality (relative risk (RR) = 0.93, 95% confidence interval (CI) = 0.86, 1.01, P = 0.08), incidence of AKI (RR 0.94, 95% CI 0.88, 1.00, P = 0.06) or RRT use rate (RR 0.94, 95% CI 0.69, 1.27, P = 0.67) between balanced crystalloids and normal saline groups. However, TSA did not provide conclusive evidence. ConclusionsAmong critically ill patients receiving crystalloid fluid therapy, use of a balanced crystalloid compared with normal saline did not reduce the mortality, risk of severe AKI or RRT use rate. Further large randomized clinical trials are needed to confirm or refute this finding. Trial registrationA protocol of this meta-analysis has been registered on PROSPERO (registration number: CRD42018094857).

Pneumonia in patients with chronic kidney disease V D stage: pathogenetic aspects of complex therapy and outcomes

Abstract.The aim of our study was to increase the effectiveness of treatment of comorbid pneumonia in patients with CKD VD stage.&#x0D; Materials and Methods. 73 patients with CKD VD st. (59 on HD and 14 on PD) with mild to moderate comorbid pneumonia who received renal replacement therapy (RRT) during 2013-2016 were included in the observational prospective open-label randomized trial. Patients were randomized into two groups: group 1 (n = 42) included patients who in addition to the conventional therapy of pneumonia received medication «Lipin» as a complex therapy; group 2 included patients (n = 31) who received only basic (traditional) therapy. The groups were representative by the main demographic, social and clinical-laboratory findings, severity of pneumonia, duration and modality of RRT. The primary endpoints were death from any cause and episodes of rehospitalization. The overall assessment of the clinical efficacy of the therapy was based on a comparison of the duration of hospitalization, antibiotic therapy, intoxication syndrome, and regression of X-ray changes.&#x0D; Survival in observation groups was determined by the Kaplan-Meier method. Analyzed cases were included to October 31, 2018.&#x0D; The markers of oxidative stress (OS) were determined in 29 patients of group 1 and 14 patients of group 2 before treatment and after 14 days while treatment of pneumonia was started.&#x0D; Results. The analysis demonstrated that during a 1-year period a 17 (25,76%) episodes of rehospitalization were recorded: 11 causes (35.5%) in group 1 and 6 (14.3%) in group 2 (χ² = 4.486, p = 0.035). In total, 29 deaths were recorded during the study period: 10 (23.8%) cases in group 1, and 19 (61.3%) - in group 2 (χ² = 8.957, p = 0.003, RR - 2.574, 95% CI: 1.400-4.733). The three- and five-year cumulative survival rates were 83% vs. 21% and 59% vs. 21%, in the group 1 and group 2, respectively (p = 0.00003). It was stated that the duration of hospitalization, antibiotic therapy, intoxication syndrome and X-ray regression were significantly lower in group 1 compared with group 2 (p &lt;0.05). The comparative analysis of dynamics in the groups shows that increasing the treatment effectiveness at complex therapy background accompanied by a significant positive dynamics of OS markers (p &lt;0,05).&#x0D; Conclusions Thus, the results of this study demonstrated the effectiveness of complex method of pneumonia treatment in patients with CKD stage 5D including Lipin medication compared traditional therapy. There is a significant difference in patient survival depending on the proposed and generally accepted treatment.

End-stage kidney disease in infancy: an educational review.

An increasing number of infants with end-stage kidney disease (ESKD) are surviving and receiving renal replacement therapy (RRT). Unique clinical issues specific to this age group of patients influence their short- and long-term outcomes. This review summarizes current epidemiology, clinical characteristics, ethical dilemmas, management concerns, and outcomes of infants requiring chronic dialysis therapy. Optimal care during infancy requires a multidisciplinary team working closely with the patient's family. Nutritional management, infection prevention, and attention to cardiovascular status are important treatment targets. Although mortality rates remain higher among infants on dialysis compared to older pediatric dialysis patients, outcomes have improved over time. Most importantly, infants who subsequently receive a kidney transplant are now experiencing graft survival rates that are comparable to older pediatric patients.