Requiring Renal Replacement Therapy Research Articles

Much ado about nothing: the impact of coronary angiography on kidney function in individuals with chronic kidney disease

Abstract Background and Objectives Chronic kidney disease (CKD) is associated with premature coronary artery disease and an increased risk of cardiovascular morbidity and mortality (1). Historically, there has been a tendency to delay or even avoid coronary angiography (CA) in those with CKD due to an increased risk of contrast-induced nephropathy or concern over precipitating the need for chronic dialysis. Such "renal nihilism" may account for the poorer outcomes observed in CKD patients who present with acute coronary syndromes (2). The role of this retrospective analysis was to evaluate the impact of CA on the temporal trend in kidney function in individuals with CKD over a 24-month period. Methods The clinical details of 120 individuals under long-term local follow-up by various Nephrology clinics (CKD clinic, low creatine clearance, polycystic kidney disease, transplant and immunosuppression clinics) was collected. All underwent CA locally. Kidney function was observed at set intervals of 12-, 9-, 6- and 3-months prior to CA, immediately post-CA, and at 3-, 6-, 9- and 12-months post-CA. Only results obtained after the desired time point but within 28 days were included. All CAs regardless of either their indication (elective or urgent) or whether percutaneous intervention (PCI) was performed, were included. Patients already on dialysis at the time of the CA were excluded. Statistical analysis was performed via one-way ANOVA. Results Patient characteristics are summarised in table 1. The average age of patients was 67, with a male preponderance (72%). 22% had CKD 3, 24% had CKD 4 and 12% had CKD 5. 9% were kidney transplant recipients. 37% underwent urgent CA whilst a total of 22% had PCI. 27% progressed to requiring renal replacement therapy (RRT). The mean length to RRT was 2.8 years. The rate of decline in kidney function in the last 12 months prior to CA was 7.7% and 6.3% in the year after CA (figure 1). There was no statistically significant difference in kidney function after CA (p = 0.395). This was replicated in analyses focussing on CKD classes 3, 4 and 5 individually, within stable kidney transplant recipients, and within analysis comparing PCI vs non-intervention CAs. Conclusion The results demonstrate CA does not accelerate the decline in kidney function in those with known CKD over a 12-month period, and suggests where appropriate, an invasive treatment strategy should be consider and utilised more often in this population.Table 1:Patient characteristicsFigure 1:Trend in eGFR relative to CA

Trends in the Incidence of Renal Replacement Therapy Due to Rapidly Progressive Glomerulonephritis in Japan, 2006-2021.

Objective Patients with rapidly progressive glomerulonephritis (RPGN) are at a high risk of progression to end-stage kidney disease (ESKD), requiring renal replacement therapy (RRT). The present study examined recent trends in the incidence of RRT due to RPGN in Japan. Methods The number of patients with incident RRT due to RPGN by sex from 2006 to 2021 was extracted from the Japanese Society of Dialysis Therapy Registry. The incidence rates of RRT were calculated for four-year periods with the census population as the denominator. Standardized incidence ratios (SIRs) and age-specific incidence rates were also calculated. Results From 2006 to 2021, the crude number of patients with incident RRT due to RPGN increased by 34% and 58% in men and women, respectively. The SIRs decreased significantly in 2010-2013 relative to the first period (2006-2009) for both men [0.90 (95% confidence interval (CI) 0.85-0.96)] and women [0.92 (0.86-0.99)] but then increased to 1.01 (0.96-1.07) for men and 1.20 (1.13-1.27) for women in 2018-2021. In the older age groups (≥70 years old), age-specific incidence rates initially decreased in 2010-2013 but increased thereafter, peaking in 2018-2021. Conclusion From 2006 to 2021, the number of patients with incident RRT due to RPGN increased, with an increase in the age-specific incidence of RRT due to RPGN in the older age groups (≥70 years old), suggesting that the number of patients with incident RRT due to RPGN will continue to increase as the population ages in Japan.

Epidemiological changes and outcomes of people living with HIV admitted to the intensive care unit: a 14-year retrospective study.

Since 2016, the World Health Organization has recommended universal antiretroviral therapy (ART) for all people living with Human Immunodeficiency Virus (PLHIV). This recommendation may have influenced the characteristics and outcomes of PLHIV admitted to the Intensive Care Unit (ICU). This study aims to identify changes in the epidemiological and clinical characteristics of PLHIV admitted to the ICU, and their short- and medium-term outcomes before and after the implementation of universal ART (periods 2006-2015 and 2016-2019). This retrospective, observational, single-center study included all adult PLHIV admitted to the ICU of a University Hospital in Barcelona from 2006 to 2019. The study included 502 admissions involving 428 patients, predominantly men (75%) with a median (P25-P75) age of 47.5years (39.7-53.9). Ninety-one percent were diagnosed with HIV before admission, with 82% under ART and 60% admitted from the emergency department. In 2016-2019, there were more patients on ART pre-admission, reduced needs for invasive mechanical ventilation (IMV) and fewer in-ICU complications. ICU mortality was also lower (14% vs 7%). Predictors of in-ICU mortality included acquired immunodeficiency syndrome defining event (ADE)-related admissions, ICU complications, higher SOFA scores, IMV and renal replacement therapy (RRT) requirement. ART use during ICU admission was protective. Higher SOFA scores, admission from hospital wards, and more comorbidities predicted one-year mortality. The in-ICU mortality of critically ill PLHIV has decreased in recent years, likely due to changes in patient characteristics. Pre- and ICU admission features remain the primary predictors of short- and medium-term outcomes.

Desmopressin use in major cardiac surgery is associated with renal impairment: a retrospective single-center analysis

BackgroundDesmopressin acetate (1-deamino-8-d-arginine vasopressin—DDAVP) is a analogue of the antidiuretic hormone vasopressin. DDAVP is suggested to reduce bleeding after cardiac surgery using cardiopulmonary bypass. The aim of this study was to determine if DDAVP has any negative impact on renal function leading to acute kidney injury (AKI) and therefore increases the need for renal replacement therapy (RRT).MethodsWe performed a retrospective single institutional cohort analysis of 2,179 patients undergoing elective and urgent cardiac surgery with CPB from 2017 to 2021. Logistic regression analysis was used to investigate any association between DDAVP, the incidence of AKI KDIGO class 3 and the need for RRT, respectively. The model was adjusted for relevant covariates, including preexisting renal impairment, pharmacological hemodynamic support with vasopressors, complexity of the surgery and postoperative lactate. Secondary outcomes included, in hospital mortality and the need for allogenic blood transfusion.ResultsA total of 992 (45.5%) patients received DDAVP intraoperatively during surgery or shortly thereafter. The use of DDAVP was associated with a significant increase in in AKI KDIGO class 3 (OR 2.27; 95% CI 1.46–3.55; p < 0,001) and the need for RRT (OR 2.19; 95%CI 1.48–3.24; p < 0,001). Both findings persisted after covariate adjusting. No increased in-hospital mortality was associated with DDAVP.ConclusionIn cardiac surgery, the use of DDAVP was associated with an increased rate of server AKI and the requirement for RRT. Given the severity of the potential harm associated with DDAVP, an evidence-based reevaluation is needed to enable an accurate risk and benefit assessment.

A new score predicting renal replacement therapy in patients with crush injuries: Analysis of a major earthquake

BackgroundIt is important to predict which patients may require renal replacement therapy (RRT) at the time of initial presentation after crush injuries. There is limited data in the literature examining the predictors of RRT. MethodsThis study was conducted by evaluating 2232 patients who presented to our hospital following two major earthquakes of magnitudes 7.6 and 7.7 Mw that occurred in Kahramanmaras, Turkey, on February 6, 2023. A total of 314 patients who were hospitalized upon being rescued from the rubble and had a creatine kinase (CK) level above 1000 U/L were included in the final analysis. Factors predicting the need for RRT were investigated, and a dialysis score was developed for this prediction. Resultsthe 314 patients included in the study, 95 (30.2 %) developed acute kidney injury (AKI). RRT was performed on 68 (21.6 %) patients. The optimal cut-off value of CK for the prediction of AKI was 23,000 U/L. Multivariate analysis revealed that factors predicting RRT were the number of traumatized sides (odds ratio [OR]: 2.2, 95 % confidence interval [CI]: 1.09–4.39, p = 0.026), albumin (OR:0.11, 95 % CI: 0.04–0.32, p < 0.001), and CK (OR: 1.00, 95 % CI 1.00–1.00, p < 0.001). A dialysis score was developed ranging from 0 to 7 based on the number of traumatized sides, albumin, and CK. The area under the curve (AUC) of the dialysis score in receiver operating characteristic analysis was 0.974. A dialysis score of 4 or higher had a sensitivity of 97.1 % and a specificity of 89.4 % for predicting the need for RRT. ConclusionsThe dialysis score predicts the need for RRT quite well. The simplicity of use and high sensitivity and specificity of this score in earthquake-related crush injuries will greatly facilitate clinicians in patient triage and follow-up.

Sex-Related Differences in Outcome of Patients Treated With Microaxial Percutaneous Left Ventricular Assist Device for Cardiogenic Shock

The use of microaxial percutaneous left ventricular assist devices (pLVADs) in cardiogenic shock (CS) has increased in recent years, despite limited evidence, and data on sex disparities are particularly scarce. This study aimed to compare short-term outcomes between males and females. Data were retrospectively collected from the Dresden Impella Registry, which is a large, prospective, single-centre registry that consecutively enrolled patients who received microaxial pLVAD. Inclusion criteria were CS due to left ventricular failure with serum lactate >4 mM. Patients with pLVAD other than Impella CP were excluded. The primary endpoint was the composite of all-cause mortality at 30 days or requirement of renal replacement therapy (RRT). Secondary endpoints were the components of the primary endpoint alone. Propensity score matched (PSM) analysis was used to adjust for baseline characteristics. A total of 319 male (69 years; body mass index, 26.7 kg/m2) and 113 female patients (74 years; 27.9 kg/m2) were included in the study. The primary composite endpoint occurred less frequently in female patients in the unmatched analysis (♂ 75.9% [n=239] vs ♀ 64.4% [n=72]; p=0.040) but not in the PSM analysis (♂ 81.1% [n=73] vs ♀ 68.9% [n=42]; p=0.056). However, females less frequently required RRT in both analyses (♂ 48.2% [n=126] vs ♀ 25.9% [n=25]; p=0.001; PSM: ♂ 49.1% [n=36] vs ♀ 23.3% [n=12]; p=0.007). All-cause mortality did not differ between the cohorts. This study showed no differences in all-cause mortality at 30 days between male and female patients receiving microaxial pLVAD in CS. Larger studies are required to confirm whether female sex is associated with reduced requirement of RRT in CS treated with microaxial pLVAD.

Hemodynamic management of acute kidney injury

Purpose of review To discuss the role of hemodynamic management in critically ill patients with acute kidney injury. Recent findings Acute kidney injury (AKI) may be associated with persistent alterations in renal perfusion, even when cardiac output and blood pressure are preserved. The effects of interventions aiming at increasing renal perfusion are best evaluated by renal Doppler or contrast enhance ultrasound. However, limited data have been acquired with these techniques and the essential of the literature is based on surrogates of renal function such as incidence of use of renal replacement therapy. Fluids may increase renal perfusion but their effects are quite unpredictable and can be dissociated from their impact on cardiac output and arterial pressure. Inotropes can also be used in selected conditions. At the de-escalation phase, fluid withdrawal should be considered. Safe fluid withdrawal may be achieved when applied in selected patients with preserved tissue perfusion presenting signs of fluid intolerance. When applied, stopping rules should be set. Dobutamine, milrinone and levosimendan increase renal perfusion in AKI associated with cardiac failure or after cardiac surgery. However, the impact of these agents in sepsis is not well defined. Regarding vasopressors, norepinephrine is the first-line vasopressor agent, but vasopressin derivative may limit the requirement of renal replacement therapy. Angiotensin has promising effects in a limited size post-Hoc analysis of a RCT, but these data need to be confirmed. While correction of severe hypotension is associated with improved renal perfusion and function, the optimal mean arterial pressure (MAP) target level remains undefined, Systematic increase in MAP results in variable changes in renal perfusion. It sounds reasonable to individualize MAP target, paying attention to central venous and intraabdominal pressures, as well as to the response to an increase in MAP. Summary Recent studies have refined the impact of the various hemodynamic interventions on renal perfusion and function in critically ill patients with AKI. Though several of these interventions improve renal perfusion, their impact on renal function is more variable.

Homeless patients requiring haemodialysis: incidence, caseload characteristics, and implications for care

Background Homelessness is a recognized risk factor for the development of kidney failure. However, the risk of requiring renal replacement therapy (RRT) in homeless populations remains unknown. Furthermore, access to and provision of RRT for homeless populations have not been described. Methods We performed a retrospective study of all patients who newly commenced in-centre haemodialysis at St. James’s Hospital, Dublin, from January 2021 to December 2023. Housing status was captured using registered addresses and a review of social workers’ assessments. Homelessness was defined according to the European Typology on Homelessness and Housing Exclusion Criteria. Using publicly available census and homelessness data, we estimated the risk of commencing haemodialysis among homeless and non-homeless populations in the catchment area. Results The overall prevalence of homelessness among adults in the catchment area was approximately 2000/270,000 (0.74%). Of the 74 patients who commenced haemodialysis over the 3-year period, 13 (17.6%) were homeless. There was a significant difference in the incidence of commencing haemodialysis between non-homeless and homeless individuals in the catchment area (p&lt;0.001, chi-square test). Among patients who commenced haemodialysis, the mean age was 53 years in homeless patients and 62 years in non-homeless patients (p&lt;0.05, one-way ANOVA). 3/13 homeless patients (23%) had received nephrology healthcare at least 3 months prior to haemodialysis, compared with 39/61 non-homeless patients (64%) (p &lt;0.05, chi-square). Of the three homeless patients who had received three months of nephrology healthcare prior to haemodialysis, all three patients commenced haemodialysis via an arteriovenous fistula. Mental health comorbidities were more frequent among homeless patients than among non-homeless patients (23% versus 8%) (not statistically significant), as were substance use disorders (38% versus 7%) (p&lt;0.05, chi-squared test). Conclusion The incidence of kidney failure requiring haemodialysis was higher in homeless adults than in their non-homeless peers. Homeless patients were younger and started haemodialysis more urgently. There is an unmet need for nephrology healthcare for the homeless population.

Is it possible to predict persistent acute kidney injury in critically ill patients with COVID-19 infection?

Critically ill patients with coronavirus disease 2019 (COVID-19) often face a heightened risk of morbidity and mortality, particularly due to complications such as acute kidney injury (AKI). While the persistent acute kidney injury risk index (PARI) has shown promise in predicting the risk of persistent AKI (pAKI) in non-COVID patients, its effectiveness in critically ill COVID-19 patients remains to be explored. We aimed to evaluate the predictive power of the PARI in identifying pAKI and its prognostic significance in terms of clinical outcomes. This was a single-center retrospective study of patients with COVID-19 admitted at our 36-bed tertiary intensive care unit between April and December 2020. There were 152 patients who fulfilled our inclusion criteria. Fifty seven (37.5%) had developed AKI and 16 (10.25%) had developed pAKI. Vasopressor, mechanical ventilation and renal replacement therapy (RRT) requirement, sequential organ failure assessment (SOFA), and PARI were significantly higher in patients who developed pAKI than those who did not. The PARI were significantly higher in patients with short-term mortality compared to survivors. The area under the receiver operating characteristic (ROC) curve (AUC) of the PARI score for predicting pAKI was 0.66 (95% CI: 0.53-0.79), whereas short-term mortality was 0.733 (95% CI, 0.65-0.81). The PARI score was evaluated as simple, useful, and reliable in predicting pAKI in severe cases with COVID-19; and therefore, pAKI and its related RRT complications can be prevented with protective interventions. Further comprehensive studies are warranted to deepen our understanding of this relationship.

Long-term outcomes of renal AL amyloidosis patients undergoing autologous stem cell transplantation: Validating the performance of the renal staging system.

Renal AL amyloidosis can be complicated by end-stage renal disease (ESRD) requiring renal replacement therapy (RRT). In this study, we describe the long-term outcomes of renal AL amyloidosis patients undergoing autologous stem cell transplantation (ASCT) and assess the utility of the renal staging system. Retrospective study of renal AL patients (n = 697; Mayo Clinic, Boston University) who underwent ASCT between 2003 and 2020. Renal stage was assigned based on 24-h proteinuria and estimated glomerular filtration rate measurements. Renal survival was defined as the time from ASCT until initiation of RRT, while patients who were not placed on RRT were censored at their last follow-up. With a median follow-up of 10.4 years, RRT was required in 149 patients (21%). The median time from ASCT to ESRD was 3.4 years, with late events of progression to ESRD seen >10 years from ASCT. Pre-ASCT renal stage was significantly associated with the cumulative incidence of RRT: 3-year RRT rate was 3%, 10%, and 37% for renal stages I, II, and III, respectively. However, in the 2012-2020 period subset, a significant decrease in ESRD risk was noted across all renal stages (3-year RRT 0%, 5%, and 24%, respectively). In multivariate analysis, renal survival was independently associated with the pre-ASCT renal stage, lambda isotype, bone marrow plasmacytosis ≥20%, post-ASCT hematologic response, and year of ASCT. Long-term outcomes of renal AL amyloidosis treated with ASCT are presented. Renal stage reliably predicts renal outcomes in patients with AL undergoing ASCT, despite a reduction in the proportion of patients progressing to RRT in recent years.

Optimizing ICU Care: Machine Learning and PCA for Early Prediction of Renal Replacement Therapy Requirement.

Forecasting the need for Renal Replacement Therapy (RRT) in intensive care units (ICUs) at an early stage can enhance patient outcomes and optimize resource allocation. The study aimed to develop a model for early prediction of Renal Replacement Therapy (RRT) requirement within 24 hours of ICU admission, utilizing machine learning techniques and SHapley Additive exPlanations (SHAP). It assessed various models including Random Forest (RF), Neural Network (NN), and XGBoost, using data from 34,000 ICU admissions. XGBoost showed superior performance in terms of AUPRC, while RF performed better in AUC-ROC. Results were consistent before and after Principal Component Analysis (PCA) and feature evaluation analysis. The top 10 feature models outperformed the PCA model while using fewer inputs. These findings suggest the potential utility of the developed models in accurately predicting RRT requirement within 24 hours of ICU admission, aiding in efficient critical care delivery.

Acute kidney injury and COVID-19: the predictive power of BUN/albumin ratio for renal replacement therapy requirement.

To investigate the predictive power of the BUN/albumin ratio (BAR) measured in the emergency department (ED) for the requirement of renal replacement therapy (RRT) in patients admitted to the intensive care unit (ICU) with severe COVID-19 pneumonia and acute kidney injury (AKI). The study included 117 patients with AKI who were admitted to the ICU and had COVID-19 pneumonia detected on chest computed tomography (CT) taken in the ED's pandemic area between November 1, 2020, and June 1, 2021. The predictive power of laboratory values measured at the time of ED admission for the requirement of RRT was analyzed. Of the patients, 59.8% (n = 70) were male, with an average age of 71.7 ± 14.8years. The mortality rate of the study was 35% (n = 41). During follow-up, 23.9% (n = 28) of the patients required RRT. Laboratory parameters measured at the time of ED admission showed that patients who required RRT had significantly higher BAR, BUN, and creatinine levels, and significantly lower albumin levels (all p < 0.001). ROC analysis to determine the predictive characteristics for RRT requirement revealed that the BAR had the highest AUC value (AUC, 0.885; 95% CI 0.825-0.945; p < 0.001). According to the study data, for BAR, a cut-off value of 1.7 resulted in a sensitivity of 96.4% and a specificity of 71.9%. In patients with severe pneumonia who develop acute kidney injury, the BUN/albumin ratio may guide clinicians early in predicting the need for renal replacement therapy.

A Comparative Study Between Patients with Community Acquired Acute Kidney Injury and Hospital Acquired Acute Kidney Injury from A Tertiary Care Hospital In Eastern Nepal

BACKGROUND Acute kidney injury is increasingly prevalent in both low and high income countries and is associated with increased morbidity and mortality. This study aims to compare the outcomes of community acquired AKI (CA-AKI) and hospital acquired AKI (HA-AKI) among patients admitted to the department of internal medicine, B.P.Koirala Institute Of Health Sciences (BPKIHS), Dharan. METHODS The study was a hospital based prospective, observational study conducted in internal medicine ward of a tertiary care hospital. The study duration was one year, from November 2019 to October 2020. A total of 100 patients were enrolled out of which 50 were patients with CA-AKI and 50 were patients with HA-AKI. Demographic and serum creatinine at baseline, on the day of discharge or 7th day and after 3 months were collected using pre-designed questionnaire and recorded in a structured porforma. Patients were followed up at 3months after discharge to evaluate treatment outcome as recovery from AKI, chronic kidney disease (CKD), requirement for Renal Replacement Therapy and mortality in both groups. RESULTS The mean age was 51.93±20.55 years with HA-AKI patients older than CA-AKI. Common co-morbidities were systemic hypertension(24% in CA-AKI and 34% in HA-AKI) followed by Diabetes mellitus(16% in CA-AKI and 28 in HA-AKI), CLD(6% in CA-AKI and 2% in HA-AKI), heart failure(6%in CA-AKI and 10% in HA-AKI).The mortality at 3 months was 20.00% in HA-AKI and 8.89% in CA-AKI. CKD was 8.88% in HA-AKI and 24.44% in CA-AKI. The need for hemodialysis was higher in CA-AKI patients than HA-AKI patients (14% vs. 2%; p=0.05). Most common cause of AKI in both the groups was infection. HA-AKI patients were found to have higher length of hospital stay than CA-AKI (8.5±6.8 days vs. 7.30±3.60 days; p=0.28) . CONCLUSIONS Patients with CA-AKI seem to have a higher requirement for renal replacement therapy. Mortality or incidence of CKD was similar in both the groups at 3 months. HA-AKI patients were found to have higher length of hospital stay than CA-AKI.

Urine Output and Development of Acute Kidney Injury in Sepsis: A Multicenter Observational Study.

Acute kidney injury (AKI) is common in sepsis and a urine output <0.5 mL/kg/h associated with increased mortality is incorporated into AKI diagnosis. We aimed to identify the urine-output threshold associated with increased AKI incidence and hypothesized that a higher urine output than a specified threshold, which differs from the predominantly used 0.5 mL/kg/h threshold, would be associated with an increased AKI incidence. This was a post-hoc analysis of a nationwide prospective observational study. This study included adult patients newly diagnosed with sepsis and requiring intensive care. Urine output on the day of sepsis diagnosis was categorized as low, moderate, or high (<0.5, 0.5-1.0, and >1.0 mL/kg/h, respectively), and we compared AKI incidence, renal replacement therapy (RRT) requirement, and 28-day survival by category. Estimated probabilities for these outcomes were also compared after adjusting for patient background and hourly fluid administration. Among 172 eligible patients, AKI occurred in 46.3%, 48.3%, and 53.1% of those with high, moderate, and low urine output, respectively. The probability of AKI was lower in patients with high urine output than in those with low output (43.6% vs 56.5%; P = .028), whereas RRT requirement was lower in patients with high and moderate urine output (11.7% and 12.8% vs 49.1%; P < .001). Patients with low urine output demonstrated significantly lower survival (87.7% vs 82.8% and 67.8%; P = .018). Cubic spline curves for AKI, RRT, and survival prediction indicated different urine-output thresholds, including <1.2 to 1.3 mL/kg/h for AKI and <0.6 to 0.8 mL/kg/h for RRT and mortality risk. Urine output >1.0 mL/kg/h on the day of sepsis diagnosis was associated with lower AKI incidence. The urine-output threshold was higher for developing AKI than for RRT requirement or mortality.

Outcomes of ultra-low contrast percutaneous coronary intervention in patients with advanced chronic kidney disease.

Coronary angiography and percutaneous coronary intervention (PCI) in patients with chronic kidney disease (CKD) is associated with increased risk of contrast induced nephropathy (CIN) and requirement for renal replacement therapy (RRT). We aimed to evaluate our single center experience of ultra-low contrast PCI in patients with CKD and to characterize 1 year outcomes. We performed a retrospective analysis of ultra-low contrast PCI at our institution between 2016 and 2022. Patients with CKD3b-5 (eGFR <45 mL/min/1.73m2), not on RRT who underwent ultra-low contrast PCI ( < 30 mL of contrast during PCI) were included. Primary outcomes included change in eGFR post-procedurally, and death, RRT requirement, and major adverse cardiac events (MACE) at 1 year follow-up. One hundred patients were included in the study. The median age was 67 years old and 28% were female. The median baseline eGFR was 21.5 mL/min/1.73m2 (IQR 14.08-32.0 mL/min/1.73m2). A median of 8.0 mL (IQR 0-15 mL) of contrast was used during PCI. Median contrast use to eGFR ratio was 0.37 (IQR 0-0.59). There was no significant difference between pre-and postprocedure eGFR (p = 0.84). At 1 year, 8% of patients died, 11% required RRT and 33% experienced MACE. The average time of RRT initiation was 7 months post-PCI. Forty-four patients were undergoing renal transplant evaluation, of which 17 (39%) received a transplant. In patients with advanced CKD, ultra-low contrast PCI is feasible and safe with minimal need for peri-procedural RRT. Moreover, ultra-low contrast PCI may allow for preservation of renal function in anticipation of renal transplantation.

Nadir Creatinine in Congenital Anomalies of the Kidney and Urinary Tract (CAKUT): A Single-Center Experience.

Congenital anomalies of the kidney and urinary tract (CAKUT) are the main cause of chronic kidney disease (CKD) requiring renal replacement therapy (RRT) in children, being the leading cause (50-70%) of end-stage renal disease (ESRD) in children and young adults. Our study aimed to assess the natural evolution of various antenatally diagnosed renal malformations and to identify potential prognostic factors to guide the therapeutic management of patients with CAKUT. We conducted a retrospective study on 205 children with CAKUT. For each patient, analyzing their medical records, we established the nadir value of serum creatinine, defined as the lowest creatinine level during the first year of life. We assessed the value of nadir creatinine as a prognostic marker in patients with CAKUT, and using an ROC curve, we also determined a threshold value of nadir creatinine that predicted progression to ESRD. The male-to-female ratio was 2.8 to 1. The mean gestational age at detection was 29.85 weeks (±6.71). A total of 36 patients (17.6%) had impaired renal function, of which 8 (3.9% of the total) progressed to ESRD. The mean nadir creatinine in patients with ESRD was 1.39 mg/dL. A nadir creatinine cut-off of 0.98 mg/dL had high sensitivity and specificity in identifying patients with progression to ESRD, with an AUC of 0.95 and a 95% confidence interval between 0.86 and 1.05 mg/dL. Our results support the value of nadir creatinine in predicting progression to ESRD, consistent with previously published data.

Features of the course of the new coronavirus infection COVID-19 in patients with chronic kidney disease

BACKGROUND: CKD is one of the main comorbidities in those who die from COVID-19. Renal injury is the most common nonpulmonary infection of SARS-CoV-2 and has a wide range of manifestations, ranging from mild proteinuria and hematuria to progressive acute kidney injury (AKI) requiring renal replacement therapy (RRT).THE AIM: to study the features of the course of the new coronavirus infection COVID-19 in patients with chronic kidney disease.PATIENTS AND METHODS: The study included 79 patients with confirmed new coronavirus infection COVID-19 who hospitalized. The first group consisted of people with a history of CKD (44 people), the second group included people without a history of CKD (35 people). The diagnosis of CKD established based on the calculation of glomerular filtration rate using the CKD-EPI formula. The comorbidity index calculated using two scales: Charlson and CIRS-G. Statistical data analysis carried out using the Statistica 12.0 application package (StatSoft Inc., USA).RESULTS: Patients with COVID-19 and CKD had a higher comorbidity index: according to the Charlson index in one group of patients the indicator was 7 [5.0-9.0], and in group 2 it was 5 [4.0-6.0] (p&lt;0.001). According to the CIRS-G index, in one group the indicator was 9 [7-11.5], in two group it was 4 [2-6] (p &lt;0.001). Patients in one group had a greater degree of damage to the lung tissue according to MSCT of the OGK; in laboratory tests, the levels of CRP, ferritin, LDH, and d-dimer were higher; leukocytosis with a neutrophil shift in the leukocyte count observed.CONCLUSION: Patients with a history of chronic kidney disease (CKD) had more severe COVID-19 and higher mortality.

Predictive enrichment for the need of renal replacement in sepsis-associated acute kidney injury: combination of furosemide stress test and urinary biomarkers TIMP-2 and IGFBP-7

BackgroundIn sepsis, initial resuscitation with fluids is followed by efforts to achieve a negative fluid balance. However, patients with sepsis-associated acute kidney injury (SA-AKI) often need diuretic or renal replacement therapy (RRT). The dilemma is to predict whether early RRT might be advantageous or diuretics will suffice. Both the Furosemide Stress Test (FST) and measurements of the urinary biomarkers TIMP-2*IGFBP-7, if applied solely, do not provide sufficient guidance. We tested the hypothesis that a combination of two tests, i.e., an upstream FST combined with downstream measurements of urinary TIMP-2*IGFBP-7 concentrations improves the accuracy in predicting RRT necessity.MethodsIn this prospective, multicenter study 100 patients with sepsis (diagnosed < 48h), AKI stage ≥ 2, and an indication for negative fluid balance were included between 02/2020 and 12/2022. All patients received a standardized FST and urinary biomarkers TIMP-2*IGFBP-7 were serially measured immediately before and up to 12 h after the FST. The primary outcome was the RRT requirement within 7 days after inclusion.Results32% (n = 32/99) of SA-AKI patients eventually required RRT within 7 days. With the FST, urine TIMP-2*IGFBP-7 decreased within 2 h from 3.26 ng2/mL2/1000 (IQR: 1.38–5.53) to 2.36 ng2/mL2/1000 (IQR: 1.61–4.87) in RRT and 1.68 ng2/mL2/1000 (IQR: 0.56–2.94) to 0.27 ng2/mL2/1000 (IQR: 0.12–0.89) and non-RRT patients, respectively. While TIMP-2*IGFBP-7 concentrations remained low for up to 12 h in non-RRT patients, we noted a rebound in RRT patients after 6 h. TIMP-2*IGFBP-7 before FST (accuracy 0.66; 95%-CI 0.55–0.78) and the FST itself (accuracy 0.74; 95%-CI: 0.64–0.82) yielded moderate test accuracies in predicting RRT requirement. In contrast, a two-step approach, utilizing FST as an upstream screening tool followed by TIMP-2*IGFBP-7 quantification after 2 h improved predictive accuracy (0.83; 95%-CI 0.74–0.90, p = 0.03) compared to the FST alone, resulting in a positive predictive value of 0.86 (95%-CI 0.64–0.97), and a specificity of 0.96 (95%-CI 0.88–0.99).ConclusionsThe combined application of an upstream FST followed by urinary TIMP-2*IGFBP-7 measurements supports highly specific identification of SA-AKI patients requiring RRT. Upcoming interventional trials should elucidate if this high-risk SA-AKI subgroup, identified by our predictive enrichment approach, benefits from an early RRT initiation.

Prevalence and Neurological Outcomes of Comatose Patients With Extracorporeal Membrane Oxygenation

To investigate prevalence, risk factors, and in-hospital outcomes of comatose extracorporeal membrane oxygenation (ECMO) patients. Retrospective observational. Tertiary academic hospital. Adults received venoarterial (VA) or venovenous (VV) ECMO support between November 2017 and April 022. None. We defined 24-hour off sedation as no sedative infusion (except dexmedetomidine) or paralytics administration over a continuous 24-hour period while on ECMO. Off-sedation coma (comaoff) was defined as a Glasgow Coma Scale score of ≤8 after achieving 24-hour off sedation. On-sedation coma (comaon) was defined as a Glasgow Coma Scale score of ≤8 during the entire ECMO course without off sedation for 24 hours. Neurological outcomes were assessed at discharge using the modified Rankin scale (good, 0-3; poor, 4-6). We included 230 patients (VA-ECMO 143, 65% male); 24-hour off sedation was achieved in 32.2% VA-ECMO and 26.4% VV-ECMO patients. Among all patients off sedation for 24 hours (n = 69), 56.5% VA-ECMO and 52.2% VV-ECMO patients experienced comaoff. Among those unable to be sedation free for 24 hours (n = 161), 50.5% VA-ECMO and 17.2% VV-ECMO had comaon. Comaoff was associated with poor outcomes (p < 0.05) in VA-ECMO and VV-ECMO groups, whereas comaon only impacted the VA-ECMO group outcomes. In a multivariable analysis, requirement of renal replacement therapy was an independent risk factor for comaoff after adjusting for ECMO configuration, after adjusting for ECMO configuration, acute brain injury, pre-ECMO partial pressure of oxygen in arterial blood, partial pressure of carbon dioxide in arterial blood, pH, and bicarbonate level (worst value within 24 hours before cannulation). Comaoff was common and associated with poor outcomes at discharge. Requirement of renal replacement therapy was an independent risk factor.

Risk factors of death or chronic renal replacement therapy requirements in patients with thrombotic microangiopathies without ADAMTS-13 deficiency.

Thrombotic microangiopathy (TMA), characterized by microangiopathic hemolytic anemia, thrombocytopenia, and multisystem organ dysfunction, is a life-threatening disease. Patients with TMA who do not exhibit a severe ADAMTS-13 deficiency (defined as a disintegrin-like and metalloprotease with thrombospondin type 1 motif no. 13 activity ≥10%: TMA-13n) continue to experience elevated mortality rates. This study explores the prognostic indicators for augmented mortality risk or necessitating chronic renal replacement therapy (composite outcome: CO) in TMA-13n patients. We included 42 TMA-13n patients from January 2008 to May 2018. Median age of 41 years and 60% were female. At presentation, 62% required dialysis, and 57% warranted intensive care unit admission. CO was observed in 45% of patients, including a 9-patient mortality subset. Multivariate logistic regression revealed three independent prognostic factors for CO: early administration of eculizumab (median time from hospitalization to eculizumab initiation: 5 days, range 0-19 days; odds ratio [OR], 0.14; 95% confidence interval [CI], 0.02-0.94), presence of neuroradiological lesions (OR, 6.67; 95% CI, 1.12-39.80), and a PLASMIC score ≤4 (OR, 7.39; 95% CI, 1.18-46.11). In conclusion, TMA-13n patients exhibit a heightened risk of CO in the presence of low PLASMIC scores and neuroradiological lesions, while early eculizumab therapy was the only protective factor.