Renal Replacement Therapy In Patients Research Articles

Transversus abdominis plane block to the rescue

Chronic kidney disease (CKD) is one of the most prevalent conditions worldwide. Patients with CKD require haemodialysis on a regular basis. Peritoneal dialysis is the procedure of choice for renal replacement therapy in patients with end stage renal disease (ESRD). A 43-year-old female patient, diagnosed with cardio renal syndrome (CRS) type 2 was scheduled for continuous ambulatory peritoneal dialysis catheter (CAPD) insertion. Considering the poor condition of her heart and kidneys, bilateral transversus abdominis plane (TAP) block (midline incision) along with monitored anaesthesia care (MAC) was administered thus reducing the perioperative complications.

Risk factors associated with outcomes of peritoneal dialysis in Taiwan: An analysis using a competing risk model.

Peritoneal dialysis (PD) is one option for renal replacement therapy in patients with end-stage renal disease (ESRD). Maintenance of the PD catheter is an important issue for patient outcomes and quality of life. The aim of this retrospective cohort study is to clarify the risk factors of technique failure and outcomes at a single institute in Taiwan.The study enrolled ESRD patients who had received PD catheters in a tertiary hospital in northern Taiwan. Using a competing risks regression model, we reviewed clinical data and analyzed them in terms of the time to technical failure and clinical outcomes, including PD-related peritonitis and mortality.A total of 514 patients receiving PD between 2001 and 2013 were enrolled in the study. According to the multivariate analysis model, we found that diabetes mellitus was a risk factor for PD-related peritonitis (subdistribution hazard ratio [SHR] 1.47, 95% confidence interval [CI] 1.06-2.04, P = .021). Female gender and higher serum albumin levels were associated with lower risks of technique failure (SHR 0.67, 95% CI 0.48-0.94, P = .02; SHR 0.75, 95% CI 0.58-0.96, P = .023, respectively), but Gram-negative and polymicrobial infection increased the technique failure rate (SHR 1.68, 95% CI 1.08-2.61, P = .021; SHR 1.93, 95% CI 1.11-3.36, P = .02, respectively). Female gender was a risk factor associated with overall mortality (SHR 6.4, 95% CI 1.42-28.81, P = .016). Higher weekly urea clearance (Kt/V) and weekly creatinine clearance (WCCr) were associated with a lower risk of mortality (SHR 0.1, 95% CI 0.01-0.89, P = .04; SHR 0.97, 95% CI 0.96-0.99, P = .004, respectively).Diabetes mellitus is a risk factor contributing to PD-related peritonitis. Male patients and lower serum albumin levels were associated with higher rates of technique failure. Female gender, lower Kt/V, and WCCr are risk factors for overall mortality in PD patients.

Antioxidant Supplementation in Renal Replacement Therapy Patients: Is There Evidence?

The disruption of balance between production of reactive oxygen species and antioxidant systems in favor of the oxidants is termed oxidative stress (OS). To counteract the damaging effects of prooxidant free radicals, all aerobic organisms have antioxidant defense mechanisms that are aimed at neutralizing the circulating oxidants and repair the resulting injuries. Antioxidants are either endogenous (the natural defense mechanisms produced by the human body) or exogenous, found in supplements and foods. OS is present at the early stages of chronic kidney disease, augments progressively with renal function deterioration, and is further exacerbated by renal replacement therapy. End-stage renal disease patients, on hemodialysis (HD) or peritoneal dialysis (PD), suffer from accelerated OS, which has been associated with increased risk for mortality and cardiovascular disease. During HD sessions, the bioincompatibility of dialyzers and dialysate trigger activation of white blood cells and formation of free radicals, while a significant loss of antioxidants is also present. In PD, the bioincompatibility of solutions, including high osmolality, elevated lactate levels, low pH, and accumulation of advanced glycation end-products trigger formation of prooxidants, while there is significant loss of vitamins in the ultrafiltrate. A number of exogenous antioxidants have been suggested to ameliorate OS in dialysis patients. Vitamins B, C, D, and E, coenzyme Q10, L-carnitine, a-lipoic acid, curcumin, green tea, flavonoids, polyphenols, omega-3 polyunsaturated fatty acids, statins, trace elements, and N-acetylcysteine have been studied as exogenous antioxidant supplements in both PD and HD patients.

Early mobilisation in intensive care during renal replacement therapy: A quality improvement project

ObjectiveTo improve mobility for patients undergoing renal replacement therapy within intensive care. DesignA quality improvement study utilising a step-wise mobility protocol within a before-and-after audit design. SettingTwenty-four bed Trauma/Surgical intensive care unit within a level one trauma and academic centre. Main outcomeImprovement of compliance to the mobility plan following introduction of a step-wise mobility protocol. ResultsA total of fifty-six renal replacement therapy patients were measured on a randomly selected day each week during the nine month before-and-after protocol audit period. Before introducing the protocol, compliance to mobility was 12.5%, compared to 62.5% after the protocol was introduced. There were no identified negative outcomes, such as catheter loss, filter loss or bleeding, associated with mobilising these patients following implementation of the protocol. ConclusionThe use of a step-wise mobility protocol was effective and safe strategy to increase mobility in the renal replacement therapy patient population.

Potentially Modifiable Predictors for Renal Replacement Therapy in Patients with Cardiac Surgery Associated-Acute Kidney Injury: a Propensity Score-Matched Case-Control Study.

ObjectiveTo discover potentially modifiable perioperative predictors for renal replacement therapy (RRT) in patients with cardiac surgery-associated acute kidney injury (CSA-AKI).MethodsA cohort of 1773 consecutive cardiac surgery patients with postoperative acute kidney injury (AKI) from January 2013 to December 2015 were included retrospectively. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. The primary outcome was CSA-AKI requiring renal replacement therapy (AKI-RRT). The initiation of RRT was based on clinical judgment regarding severe volume overload, metabolic abnormality (e.g., acidosis, hyperkalemia), and oliguria. Patients with AKI-RRT were matched 1:1 with patients without AKI-RRT by a propensity score, to exclude the influence of patients' demographics, comorbidities, and baseline renal function. Multivariable regression was performed to identify the predictors in the matched sample.ResultsAKI-RRT occurred in 4.4% of the entire cohort (n=78/1773), with 28.2% of in-hospital mortality (n=22/78). With the propensity score, 78 pairs of patients were matched 1:1 and the variables found to be predictors of AKI-RRT included the contrast exposure within 3 days before surgery (odds ratio [OR]=2.932), central venous pressure (CVP) >10 mmHg on intensive care unit (ICU) admission (OR=1.646 per mmHg increase), and erythrocyte transfusions on the 1st day of surgery (OR=1.742 per unit increase).ConclusionAKI-RRT is associated with high mortality. The potentially modifiable predictors found in this study require concern and interventions to prevent CSA-AKI patients from worsening prognosis.

Multiple renal arteries in kidney transplantation

Kidney transplantation has become the preferred renal replacement therapy for patients suffering from end-stage renal disease. Today, the results of kidney transplantation have improved enormously due to advances in organ harvesting, organ preservation, surgical techniques, and last but not least immunosuppressive regimens. Renal transplantation is more cost-effective than hemodialysis and provides better quality of life. The success story of transplantation has led to significant demand for organs, which is not met by the current supply of donors be it living or deceased. Besides augmentation of the number of living kidney donation, the lack of organs is partially compensated by extended donor criteria including multiple renal arteries. This article reviews the techniques and pitfalls of arterial reconstruction during renal transplantation.

Prediction of mortality and need for renal replacement therapy in patients of acute kidney injury using fibroblast growth factor 23.

Acute kidney injury (AKI) occurs in up to 50% of patients admitted to the intensive care units. Fibroblast growth factor 23 (FGF23), which plays an important role in regulating phosphate, rises early in AKI. Few studies were conducted to correlate the level of FGF23 and adverse outcomes in AKI. The study was conducted on 30 participants with AKI, which was defined according to AKI network criteria, admitted to the Critical Care Department, Kasr El Aini Hospital, Cairo University between July 2016 and May 2017, and serum FGF23 was measured within 24 h of AKI onset to correlate the level of FGF23 with mortality and need for renal replacement therapy (RRT). Enrollment FGF23 levels were significantly higher among patients who died than in the survival group (mean level: 544.2 vs. 59.3 pg/mL, P = 0.004). Furthermore, FGF23 levels were significantly higher in patients who needed RRT than in other participants (mean level: 529.5 vs. 285.11 pg/mL, P = 0.04). There was a statistically significant positive relationship between FGF23 level and sequential organ failure assessment score (P = 0.03). In patients with AKI, higher FGF23 levels are associated with increased risk of mortality and need for RRT.

ACUTE KIDNEY INJURY IN ELDERLY PATIENTS

In the elderly, impairment of kidney function occurs. Renal diseases overlap with anatomic and functional changes related to age-related involutionary processes. Mortality among patients with acute renal injury is approximately 50%, despite advances in treatment and diagnosis of AKI. To assess the incidence of acute kidney injury in elderly patients and to analyze the causes of acute renal failure depending on age. A retrospective analysis included medical documentation of patients hospitalized in the Nephrology Clinic during the 6-month period. During this period 452 patients were hospitalized in the clinic. A group of 77 patients with acute renal failure as a reason for hospitalization was included in the study. The prerenal form was the most common cause of AKI in both age groups. In both age groups, the most common cause was dehydration; in the group of patients up to 65 years of age, dehydration was 29.17%; in the group of people over 65 years - 43.39%. Renal replacement therapy in patients with AKI was used in 14.29% of patients. In the group of patients up to 65 years of age hemodialysis was 16.67% and above 65 years of age. -13.21% of patients. The average creatinine level in the group of younger patients at admission was 5.16 ± 3.71 mg / dl, in the group of older patients 3.14 ± 1.63 mg / dl. The size of glomerular filtration GFR in the group of younger patients at admission was 21.14 ± 19.54 ml / min, in the group of older patients 23.34 ± 13.33 ml / min. The main cause of acute kidney injury regardless of the age group was dehydration. Due to the high percentage of AKI in the elderly, this group requires more preventive action, not only in the hospital but also at home.

NT-proBNP in the Prognosis of Death or Need for Renal Replacement Therapy in Patients with Stage 3–5 Chronic Kidney Disease

Background: The risk of cardiovascular (CV) complications is much greater in patients with chronic kidney disease (CKD). The aim of this study was to assess predictors of mortality, renal failure progression, and the need for dialysis in patients with CKD. Methods: The study group consisted of 70 patients with stage 3–5 CKD, followed up on average for 33.4 ± 15.6 months. Laboratory tests and echocardiography were performed on all patients. Composite endpoints were defined as (1) all-cause mortality and (2) mortality or renal replacement therapy (RRT), defined as the initiation of dialysis therapy. Results: During the observation period, 13 patients died and 11 began dialysis therapy. NT-proBNP was found to be a significant predictor in receiver operating characteristic curve analysis for all study endpoints. The optimal cutoff value for NT-proBNP as a predictor of mortality was 569.8 pg/mL, with a sensitivity of 53.8% and a specificity of 89.1%. For mortality or RRT, the cutoff value for NT-proBNP was 384.9 pg/mL, with a sensitivity and specificity of 70.8 and 72.7%, respectively. In a multivariate regression analysis, NT-proBNP was an independent predictor of mortality with an OR = 7.5 (95% CI: 1.05–53.87; p = 0.044) and of mortality or RRT with an OR = 4.7 (95% CI: 1.01–22.66; p = 0.048). Conclusions: NT-proBNP is an independent predictor of mortality in patients with CKD and can also be useful for CV risk stratification in this patient population.

Phase angle and mid arm circumference as predictors of protein energy wasting in renal replacement therapy patients.

Objective: to analyze the association between phase angle (PA) and mid arm circumference (MAC) with protein energy wasting (PEW) in renal replacement therapy (RRT) patients. Methods: cross-sectional study. Hemodiafiltration (HDF) and automated peritoneal dialysis (PD) patients were enrolled in the study. MAC and body composition were measured using impedance bioelectric (BIA); PA, fat free mass (FFM), fat mass (FM) and ECW/TBW were obtained. Biochemical (serum albumin and cholesterol) and dietary data (energy and protein intake) were collected. Body mass index (BMI) was calculated. Patients were classified with PEW according to ISRNM criteria (low BMI, low albumin or cholesterol concentrations, low muscle mass and overhydration). Cut-off point of PA and MAC was obtained by ROC analysis. Logistic regression analysis was applied to evaluate the ability of both indicators to predict PEW. Results: sixty-nine patients were included in the study. Fifty-two (52%) were female. Thirty-nine (39%) patients had PEW. The ROC curve reveals that the optimal PA cut-off value for malnutrition risk was 4.64° with 77.8% sensitivity and 76.2% specificity. For MAC, a cut-off value of 29.6 cm shows a sensitivity of 66.6% and specificity of 69.0%. Both indicators showed significant association to PEW after multivariate adjustment. Conclusion: PEW is present almost in 39% of the RRT patients. PA and MAC are useful, simple and independents indicators for predicting PEW in Chronic Kidney disease patients on RRT.

Frequency of renal dysfunction in cardiac surgery patients and its effect on outcome

The purpose of this study was to define the frequency of renal dysfunction, including acute kidney injury (AKI), in cardiac surgery patients and its effect on outcome.
 Materials and methods. Patients 18 years old or older underwent cardiac surgery were included in the study. AKI and chronic kidney disease (CKD) was defined and staged according KDIGO 2012 guidelines. Glomerular filtration rate (GFR) was calculated with CKD-EPI formula. Clinical, laboratory and instrumental investigations were performed to all patients. As well, continuous hemodynamic monitoring was performed in postoperative period. Statistical analysis was conducted with SPSS for Windows v. 17.0.0.
 Results. 239 patients (170 (72,8 %) – male, 65 (27,2 %) – female) underwent cardiac surgery in M.M. Amosov National Institute of Cardio-Vascular Surgery between 29.06.16 and 30.10.16 were included in the study.
 79 patients had a renal dysfunction before surgery: 19 (7.9%) – CKD and 60 (25.1%) – AKI. Renal replacement therapy (RRT) was used in 7 patients (4 — with CKD and 3 — with AKI). AKI was developed in 38 patients (15.9%) in postoperative period and RRT was started in one case.
 Statistically significant risk factors associated with AKI development in postoperative period were epinephrine usage (р<0.05) and heart failure development (р<0,001).
 Hospital mortality was 5.9% - 14 patients (7 (50%) - male, 7 (50 %) - female). All died patients have had renal dysfunction (3 (21.4%) have had AKI on CKD and 11 (78.6%) — AKI). Among them 8 (57.1%) patients have had AKI I, 1 (7.1%) - AKI II and 5 (35.7%) - AKI III.
 Statistically significant risk factors associated with hospital death were multiorgan dysfunction syndrome (р<0.001), sepsis (р<0.001), epinephrine (р<0.001) and norepinehrine (р<0.001) usage. Dobutamine use was associated with significant improvement in hospital mortality (р<0.05).
 Conclusions: Near half of cardiac surgery patients had renal dysfunction in perioperative period. RRT was used in 3.4% patients. Because the majority of died patients have had the first stage of AKI, which rather means the risk of renal dysfunction, and statistical analysis reveals no significant association between renal function and outcome, developing of AKI in cardiac surgery patients is an indicator of severity of main disease, but not a cause of death. Renal dysfunction regardless of time of it development in relation to cardiac surgery is not risk factor of death, in contrast to multiorgan dysfunction syndrome and sepsis, which warrant the use of epinephrine.

Impact of Early versus Late Initiation of Renal Replacement Therapy in Patients with Cardiac Surgery-Associated Acute Kidney Injury: Meta-Analysis with Trial Sequential Analysis of Randomized Controlled Trials.

Background Previous studies have examined the effect of the initiation time of renal replacement therapy (RRT) in patients with cardiac surgery-associated acute kidney injury (CSA-AKI), but the findings remain controversial. The aim of this meta-analysis was to systematically and quantitatively compare the impact of early versus late initiation of RRT on the outcome of patients with CSA-AKI. Methods Four databases (PubMed, the Cochrane Library, ISI Web of Knowledge, and Embase) were systematically searched from inception to June 2018 for randomized clinical trials (RCTs). Two investigators independently performed the literature search, study selection, data extraction, and quality evaluation. Meta-analysis and trial sequential analysis (TSA) were used to examine the impact of RRT initiation time on all-cause mortality (primary outcome). The Grading of Recommendations Assessment Development and Evaluation (GRADE) was used to evaluate the level of evidence. Results We identified 4 RCTs with 355 patients that were eligible for inclusion. Pooled analyses indicated no difference in mortality for patients receiving early and late initiation of RRT (relative risk [RR] = 0.61, 95% confidence interval [CI] = 0.33 to 1.12). However, the results were not confirmed by TSA. Similarly, early RRT did not reduce the length of stay (LOS) in the intensive care unit (ICU) (mean difference [MD] = -1.04; 95% CI = -3.34 to 1.27) or the LOS in the hospital (MD = -1.57; 95% CI = -4.62 to 1.48). Analysis using GRADE indicated the certainty of the body of evidence was very low for a benefit from early initiation of RRT. Conclusion Early initiation of RRT had no beneficial impacts on outcomes in patients with CSA-AKI. Future larger and more adequately powered prospective RCTs are needed to verify the benefit of reduced mortality associated with early initiation of RRT. Trial Registration This trial is registered with PROSPERO registration number CRD42018084465, registered on 11 February 2018.

Lower short-term mortality in ICU patients on chronic dialysis than in those requiring acute dialysis.

In ICU patients, we aimed to describe the outcomes of those with end-stage renal disease (ESRD) as compared to those requiring acute renal replacement therapy (RRT). Retrospective analysis of all adult patients admitted to a general, university hospital ICU from 2005 to 2012. ESRD was defined as use of chronic RRT >90days prior to admission. We included 5927 patients of whom 1004 (17%) received acute RRT and 161 (3%) had pre-existing ESRD requiring RRT. Thirty-day mortality was 42% vs 28% for acute RRT vs ESRD patients (adjusted hazard ratio (aHR) 0.90 (0.61-1.34)), and 16% for those not requiring RRT (aHR 0.91 (0.60-1.38) compared to ESRD patients). Ninety-day mortality was 55% vs 45% for acute RRT vs ESRD patients (aHR 0.96 (0.70-1.31)), and 22% for those not requiring RRT (aHR 1.19 (0.84-1.67) compared to ESRD patients). Ninety-day ESRD survivors were younger, less severely ill and needed less vasopressor treatment than 90-day ESRD non-survivors. Five-year mortality was 68% vs 69% for acute RRT vs ESRD patients (aHR 1.06 (0.81-1.39)), and 38% for those not requiring RRT (aHR 1.31 (0.99-1.74) compared to ESRD patients). The crude mortality for patients with pre-existing ESRD was high. Short-term mortality was within range of those not receiving RRT when adjusted for confounders. The severity of acute illness and the burden of comorbidities may be more important than the lack of kidney function per se for the short-term prognosis of RRT patients in the ICU.

CRRT for sepsis-induced acute kidney injury.

Sepsis-induced acute kidney injury (SI-AKI) represents the first cause of AKI in ICUs, and renal replacement therapy (RRT) is frequently applied in advanced AKI stages. The debate between 'rescue' indications for RRT start in patients with severe AKI (acidosis, hyperkalemia, uremia, oliguria/anuria, volume overload) and a proactive RRT initiation is still ongoing. In addition, current SI-AKI pathophysiologic theory has identified the toxic effects of soluble middle-molecules released during sepsis and inflammation (pathogen and damaged associated molecular patterns).The purpose of the present review is to summarize the recent literature on RRT for patients with SI-AKI. Supportive or replacement measures for severe stages of renal dysfunction and blood purification techniques for sepsis syndrome will be reviewed. Anticipated RRT for SI-AKI does not seem to improve survival or renal recovery. There is no clinical advantage by delivering continuous RRT at high doses for blood purification purposes. Similarly, specific applications with dedicated devices and membranes have yielded no clinical benefit in these patients, so far. In the present review, the recent insights and results from large randomized and nonrandomized trials in the area of RRT applied both as supportive measures for kidney failure and blood purification techniques are described.

Postdischarge Major Adverse Cardiovascular Events of ICU Survivors Who Received Acute Renal Replacement Therapy.

Long-term risk of a major adverse cardiovascular events in ICU survivors who underwent acute renal replacement therapy requires further investigation. Nationwide population-based study using the claims database of Korea. Index admission cases of ICU survivors in government-designated tertiary hospitals PATIENTS:: The study group consisted of ICU survivors who underwent acute renal replacement therapy, and the control group consisted of those without acute renal replacement therapy. Patients were excluded if they 1) were under age 20, 2) expired within 30 days after discharge, 3) received ICU care for less than 24 hours, 4) had a previous ICU admission, 5) had a history of major adverse cardiovascular event, or 6) had a major adverse cardiovascular event-related cardio/cerebrovascular diseases. The outcomes of the patients who received continuous renal replacement therapy were compared with those of patients who received only intermittent renal replacement therapy. None. Information regarding patient characteristics and treatment modalities was collected and adjusted. The main outcome was major adverse cardiovascular event, including acute myocardial infarction, revascularization, and acute ischemic stroke. Patient mortality and progression to end-stage renal disease were also evaluated. We included 12,380 acute renal replacement therapy patients and 382,018 patients in the control group. Among the study group, 6,891 patients were included in the continuous renal replacement therapy group, and 5,034 in the intermittent renal replacement therapy group. The risks of major adverse cardiovascular event (adjusted hazard ratio, 1.463 [1.323-1.619]; p < 0.001), all-cause mortality (adjusted hazard ratio, 1.323 [1.256-1.393]; p < 0.001), and end-stage renal disease (adjusted hazard ratio, 18.110 [15.779-20.786]; p < 0.001) were higher in the acute renal replacement therapy patients than the control group. When we compared the continuous renal replacement therapy patients with the intermittent renal replacement therapy patients, the risk of major adverse cardiovascular event was comparable (adjusted hazard ratio, 1.049 [0.888-1.239]; p = 0.575). Clinicians should note the increased risk of a long-term major adverse cardiovascular event in acute renal replacement therapy patients and consider appropriate risk factor management. Significant difference in the risk of postdischarge major adverse cardiovascular event was not identified between continuous renal replacement therapy and intermittent renal replacement therapy.

No Mortality Benefit for Early Renal Replacement Therapy in Patients with Septic Shock

The timing of renal replacement therapy (RRT) initiation for critically ill patients with acute kidney injury (AKI) remains a subject of debate, with

85] Laparoscopic donor nephrectomy

Objective To present a live demonstration of laparoscopic donor nephrectomy. Renal transplantation is a universally accepted renal replacement therapy for patients with end-stage renal disease. However, this option of treatment is in its infancy in Dubai and plans are underway to promote renal transplantation programme for the benefit of the dialysis-dependent local population with chronic kidney disease.Methods The International Modern Hospital at Dubai is part of Sunrise Group of Hospitals, where an active renal transplantation programme is underway.Results The following video is a live demonstration of such a procedure in a patient with two renal arteries. After donor nephrectomy, both arteries were joined together into a single stump at the back table, prior to carrying out renal transplantation in the recipient.Conclusion Plans are underway to promote a renal transplantation programme in Dubai.

Timing of Renal-Replacement Therapy in Patients with Acute Kidney Injury and Sepsis

BackgroundAcute kidney injury is the most frequent complication in patients with septic shock and is an independent risk factor for death. Although renal-replacement therapy is the standard of care for severe acute kidney injury, the ideal time for initiation remains controversial.MethodsIn a multicenter, randomized, controlled trial, we assigned patients with early-stage septic shock who had severe acute kidney injury at the failure stage of the risk, injury, failure, loss, and end-stage kidney disease (RIFLE) classification system but without life-threatening complications related to acute kidney injury to receive renal-replacement therapy either within 12 hours after documentation of failure-stage acute kidney injury (early strategy) or after a delay of 48 hours if renal recovery had not occurred (delayed strategy). The failure stage of the RIFLE classification system is characterized by a serum creatinine level 3 times the baseline level (or ≥4 mg per deciliter with a rapid increase of ≥0.5 mg per deciliter), urine output less than 0.3 ml per kilogram of body weight per hour for 24 hours or longer, or anuria for at least 12 hours. The primary outcome was death at 90 days.ResultsThe trial was stopped early for futility after the second planned interim analysis. A total of 488 patients underwent randomization; there were no significant between-group differences in the characteristics at baseline. Among the 477 patients for whom follow-up data at 90 days were available, 58% of the patients in the early-strategy group (138 of 239 patients) and 54% in the delayed-strategy group (128 of 238 patients) had died (P=0.38). In the delayed-strategy group, 38% (93 patients) did not receive renal-replacement therapy. Criteria for emergency renal-replacement therapy were met in 17% of the patients in the delayed-strategy group (41 patients).ConclusionsAmong patients with septic shock who had severe acute kidney injury, there was no significant difference in overall mortality at 90 days between patients who were assigned to an early strategy for the initiation of renal-replacement therapy and those who were assigned to a delayed strategy. (Funded by the French Ministry of Health; IDEAL-ICU ClinicalTrials.gov number, NCT01682590.)

Can we predict when to start renal replacement therapy in patients with chronic kidney disease using 6 months of clinical data?

PurposeWe aimed to develop a model of chronic kidney disease (CKD) progression for predicting the probability and time to progression from various CKD stages to renal replacement therapy (RRT), using 6 months of clinical data variables routinely measured at healthcare centers.MethodsData were derived from the electronic medical records of Ajou University Hospital, Suwon, South Korea from October 1997 to September 2012. We included patients who were diagnosed with CKD (estimated glomerular filtration rate [eGFR] < 60 mL·min–1·1.73 m–2 for ≥ 3 months) and followed up for at least 6 months. The study population was randomly divided into training and test sets.ResultsWe identified 4,509 patients who met reasonable diagnostic criteria. Patients were randomly divided into 2 groups, and after excluding patients with missing data, the training and test sets included 1,625 and 1,618 patients, respectively. The integral mean was the most powerful explanatory (R2 = 0.404) variable among the 8 modified values. Ten variables (age, sex, diabetes mellitus[DM], polycystic kidney disease[PKD], serum albumin, serum hemoglobin, serum phosphorus, serum potassium, eGFR (calculated by Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI]), and urinary protein) were included in the final risk prediction model for CKD stage 3 (R2 = 0.330). Ten variables (age, sex, DM, GN, PKD, serum hemoglobin, serum blood urea nitrogen[BUN], serum calcium, eGFR(calculated by Modification of Diet in Renal Disease[MDRD]), and urinary protein) were included in the final risk prediction model for CKD stage 4 (R2 = 0.386). Four variables (serum hemoglobin, serum BUN, eGFR(calculated by MDRD) and urinary protein) were included in the final risk prediction model for CKD stage 5 (R2 = 0.321).ConclusionWe created a prediction model according to CKD stages by using integral means. Based on the results of the Brier score (BS) and Harrel’s C statistics, we consider that our model has significant explanatory power to predict the probability and interval time to the initiation of RRT.

Timing for initiation of sequential continuous renal replacement therapy in patients on extracorporeal membrane oxygenation.

BackgroundExtracorporeal membrane oxygenation (ECMO) is a lifesaving therapy used in critically ill patients with severe cardiopulmonary dysfunction. Continuous renal replacement therapy (CRRT) is supplemented to treat fluid overload, acute kidney injury, and electrolyte disturbances during ECMO. However, the best time to initiate CRRT is not well-defined. We performed this study to identify the optimal timing of CRRT for ECMO.MethodsWe conducted a multicenter retrospective cohort study of 296 patients over 12 years. Patients received CRRT during ECMO at Seoul National University Hospital, Seoul National University Bundang Hospital, or Yonsei University Hospital. We assigned patients to an early or late CRRT group depending on the CRRT initiation time. We considered early CRRT to be CRRT instituted within 72 hours of ECMO initiation.ResultsAmong 296 patients, 212 patients (71.6%) received early CRRT. After using a propensity score matching method, 47 patients were included in each group. The time from ECMO initiation to CRRT initiation was 1.1 ± 0.9 days in the early CRRT group and 14.6 ± 18.6 days in the late CRRT group. No difference in patients’ mortality (P = 0.834) or hospital stay (P = 0.627) between the early and late CRRT groups was found. After adjusting all covariables, there was no significant difference in mortality between the early and late CRRT groups (hazard ratio, 0.697; 95% confidence interval, 0.410–1.184; P = 0.182).ConclusionThis study showed that early CRRT may not be superior to late CRRT in ECMO patients. Further clinical trials are warranted.