Requiring Renal Replacement Therapy Research Articles

Acute kidney injury in critically ill adults: A cross-sectional study.

Background:Wide differences in the estimates of acute kidney injury (AKI) have been reported in studies from various parts of the world. Due to dearth of data from the region, we carried out the present study to assess the incidence and the associated factors for AKI in our critically ill population.Methods:A prospective, observational study in critically ill adults who developed AKI was carried out. The diagnosis of AKI was attained by AKI Network (AKIN) criteria. The key details collected included details related to demographics, APCAHE score, concomitant diagnoses, whether mechanical ventilation was provided or not, radiological findings, drugs with potential nephrotoxicity, requirement of renal replacement therapy (RRT), whether recovered from AKI and time taken for recovery, duration of stay in the intensive care unit, and outcome (died/alive).Results:One hundred patients out of the total 560 with an incidence of 17.9% developed AKI. Forty-five had Stage 1, 22 had Stage 2, and 33 had Stage 3 AKI, and a significantly higher mortality was observed with Stage 3 AKIN Class compared to Stages 1 and 2. Two-thirds of the patients had septic shock, while 29 had contrast-induced nephropathy. Ninety-five patients received at least one drug with potential nephrotoxicity. Sixty-three patients recovered from AKI episodes. Only 29 patients underwent RRT of which 41% died.Conclusion:We observed an incidence of 17.9% for AKI in our critically ill patients. The estimates from this study will serve as a baseline for future studies in the region.

Renal Replacement Therapy at the Time of Left Ventricular Assist Device: A Single Center 9-Year Experience

<h3>Purpose</h3> In the current era patients requiring LVAD are getting to be more complex due to the increasing number of comorbidities they have. A common comorbid condition is renal failure either acute or chronic. There is a lack of long term data on those patients that require in particular renal replacement therapy at the time of implantation of the LVAD in terms of mortality, readmissions, length of stay and other clinical parameters. <h3>Methods</h3> This is a retrospective single center study-reporting patients who required renal replacement therapy at the time of LVAD implantation at our institution from January 2012 to March 2021, over 190 patients in all. <h3>Results</h3> 2-year survival rate of those patients receiving dialysis versus those patients was 42.1% vs. 76.4% survival rates. This represents a hazard ration of 3.31 and a P value of < .001. Length of stay showed a mean length of stay in of 46 days versus 20 days for those patients who needed dialysis. This represented a statistically significant p value of < .001.The proportion of days beyond 30 days, patients receiving LVAD and renal replacement versus those receiving LVAD alone showed that patients who received dialysis at the time of implant at a .31 higher likelihood versus the .06 likelihood those who did not. The odds ratio of this was 9.08 and p value of less than .001. <h3>Conclusion</h3> In this single center study on the requirement of renal replacement therapy at the time of LVAD implantation showed worse outcomes versus those that did not require it across device type and demographics. Survival rates at 2 years, length of stay, proportion of days beyond 30 days spent in the hospital was significantly worse and longer than those who did not receive renal replacement therapy.

Comparison of clinical characteristics and outcomes of COVID-19 patients undergoing early versus late intubation from initial hospital admission: A systematic review and meta-analysis.

BackgroundThe true impact of intubation and mechanical ventilation in coronavirus disease 2019 (COVID-19) patients remains controversial.MethodsWe searched Pubmed, Cochrane Library, Embase, and Web of Science databases from inception to October 30th, 2021 for studies containing comparative data of COVID-19 patients undergoing early versus late intubation from initial hospital admission. Early intubation was defined as intubation within 48 h of hospital admission. The primary outcomes assessed were all-cause in-hospital mortality, renal replacement therapy (RRT), and invasive mechanical ventilation (IMV) duration.ResultsFour cohort studies with 498 COVID-19 patients were included between February to August 2020, in which 28.6% had early intubation, and 36.0% underwent late intubation. Although the pooled hospital mortality rate was 32.1%, no significant difference in mortality rate was observed (odds ratio [OR] 0.81; 95% confidence interval 0.32–2.00; P = 0.64) among those undergoing early and late intubation. IMV duration (mean 9.62 vs. 11.77 days; P = 0.25) and RRT requirement (18.3% vs. 14.6%; OR 1.19; P = 0.59) were similar regardless of intubation timing. While age, sex, diabetes, and body mass index were comparable, patients undergoing early intubation had higher sequential organ failure assessment (SOFA) scores (mean 7.00 vs. 5.17; P < 0.001).ConclusionsThe timing of intubation from initial hospital admission did not significantly alter clinical outcomes during the early phase of the COVID-19 pandemic. Higher SOFA scores could explain early intubation. With the advancements in COVID-19 therapies, more research is required to determine optimal intubation time beyond the first wave of the pandemic.

Relationship between intraoperative dopamine infusion and postoperative acute kidney injury in patients undergoing open abdominal aorta aneurysm repair

BackgroundAcute kidney injury (AKI) is one of the most common complications in patients undergoing open abdominal aortic aneurysm (AAA) repair. Dopamine has been frequently used in these patients to prevent AKI. We aimed to clarify the relationship between intraoperative dopamine infusion and postoperative AKI in patients undergoing open AAA repair.MethodsWe analyzed 294 patients who underwent open AAA repair at a single tertiary center from 2009 to 2018, retrospectively. The primary outcome was the incidence of postoperative AKI, determined by the Kidney Disease Improving Global Outcomes definition, after open AAA repair. Secondary outcomes included survival outcome, hospital and intensive care unit length of stay, and postoperative renal replacement therapy (RRT).ResultsPostoperative AKI occurred in 21.8% (64 out of 294 patients) The risk of postoperative AKI by intraoperative dopamine infusion was greater after adjusting for risk factors (odds ratio [OR] 2.56; 95% confidence interval [CI], 1.09–5.89; P = 0.028) and after propensity score matching (OR 3.22; 95% CI 1.12–9.24; P = 0.030). On the contrary, intraoperative norepinephrine use was not associated with postoperative AKI (use vs. no use; 19.3 vs. 22.4%; P = 0.615). Patients who used dopamine showed higher requirement for postoperative RRT (6.8 vs. 1.2%; P = 0.045) and longer hospital length of stay (18 vs. 16 days, P = 0.024).ConclusionsIntraoperative dopamine infusion was associated with more frequent postoperative AKI, postoperative RRT, and longer hospital length of stay in patients undergoing AAA repair, when compared to norepinephrine. Further prospective randomized clinical trial may be necessary for this topic.

513 Fluid Over-Resuscitation in Burn Patients After Initial 24-Hours of Care is Associated with Increased Mortality

IntroductionFluid resuscitation is a cornerstone of modern burn care. Despite the use of well-established formulae to determine the appropriate amount of fluid resuscitation for the first 24 hours of care, there is increasing recognition that patients receive fluids in excess of predicted volumes, a phenomenon termed fluid creep. Underscoring the significance of this phenomenon is the association between large volumes of fluid resuscitation and adverse outcomes. Although research in non-burn ICU patients reveals a clear association between overall fluid intake and increased morbidity, minimal burn-related literature exists regarding fluid patterns after the initial 24-hour period and their impact on outcomes. We hypothesized that increased fluid administration after the standard initial resuscitation period is associated with increased morbidity and mortality.MethodsA retrospective chart review was performed for 113 patients with ≥20% TBSA burns admitted to an American Burn Association-verified burn center between 2010 and 2020. Patients admitted with Stevens-Johnson Syndrome and/or Toxic Epidermal Necrolysis, with length of stay ≤ 72 hours, who required renal replacement therapy (RRT) within 72 hours of admission, and those with withdrawal of care ≤ 7 days of admission were excluded. Univariate and multivariate logistic regression was used to determine the association between the primary outcome of in-hospital mortality and secondary outcomes of increased ventilator days, acute kidney injury, need for RRT, and hospital length of stay, with increasing total and net fluid volumes from days 2 through 7 of treatment. Additionally, the association between first OR day and total fluid volumes in the first week were assessed.ResultsMedian age was 41 years (IQR 23-55) and TBSA was 31% (IQR 24-43). 21 patients (18.6%) died during hospitalization. Increase in net fluid balance from days 2-7 were associated with increased mortality (OR 1.016, 95% CI 1.00 – 1.03, p = 0.013). Increasing total fluid volumes were significantly associated with increased ventilator days (OR 1.027, 95% CI 1.008-1.047, p = 0.006) and acute kidney injury (OR 1.003, 95% CI 1.000-1.006, p = 0.017). Early first OR day was associated with decreased net fluid balance between hospital days 2-7 (OR 0.993, 95% CI 0.989-0.997, p = 0.001).ConclusionsSimilar to studies on other ICU populations, increasing total fluid volumes and net fluid balance is associated with adverse outcomes in critically ill burn patients. Additionally, earlier initial OR is associated with less total fluid volumes and lower net fluid balance in the first week of hospitalization. Further investigation is needed to elucidate optimal markers of resuscitation in burn patients in an effort to decrease adverse fluid administration.

Impact of Pretransplant Renal Replacement Therapy on Clinical Outcome After Isolated Heart Transplantation.

End stage renal disease (ESRD) is a contraindication to isolated heart transplantation (HT). However, heart candidates with cardiogenic shock may experience acute kidney injury and require renal replacement therapy (RRT) and isolated HT as a life-saving operation. The outcomes, including survival and renal function, are rarely reported. We enrolled 569 patients undergoing isolated HT from 1989 to 2018. Among them, 66 patients required RRT before HT (34 transient and 32 persistent). The survival was worse in patients with RRT than those without (65.2% vs 84.7%; 27.3% vs 51.1% at 1- and 10-year, p < 0.001 and p = 0.012, respectively). Multivariate Cox analysis identified pre-transplant hyperbilirubinemia (Hazard ratio (HR) 2.534, 95% confidence interval (CI) 1.098–5.853, p = 0.029), post-transplant RRT (HR 5.551, 95%CI 1.280–24.068, p = 0.022) and post-transplant early bloodstream infection (HR 3.014, 95%CI 1.270–7.152, p = 0.012) as independent risk factors of 1-year mortality. The majority of operative survivors (98%) displayed renal recovery after HT. Although patients with persistent or transient RRT before HT had a similar long-term survival, patients with persistent RRT developed a high incidence (49.2%) of dialysis-dependent ESRD at 10 years. In transplant candidates with pretransplant RRT, hyperbilirubinemia should be carefully re-evaluated for the eligibility of HT whereas prevention and management of bloodstream infection after HT improve survival.

CALL-K score: predicting the need for renal replacement therapy in cardiogenic shock.

The clinical predictors and outcomes of patients with cardiogenic shock (CS) requiring renal replacement therapy (RRT) have not been studied previously. This study assesses the impact of RRT on mortality in patients with CS and aims to identify clinical factors that contribute to the need of RRT. Consecutive patients presenting with CS were included from a prospective registry of cardiac intensive care unit admissions at a single institution between 2014 and 2020. Of the 1030 patients admitted with CS, 123 (11.9%) received RRT. RRT was associated with higher 1-year mortality [adjusted hazard ratio = 1.62, 95% confidence interval (CI) 1.02-2.14], and a higher in-hospital incidence of sepsis [risk ratio = 2.76, P < 0.001], and pneumonia (risk ratio = 2.9, P = 0.001). Those who received RRT were less likely to receive guideline-directed medical treatment at time of discharge, undergo heart transplantation (2.4% vs. 11.5%, P = 0.002) or receive a durable left ventricular assist device (0.0% vs. 11.6%, P < 0.001). Five variables at admission best predicted the need for RRT (age, lactate, haemoglobin, use of pre-admission loop diuretics, and admission estimated glomerular filtration rate) and were used to generate the CALL-K 9-point risk score, with better discrimination than creatinine alone (P = 0.008). The score was internally validated (area under the curve = 0.815, 95% CI 0.739-0.835) with good calibration (Hosmer-Lemeshow P = 0.827). RRT is associated with worse outcomes, including a lower likelihood to receive advanced heart failure therapies in patients with CS. A risk score comprising five variables routinely collected at admission can accurately estimate the risk of needing RRT.

Urinary Activin A: A Novel Biomarker for Human Acute Kidney Injury.

Activin is a multifunctional cytokine belonging to the transforming growth factor (TGF)-β superfamily that regulates the growth and differentiation of cells in various organs. We previously reported that activin A, which is absent in normal kidneys, was significantly increased in the ischemic kidney, and that the blockade of activin action by follistatin, an activin antagonist, significantly enhanced tubular regeneration after renal ischemia, suggesting that activin A acts as an endogenous inhibitor of tubular repair after kidney injury in rodents. However, the role of activin A in human acute kidney injury (AKI) remains unclear. In this analysis, we measured serum and urinary activin A in human AKI (n = 39) and tested if activin A might serve as a biomarker for AKI. Urinary activin A, which was undetectable in healthy controls, was significantly increased in AKI (0.0 ± 0.0 vs. 173.4 ± 58.8 pg/mL, p < 0.05). The urinary activin A level in patients with AKI stage 3, was significantly higher than that in patients with AKI stages 1 and 2. Patients who required renal replacement therapy (RRT) had a significantly higher urinary activin A level than patients who did not require RRT. Urinary activin A might be a useful non-invasive biomarker for the severity of AKI.

A Machine Learning-Based Prediction Model for Acute Kidney Injury in Patients With Congestive Heart Failure.

BackgroundMachine learning (ML) has been used to build high performance prediction model. Patients with congestive heart failure (CHF) are vulnerable to acute kidney injury (AKI) which makes treatment difficult. We aimed to establish an ML-based prediction model for the early identification of AKI in patients with CHF.MethodsPatients data were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database, and patients with CHF were selected. Comparisons between several common ML classifiers were conducted to select the best prediction model. Recursive feature elimination (RFE) was used to select important prediction features. The model was improved using hyperparameters optimization (HPO). The final model was validated using an external validation set from the eICU Collaborative Research Database. The area under the receiver operating characteristic curve (AUROC), accuracy, calibration curve and decision curve analysis were used to evaluate prediction performance. Additionally, the final model was used to predict renal replacement therapy (RRT) requirement and to assess the short-term prognosis of patients with CHF. Finally, a software program was developed based on the selected features, which could intuitively report the probability of AKI.ResultsA total of 8,580 patients with CHF were included, among whom 2,364 were diagnosed with AKI. The LightGBM model showed the best prediction performance (AUROC = 0.803) among the 13 ML-based models. After RFE and HPO, the final model was established with 18 features including serum creatinine (SCr), blood urea nitrogen (BUN) and urine output (UO). The prediction performance of LightGBM was better than that of measuring SCr, UO or SCr combined with UO (AUROCs: 0.809, 0.703, 0.560 and 0.714, respectively). Additionally, the final model could accurately predict RRT requirement in patients with (AUROC = 0.954). Moreover, the participants were divided into high- and low-risk groups for AKI, and the 90-day mortality in the high-risk group was significantly higher than that in the low-risk group (log-rank p < 0.001). Finally, external validation using the eICU database comprising 9,749 patients with CHF revealed satisfactory prediction outcomes (AUROC = 0.816).ConclusionA prediction model for AKI in patients with CHF was established based on LightGBM, and the prediction performance of this model was better than that of other models. This model may help in predicting RRT requirement and in identifying the population with poor prognosis among patients with CHF.

Māori Health Outcomes in Intensive Care Following Cardiac Surgery in Aotearoa New Zealand

Māori, the indigenous peoples of Aotearoa New Zealand (NZ) experience disproportionately worse outcomes in cardiovascular health compared to non-Māori. Waikato Hospital provides tertiary cardiothoracic services to the Midland region of NZ, and has instituted an official policy to eliminate ethnic inequity in health. We aimed to audit the outcomes of our cardiothoracic intensive care unit (ICU) against this standard. We analysed data from the prospectively-entered Australia and NZ Intensive Care Society database for all planned cardiothoracic ICU admissions from 2014 to 2018 at Waikato Hospital for patients aged 15-years and older (n=2,736). Outcomes measured were in-ICU, in-hospital, and 1-year mortality. Māori were under-represented in this cohort (17.9%) compared to the general Midland population. Māori patients were younger (median 60 vs 68-years old, p<0.001), were more commonly female (34.8% vs 23.6%, p<0.001), domiciled in more deprived areas (2018 NZ Index of Deprivation of 9 vs 6, p<0.001), and more likely to have rheumatic heart disease (35.6% vs 16.6%, p<0.001). More non-Māori required coronary vessel only surgery (57.4% vs 45.2%), whilst more Māori required valvular only surgery (41.1% vs 31.2%) (p<0.001 overall). Baseline Acute Physiology and Chronic Health Evaluation (APACHE) III risk of death score was higher for Māori (1.53% vs 0.89%, p<0.001), as was the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (2.04% vs 1.55%, p<0.001). Unadjusted mortality was higher for Māori in-ICU (3.1% vs 1.3%, p=0.005) and at 1-year (7.1% vs 3.8%, p=0.002). Adjusted in-ICU mortality, however, was predicted by combined coronary-valvular surgery (adjusted odds ratio, AOR 25.5 [95% confidence interval (CI) 3.30-348.46], p=0.005), Australia and New Zealand Risk of Death (ANZROD) score (AOR 1.11 [CI 1.05-1.19] p<0.001), and renal replacement therapy requirement (AOR 154.56 [CI 30.86-1,107.17] p<0.001), but not by Māori ethnicity (AOR 0.27 [CI 0.03-1.43] p=0.156). Our audit has identified significant inequity for Māori at our cardiothoracic ICU. Māori are sicker on presentation for planned cardiac surgery, as evidenced by higher admission severity scores, and experience higher unadjusted mortality up to 1-year compared to non-Māori. Māori also appear under-represented despite a greater burden of cardiovascular disease in the community. Further study is required to identify if upstream risk factors, including failure of early detection and referral for disease, contribute to these findings.

Impact of targeted hypothermia in expanded-criteria organ donors on recipient kidney-graft function: study protocol for a multicentre randomised controlled trial (HYPOREME)

IntroductionExpanded-criteria donors (ECDs) are used to reduce the shortage of kidneys for transplantation. However, kidneys from ECDs are associated with an increased risk of delayed graft function (DGF), a risk...

Outcomes following severe septic shock in a cohort of Aboriginal and Torres Strait Islander people: a nested cohort study from the ADRENAL trial

Objective: To describe the pattern of acute illness and 6-month mortality and health-related quality-of-life outcomes for a cohort of Aboriginal and Torres Strait Islander patients presenting with septic shock. Design: Nested cohort study of Aboriginal and Torres Strait Islander participants recruited to a large randomised controlled trial of corticosteroid treatment in patients with septic shock. Setting: Royal Darwin Hospital, Northern Territory. Participants: All Aboriginal and Torres Strait Islander patients recruited to the Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock (ADRENAL) trial at Royal Darwin Hospital were compared with a non-Indigenous cohort drawn from the same site, and a cohort matched for age, sex and severity of disease. Main outcome measures: Mortality at 90 days and 6 months, time to shock resolution, mechanical ventilation requirement, renal replacement therapy requirement, and five-domain, five-level EuroQol questionnaire (EQ-5D-5L) score at 6 months. Results: Aboriginal and Torres Strait Islander patients had significantly reduced risk of death at 90 days when compared with non-Indigenous patients recruited to ADRENAL at Royal Darwin Hospital (12/60 v 23/62; adjusted odds ratio, 0.40 [95% CI, 0.17 to 0.94]) which was robust to additional adjustment for baseline covariates (odds ratio, 0.35 [95% CI, 0.14 to 0.90]). When compared with the matched population drawn from the broader ADRENAL cohort, there was no significant difference in 90-day mortality (12/60 v 16/61; adjusted odds ratio, 1.43 [95% CI, 0.60 to 3.39]; P = 0.42). Only nine Aboriginal and Torres Strait Islander patients provided 6-month health-related quality-of-life data. Conclusions: Aboriginal and Torres Strait Islander patients had reduced risk of death at 90 days when compared with non- Indigenous patients recruited to the ADRENAL trial at Royal Darwin Hospital, which was robust to adjustment for covariates, but similar outcomes when compared with a cohort matched for age, sex and severity of disease.

The predictive value of the prognostic nutritional index for contrast-induced nephropathy

Aim: This study aims to evaluate the association between prognostic nutritional index (PNI) and contrast-induced nephropathy (CIN). Material and methods: A total of 251 patients who were at high risk for contrast nephropathy were included in the study. The patients were grouped according to their PNI score (PNI score <45 or PNI score ≥45). CIN was defined as a 25% relative increase, or 0.5 mg/dL absolute increase in serum creatinine level above baseline within 72 hours of contrast exposure, in the absence of an alternative explanation. Results: Two groups were assigned according to the PNI score. The first group consists of 111 patients (PNI<45) and the second group has 140 patients (PNI≥45). CIN developed in 162 (%64.8) patients. C-reactive protein was higher in the low-PNI group. Also, the patients with the low-PNI group had lower ejection fraction, lower serum albumin levels, and lower hemoglobin levels. CIN, postprocedure renal replacement therapy requirement and in-hospital mortality were higher in the low PNI group. Multivariable logistic regression analysis revealed that advanced age (p=0.012, [OR] = 1.044 [1.009-1.079]), low baseline GFR (p=0.033, [OR]= 1.022 [1.002-1.043]), high amount of contrast media (p=0.022, [OR]= 1.017 [1.002-1.031]), and low PNI score (p=0.033 , [OR]= 2.069 [1.060-4.039]) were independent predictors of CIN. Conclusion: Our study demonstrated that the PNI score was an independent risk factor for the development of CIN.

Evaluating proximal clamp site and intraoperative ischemia time among open repair of juxtarenal aneurysms

BackgroundThe proportion of open aneurysm repairs requiring at least a suprarenal clamp has increased in the past few decades, partly owing to preferred endovascular approaches for most patients with infrarenal aneurysms, suggesting that the management of aortic clamp placement has become even more relevant. This study evaluated the association between the proximal clamp site and intraoperative ischemia times with postoperative renal dysfunction and mortality. MethodsWe used the Vascular Quality Initiative to identify all patients undergoing open repairs of elective or symptomatic juxtarenal AAAs from 2004 to 2018 and compared outcomes by clamp site: above one renal artery, above both renal arteries (suprarenal), or above the celiac trunk (supraceliac). Outcomes evaluated included acute kidney injury (AKI), new-onset renal failure requiring renal replacement therapy (RRT), 30-day mortality, and 1-year mortality. We used multilevel logistic regressions and Cox proportional hazards models, clustered at the hospital level, to adjust for confounding. ResultsWe identified 3976 patients (median age, 71 years; 70% male; 8.2% non-Caucasian), with a median aneurysm diameter of 5.9cm (interquartile range [IQR], 5.4-6.8 cm). Proximal clamp sites were above one renal artery (31%), suprarenal (52%), or supraceliac (17%). The rates of unadjusted outcomes were 20.5% for AKI, 4.1% for new-onset RRT, 4.9% for 30-day mortality, and 8.3% for 1-year mortality. On adjusted analyses, independent of ischemia time, suprarenal clamping relative to clamping above a single renal artery had higher odds of postoperative AKI (adjusted odds ratio [aOR], 1.50; 95% confidence interval; 95% CI, CI, 1.28-1.75), but similar odds for new-onset RRT (aOR, 1.27; 95% CI, 0.79-2.06) and 30-day mortality (aOR, 1.12; 95% CI, 0.79-1.58) and hazards for 1-year mortality (adjusted hazard ratio, 1.12; 95% CI, 0.86-1.45). However, every 10 minutes of prolonged intraoperative ischemia time was associated with an increase in odds or hazards ratio of postoperative AKI by 7% (IQR, 3%-11%), new-onset RRT by 11% (IQR, 4%-17%), 30-day mortality by 11% (IQR, 6%-17%), and 1-year mortality by 7% (IQR, 2%-13%). Patients with more than 40 minutes of ischemia time had notably higher rates of all four outcomes. ConclusionsSuprarenal clamping relative to clamping above a single renal artery was associated with AKI, but not new-onset RRT or 30-day mortality. However, the intraoperative renal ischemia time was independently associated with all four postoperative outcomes. Although further studies are warranted, our findings suggest that an expeditious proximal anastomosis creation is more important than trying to maintain clamp position below one renal artery, suggesting that suprarenal clamping may be the best strategy for open AAA repair when needed to efficiently perform the proximal anastomosis.

Abstract WP135: Impact Of End Stage Renal Disease On Outcomes After Intracerebral Hemorrhage - A Nationwide Analysis

Introduction: Intracerebral hemorrhage (ICH) is a devastating form of stroke that is usually related to chronic hypertension. End stage renal disease (ESRD) requiring renal replacement therapy (RRT) often leads to chronic hypotension, and fluid shifts during dialysis might increase the severity of brain edema. We sought to better understand the impact of ESRD on outcomes after ICH, with a focus of the presence of hypertension or hypotension during hospitalization. Methods: We analyzed the National Inpatient Sample (NIS) database and extracted all cases of ICH (ICD-9 431 or ICD-10 I61) between 2012 and 2017. Patients were classified as requiring RRT (ICD9: V56, V4511, 5856; ICD 10: N186, Z49, Z992) or not. We also noted the presence of codes for hypertension, hypotension, or cerebral herniation. The main outcome measure was death at discharge. Logistic regression was used to calculate odds ratios for mortality with adjustment for ICH severity using a compilation of codes for common complications. Results: 116,812 ICH patients were identified, 3,329 (2.8%) of whom received RRT. Mortality in the non-RRT group was 18% as opposed to 32% in the RRT group (severity adjusted odds ratio 2.1, 95% CI 2.0–2.3, P&lt;0.001). Hypertension was common (67%) and hypotension uncommon (1.7%) in the non-RRT group. Hypotension was associated with much higher mortality (32%) than patients who were hypertensive (18%) or normotensive (23%) in non-RRT patients. By contrast, hypertension in the RRT group occurred much less frequently (21%) and hypotension was slightly more common in the RRT group (2.1%). There was no significant relationship between extremes of blood pressure and mortality in the RRT group. Compared to normotensive patients, herniation occurred more frequently in hypotensive non-RRT patients (28% vs 14%, OR 1.5, 95% CI 1.5–1.7, P&lt;0.001). No relationship between BP and herniation was identified in patients with ESRD. Conclusion: ESRD requiring RRT is associated with a 78% relative increase in mortality after ICH. Whereas hypotension increases the risk of death in ICH patients with preserved renal function, hypotension is much more common in ESRD patients and does not confer the same hazard. Further research is needed to understand how ESRD increases mortality after ICH.

POS-840 Acute kidney injury in critically ill COVID- 19 infected patients requiring renal replacement therapy

Acute kidney injury (AKI) is a common complication in patients infected with SARS COV-2. The incidence rates are very high (76%) in patients admitted in the intensive care unit. A high percentage of critically ill patients have severe acute kidney injury and require renal replacement therapy (RRT) with consequent high mortality. The prospective study looks into the clinical presentation, laboratory parameters and therapeutic interventions in critically sick patients with AKI requiring RRT admitted in the intensive care unit of our hospital from April 2020 to December 2020. The demographic details, laboratory parameters , therapeutic interventions and outcome details were collected. Data was analyzed to detect significant patient variables which had an association with mortality. Initial chi- square test was performed to look at significant association. All significant variables were then included in a multivariate analysis. All statistical analyses were done using SPSS Version 21. A total of 632 critically ill patients were admitted in our ICU. Of these 144 (22.8%) had severe acute kidney injury requiring renal replacement therapy. In this subgroup majority (n=107,74.3%) were males. The mean(±sd) age was 58.8(±15.1) years. The majority of these patients presented with fever (51.4%) and breathlessness (73.6%). At the time of initiation of RRT , 128 patients were oliguric. There was a significant difference in hemoglobin (p=0.000), serum albumin (p=0.018) and LDH (p=0.000) levels between the survivors and non survivors. Echocardiography was done in 121 patients, of which 23(19%) showed evidence of regional wall motion abnormality. 48.5% were ventilated invasively and another 8.3% required non-invasive ventilation. The most common RRT modality in these patients was slow low efficiency daily dialysis (40.3%).Nobody was offered peritoneal dialysis. 98(68%) of these patients died. The presence of diabetes mellitus was a poor prognostic indicator.(p=0.017) The clinical parameters associated with mortality were presentation with fever (p=0.04) and breathlessness (p=0.001). Patients on ventilatory support (p=0.00001) and RRT (p=0.00001) had a poorer prognosis. 91% of patients requiring both ventilation and RRT died (p=0.000001). In a multiple regression analysis, older age and the presence regional wall motion abnormality were the only parameters predicting mortality. The type of RRT was not a significant parameter in predicting outcome. Regional wall motion abnormality in echocardiography may signify the presence of myocarditis in these COVID 19 infected patients. Data from our center suggests a very high mortality in COVID 19 infected patients who develop acute kidney injury and undergo renal replacement therapy in the intensive care unit. A better understanding of the prognostic parameters will help us formulate interventions in these critically sick patients in a resource constrained setting.

Using dipstick urinalysis to predict development of acute kidney injury in patients with COVID-19

BackgroundAcute kidney injury (AKI) is a common complication in patients hospitalized with COVID-19 and may require renal replacement therapy (RRT). Dipstick urinalysis is frequently obtained, but data regarding the prognostic value of hematuria and proteinuria for kidney outcomes is scarce.MethodsPatients with positive severe acute respiratory syndrome-coronavirus 2 (SARS-CoV2) PCR, who had a urinalysis obtained on admission to one of 20 hospitals, were included. Nested models with degree of hematuria and proteinuria were used to predict AKI and RRT during admission. Presence of Chronic Kidney Disease (CKD) and baseline serum creatinine were added to test improvement in model fit.ResultsOf 5,980 individuals, 829 (13.9%) developed an AKI during admission, and 149 (18.0%) of those with AKI received RRT. Proteinuria and hematuria degrees significantly increased with AKI severity (P < 0.001 for both). Any degree of proteinuria and hematuria was associated with an increased risk of AKI and RRT. In predictive models for AKI, presence of CKD improved the area under the curve (AUC) (95% confidence interval) to 0.73 (0.71, 0.75), P < 0.001, and adding baseline creatinine improved the AUC to 0.85 (0.83, 0.86), P < 0.001, when compared to the base model AUC using only proteinuria and hematuria, AUC = 0.64 (0.62, 0.67). In RRT models, CKD status improved the AUC to 0.78 (0.75, 0.82), P < 0.001, and baseline creatinine improved the AUC to 0.84 (0.80, 0.88), P < 0.001, compared to the base model, AUC = 0.72 (0.68, 0.76). There was no significant improvement in model discrimination when both CKD and baseline serum creatinine were included.ConclusionsProteinuria and hematuria values on dipstick urinalysis can be utilized to predict AKI and RRT in hospitalized patients with COVID-19. We derived formulas using these two readily available values to help prognosticate kidney outcomes in these patients. Furthermore, the incorporation of CKD or baseline creatinine increases the accuracy of these formulas.

Clinicohistological Profile and Outcomes of Rapidly Progressive Glomerulonephritis: A Prospective Study from North India.

The prevalence of this rare and fatal entity varies in different regions and ethnicities. The objective of this study was to determine clinicopathological characteristics and predictors of outcome in rapidly progressive glomerulonephritis (RPGN). We aimed to prospectively study the clinicopathological profile and determine the predictors of renal outcome in patients with RPGN. This study included 40 patients of biopsy-proven RPGN. The diagnosis of RPGN was based on renal histology showing crescents in >50% of glomeruli. All patients were given induction with intravenous (IV) methylprednisolone (0.5 g) for three days followed by maintenance with oral prednisolone (1 mg/kg/day) and six IV pulses of cyclophosphamide (0.5 g) given fortnightly followed by maintenance therapy with azathioprine (2 mg/kg/day). The outcomes were recorded. Three-fourth of the patients (77.4%) required renal replacement therapy (RRT) at diagnosis. More than half of patients (57.5%) were antineutrophil cytoplasmic antibodies mediated. Immune complex and anti-glomerular basement membrane (GBM) disease constituted 25% and 17.5%, respectively. Clinical features, biochemical parameters, histological features, and type of RPGN were analyzed for association with primary outcomes. Entry serum creatinine, entry estimated glomerular filtration rate (eGFR), RRT on admission, interstitial fibrosis, tubular atrophy, and interstitial infiltrates were the parameters which showed association with primary outcomes of the study (P <0.05). In secondary outcomes, infections were the most common (55%), followed by neutropenia (40%). One-fourth of the patients (25%) died during the course of the study. Cause of mortality was infections (50%), cardiovascular system (30%), stroke (10%), and unknown (10%). Our prospective study from north India shows that RPGN is not an uncommon cause of renal failure and there is preponderance in the elderly patients (>60 years). Pauci-immune RPGN is the most common cause of RPGN followed by immune-complex and anti-GBM disease. Entry serum creatinine, eGFR, and RRT on admission predicted the outcome.

POS-878 Peritoneal Dialysis during COVID-19 pandemic. A report from a third level center from Mexico. The COVMEX-PD Cohort

Kidney involvement is frequent in COVID-19 in many manifestations. Acute kidney injury (AKI) affects 20-40% of critically ill patients with COVID-19. Many of these patients require RRT, which implies a high demand for material resources and medical staff. During the most critical time of the pandemic, some RRT some modalities were insufficient, forcing medical centers to diversify the RRT modalities offered. Chronic kidney disease (CKD) patients who require renal replacement therapy (RRT) commonly have comorbidities and chronic immunosuppressive state that could predispose them to worse outcomes during COVID-19.

Therapeutic plasma exchange. Experience in 102 patients

Therapeutic Plasma Exchange (TPE) is a procedure in which plasma and harmful macromolecules are separated from the rest of the blood components by centrifugation or filtration through membranes and are replaced with solutions with albumin and/or plasma. To communicate our experience using TPE by filtration. Review of records of 655 TPE sessions performed in 102 patients aged 50 ± 18 years (64% women). The requirement of renal replacement therapy (RRT) and seven days and one year mortality were recorded. Forty five percent of patients had hypertension or diabetes. The main indications for TPE were pulmonary-renal syndrome (PRS) (62%) and antibody mediated graft rejection (29%), followed by neurological diseases (36%). Fifteen percent of patients required RRT for one year. Mortality at seven days and one year was 20 and 30%, respectively. Out of the total of deaths associated with kidney diseases, 88% corresponded to PRS and ANCA vasculitis. The main complications were thrombocytopenia in 41%, hypocalcemia in 18%, and hypotension in 16%. In our experience, TPE by filtration is a safe technique, with mild and preventable complications. Despite this, the reported mortality is high, which reflects the severity of the diseases that motivated the indication for TPE.