Requiring Renal Replacement Therapy Research Articles

Construction and validation of risk prediction models for renal replacement therapy in patients with acute pancreatitis.

Renal replacement therapy (RRT) plays a crucial role in managing acute pancreatitis (AP). This study aimed to develop and evaluate predictive models for determining the need for RRT among patients with AP in the intensive care unit (ICU). A retrospective selection of patients with AP was made from the Medical Information Mart for Intensive Care IV (MIMIC-IV, version V2.0). The cohort was randomly divided into a training set (447 patients) and a validation set (150 patients). The least absolute shrinkage and selection operator (LASSO) regression cross-validation method was utilized to identify key features for model construction. Using these features, four machine learning (ML) algorithms were developed. The optimal model was visualized and clarified using SHapley Additive exPlanations (SHAP) and presented as a nomogram. The mean age of the cohort was 59.17years, with an average Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 17.55. Acute kidney injury (AKI) was observed in 52.43% of patients with AP, and 9.05% required RRT. After feature selection, four of 41 clinical factors were ultimately chosen for use in model construction. The Lasso-Logistic Regression (Lasso-LR) model showed a high discriminative ability to predict RRT risk in patients with AP, with an area under the receiver operating characteristic (AUROC) of 0.955 (95% CI 0.924-0.987) in the training set. In the validation set, it maintained its discriminative performance, achieving an AUROC of 0.985 (95% CI 0.970-1.000). Calibration curves indicated an excellent fit in both sets (Brier scores: 0.039 and 0.032, respectively), suggesting high consistency. Decision curve analysis (DCA) highlighted the Lasso-LR model's significant clinical utility in predicting RRT likelihood in patients with AP. Developed via the LASSO regression cross-validation method, the Lasso-LR model significantly excels in predicting the requirement for RRT in patients with AP, demonstrating its potential for clinical application.

Impact of mechanical ventilation on severe acute kidney injury in critically ill patients with and without COVID-19 – a multicentre propensity matched analysis

BackgroundAcute kidney injury (AKI) is common in critically ill patients and is associated with increased morbidity and mortality. Its complications often require renal replacement therapy (RRT). Invasive mechanical ventilation (IMV) and infections are considered risk factors for the occurrence of AKI. The use of IMV and non-invasive ventilation (NIV) has changed over the course of the pandemic. Concomitant with this change in treatment a reduction in the incidences of AKI and RRT was observed. We aimed to investigate the impact of IMV on RRT initiation by comparing critically ill patients with and without COVID-19. Furthermore, we wanted to investigate the rates and timing of RRT as well as the outcome of patients, who were treated with RRT.ResultsA total of 8,678 patients were included, of which 555 (12.8%) in the COVID-19 and 554 (12.8%) in the control group were treated with RRT. In the first week of ICU stay the COVID-19 patients showed a significantly lower probability for RRT initiation (day 1: p < 0.0001, day 2: p = 0.021). However, after day 7 a reversed HR was found. In mechanically ventilated patients the risk was significantly higher for the initiation of RRT over the entire stay. While in non-COVID-19 patients this was a non-significant trend, in COVID-19 patients the risk for RRT was significantly increased. The median delay between initiation of IMV and requirement of RRT was observed to be longer in COVID-19 patients (5 days [IQR: 2–11] vs. 2 days [IQR: 1–5]). The analysis restricted to patients with RRT showed a significantly higher risk for ICU death in patients requiring IMV compared to patients without IMV.ConclusionThe analysis demonstrated that IMV as well as COVID-19 are associated with an increased risk for initiation of RRT. The association between IMV and risk of RRT initiation was given for all investigated time intervals. Additionally, COVID-19 patients showed an increased risk for RRT initiation during the entire ICU stay within patients admitted to an ICU due to respiratory disease. In COVID-19 patients treated with RRT, the risk of death was significantly higher compared to non-COVID-19 patients.

Comparison of integrated versus parallel continuous renal replacement therapy combined with veno-venous extracorporeal membrane oxygenation in patients with COVID-19 ARDS

IntroductionAcute kidney injury (AKI) is a common complication of acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS) in patients receiving extracorporeal membrane oxygenation (ECMO) support, leading to requirement of continuous renal replacement therapy (CRRT) in 70% of ECMO patients. Parallel arrangement of CRRT and ECMO circuits is common in adult patients. However, CRRT may also be integrated directly into the ECMO circuit. This study compares the safety of both approaches.MethodsThis retrospective analysis included 105 patients treated with continuous veno-venous haemodiafiltration and veno-venous ECMO (Cardiohelp©) for COVID-19-induced ARDS between April 2020 and December 2021. Of these, 48 patients received a parallel connected CRRT running independently from ECMO (parallel approach), while in 57 patients, CRRT was integrated into the ECMO circuit (integrated approach) by connecting the CRRT access line to the post-oxygenator port and the CRRT return line to the pre-oxygenator position. Local protocol for risk assessment of this device combination mandated a maximum return line pressure below 250 mmHg in the CRRT system.ResultsAt CRRT initiation, the integrated group had significantly higher median pressures in CRRT lines compared to the parallel approach group (access line 110 mmHg vs. -25 mmHg, return line 170 mmHg vs. 50 mmHg; p < 0.01). However, median transmembrane pressures were similar between both groups (20 mmHg vs. 20 mmHg, p = 0.16). In-hospital mortality (p = 0.99), catheter associated infections (p = 0.47), bacteraemia (p = 0.96), filter clotting (p = 0.58) and unplanned CRRT system changes (p = 0.45) within the first 72 h of CRRT were comparable between both groups. The integrated group exhibited higher rates of bleeding events (37% vs. 23%; p = 0.08). Thromboembolism occurred in four cases in the integrated group, while one pneumothorax was observed in the parallel group. No cases of air embolism, device associated haemolysis or blood leakage was documented.ConclusionsDespite higher pressures in CRRT lines, the integrated approach provided comparable safety to the parallel approach. In case of hygienically challenging settings (such as the COVID-19 pandemic), the minimization of extracorporeal accesses and the streamlining of alarm management are decisive factors in providing intensive care medicine. Therefore, the integrated configuration of CRRT into the ECMO circuit can be advantageous in daily intensive care medicine.

Effect of acute kidney injury care bundle on kidney outcomes in cardiac patients receiving critical care: a systematic review and meta-analysis

BackgroundCardiac surgery is a major contributor to acute kidney injury (AKI); approximately 22% of patients who undergo cardiac surgery develop AKI, and among them, 2% will require renal replacement therapy (RRT). AKI is also associated with heightened risks of mortality and morbidity, longer intensive care stays, and increased treatment costs. Due to the challenges of treating AKI, prevention through the use of care bundles is suggested as an effective approach. This review aimed to assess the impact of care bundles on kidney outcomes, mortality, and hospital stay for cardiac patients in critical care.MethodsPubMed, Scopus, Web of Science, and EMBASE were searched up to November 2024. Inclusion criteria were studies on individuals with cardiac diseases receiving critical care, that used AKI care bundle as the intervention, and reported outcomes related to AKI, mortality, and other kidney-related events. We used the Cochrane Collaboration’s risk of bias tool 2 and the Newcastle-Ottawa scale for quality assessment. Pooled odds ratios (ORs) or risk ratios (RRs) with 95% confidence intervals (CIs) were calculated.ResultsSeven studies on total 5045 subjects, including five observational and two randomized controlled trials (RCTs) were included. The implementation of care bundles significantly reduced the incidence of all-stage AKI (OR: 0.78; 95%CI: 0.61–0.99) and moderate-severe AKI (OR: 0.56; 95%CI: 0.43–0.72). Also, the implementation of care bundle increased the incidence of persistent renal dysfunction after 30 days by 2.39 times. However, there were no significant changes in RRT, major adverse kidney events, or mortality between the groups. The mean quality assessment score for observational studies was 7.2 out of ten, while there were noted concerns in the risk of bias assessment of the RCTs.ConclusionsThe application of care bundles in patients, including those undergoing cardiac surgeries as well as non-cardiac critical illness, appears to be effective in reducing AKI, particularly in moderate and severe stages. However, given the inclusion of non-cardiac patients in some studies, the observed effect may not be solely attributable to cardiac surgery cases. Future large-scale RCTs focusing specifically on cardiac surgery patients are recommended to clarify the impact of care bundles within this subgroup.Registration ID in PROSPEROCRD42024498972.

REEVALUATING MEAN ARTERIAL PRESSURE TARGETS IN SEPSIS AND SEPTIC SHOCK: INSIGHTS FROM A SYSTEMATIC REVIEW AND META-ANALYSISREEVALUATING MEAN ARTERIAL PRESSURE TARGETS IN SEPSIS AND SEPTIC SHOCK: INSIGHTS FROM A SYSTEMATIC REVIEW AND META-ANALYSIS

The conflicting evidence on the clinical impact of higher versus lower mean arterial pressure (MAP) targets in sepsis and septic shock underscores the urgent need to redefine optimal MAP thresholds to improve outcomes in these critical illnesses. This systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. A data search was conducted on July 1, 2024, for randomized controlled trials and observational studies published from January 2004 to December 2023, assessing patient outcomes based on MAP goal parameters. The primary outcomes were all-cause mortality and overall adverse events. Patients with elevated MAP targets exhibited significantly higher odds of all-cause mortality (odds ratio [OR]: 1.10, 95% confidence interval [CI]: 1.00–1.22), atrial fibrillation (OR: 2.52, 95% CI: 1.25–5.07), and supraventricular arrhythmia (OR: 1.81, 95% CI: 1.07–3.04) compared to those with lower MAP targets (all p≤0.05). In contrast, higher MAP patients with chronic hypertension and sepsis had significantly lower odds of requiring renal replacement therapy (RRT) (OR: 0.77, 95% CI: 0.62–0.97; p=0.03). No significant differences were observed in overall adverse events, acute myocardial infarction, intensive care unit length of stay, major bleeding, mesenteric ischemia, RRT, 28-day survival, or ventricular tachycardia between the groups. This study highlights that targeting higher MAP in sepsis patients may elevate the risk of cardiac complications, such as atrial fibrillation and supraventricular arrhythmia, without having substantial benefits in reducing mortality or adverse events. The conflicting evidence on the clinical impact of higher versus lower mean arterial pressure (MAP) targets in sepsis and septic shock underscores the urgent need to redefine optimal MAP thresholds to improve outcomes in these critical illnesses. This systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. A data search was conducted on July 1, 2024, for randomized controlled trials and observational studies published from January 2004 to December 2023, assessing patient outcomes based on MAP goal parameters. The primary outcomes were all-cause mortality and overall adverse events. Patients with elevated MAP targets exhibited significantly higher odds of all-cause mortality (odds ratio [OR]: 1.10, 95% confidence interval [CI]: 1.00–1.22), atrial fibrillation (OR: 2.52, 95% CI: 1.25–5.07), and supraventricular arrhythmia (OR: 1.81, 95% CI: 1.07–3.04) compared to those with lower MAP targets (all p≤0.05). In contrast, higher MAP patients with chronic hypertension and sepsis had significantly lower odds of requiring renal replacement therapy (RRT) (OR: 0.77, 95% CI: 0.62–0.97; p=0.03). No significant differences were observed in overall adverse events, acute myocardial infarction, intensive care unit length of stay, major bleeding, mesenteric ischemia, RRT, 28-day survival, or ventricular tachycardia between the groups. This study highlights that targeting higher MAP in sepsis patients may elevate the risk of cardiac complications, such as atrial fibrillation and supraventricular arrhythmia, without having substantial benefits in reducing mortality or adverse events.

Definitions of Hemodynamic Instability Related to Renal Replacement Therapy in Critically Ill Patients: A Systematic Review Protocol.

Hemodynamic instability related to renal replacement therapy (HIRRT) is a common complication affecting critically ill patients that require renal replacement therapy (RRT). There is currently no consensus regarding the definition of HIRRT in critically ill patients. In this context, the impacts of HIRRT on clinical outcomes such as mortality or renal recovery in critically ill patients are unclear. The primary objective of this proposed systematic review is to evaluate the association between HIRRT and clinical outcomes, as reported within randomized control trials in the literature. The secondary objective of this systematic review is to compare rates of HIRRT, according to various definitions used by randomized controlled trials, across different RRT modalities used to treat critically ill patients, with the goal of paving the way toward a common definition of HIRRT for future research. Systematic review and meta-analysis. The rates of HIRRT, mortality, and renal recovery will be reported according to each definition of HIRRT. Critically-ill adults with acute kidney injury admitted to intensive care units. The search strategy will be developed to identify articles in Medline, MEDLINE In-Process, EMBASE, and Cochrane CENTRAL Registry. We will include randomized control trials examining renal replacement therapy in critically ill patients. This will include intermittent hemodialysis (iHD), all forms of prolonged intermittent RRT (PIRRT), and continuous renal replacement therapy (CRRT). Only articles that report a definition of HIRRT and the rates of HIRRT will be included in our analysis. Two reviewers will independently screen all articles for inclusion and exclusion. Data extraction and quality assessment will be also performed in duplicate. All disagreements will be resolved through discussion or a third reviewer. The heterogeneity in the definitions of HIRRT and outcome reporting may limit the ability to perform meta-analysis and perform comparisons in the rates of HIRRT between RRT modalities. This systematic review aims to assess the association between HIRRT and important clinical outcomes. In doing so, we will identify definitions of HIRRT within the current literature and the rates of HIRRT associated with these definitions. HIRRT can result in early discontinuation of dialysis, organ injury from hypoperfusion, and may negatively impact mortality and renal recovery in critically ill patients. This systematic review will synthesize the impact and frequency of HIRRT reported in the literature and, in doing so, may help determine the extent to which common definitions of HIRRT might be recommended for standardized use in future research related to HIRRT. PROSPERO registration number: CRD42023396550.

Apakah Sepsis Perlu Dilakukan CRRT

Sepsis is a condition of systemic inflammation due to dysregulation of the immune system against infection which causes multiorgan failure. One of the most frequent complications of sepsis and has a high mortality rate is acute renal failure (AKI). Often, sepsis that has already occurred requires renal replacement therapy (RRT). The continuous renal replacement therapy (CRRT) technique is currently more widely used than other techniques, namely intermittent hemodialysis (IHD). IHD often causes hemodynamic problems and even causes cardiac arrest in patients who experience hemodynamic disorders in the ICU. Apart from being useful in AKI, CRRT is also useful in eliminating mediators in sepsis. This aims to reduce the severity of cytokine storms and pro-inflammatory endotoxins thereby improving patient outcomes. Several methods and devices such as high cut-off membranes, Oxiris®-AN69 membranes, CytoSorb® and HA380 cytokine hemoadsorption, polymyxin B endotoxin adsorption and plasmapheresis have been widely observed as ways to improve outcomes in septic patients. However, until now data regarding actual benefits is still controversial. This article reviews the benefits and standard operational procedures of RRT in sepsis patients.

Fluid Management in Critical Care: New Insights Into Optimal Fluid Therapy.

Fluid management is a crucial critical care component, influencing outcomes such as organ function, renal integrity, and survival in critically ill patients. Recent evidence suggests that balanced crystalloids may offer advantages over isotonic saline, particularly in reducing the risk of acute kidney injury (AKI) and other complications. This study aimed to evaluate the impact of balanced crystalloids versus isotonic saline on clinical outcomes in the intensive care unit (ICU), focusing on AKI, renal replacement therapy (RRT), and mortality. The study also assessed the role of fluid restriction in specific patient populations, including those with acute respiratory distress syndrome (ARDS), sepsis, and heart failure. A retrospective cohort study included 600 adult patients admitted to the ICU who received fluid therapy between January 2023 and January 2024. Patients were categorized into two groups based on the type of fluid received: 300 patients received balanced crystalloids and 300 received isotonic saline. Outcomes of interest included the incidence of AKI, the need for RRT, overall ICU mortality, oxygenation status (PaO2/FiO2 ratio), duration of mechanical ventilation, cumulative fluid balance, and length of ICU stay. Statistical analyses included multivariate logistic regression to adjust for potential confounders. The incidence of AKI was significantly lower in the balanced crystalloids group (12% vs. 22%, p = 0.01), with an adjusted odds ratio (OR) of 0.50 (95% CI 0.32-0.78, p = 0.002). The need for RRT was also reduced (8% vs. 15%, p = 0.03), with an adjusted OR of 0.55 (95% CI 0.30-0.95, p = 0.03). Although ICU mortality was lower in the balanced crystalloids group (18% vs. 24%), this difference did not reach statistical significance (p = 0.08). Subgroup analysis showed that in ARDS patients, fluid restriction combined with balanced crystalloids improved oxygenation (PaO2/FiO2 ratio of 220 vs. 180, p = 0.02) and reduced the duration of mechanical ventilation (six vs. nine days, p = 0.01). Similar benefits were observed in sepsis and heart failure patients. Balanced crystalloids are associated with a significant reduction in AKI incidence and RRT requirement compared to isotonic saline. Fluid restriction, particularly when combined with balanced crystalloids, improves clinical outcomes in patients with ARDS, sepsis, and heart failure. These findings support the preferential use of balanced crystalloids in critically ill patients and highlight the importance of individualized fluid management strategies in the ICU. Further research is needed to confirm these benefits and optimize fluid therapy protocols in diverse ICU populations.

The influence of intermittent venovenous hemodiafiltration on the course of acute kidney injury in multiple trauma victims

Background. Acute kidney injury (AKI) is a common complication of polytrauma that requires renal replacement therapy (RRT) in 10 to 28 % of cases. RRT methods can be divided into discrete, or intermittent, and continuous. There are currently no clear recommendations regarding the choice of the RRT method. The purpose was to study the effect of intermittent venovenous hemodiafiltration (HDF) on indicators of renal function, hemodynamics, homeostasis and inflammation in multiple trauma victims with rhabdomyolysis and AKI. Materials and methods. Fifty victims with multiple trauma complicated by rhabdomyolysis and AKI were examined. We investigated the levels of total creatine kinase and myoglobin, indicators of kidney function, frequency of vasopressor support, indicators of general blood analysis, liver complex, coagulogram, acid-base and gas composition of blood. The study was conducted upon admission, before the start and after the end of each HDF session and on the last day of treatment. Results. Multiple trauma with massive rhabdomyolysis led to AKI, manifested by oliguria and hyperazotemia (and from the 3rd day, by hyperkalemia), as well as cardiovascular failure, anemia, liver dysfunction, and inflammatory response. AKI progression to renal failure despite conservative therapy led to the beginning of HDF on 3.6 ± 0.8 days of hospital stay. HDF allowed to effectively reduce indicators of the renal complex and normalize the potassium level, and at the same time did not have a negative effect on hemostasis or other indicators of homeostasis. 72.9 % of victims needed two HDF sessions, 47.9 % — three, 31.3 % — four or more. The most pronounced reduction of hyperazotemia was observed after the second session. Among the survivors, restoration of adequate diuresis by the day 14 was observed in 39.3 % of cases. The mortality rate was 34.0 %. Laboratory markers of renal function were not significantly different between survivors and deceased; the difference was in markers of liver function, coagulogram and acid-base balance, as well as the need for vasopressor support. That is, the mortality was due to the progression not so much of kidney failure, but of the failure of other organs and systems. It should also be noted that the injury severity score among survivors was 23.5 ± 4.0 points, and among non-survivors — 40.5 ± 6.8 points (p &lt; 0.001). Conclusions. Multiple trauma with massive rhabdomyolysis leads to the development of multiple organ failure. Intermittent HDF allows to quickly and effectively reduce azotemia and normalize potassium levels without adversely affecting coagulation or other indicators of homeostasis. Most multiple trauma victims need 2 or more sessions of HDF. Mortality remains high and primarily depends on the severity of anatomical injuries and the addition of other organs and systems failure.

SGLT2 Inhibitors and Finerenone: A friendly Duo in the Treatment of Diabetic Kidney Disease?

For decades, achieving glycemic control, target blood pressure, and renin-angiotensin-aldosterone system (RAAS) blockade remained to be the therapeutic interventions for retarding diabetic kidney disease (DKD) progression. The management of DKD showed major transformation when SGLT2 inhibitors were recommended to reduce the risk of progressive deterioration in estimated glomerular filtration rate (eGFR), end-stage renal disease (ESRD), and renal death following results of CREDENCE and DAPA-CKD trials. Despite currently available therapeutic approaches, the risk of cardiac death, progression to ESRD, and requirement of renal replacement therapy remains high. Finerenone is the newer potent selective nonsteroidal mineralocorticoid receptor antagonist (MRA) that showed reduction in primary composite renal and CV outcomes in FIDELIO-DKD and FIGARO-DKD studies, respectively. While SGLT2 inhibitors have direct effects on cellular and metabolic functions besides reduction in glomerular hyperfiltration, finerenone primarily inhibits mineralocorticoid pathway-dependent inflammation and fibrosis. The renal benefits of dapagliflozin in the DAPA-CKD trial were regardless of MRA, and likewise, the benefits of finerenone in FIDELIO and FIGARO studies were irrespective of SGLT2i. Moreover, the risk of serious hyperkalemia with MRA was significantly reduced by concomitant use of SGLT2 inhibitors, making this combination a safer choice. Even though available data support the fact that this duo possibly has distinct as well as complementary mechanisms in protecting renal and cardiac functions, strong evidence to recommend routine use of the combination of SGLT2 inhibitors and MRA in DKD is currently lacking. However, the results of the ongoing CONFIDENCE study evaluating superiority of dual therapy of empagliflozin and finerenone will be worthwhile to understand the benefits of this friendly duo.

Sex-related differences in patients with acute myocardial infarction complicated by cardiogenic shock: A systematic review and meta-analysis.

This review aims to analyze sex-related differences in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). 10 studies were retrieved from PubMed and Embase comparing outcomes between men and women admitted with AMI complicated by CS. Pooled log odds ratios (OR) were calculated for binary outcomes using the Mantel-Haenszel method, and Hedges' g with the inverse-variance method was used for continuous outcomes. The primary endpoints were in-hospital mortality and 30-day mortality. The secondary endpoints were reinfarction rate, length of hospital stay (LOS), requirement of renal replacement therapy (RRT), and stroke (ischemic and hemorrhagic). Males exhibited a lower risk of in-hospital mortality (OR 0.77, 95 % CI 0.69-0.85, I2 = 97 %, p < 0.0001), 30-day mortality (OR 0.69, 95 % CI: 0.61-0.78, I² = 0 %, p < 0.0001) and stroke (OR 0.91, 95 % CI 0.87-0.95, I2 = 36 %, p < 0.0001) compared to females. In contrast, males were more likely to require renal replacement therapy (RRT) (OR 1.27, 95 % CI 1.09-1.48, I2 = 69 % p = 0.0017). However, there were no statistically significant differences between females and males in terms of reinfarction rate (OR 0.88, 95 % CI 0.66-1.18, I2 = 56 %, p = 0.3936) or length of hospital stay during hospitalization (Hedges's g 0.35 days, 95 % CI -0.38-1.07, I2 = 100 %, p = 0.34). Females with AMI and CS have higher in-hospital mortality, 30-day mortality, and stroke risk than men. Men are more likely to require RRT. Further research is needed to understand underlying mechanisms and improve outcomes for both genders.

The effect of catecholamine versus non-catecholamine vasopressors on renal function and recovery in vasodilatory shock: A systematic review of preclinical and clinical studies.

Background: Acute kidney injury (AKI) is a common complication of vasodilatory shock. AKI is associated with an increased risk of death, prolonged hospital stays, and subsequent transition to chronic kidney disease. Catecholamines have historically been used as the first-line vasopressors for vasodilatory shock; however, they may adversely affect renal function and recovery.Objectives: To compare the effects of catecholamine and non-catecholamine vasopressors on AKI risk and recovery in preclinical and clinical studies of vasodilatory shock.Methods: Medline, Embase, and Cochrane Central Register of Controlled Trials were systematically searched to identify studies reporting renal outcomes associated with catecholamine (norepinephrine, epinephrine, metaraminol, phenylephrine, dopamine) and non-catecholamine vasopressors (vasopressin, angiotensin II), in preclinical models or adult cohorts of vasodilatory shock. Two independent reviewers screened studies and extracted data using a prespecified form for qualitative synthesis and risk of bias assessment.Results: Of 3,504 citations, 90 studies were eligible for inclusion: 41 preclinical studies, 17 non-randomized clinical studies, 28 randomized clinical studies, and 4 post-hoc analyses. Risk of bias was generally low in preclinical studies and low to moderate in clinical studies. In preclinical studies, catecholamine vasopressors exacerbated medullary hypoxia and intrarenal inflammation compared to non-catecholamine vasopressors. In clinical studies, catecholamines were associated with higher serum creatinine, lower urine output, and increased requirements for renal replacement therapy (RRT) compared to non-catecholamine vasopressors. In patients on high dose catecholamines, adjunctive angiotensin II was associated with improved RRT liberation.Conclusions: Preclinical and clinical studies suggest that non-catecholamine vasopressors may confer renal benefits compared to catecholamine vasopressors. These hypothesis-generating observations suggest the need for comparative studies focused on renal outcomes.Systematic Review Registration: PROSPERO 2024 CRD42024527773.

A cost effectiveness analysis of a quality improvement intervention to increase preferential balanced fluid prescribing

BackgroundThe higher cost of balanced fluids has historically contributed to preferential normal saline (NS) use. Recent clinical trials demonstrated that balanced fluids reduced the incidence of major adverse kidney events among hospitalized patients and also reduced mortality among critically ill patients. This study sought to conduct an economic evaluation of a recently published quality improvement (QI) intervention to increase preferential balanced fluid prescribing, which significantly increased the relative proportion of balanced fluid orders.MethodsUsing clinical trial data and real-world data from our prior QI intervention in conjunction with local and regional cost data, we constructed a decision tree to examine the economic cost and clinical consequences of using NS, lactated ringers (LR), and plasma-lyte for 30,000 hypothetical adult patients and 1,290 hypothetical critically ill adult patients with sepsis admitted to our institution over one year. Clinical outcomes (hospitalization to day 30) included development of acute kidney injury (AKI), new requirement for renal replacement therapy (RRT), and in-hospital mortality. The primary economic outcome was the difference in cost between the pre- and post-QI intervention periods. Sensitivity analyses and breakeven analyses were performed. Evaluation was conducted from South Carolina hospitals’ perspective.ResultsFor the overall cohort, simulation predicted that 53 AKIs, 2 instances of RRT, and 62 deaths were avoided in the post-intervention year with a net cost savings of $704,507. For the critically ill patients with sepsis, simulation predicted that 32 AKIs, 4 instances of RRT, and 12 deaths were avoided with a net cost savings of $474,676. Sensitivity analyses using outcome data from additional clinical trials also estimated annual cost savings ($77,677-$414,872).ConclusionsThe QI intervention was predicted to improve patient outcomes while yielding significant cost-savings. The marginally increased cost of balanced fluids should not discourage implementation of interventions aimed at increasing evidence-supported balanced fluid prescribing.

Epidemiological study of hospital acquired acute kidney injury in critically ill and its effect on the survival

In the intensive care unit (ICU), acute kidney injury (AKI) is the most common cause of morbidity and mortality. Hospital-acquired acute kidney injury (HAAKI) is AKI developing after 48 h. We aimed to study the development of AKI and its associated risk factors. We conducted a longitudinal observational study. Inclusion criteria were patients > 18 years of age admitted to ICU. The primary outcome was the development of AKI as defined by Kidney Disease Improving Global Outcomes (KDIGO) criteria. A total of 273 patients were included in the study. Out of 273, 44(16.11%) patients developed AKI. The mean age was 45.80(17.39) years, and 60.81% were males. The median acute physiology and chronic health evaluation (APACHE II) and sequential organ failure assessment (SOFA) scores were 12(8–18) and 5(3–7), respectively. Diabetes mellitus (23.44%) and hypertension (23.81%) were predominant comorbidities. The risk factors associated with AKI were serum chloride level, colistin, invasive ventilation, positive end-expiratory pressure (PEEP), and fluid balance. The hospital mortality was significantly higher in patients with AKI (43.18%) as compared with no AKI (14.41%). Among the secondary outcomes, 7 (15.90%) patients required renal replacement therapy (RRT) during hospitalisation. The length of ICU stay was higher in patients with AKI 8(5–13) compared to no AKI 5(3–8). A total of 16.11% developed HAAKI, and mortality was 43.18%. Post 6 months follow-up of AKI patients, mortality was 23%. Among survivors none of the patients were on RRT.Patients admitted with normal kidney function can develop AKI. Hence, careful monitoring of ICU patients is necessary.

Association between delayed invasive blood pressure monitoring and all-cause mortality in intensive care unit patients with sepsis: a retrospective cohort study.

Haemodynamic management is essential in sepsis management. Invasive blood pressure (IBP) monitoring is the gold standard for blood pressure (BP) assessment. Here, we identified the most advantageous time frame for IBP monitoring to mitigate adverse outcomes in patients with sepsis. We included data on patients with sepsis from the Medical Information Mart for Intensive Care IV database. The primary endpoints comprised 28-and 90-day mortality rates, whereas secondary endpoints were acute kidney injury (AKI) rates and continuous renal replacement therapy (CRRT) requirement. To confirm our findings' robustness, we performed multivariable Cox regression and logistic regression models, augmented by propensity score matching (PSM). Of 18,326 patients hospitalised for sepsis, 9,056 (49.42%) and 9,270 (50.58%) were included in the early and delayed IBP-monitoring groups, respectively. Our multivariable Cox regression models revealed 20 and 21% significant increases in 28-and 90-day mortality in the delayed IBP monitoring group, respectively [hazard ratios (95% confidence intervals) = 1.20 (1.11-1.31) and 1.21 (1.12-1.31), respectively; both p < 0.001]. Moreover, significant increases were noted in AKI, CRRT and mechanical ventilation requirement risks in the delayed IBP monitoring group [odds ratios (95% confidence intervals) = 1.44 (1.34-1.56), 1.50 (1.26-1.78) and 1.79 (1.67-1.92), respectively; both p < 0.001]. PSM further confirmed the validity of our findings. Delayed IBP monitoring prolonged intensive care unit (ICU) stay without extending vasopressor use duration. Prolonged delay in IBP monitoring (≥3 h) may increase mortality risks in ICU patients with sepsis. Nevertheless, early IBP monitoring may reduce AKI, CRRT and mechanical ventilation requirement risks and shorten ICU stay. However, these results warrant further validation through randomised controlled trials.

An umbrella analysis assessing the risk of acute kidney injury in COVID-19 patients.

A number of research studies have indicated a potential association between COVID-19 and acute kidney injury (AKI). However, the methodologies employed and the risk estimates derived from these studies vary. Therefore, an umbrella review of systematic reviews and meta-analyses was conducted to determine the incidence of AKI in COVID-19 patients and AKI-associated mortality. A complete literature search was undertaken in PubMed, Embase, Scopus, and the Cochrane Library. The methodological rigor of the included papers was evaluated using the Assessment of Multiple Systematic Reviews (AMSTAR-2) instrument. The pooled risk ratio (RR) and odds ratio (OR) of the included studies were calculated to establish the strength of the association between AKI cases and COVID-19 infections. This umbrella review included 20 studies. Two of the 20 studies assessed adult COVID-19 patient risk factors for AKI, 1 examined survival rates and 7 examined the incidence of AKI. The remaining 10 investigations revealed that patients with coronavirus were susceptible to AKI. The umbrella analysis comprised reviews that contained a range of 6 to 54 papers. The AMSTAR-2 ratings yielded a total of 14 studies deemed to be of high quality, with 6 studies classified as intermediate quality. Statistical analysis of included reviews revealed a 1.50 RR for AKI incidence in COVID-19 patients (95% confidence interval (95% CI): 1.40-1.60, I2 69%, p < 0.0001) and a 2.02 RR (95% CI: 1.79-2.29, I2 56%, p < 0.0001) for AKI-associated death. This umbrella review revealed that individuals infected with the novel coronavirus often develop AKI. SARS-CoV-2 infections were associated with AKI due to advanced age, male gender, coronary artery disease, diabetes, and hypertension. However, AKI and a renal replacement therapy (RRT) requirement independently predicted unfavorable COVID-19 results.

A Balancing Act: Outcomes of Post-Transplant Cyclophosphamide in Older Patients

Background: Post-transplant cyclophosphamide (PTCy) has emerged as a definitive regimen for graft versus host disease (GvHD) prophylaxis in hematopoietic stem cell transplants (HCT). However, there are concerns that when combined with myeloablative or even reduced intensity conditioning (RIC) regimens, PTCy can lead to intolerable toxicities in some patients. In the haploidentical setting, Fludarabine and Melphalan (Flu-Mel) conditioning has been associated with high levels of transplant related mortality (TRM) and renal failure when combined with PTCy (Eastburg et al, 2022). Methods: We performed a single-center, retrospective analysis of all patients receiving an allogeneic HCT in 2023 that received PTCy for GvHD prophylaxis for a wide array of hematologic malignancies. We used our prospectively collected database to collect demographic data, transplant characteristics, and treatment outcomes including toxicities within the first 100 days of transplant. We excluded second HCT and one patient with prior end stage kidney disease (ESKD). Results: Fifty patients were included in the analysis. The majority (24; 48%) had acute myeloid leukemia (AML), followed by acute lymphoblastic leukemia (ALL) (9; 18%), and myelodysplastic syndrome (MDS) (6; 12%). The median age of patients was 61 (range 24-76). Eighteen patients (36%) had a Hematopoietic Cell Transplantation-Specific Comorbidity Index (HCT-CI) score &amp;gt;3 and six (12%) had a HCTCI score &amp;gt;5. Twelve (24%) patients had a GFR &amp;lt;90 prior to starting their conditioning regimen. . Eight patients had a matched sibling donor; two had a haploidentical donor, thirty-one had a matched unrelated , and nine had a mismatched unrelated donor (eight with 7/8 and one with 6/8 HLA-matched). The most common regimen was a reduced intensity conditioning regimen involving Flu-Mel with or without 200-400 centigray (cGy) total body irradiation (TBI). Seven patients with ALL received a myeloablative conditioning regimen with Etoposide and TBI at 1200 cGy. Eight patients died (16%) at a median of 73 days post-HCT (range 18 - 177 days). Seven patients relapsed after transplant, and two of these patients died from progression of disease. Disease free survival was 74% at day 100 and 66.6% at 1 year. Nineteen patients (38%) developed acute GvHD, with five patients (10%) developing grade 3 or 4 GvHD. The most common grade 3or higher toxicities in the first 100 days post-transplant (excluding expected cytopenias) were neutropenic fever (28; 56%), bacteremia (19; 38%), and acute kidney injury (19; 38%). Of the nineteen patients with AKI, twelve were over the age of 60, and six had a GFR &amp;lt; 90 on day of admission (53-89 mL/min). Other common grade 3 or higher toxicities included mucositis (14; 28%), anorexia (10; 20%), diarrhea (6; 12%), and cardiomyopathy (3; 6%). We further analyzed the six patients who died from transplant related complications. One younger patient with heavily pretreated NK/T-cell lymphoma of the nasopharynx died of diffuse alveolar hemorrhage from aspiration. The other five patients were over age 60, including three over age 70, and four patients were male. They received a total of fludarabine 90mg/m2 and one dose of melphalan at 100 or 140mg/m2, and two of them received TBI at 200 or 400cGy. Three of these patients had a GFR &amp;lt; 90 on day of admission, and all five eventually developed grade 4 nephrotoxicity requiring renal replacement therapy (RRT) prior to death. Conclusions: Overall, our patient outcomes were favorable when adding PTCy for GVHD prophylaxis to both RIC and myeloablative conditioning regimens. Older patients who had underlying renal dysfunction had significantly greater morbidity and mortality. For patients that required RRT, mortality was 100%. In older patients (&amp;gt;60 years of age), PTCy should be used with caution in combination with higher intensity conditioning regimens. This observational study provides a rationale for studying reduced dosing of PTCy in patients who have underlying renal insufficiency.

Micronutrient needs in critically Ill children undergoing continuous renal replacement therapy and protein requirements in acute kidney injury patients

Abstract Nutrition is one of the cornerstones in the treatment and support of critically ill patients. Nutritional support includes the provision of calories, protein, electrolytes, vitamins, and trace elements through enteral or parenteral routes. Acute kidney injury (AKI) is a common problem in critically ill patients and can lead to severe consequences, impacting metabolism and nutritional status significantly. Furthermore, regardless of the modality used, renal replacement therapy (RRT) has profound effects on metabolism. Evidence on nutritional support during continuous renal replacement therapy (CRRT) is limited, and there are no established clinical guidelines for nutritional adaptations during CRRT in critically ill patients. This review outlines some essential principles for providing micronutrient support in critically ill patients undergoing CRRT and protein requirements in AKI patients.

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

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

It 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. This 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 1000U/L were included in the final analysis. Factors predicting the need for RRT were investigated, and a dialysis score was developed for this prediction. Of the 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 23,000U/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. The 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.