AKI Treated with Renal Replacement Therapy in Critically Ill Patients with COVID-19

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急性肾损伤患者行连续性床旁血液净化治疗时机的临床研究

目的：探讨连续性床旁血液净化（continuous renal replacement therapy,CRRT）治疗时机对急性肾损伤（acute kidney injury, AKI）患者临床预后的影响.方法：选取符合AKI诊断标准并行CRRT治疗的患者83例,以BUN 22 mmol/L为界值,分为早期透析组50例,晚期透析组33例.记录一般临床资料,观察透析开始后28 d、90 d死亡率、肾功能恢复率.结果：（1）早期透析组、晚期透析组28 d、90 d死亡率分别为50.0% vs 72.7%、56.0% vs 78.8%,P＜0.05.Kaplan-Meier生存曲线提示早期透析组生存时间显著高于晚期透析组（P＜0.05）.晚期透析患者28 d、90 d死亡危险分别是早期透析患者的2.667倍、2.918倍（P＜0.05）.（2）早期透析组、晚期透析组28 d、90 d肾功能恢复率分别为44% vs 15.2%、46% vs 15.2%,P＜0.01.晚期透析患者28 d、90 d不能脱离透析的危险性是早期透析患者的4.563倍、4.954倍（P＜0.01）.结论：早期CRRT治疗可改善AKI患者的肾功能,降低死亡风险.     

Palliative Medicine Referral in Patients Undergoing Continuous Renal Replacement Therapy for Acute Kidney Injury

Abstract

Background: Referral patterns for palliative medicine consultation (PMC) by intensivists for patients requiring continuous renal replacement therapy (CRRT) have not been studied. Methods: We retrospectively analyzed clinical data on patients who received CRRT in a tertiary referral center between 1999 and 2006 to determine timeliness and effectiveness of PMC referrals and mortality rate as a surrogate for safety among patients receiving CRRT for acute kidney injury. Results: Over one-fifth (21.1%) of the 230 CRRT patients studied were referred for PMC (n = 55). PMC was requested on average after median of 15 hospital and 13 intensive care unit (ICU) days. Multivariate regression analysis revealed no association between mortality risk and PMC. Total hospital length of stay for patients who died after PMC referral was 18.5 (95% CI = 15–25) days compared with 12.5 days (95% CI = 9–17) for patients who died without PMC referral. ICU care for patients who died and received PMC was longer than for patients with no PMC [11.5 (95% CI = 9–15) days vs. 7.0 (95% CI = 6–9) days, p < 0.01]. CRRT duration was longer for patients who died and received PMC referral than for those without PMC [5.5 (95% CI = 4–8) vs. 3.0 (95% CI = 3–4) days; p < 0.01]. Conclusions: PMC was safe, but referrals were delayed and ineffective in optimizing the utilization of intensive care in patients receiving CRRT. A proactive, “triggered” referral process will likely be necessary to improve timeliness of PMC and reduce duration of non-beneficial life-sustaining therapies.     

Timing of Initiation of Renal Replacement Therapy in Acute Kidney Injury: A Systematic Review and Meta-analysis

The indications for dialysis in patients with acute kidney injury (AKI), as well as the dose and timing of initiation, remain uncertain. Recent data have suggested that early initiation of renal replacement therapy (RRT) may be associated with decreased mortality but not with the recovery of kidney function. A blood urea nitrogen (BUN) level of 75 mg/dL is a useful indicator for dialysis in asymptomatic patients, but one that is based on studies with limitations. Different parameters, including absolute and relative indicators, are needed. Currently, nephrologists should consider the trajectory of disease, and the clinical condition and prognosis of the patient are more important than numerical values in the decision to initiate dialysis.     

Combination of Renal Biomarkers Predicts Acute Kidney Injury in Critically Ill Adults

Objective: Most studies so far have focused on the performance of individual biomarkers to detect early acute kidney injury (AKI) in the adult intensive care unit (ICU) patients; however, they have not determined the predictive ability of their combinations. The aim of this study was to compare the predictive abilities of plasma neutrophil gelatinase-associated lipocalin (pNGAL), urine neutrophil gelatinase-associated lipocalin (uNGAL), plasma cystatin C (pCysC), serum creatinine (sCr), and their combinations in detecting AKI in an adult general ICU population. Methods: A total of 100 consecutive ICU patients were included in the analysis. AKI was defined according to RIFLE criteria. Biomarker predictive abilities were evaluated by area under the curve (AUC), net reclassi?cation improvement (NRI), and integrated discrimination improvement (IDI). Results: AKI occurred in 36% of patients 7 days post-admission. All three novel biomarkers as well as sCr had moderate predictive abilities for AKI occurrence. The most efficient combinations (pNGAL + sCr and pNGAL + uNGAL + sCr) were selected to participate in the subsequent analyses. Both combinations, when added to a reference clinical model, increased its AUC significantly (0.858, p = 0.04). Their NRI (0.78, p = 0.0002) was equal to that of pNGAL, but higher than that of the other three biomarkers, whereas their IDI was higher than that of any individual biomarker (0.23, p = 0.0001). Both combinations had better specificities, positive likelihood ratios, and positive predictive values than those of any individual biomarker. Conclusion: The biomarker combinations had better predictive characteristics compared with those of each biomarker alone.     

A Multi-Center Evaluation of Early Acute Kidney Injury in Critically Ill Trauma Patients

Rationale. Few studies have evaluated the epidemiology of acute kidney injury (AKI) in trauma. Objective. To evaluate the incidence, risk factors, and outcomes associated with early AKI (evident within 24 hours of admission) in critically ill trauma patients. Methods. A retrospective interrogation of prospectively collected data from the Australian New Zealand Intensive Care Society Adult Patient Database. A total of 9,449 trauma patients were admitted for ≥24 hours to 57 intensive care units across Australia from January 1^st, 2000, to December 31^st, 2005. Main Findings. The crude incidence of AKI was 18.1% (n = 1,711). Older age, female sex (OR 1.60, 95% CI, 1.43–1.78, p < 0.0001), and the presence of co-morbid illness (OR 2.70, 95% CI 2.3–3.2, p < 0.0001) were associated with higher odds of AKI. Those with trauma not associated with brain injury (OR 2.40, 95% CI, 2.1–2.7, p < 0.0001) and a higher illness severity (OR 1.12, 95% CI, 1.11–1.12, p < 0.001) also had higher likelihood of AKI. Overall, AKI was associated with a higher crude mortality (16.7% vs. 7.8%, OR 2.36, 95% CI, 2.0–2.7, p < 0.001). Each RIFLE category of AKI was independently associated with hospital mortality in multi-variable analysis (risk: OR 1.69; injury OR 1.88; failure 2.29). Conclusions. Trauma admissions to ICU are frequently complicated by early AKI. Those at high risk for AKI appear to be older, female, with co-morbid illnesses, and present with greater illness severity. Early AKI in trauma is also independently associated with higher mortality. These data indicate a higher burden of AKI than previously described.     

In Critically Ill Patients Requiring CRRT,AKI Is Associated with Increased Respiratory Failure and Death Versus ESRD

Background/aims: To compare outcomes of critically ill patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) versus those with pre-existing end-stage renal disease (ESRD) requiring CRRT to identify factors that contribute to the increased mortality seen in AKI patients. Methods: Retrospective cohort of 257 intensive care unit (ICU) patients who received CRRT. AKI is defined as requiring CRRT with an admission serum creatinine ≤1 mg/dL; ESRD is defined as chronic dialysis dependence. Primary outcome was hospital mortality. Multivariate logistic regression was performed to determine the impact of APACHE II score, intubation, vasopressors, infection, diabetes, hypertension, gender, and race on mortality. Results: Of 257 patients requiring CRRT, 28 had ESRD and 108 had AKI. Hospital mortality was higher in patients with AKI versus ESRD (69% vs. 39%, p = 0.0032). Severity of illness using APACHE II was similar in AKI and ESRD. Patients with AKI were more likely to require mechanical ventilation (89% vs. 57%, p = 0.0003). After multivariate analysis, the requirement for mechanical ventilation was the single factor associated with increased hospital mortality [odds ratio (OR): 3.1]. Conclusions: In ICU patients requiring CRRT, patients with AKI have a higher mortality than patients with ESRD due to an increased need for mechanical ventilation.     

Analyzing Chinese Patients with Post-Operative Acute Kidney Injury

Abstract

Background: To investigate clinical characteristics and risk factors of Chinese patients with post-operative acute kidney injury (PO-AKI). Methods: Patients with PO-AKI in Ruijin Hospital from December 1997 to December 2005 were retrospectively studied. Results: Patients’ mean age was 62.2 ± 18.1 years. There were 111 males and 57 females. The mean serum creatinine at diagnosis was 370.41 ± 320.92 μmol/L and the mean estimated glomerular filtration rate was 33.56 ± 24.24 mL/min. For the outcome of the patients, 38 died and the mortality rate was 22.6%. There were 17 patients (10.1%) with Acute Dialysis Quality Initiative-RIFLE (risk-injury-failure-loss-end classification) phase R, 21 (12.5%) with phase I, and 130 (77.4%) with phase F. There was no significant difference in mortality regarding patients who underwent different types of surgeries. For the risk factors related to PO-AKI, acute tubular necrosis (ATN) increased relative risk of mortality PO-AKI (odds ratio = 7.089, 95% confidence interval = 2.069–24.288, p < 0.001). Multivariate regression models showed that ATN had a positive correlation with mortality of PO-AKI. Conclusions: PO-AKI is one of the most common causes of AKI in patients who underwent operations. Special attention should be paid to risk factors related to PO-AKI in order to improve prognosis.     

A Simple and Early Prognostic Index for Acute Renal Failure Patients Requiring Renal Replacement Therapy

Recent advances in technology have not substantially changed the high mortality rate associated with acute renal failure (ARF). To obtain a simple, valid prognostic index, we retrospectively evaluated the relative importance of demographic data, causes (acute insults) of renal failure, and comorbid clinical conditions for the outcome in 102 ARF patients who received renal replacement therapy with an overall mortality rate of 65% (66 of 102). There were no significant differences between survivors and nonsurvivors in age and gender. Mortality according to acute insults was similar to that of the whole population studied. Of the 10 clinical conditions at the time of the first renal replacement therapy, mechanical ventilation (p = 0.0002), cardiac failure (p = 0.0006), hepatic failure (p = 0.003), central nervous system dysfunction (p = 0.005), and oliguria (p = 0.04) were found to be significantly related to mortality by univariate analysis. Furthermore, multivariate analysis demonstrated that only mechanical ventilation, cardiac failure, and hepatic failure were significant risk factors. Survival was directly related to the number of significant variables in univariate analysis: zero, 89% (8 of 9); one, 62% (21 of 34); two, 19% (5 of 27); three, 10% (2 of 20); four, 0% (0 of 8); five, 0% (0 of 4). This simple and early prognostic index, derived from the assessment of clinical conditions which were easily de-termined at the patient's bedside, could be useful for outcome prediction in ARF patients requiring renal replacement therapy.     

Outcomes Among Patients Hospitalized With COVID-19 and Acute Kidney Injury

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Comparison of Sustained Hemodiafiltration With Continuous Venovenous Hemodiafiltration for the Treatment of Critically Ill Patients With Acute Kidney Injury

Despite improvements in medical care, the mortality of critically ill patients with acute kidney injury (AKI) who require renal replacement therapy (RRT) remains high. We describe a new approach, sustained hemodiafiltration, to treat patients who suffered from acute kidney injury and were admitted to intensive care units (ICUs). In our study, 60 critically ill patients with AKI who required RRT were treated with either continuous venovenous hemodiafiltration (CVVHDF) or sustained hemodiafiltration (S‐HDF). The former was performed by administering a postfilter replacement fluid at an effluent rate of 35 mL/kg/h, and the latter was performed by administering a postfilter replacement fluid at a dialysate‐flow rate of 300–500 mL/min. The S‐HDF was delivered on a daily basis. The baseline characteristics of the patients in the two treatment groups were similar. The primary study outcome—survival until discharge from the ICU or survival for 30 days, whichever was earlier—did not significantly differ between the two groups: 70% after CVVHDF and 87% after S‐HDF. The hospital‐survival rate after CVVHDF was 63% and that after S‐HDF was 83% (P < 0.05). The number of patients who showed renal recovery at the time of discharge from the ICU and the hospital and the duration of the ICU stay significantly differed between the two treatments (P < 0.05). Although there was no significant difference between the mean number of treatments performed per patient, the mean duration of daily treatment in the S‐HDF group was 6.5 ± 1.0 h, which was significantly shorter. Although the total convective volumes—the sum of the replacement‐fluid and fluid‐removal volumes—did not differ significantly, the dialysate‐flow rate was higher in the S‐HDF group. Our results suggest that in comparison with conventional continuous RRT, including high‐dose CVVHDF, more intensive renal support in the form of postdilution S‐HDF will decrease the mortality and accelerate renal recovery in critically ill patients with AKI.