Role Of Renal Replacement Therapy Research Articles

Abstract 12228: Prognostic Role of Renal Replacement Therapy Among Hospitalized Patients With Heart Failure in the Brazilian National Public Health System

Introduction: Data on survival and prognostic factors of patients hospitalized with HF in Brazil are scarce. Aims: To determine the in-hospital all-cause mortality rate, in-hospital renal replacement therapy (RRT) rate, and its association with in-hospital mortality in a population of patients admitted with HF to hospitals from the Brazilian National Public Health System (SUS). Methods: We included adult patients with a documented diagnosis of HF (ICD-10 I50.X) admitted to any public hospital in the SUS Hospital Information System (SIHSUS) registry from April 2017 to August 2021. RRT included intermittent hemodialysis, continuous hemodialysis, and peritoneal dialysis. Descriptive statistics and univariate and multivariate Cox regression were employed. Results: Of the 910,128 HF hospitalizations identified, 106,383 (11.7%) resulted in in-hospital death (Table 1). RRT (required by 8,179 non-survivors [7.7%] and 11,496 survivors [1.4%, p < 0.001]) was associated with a 56% increase in the risk of death (HR 1.56, 95% CI 1.52 - 1.59) (Fig 1). All forms of RRT were independently associated with in-hospital mortality (Fig 2). Female sex (HR 1.04, 95% CI 1.03-1.06) and COVID-19 (HR 1.41, 95% CI 1.14-1.81) were identified as risk factors for in-hospital mortality, while heart transplantation improved survival (HR 0.37, 95% CI 0.29-0.47). Hospitalizations requiring RRT and hospitalizations resulting in death were both longer and costlier (Fig 3, 4). Conclusion: In this nationwide registry of patients admitted with HF to Brazilian public hospitals, we found an alarming mortality rate double the estimates reported in European and North American countries. RRT was strongly associated with a prolonged hospital stay, higher cost-of-hospitalization, and in-hospital death. Our findings highlight the significance of optimizing medical therapy for patients admitted with HF to prevent the deterioration of their renal function and the need for RRT.

Prognostic role of renal replacement therapy among hospitalized patients with heart failure in the Brazilian national public health system.

Data on patients hospitalized with acute heart failure in Brazil scarce. We performed a cross-sectional, retrospective, records-based study using data retrieved from a large public database of heart failure admissions to any hospital from the Brazilian National Public Health System (SUS) (SUS Hospital Information System [SIHSUS] registry) to determine the in-hospital all-cause mortality rate, in-hospital renal replacement therapy rate and its association with outcome. In total, 910,128 hospitalizations due to heart failure were identified in the SIHSUS registry between April 2017 and August 2021, of which 106,383 (11.7%) resulted in in-hospital death. Renal replacement therapy (required by 8,179 non-survivors [7.7%] and 11,496 survivors [1.4%, p < 0.001]) was associated with a 56% increase in the risk of death in the univariate regression model (HR 1.56, 95% CI 1.52 -1.59), a more than threefold increase of the duration of hospitalization, and a 45% or greater increase of cost per day. All forms of renal replacement therapy remained independently associated with in-hospital mortality in multivariable analysis (intermittent hemodialysis: HR 1.64, 95% CI 1.60 -1.69; continuous hemodialysis: HR 1.52, 95% CI 1.42 -1.63; peritoneal dialysis: HR 1.47, 95% CI 1.20 -1.88). The in-hospital mortality rate of 11.7% observed among patients with acute heart failure admitted to Brazilian public hospitals was alarmingly high, exceeding that of patients admitted to North American and European institutions. This is the first report to quantify the rate of renal replacement therapy in patients hospitalized with acute heart failure in Brazil.

Role of renal replacement therapy in pregnancy related acute kidney injury and its outcome.

ABSTRACTBackground:Pregnancy-related acute kidney injury (PRAKI) has bimodal distribution. The rates of maternal mortality and perinatal mortality in patients with PRAKI have increased. The aim of this study was to evaluate magnitude of PRAKI in North Indian women and to assess morbidity, mortality, and outcomes in patients who received renal replacement therapy.Materials and Methods:This prospective observational study was carried out in the Department of Obstetrics and Gynaecology, in collaboration with nephrology. A total of 150 women suffering from PRAKI were recruited and total 98 obstetrics AKI, requiring renal replacement therapy, classified as per KDIGO guidelines 2012 were enrolled for dialysis. Six patients were lost to follow up before final analysis. Haemodialysis was carried out by B. Brawn machineResults:Approximately 82% cases of PRAKI diagnosed in postpartum period. Mean cycles of dialysis was 9.06 ± 7.75 approximately half of the females required 1–5 cycles of dialysis. Higher percentages of maternal deaths were observed within 1–5 cycles of dialysis. Women received dialysis after 72 h showed increased chances of partial recovery. After 3 months of follow-up, rate of complete recovery was significantly higher in Stage I (100%) and Stage II (84.6%) PRAKI while rate of partial recovery and deaths were significantly higher in Stage III PRAKI (37.3%). Stage of AKI, baseline K+ levels, treatment modality, duration of ICU stay and use of Vasopressure showed significant association with adverse outcomeConclusion:Higher percentages of deaths were observed in those who referred late and delay in initiation of dialysis and it was observed within 1–5 cycles of dialysis.

Beta 2 microglobulin in kidney failure: A review and an algorithm for renal replacement therapy.

For decades, beta 2 microglobulin (B2M) has been a subject of great interest in nephrology and other fields such as multiple myeloma. B2M, a 99 amino acid protein, is associated with amyloid deposits in patients undergoing renal replacement therapy (RRT). The source of information is published articles on B2M in chronic renal failure since 1960. We have reviewed literature published since 1960 to date, highlighting the milestones of the role of B2M in chronic kidney disease (CKD) and B2M serum values in patients treated by various RRTs. B2M deposits associated with the disease include carpal tunnel syndrome, spondyloarthropathy, and arthritis of large joints such as the shoulders. The role of RRT in the removal of B2M in CKD is discussed. Recent reports include factors affecting the process of fibrillation and deposition of B2M in tissues. A comparative report of various modalities of treatment on the serum levels of B2M is provided. The presence of significant residual urine output in continuous ambulatory peritoneal dialysis patients may explain why peritoneal dialysis is a modality that is associated with the lowest level of serum B2M. Patients treated with hemodiafiltration or hemodialysis (HD) using high flux dialyzers have lower levels of B2M than those treated by HD with low flux dialyzers. Finally, based on the literature review, an algorithm for RRT using B2M level monitoring and other variables is proposed and needs evaluation in a controlled trial.

Role of Renal Replacement Therapy During the Peri-Transplant Period of Heart Transplantation.

BackgroundHeart transplantation (HT) is the most useful treatment modality for heart failure. Although several studies have reported the impact of acute kidney injury (AKI) on clinical outcomes after transplantation, little is known about the impact of peri-transplant renal replacement therapy (RRT) on clinical outcomes. We compared the clinical outcomes according to RRT use status among patients with AKI during the peri-transplant period.Material/MethodsThe medical records of 21 patients who underwent HT from January 2006 to May 2019 were reviewed. We assessed the heart failure cause, comorbidities, immunosuppressant type, requirement for extracorporeal membrane oxygenation, AKI incidence, and cardiac and renal functions over time. The patients were divided into 3 groups: those without AKI (non-AKI group, n=6), those who underwent perioperative RRT (RRT group, n=10), and those who did not undergo RRT (non-RRT group, n=5).ResultsThe most common cause of HT was dilated cardiomyopathy (52.4%). Fifteen patients (71.4%) experienced AKI during the peri-transplant period. Among them, 9 (90%) in the RRT group underwent continuous RRT and only 1 (10%) underwent intermittent hemodialysis. Until 6 months after HT, the renal function of the RRT group was worse than that of the non-RRT group (estimated glomerular filtration rate 44.2 vs. 69.2 mL/min/1.73 m2, P=0.015), but the differences dissipated by 9 months. Finally, all patients, even in the RRT group, withdrew from dialysis.ConclusionsRRT during the peri-transplant period in HT may be a good bridge therapy for renal function recovery in patients with cardiorenal AKI.

Acute Renal Failure in Critically Ill COVID-19 Patients With a Focus on the Role of Renal Replacement Therapy: A Review of What We Know So Far.

Acute renal failure remains a significant concern in all patients with the coronavirus disease 2019 (COVID-19) infection. Management is particularly challenging in critically ill patients requiring intensive care unit (ICU) level of care. Supportive care in the form of accurate volume correction and avoiding nephrotoxic agents are the chief cornerstone of the management of these patients. The pathophysiology of acute renal failure in COVID-19 is multifactorial, with significant contributions from excessive cytokine release. Gaining a better insight into the pathophysiology of renal failure will hopefully help develop more directed treatment options. A considerable number of these patients deteriorate despite adequate supportive care owing to the complexity of the disease and multi-organ involvement. Renal replacement therapy is used for a long time in critically ill septic patients who develop progressive renal failure despite adequate conservative support. Timing and choice of renal replacement therapy in critically ill COVID-19 patients remains an area of future research that may help decrease mortality in this patient population.

Management of hypercalcaemic crisis in adults: Current role of renal replacement therapy

Neoplasms and hematologic diseases are the predominant etiologies of hypercalcemic crisis in adults and the immediate treatment is mainly medical and symptomatic. The use of renal replacement therapy (RRT) is often necessary to correct the hypercalcemia, uremia and electrolyte disturbances related to Acute Kidney Injury (AKI). The aim of this work was to determine the etiologies and the place of RRT in treating patients with hypercalcaemic crisis. We conducted a retrospective study for 36months at the Nephrology Unit, University Hospital, Oujda, eastern of Morocco. We included all adult patients diagnosed with hypercalcemic crisis that was defined as corrected total serum calcium of >3.5mmol/l. Results12 patients were collected. All patients were female and 5 patients were elderly (≥65years). Three patients had a serum calcium value of >4mmol/l and the highest calcium value was 5.8mmol/l. Electrocardiographic abnormalities were observed in 8 cases. AKI was observed in 8 cases. Three patients had chronic kidney disease on hemodialysis. Neoplasm was noted in 9 cases. All patients received venous rehydration, glucocorticoids and biphosphonates. The use of RRT with low calcium dialysate was performed in 11 cases. Three patients died during the first 24h of hospitalization. ConclusionRRT must play its full role as first line treatment of hypercalcemia crisis. Improvements in hemodialysis techniques and the use of low calcium or calcium-free dialysates currently allows this therapeutic measure to be prescribed safely, and the benefit-risk balance is positive for the great benefit provided by dialysis.

Expanding role of renal replacement therapy in a tertiary care Picu : Unit experience

Background : The role of renal replacement therapy (RRT) in critical care is expanding. It is the cornerstone in the management of critically ill children. Continuous RRT is a mainstay of treatment in PICU for acute kidney injury (AKI) due to well-maintained hemodynamic stability with slow predictable fluid and solute removal. Apart from the classic indications RRT plays a significant role in the treatment of many other disease conditions such as septic shock and other organ-supportive strategies. Methods : We conducted a retrospective analysis of all the children who underwent RRT for critical care indications over a period from July 2015 to July 2017 at Rainbow Children’s Hospital, Marathahalli, Bangalore. Results : A total of 24 children underwent RRT over a period of 2 years with 12 males (50%) and 12 females (50%). Out of these 5 children (20.8%) had background of chronic kidney disease. Mean age of children who underwent RRT was 6 years (range:4 months-16 years). Sepsis with septic shock was the diagnosis most commonly associated to needing RRT (58.3%). The most common clinical condition associated with acute kidney injury was hemodynamic instability (58%), followed by multi-organ dysfunction syndrome (41%). The most common indication for initiating RRT was Acute Kidney Injury stage 2 with fluid overload >10% (as defined by KDIGO criteria) in 50% of the cases followed by severe metabolic acidosis refractory to medical therapy (29%). Eleven (45.8%) children who underwent RRT had Multi-organ dysfunction. There were no significant complications associated to initiation of RRT. Fifty- four percent of children survived. Among the children who died 81% had Multi-organ dysfunction syndrome. Three children (23%) required intermittent hemodialysis on follow up for complete recovery. Continuous renal replacement Therapy (CRRT) was done in 11 children (45.8%). The median duration of CRRT was 30 hours with the longest duration being 194 hours. Most common mode of CRRT used was Continuous venovenous hemodiafiltration (CVVHDF) . Newer hybrid techniques like Sustained low efficiency dialysis (SLED) was used in 5 patients (20%) with complete recovery noted during PICU stay. Conclusion : We present a diverse population of pediatric patients requiring RRT. Sepsis with septic shock was the most common diagnosis requiring RRT in our study population. CVVHDF was the common mode of RRT we used in our unit followed by newer techniques like SLED. We noticed hemodynamic instability and multi-organ dysfunction syndrome are the most common clinical conditions associated with acute kidney injury in our population. We did not observe any significant complications associated with initiation for RRT which indicates CRRT is safe in hemodynamic unstable patients. We observed that new therapies and techniques can provide supportive treatment beyond the classic renal indications.

Renal Replacement Therapy in Patients with Heart and Kidney Failure.

The incidence of chronic kidney disease (CKD) in patients with chronic heart failure (CHF) is high as CKD and CHF share underlying risk factors such as arterial hypertension, diabetes mellitus and atherosclerosis. Cardiac failure leads to renal hypoperfusion and dysfunction and then fluid overload and need for aggressive diuretic therapy. However, development of diuretic resistance represents a significant problem in the management of these patients. The role of Renal Replacement Therapy (RRT) is important for patients who do not response to conservative management of fluid overload facilitating the failing heart to restore function. According to the guidelines, venovenous isolated Ultrafiltration (UF) is indicated for patients with refractory congestion not responding to medical therapy with loop diuretics and infusion of dopamine. A systematic review of randomized controlled trials on the effect of UF vs. IV furosemide for decompensated heart failure showed a benefit of UF on total body weight loss and on readmissions due to heart failure in patients with decompensated heart failure and CKD. Peritoneal dialysis (PD) can provide efficient ultrafiltration and sodium extraction in volume overloaded patients followed by decline of hospitalization days, decrease of body weight and improvement of LVEF in patients with refractory heart failure. The continuous draw of ultrafiltrate is followed by a lesser risk of abrupt hypotension and better preservation of the residual kidney function. This represents a significant advantage of PD over intermittent UF by dialysis. In conclusion, application of UF by dialysis and PD is followed by significant total body weight loss, reduced need for hospital readmissions and better quality of life. PD has a higher probability of preservation of residual kidney function and can be used by patients at home.

Role of renal replacement therapy in patients with type 1 hepatorenal syndrome receiving combination treatment of vasoconstrictor plus albumin

PurposeUtilization of renal replacement therapy (RRT) in cirrhotic patients has been controversial and is typically dependent on the status of transplantation. A better understanding of the central role for arterial vasodilatation in the pathogenesis of hepatorenal syndrome (HRS) has led to routine use of vasoconstrictors in combination with albumin as a medical therapy for HRS with prolonged patient survival. The role of RRT in HRS patients receiving such treatment, however, has not yet been examined. MethodsA total of 80 patients with type 1 HRS who received a combination therapy of vasoconstrictors and albumin were enrolled into a retrospective cohort study. The effects of RRT status on clinical outcome were analyzed. ResultsBoth short-term (30 days) and long-term (180 days) survival was similar between RRT and non-RRT groups of patients, but the length of hospital stay was significantly longer among patients in the RRT group, which remain unchanged despite adjustment of status for liver transplantation. ConclusionsBased on our observation, routine use of RRT may not be beneficial in patients with type 1 HRS receiving combination treatment of vasoconstrictor plus albumin. Further prospective studies are needed to validate these findings and refine the specific indications for RRT in this patient population.

What is the Role of Renal Replacement Therapy in the Setting of Dabigatran Toxicity?

What is the Role of Renal Replacement Therapy in the Setting of Dabigatran Toxicity?

Renal replacement therapy in ICU

Diagnosing and managing critically ill patients with renal dysfunction is a part of the daily routine of an intensivist. Acute kidney insufficiency substantially contributes to the morbidity and mortality of critically ill patients. Renal replacement therapy (RRT) not only does play a significant role in the treatment of patients with renal failure, acute as well as chronic, but also has spread its domains to the treatment of many other disease conditions such as myaesthenia gravis, septic shock and acute on chronic liver failure. This article briefly outlines the role of renal replacement therapy in ICU.

Renal Dysfunction Associated with Intra-abdominal Hypertension and the Abdominal Compartment Syndrome

Once considered mostly a postsurgical condition, intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS) are now thought to increase morbidity and mortality in many patients receiving medical or surgical intensive care. Animal data and human observational studies indicate that oliguria and acute kidney injury are early and frequent consequences of IAH/ACS and can be present at relatively low levels of intra-abdominal pressure (IAP). Among medical patients at particular risk are those with septic shock and severe acute pancreatitis, but the adverse effects of IAH may also be seen in cardiorenal and hepatorenal syndromes. Factors predisposing to IAH/ACS include sepsis, large volume fluid resuscitation, polytransfusion, mechanical ventilation with high intrathoracic pressure, and acidosis, among others. Transduction of bladder pressure is the gold standard for measuring intra-abdominal pressure, and several nonsurgical methods can help reduce IAP. The role of renal replacement therapy for volume management is not well defined but may be beneficial in some cases. IAH/ACS is an important possible cause of acute renal failure in critically ill patients and screening may benefit those at increased risk.

Bench-to-bedside review: Treating acid–base abnormalities in the intensive care unit – the role of renal replacement therapy

Acid–base disorders are common in critically ill patients. Metabolic acid–base disorders are particularly common in patients who require acute renal replacement therapy. In these patients, metabolic acidosis is common and multifactorial in origin. Analysis of acid–base status using the Stewart–Figge methodology shows that these patients have greater acidemia despite the presence of hypoalbuminemic alkalosis. This acidemia is mostly secondary to hyperphosphatemia, hyperlactatemia, and the accumulation of unmeasured anions. Once continuous hemofiltration is started, profound changes in acid–base status are rapidly achieved. They result in the progressive resolution of acidemia and acidosis, with a lowering of concentrations of phosphate and unmeasured anions. However, if lactate-based dialysate or replacement fluid are used, then in some patients hyperlactatemia results, which decreases the strong ion difference and induces an iatrogenic metabolic acidosis. Such hyperlactatemic acidosis is particularly marked in lactate-intolerant patients (shock with lactic acidosis and/or liver disease) and is particularly strong if high-volume hemofiltration is performed with the associated high lactate load, which overcomes the patient's metabolic capacity for lactate. In such patients, bicarbonate dialysis seems desirable. In all patients, once hemofiltration is established, it becomes the dominant force in controlling metabolic acid–base status and, in stable patients, it typically results in a degree of metabolic alkalosis. The nature and extent of these acid–base changes is governed by the intensity of plasma water exchange/dialysis and by the 'buffer' content of the replacement fluid/dialysate, with different effects depending on whether lactate, acetate, citrate, or bicarbonate is used. These effects can be achieved in any patient irrespective of whether they have acute renal failure, because of the overwhelming effect of plasma water exchange on nonvolatile acid balance. Critical care physicians must understand the nature, origin, and magnitude of alterations in acid–base status seen with acute renal failure and during continuous hemofiltration if they wish to provide their patients with safe and effective care.

Drug Dosing in Acute Renal Failure: The Role of Renal Replacement Therapy in Altering Drug Pharmacokinetics

The combination of multiple medical problems requiring complex drug therapy with rapidly changing organ functions that lead to pharmacokinetic alterations makes drug regimen design in the intensive care unit challenging. Acute renal failure leads to even greater physiologic disturbances requiring additional pharmacologic, nutritional, and dialytic support. A variety of renal replacement modalities, both intermittent and continuous, are used to manage the solute, volume, and acid-base derangements of patients with acute renal failure. Renal replacement therapies differ in their impact on drug dosing. The clinician must consider the impact of both disease and treatment if drug prescribing is to be optimal. Principles of solute removal are reviewed and concepts of drug regimen design are discussed. A practical approach to drug prescribing in this setting is described. Examples of dose adjustments for intermittent and continuous renal replacement therapies are provided.