Utilization Of Renal Replacement Therapy Research Articles

Utility of renal replacement therapy in poisoning and drug overdosage

Abstract Toxic and prescribed drug ingestions are a significant cause of pediatric morbidity and mortality. Management of the poisoned patient begins with a thorough evaluation, identification of the agent(s) involved, and assessment of severity and symptoms. Therapy consists of the provision of supportive care, prevention of poison absorption, use of antidotes, and, when appropriate, the use of renal replacement therapy (RRT) to enhance the elimination of the poison. Among several elimination techniques, extracorporeal treatment such as RRT can be lifesaving as it rapidly removes the toxin independent of the patient’s indigenous clearance. Hemodialysis remains the most commonly used RRT for toxin removal, and the role of continuous RRT and therapeutic plasma exchange is emerging. To properly utilize the RRT, the clinician should understand the chemical properties of the toxins and the underlying mechanism of clearance by the concerned RRT technique. Although pediatric literature is mainly limited to case reports, timely initiation of RRT helps manage children with poisoning and drug overdose.

Renal replacement therapy prior to liver transplant and inpatient mortality in patients without advanced kidney disease: A nationwide study.

The utility of renal replacement therapy (RRT) before liver transplant (LT) in patients without end-stage renal disease (ESRD) or advanced chronic kidney disease (CKD-IV/V) is debatable and lacks data support. We aimed to evaluate the impact of RRT on patients undergoing LT. We used the National Readmission Database (2016-2019) to identify all index hospitalizations undergoing RRT before LT (cases). A matched comparison cohort of similar hospitalizations without RRT before LT was identified (controls) after 1:1 propensity score matching for age, gender, and available comorbidities. We matched 364 cases (RRT before LT) to 364 controls (LT without prior RRT). There was no statistical difference in all-cause inpatient mortality (4.9% vs 3.6% P = 0.4). A significantly greater proportion of cases were associated with ICU admission (40.7% vs 17.0%, P < 0.001) and RRT requirement post LT (100% vs 17%, P < 0.001). There was no difference in 30- (hazard ratio [HR] 1.1, 0.4-2.6), 60- (HR 0.9, 0.4-1.8), or 90-day (HR 0.8, 0.4-1.6) inpatient mortality between the groups. Also, 180-day survival estimates were comparable (P = 0.5). The results were similar in patients with no chronic kidney disease (CKD) and CKD-III. RRT prior to LT, in patients without advanced CKD or ESRD, was associated with greater instances of ICU stay and need for future RRT. Also, 30-, 60-, and 90-day inpatient mortality rates were similar, and 180-day survival estimates were comparable.

Analyzing the utility of renal replacement therapy to manage hepatorenal syndrome in alcoholic hepatitis without liver transplantation: a nationwide analysis.

Hepatorenal syndrome (HRS) frequently complicates alcoholic hepatitis (AH) and portends poor survival in this population. Published literature indicates mixed benefits from renal replacement therapy (RRT) for HRS refractory to medical management. Therefore, we sought to assess the utilization of RRT in AH and clinicaloutcomes at a national level. Using the International Classification of Diseases, Tenth Revision (ICD-10) codes, we identified adult patients with AH with a coexisting diagnosis of HRS from the National Readmission Database 2016 through 2019. Mortality, morbidity, and resource utilization were compared. We compared proportions using the Fisher exact test and computed adjusted P-values based on multivariate regression analysis. Analyses were performed using Stata, version 14.2, considering a two-sided P<0.05 as statistically significant. A total of 73 203 patients with AH were included in the analysis (mean age 46.2years). A total of 3620 individuals had HRS diagnosis (5%), of which 14.7% (n: 532) underwent RRT. HRS patients receiving RRT had a higher mortality rate than those who did not (adjusted odds ratio [aOR] 1.8, 95% confidence interval [CI]: 1.3-2.6, P: 0.01), along with higher resource utilization. Only those patients with HRS who underwent liver transplantation (LT) experienced a mortality reduction (24.4% for those not receiving RRTs and 36.5% for those receiving RRT). RRT is associated with higher mortality and morbidity when offered to patients with AH and HRS, who do not undergo LT. Therefore, our results suggest careful selection of AH patients when deciding to initiate RRT for HRS.

Impact of National Economy and Policies on End-Stage Kidney Care in South Asia and Southeast Asia.

Background The association between economic status and kidney disease is incompletely explored even in countries with higher economy (HE); the situation is complex in lower economies (LE) of South Asia and Southeast Asia (SA and SEA). Methods Fifteen countries of SA and SEA categorized as HE and LE, represented by the representatives of the national nephrology societies, participated in this questionnaire and interview-based assessment of the impact of economic status on renal care. Results Average incidence and prevalence of end-stage kidney disease (ESKD) per million population (pmp) are 1.8 times and 3.3 times higher in HE. Hemodialysis is the main renal replacement therapy (RRT) (HE-68%, LE-63%). Funding of dialysis in HE is mainly by state (65%) or insurance bodies (30%); out of pocket expenses (OOPE) are high in LE (41%). Highest cost for hemodialysis is in Brunei and Singapore, and lowest in Myanmar and Nepal. Median number of dialysis machines/1000 ESKD population is 110 in HE and 53 in LE. Average number of machines/dialysis units in HE is 2.7 times higher than LE. The HE countries have 9 times more dialysis centers pmp (median HE-17, LE-02) and 16 times more nephrologist density (median HE-14.8 ppm, LE-0.94 ppm). Dialysis sessions >2/week is frequently followed in HE (84%) and <2/week in LE (64%). “On-demand” hemodialysis (<2 sessions/week) is prevalent in LE. Hemodialysis dropout rates at one year are lower in HE (12.3%; LE 53.4%), death being the major cause (HE-93.6%; LE-43.8%); renal transplants constitute 4% (Brunei) to 39% (Hong Kong) of the RRT in HE. ESKD burden is expected to increase >10% in all the HE countries except Taiwan, 10%–20% in the majority of LE countries. Conclusion Economic disparity in SA and SEA is reflected by poor dialysis infrastructure and penetration, inadequate manpower, higher OOPE, higher dialysis dropout rates, and lesser renal transplantations in LE countries. Utility of RRT can be improved by state funding and better insurance coverage.

Incidence of acute kidney injury and use of renal replacement therapy in intensive care unit patients in Indonesia

BackgroundCurrently, there is limited epidemiology data on acute kidney injury (AKI) in Indonesia. Therefore, we assessed the incidence of AKI and the utilization of renal replacement therapy (RRT) in Indonesia.MethodsDemographic and clinical data were collected from 952 ICU participants. The participants were categorized into AKI and non-AKI groups. The participants were further classified according to the 3 different stages of AKI as per the Kidney Disease Improving Global Outcome (KDIGO) criteria.ResultsOverall incidence of AKI was 43%. The participants were divided into three groups based on the AKI stages: 18.5% had stage 1, 33% had stage 2, and 48.5% had stage 3. Primary diagnosis of renal disease and high APACHE II score were the risk factors associated with AKI (OR = 4.53, 95% CI: 1.67–12.33, p = 0.003 and OR = 1.14 per 1 unit increase, 95% CI: 1.09–1.20, p < 0.001, respectively). Chronic kidney disease was the risk factor for severe AKI. Sepsis was the leading cause of AKI. Among the AKI participants, 24.6% required RRT. The most common RRT modalities were intermittent hemodialysis (71.7%), followed by slow low-efficiency dialysis (22.8%), continuous renal replacement therapy (4.3%), and peritoneal dialysis (1.1%).ConclusionsThis study showed that AKI was a common problem in the Indonesian ICU. We strongly believe that identification of the risk factors associated with AKI will help us develop a predictive score for AKI so we can prevent and improve AKI outcome in the future.

Incidence, predictors and prognosis of acute kidney injury in nonagenarians: an in-hospital cohort study

BackgroundGiven the aging of the population, nephrologists are ever more frequently assisting nonagenarians with acute kidney injury (AKI). The management of these patients presents unique characteristics, including bioethical dilemmas, such as the utilization of renal replacement therapy (RRT) at this extreme age.MethodsWe conducted a retrospective cohort study at a tertiary hospital. Over a 10-year period, 832 nonagenarians were hospitalized for two or more days. A random sample of 461 patients was obtained; 25 subjects were excluded due to lack of essential data. AKI was defined and staged according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria.ResultsWe analyzed data from 436 patients, mean age 93.5 ± 3.3 years, 74.3% female; 76.4% required intensive care unit (ICU). The incidence of AKI was 45%. Length of hospital stay, ICU admission, vasopressors, and mechanical ventilation (MV) were independent predictors of AKI. Overall in-hospital mortality was 43.1%. Mortality was higher in the AKI compared to the no AKI group (66.8% vs. 23.8%, p < 0.001). Only 13 patients underwent RRT; all were critically ill, requiring vasopressors and 76.9% in MV. Mortality for this RRT group was 100% but not significantly higher than that observed in 26 non-RRT controls (96.1%, p = 1.0) obtained by proportional random sampling, matched by variables related to illness severity. In multivariable analysis, age, Charlson’s score, vasopressors, MV, and AKI – but not RRT – were independent predictors of mortality.ConclusionsAKI is common in hospitalized nonagenarians and carries a grave prognosis, especially in those who are critically iil. The use of RRT was not able to change the fatal prognosis of this subgroup of patients. Our data may help guide informed decisions about the utility of RRT in this scenario.

Yellow Means Caution: Correlations Between Liver Injury and Mortality with the Use of VA-ECMO

Abnormalities in markers of liver injury after venoarterial extracorporeal membrane oxygenation (VA-ECMO) initiation are of unclear distribution and clinical significance. This study included all consecutive adult patients from a single institution who underwent VA-ECMO cannulation between May 2012 and September 2016 and had liver function panels drawn during their admission (n = 223). Data points include: age, sex, body mass index, diagnosis, duration of ECMO cannulation, duration of hospitalization, pre-ECMO cardiac arrest, central nervous system (CNS) injury, the presence of chronic kidney disease or acute renal failure, renal replacement therapy utilization, lactate levels, duration of pre-ECMO intubation, admission and peak bilirubin/aspartate aminotransferase (AST)/alanine aminotransferase (ALT)/alkaline phosphatase (ALP) levels, and time to peak bilirubin/AST/ALT/ALP in relation to cannulation. Multivariate Poisson regression analyses were performed to determine associations with mortality. In-hospital mortality was 66%. Serum bilirubin elevation appeared to significantly correlate continuously with mortality. Other markers of liver injury were not significant in final multivariate models. As a univariate factor, no patient survived with a total serum bilirubin greater than 30 mg/dl, and specificity for 90% mortality was crossed at 11 mg/dl. Mortality was also significantly associated with the presence of CNS injury and elevation of lactic acid levels. Postcannulation liver injury is significantly associated with increased mortality and total serum bilirubin appears to be a biomarker of considerable clinical significance.

The Drunken Kidney: The Utility of Renal Replacement Therapy in Hepatic Encephalopathy

Severe liver failure may cause the brain to swell, leading to significantly altered sensorium. In the treatment of these patients, we utilize the ability of the gastrointestinal system to clear ammonia. However, we often come across patients who do not respond to this regimen. In this case, our patient was somnolent requiring intubation and had rising ammonia levels despite lactulose and rifaximin therapy. Although he had normal kidney function, we used continuous renal replacement therapy (CRRT) and noted improvement in the patient's mental status. 58-year-old male with history of cirrhosis with portal hypertension presented with shortness of breath and cough for 2 weeks. He was initially admitted for COPD exacerbation. CT chest then revealed left upper lobe pneumonia. He developed further worsening respiratory failure requiring intubation and antibiotic therapy. His physical examination off sedation included no purposeful movements and he was not following commands. Ammonia level returned at 199. He received lactulose enema, as well as lactulose and rifaximin through orogastric tube. However, his mental status continued to deterioate and ammonia level rose to 229. Given his minimal responsiveness and rising ammonia levels, CRRT was started. The next morning, his abdomen became increasingly distended and rigid. Abdominal X-ray revealed colonic ileus and rectal tube was placed for colonic decompression. Lactulose was switched to Miralax QID and he received another CRRT session. The following day, he had increasing output from his rectal tube. Serial abdominal X-rays revealed decreasing colonic distention. Ammonia level was 115. He began to follow commands and move his extremities purposefully and he was quickly extubated. We present the case of a patient who presented with acute respiratory failure along with altered mental status secondary to hepatic encephalopathy (HE). When conservative measures fail, clinicians sometimes consider more invasive techniques for HE, such as large portosystemic shunts or liver transplantation; however, not all patients are candidates for these procedures. Although the kidneys are not the primary site of ammonia clearance, this case sheds light on the utility of renal replacement therapy in the management of critically ill patients, even those without pre-existing kidney dysfunction or end-organ damage. Further studies are needed to quantify the extent to which renal replacement may benefit these patients.2397 Figure 1. Borderline dilatation of the ascending colon; pneumatosis cannot be excluded in this segment. Increased mild ascites. Portal hypertension, with giant gastric varices and mild splenomegaly.

Challenges and pitfalls when implementing renal replacement therapy in the ICU.

Several new methods of renal replacement therapy (RRT) are now available for treating patients in the ICU setting. However, utilization of RRT in the ICU is subject to considerable variation and the need for RRT is associated with worse outcomes. Several factors influence the application of dialysis and reflect the interplay of patient and process of care elements that are dynamic in nature. Despite multiple studies evaluating RRT and its application, there are gaps in our knowledge that must be overcome to improve outcomes. This article discusses some of the important issues that require attention in delivering RRT in critically ill patients and provides a framework for the optimal use of RRT in the ICU.

Effects of Renal Replacement Therapy on Renal Recovery after Acute Kidney Injury

Recovery of kidney function following an episode of acute kidney injury (AKI) is now acknowledged as a vital patient-centered outcome with clear health economic implications. In approximately 5-8% of critically ill patients with more severe forms of AKI, support with renal replacement therapy (RRT) is provided. Recent data have suggested that rates of RRT utilization in AKI are increasing. Despite advances in our understanding of how best to prescribe acute RRT in critically ill patients with AKI, additional aspects remain uncertain, predisposing to suboptimal delivery and variation in practice. Importantly, if, when, how, and by what principles we apply acute RRT for AKI are all treatment decision-related factors that are modifiable and may interact with recovery of kidney function. Limited data, mostly from observational studies and secondary analyses, have explored the specific association between acute RRT and recovery. Available data are not able to clarify whether providing any RRT in otherwise eligible patients with AKI impacts recovery. They are also unable to inform whether the timing or circumstance under which RRT is started impacts recovery. No studies have evaluated whether there is an optimal time to start RRT to maximize the probability of recovery. Accumulated evidence, mostly derived from observational studies, suggests initial therapy in critically ill patients with AKI with continuous RRT, compared with intermittent modalities, improves the probability of recovery to dialysis independence. Evidence from high-quality randomized trials failed to show any association between delivered dose intensity of RRT and recovery. The use of biocompatible membranes for acute RRT may improve recovery in AKI; however, data are inconsistent. Limited data have evaluated the impact of membrane flux properties on recovery. Preliminary data have suggested that circuit anticoagulation with citrate, which results in a reduction in membrane-induced oxidative stress and leukocyte activation, may be associated with improved recovery; however, further corroborative data are needed. Additional evidence, ideally from randomized trials, is clearly needed to inform best practice in the delivery of acute RRT to optimize probability of recovery of kidney function for survivors of AKI.

Incidence and outcomes of acute kidney injury following orthotopic lung transplantation: a population-based cohort study.

Acute kidney injury (AKI) is a serious complication following lung transplantation (LTx). We aimed to describe the incidence and outcomes associated with AKI following LTx. A retrospective population-based cohort study of all adult recipients of LTx at the University of Alberta between 1990 and 2011. The primary outcome was AKI, defined and classified according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria, in the first 7 post-operative days. Secondary outcomes included risk factors, utilization of renal replacement therapy (RRT), occurrence of post-operative complications, mortality and kidney recovery. Of 445 LTx recipients included, AKI occurred in 306 (68.8%), with severity classified as Stage I in 38.9% (n = 173), Stage II in 17.5% (n = 78) and Stage III in 12.4% (n = 55). RRT was received by 36 (8.1%). Factors associated with AKI included longer duration of cardiopulmonary bypass [per minute, odds ratio (OR) 1.003; 95% confidence interval (CI), 1.001-1.006; P = 0.02], and mechanical ventilation [per hour (log-transformed), OR 5.30; 95% CI, 3.04-9.24; P < 0.001], and use of cyclosporine (OR 2.03; 95% CI, 1.13-3.64; P = 0.02). In-hospital and 1-year mortality were significantly higher in those with AKI compared with no AKI (7.2 versus 0%; adjusted P = 0.001; 14.4 versus 5.0%; adjusted P = 0.02, respectively). At 3 months, those with AKI had greater sustained loss of kidney function compared with no AKI [estimated glomerular filtration rate, mean (SD): 68.9 (25.7) versus 75.3 (22.1) mL/min/1.73 m(2), P = 0.01]. By the KDIGO definition, AKI occurred in two-thirds of patients following LTx. AKI portended greater risk of death and loss of kidney function.

Predictors of mortality among bacteremic patients with septic shock receiving appropriate antimicrobial therapy

BackgroundFactors capable of impacting hospital mortality in patients with septic shock remain uncertain. Our objective was to identify predictors of hospital mortality among patients who received appropriate antimicrobial therapy for bacteremic septic shock after accounting for severity of illness, resuscitation status, and processes of care.MethodsWe conducted a secondary subgroup analysis of a prospective severe sepsis cohort study. Patients with septic shock and positive blood cultures who received appropriate antimicrobial therapy were included. Univariable analyses were used to identify differences between hospital survivors and non-survivors, and a multivariable logistic regression model revealed independent determinants of hospital mortality.ResultsFrom January 2008 to December 2010, 58 of 224 included patients died in the hospital. Multivariable logistic regression analysis demonstrated 2 independent predictors of hospital mortality. These included continuous renal replacement therapy utilization within 48 hours of septic shock recognition (adjusted odds ratio [OR], 5.52; 95% confidence interval [CI], 1.94-16.34) and intra-abdominal infection (adjusted OR, 3.92; 95% CI, 1.47-10.79). Escherichia coli was independently associated with a lower risk of hospital mortality (adjusted OR, 0.34; 95% CI, 0.11-0.90).ConclusionIntra-abdominal infection and continuous renal replacement therapy were associated with increased hospital mortality in patients with septic shock who received appropriate antimicrobial therapy. Our findings may be explained by suboptimal intra-abdominal infection management or inadequate antimicrobial concentration in these patients.

Timing of Dialysis Initiation in Acute Kidney Injury and Acute‐On‐Chronic Renal Failure

The decision to provide dialytic support and choosing the ideal moment to initiate therapy are common impasses for physicians treating patients with acute kidney injury (AKI). Although renal replacement therapy (RRT) has been extensively used in clinical practice for more than 30 years, there is a paucity of evidence to guide clinicians on the optimal utilization of RRT in AKI. In the absence of traditional or urgent indications, there is no consensus on whether dialysis should be offered and when it should be started. The lack of agreed-upon parameters to guide the decision, the fear of the risk of the procedure, and the possible contribution to worse prognosis with RRT have resulted in a considerable variation in practice among physicians and centers. In this review, we summarize the evidence evaluating time of initiation of RRT and discuss possible approaches for future trials in addressing this issue.

Acute kidney injury among critically ill patients with pandemic H1N1 influenza A in Canada: cohort study

BackgroundCanada’s pandemic H1N1 influenza A (pH1N1) outbreak led to a high burden of critical illness. Our objective was to describe the incidence of AKI (acute kidney injury) in these patients and risk factors for AKI, renal replacement therapy (RRT), and mortality.MethodsFrom a prospective cohort of critically ill adults with confirmed or probable pH1N1 (16 April 2009–12 April 2010), we abstracted data on demographics, co-morbidities, acute physiology, AKI (defined by RIFLE criteria for Injury or Failure), treatments in the intensive care unit, and clinical outcomes. Univariable and multivariable logistic regression analyses were used to evaluate the associations between clinical characteristics and the outcomes of AKI, RRT, and hospital mortality.ResultsWe included 562 patients with pH1N1-related critical illness (479 [85.2%] confirmed, 83 [14.8%] probable]: mean age 48.0 years, 53.4% female, and 13.3% aboriginal. Common co-morbidities included obesity, diabetes, and chronic obstructive pulmonary disease. AKI occurred in 60.9%, with RIFLE categories of Injury (23.0%) and Failure (37.9%). Independent predictors of AKI included obesity (OR 2.94; 95%CI, 1.75-4.91), chronic kidney disease (OR 4.50; 95%CI, 1.46-13.82), APACHE II score (OR per 1-unit increase 1.06; 95%CI, 1.03-1.09), and PaO2/FiO2 ratio (OR per 10-unit increase 0.98; 95%CI, 0.95-1.00). Of patients with AKI, 24.9% (85/342) received RRT and 25.8% (85/329) died. Independent predictors of RRT were obesity (OR 2.25; 95% CI, 1.14-4.44), day 1 mechanical ventilation (OR 4.09; 95% CI, 1.21-13.84), APACHE II score (OR per 1-unit increase 1.07; 95% CI, 1.03-1.12), and day 1 creatinine (OR per 10 μmol/L increase, 1.06; 95%CI, 1.03-1.10). Development of AKI was not independently associated with hospital mortality.ConclusionThe incidence of AKI and RRT utilization were high among Canadian patients with critical illness due to pH1N1.

Aging and ESRD Demographics: Consequences for the Practice of Dialysis

The disproportionate increase in the prevalence of chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the elderly is now recognized as a national and global reality. Among the major contributing factors are the aging of the population, a growing prevalence of CKD, greater access to care, and increased comorbidities. The utilization of renal replacement therapy in the geriatric population has concomitantly increased. It is imposing enormous challenges to the practice of ESRD care, the largest of which may be to determine the best application of clinical performance targets to a population with limitations in life expectancy. Concurrently, increased focus on quality of life will be required. The effective dialysis practitioner will need to adapt to the aging ESRD demographics with an increased focus on physical and mental well-being of the geriatric patient.

Renal Replacement Therapy in Patients with Chronic Liver Disease

As the prevalence of chronic liver disease and chronic kidney disease (CKD) increase, clinicians are likely to be increasingly faced with difficult diagnostic, treatment, and ethical challenges when facing both of these diseases in a single patient. Alterations in creatinine formation and elimination in cirrhotic patients render creatinine-based estimates of glomerular filtration rate and dialysis adequacy less accurate in this population. Furthermore, differentiating signs and symptoms of uremia from hepatic disease may be difficult and clear indications for renal replacement therapy (RRT) in these patients have not been defined. Hemodialysis is associated with a high rate of complications and has not been shown to prolong life in cirrhotic patients with acute renal failure (ARF), but has not been carefully examined in those with CKD. Peritoneal dialysis is, similarly, unhelpful in chronic liver disease complicated by ARF, but has been found to be a viable option in some cirrhotic patients with CKD. Continuous RRT is generally tolerated by patients with decompensated cirrhosis and either acute or chronic renal failure and may act to bridge patients to liver transplantation. Given the poor underlying survival of cirrhotic patients with renal failure, clinicians should carefully consider the utility of RRT in each patient.

Equity of renal replacement therapy utilization: a prospective population-based study.

This 1-year prospective survey assessed the incidence and characteristics of all patients starting renal replacement therapy (RRT) for end-stage renal disease in Scotland, and whether there is equity of utilization of RRT in terms of age, domicile and social circumstance. In the year studied, 104 patients per million population (533 patients) started RRT (390 per million population aged 65-75). In 23.5% the cause of ESRD could not be determined. Diabetes was the single most frequently identified cause (16%). The requirement for RRT rose with age, but over the country as a whole, patients aged over 75 years were under-represented. The majority of health boards provided RRT at a rate within 20% of the national rate. There was no difference in the median age at starting RRT between health boards. The spectrum of social deprivation of patients starting RRT was the same as that of the general population. There was no evidence that social deprivation influences acceptance on to the RRT program, although the relationship between ESRD and deprivation is complex. The utilization of RRT exceeded the minimum rate recommended by the Renal Association, although there was fluctuation between health board areas. The national requirement for resources to provide RRT is likely to rise further to care for an increasingly elderly population.