Effect of sustained low efficient dialysis versus continuous renal replacement therapy on renal recovery after acute kidney injury in the intensive care unit: A systematic review and meta‐analysis

Critically ill adults with acute kidney injury (AKI) experience considerable morbidity and mortality. Controversy remains regarding the optimal renal replacement intervention for these patients. Our systematic review aimed to determine the effect(s) of sustained low‐efficiency dialysis (SLED) compared with continuous renal replacement (CRRT) therapy on relevant patient outcomes. A systematic search of Medline, Embase, CINAHL and the Cochrane Library was conducted. Identified citations were screened independently in duplicate for relevance, and the methodological quality of included studies was evaluated. Data were extracted on study, patient and intervention characteristics and relevant clinical outcomes. Results were pooled using inverse variance fixed and random effects meta‐analysis. A total of 1564 patients from 18 studies were included. Meta‐analysis results indicated no statistically significant difference in our primary outcome, overall proportion of renal recovery (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.63–1.20, I2 = 66%). No significant difference was observed for the secondary outcome of time to renal recovery (mean difference 1.33, 95% CI 0.23–2.88, I2 = 0%). Statistically, SLED was marginally favoured over CRRT for the secondary outcome of mortality (RR 1.21, 95% CI 1.02–1.43, I2 = 47%); however, this diminished when sensitivity analysis of only randomized controlled trials was conducted (RR 1.25, 95% CI 1.00–1.57, I2 = 0%). There appears to be no clear for advantage continuous renal replacement in the hemodynamically unstable patient. Currently, both modalities are safe and effective means of treating AKI in the critically ill adult.     

Effect of renal replacement therapy modalities on renal recovery and mortality for acute kidney injury: A PRISMA-compliant systematic review and meta-analysis

Previous investigations showed inconsistent results for comparison in renal recovery, in-hospital, and in-intensive care unit (ICU) mortalities between acute kidney injury (AKI) patients treated with continuous renal replacement therapy (CRRT) and some kinds of intermittent renal replacement therapies (IRRTs). We systematically searched for articles published in the databases (PubMed, Web of Science, EMBASE, Medline, and Google Scholar) until June 2019. We made all statistical analysis using STATA 12.0 software. In the present meta-analysis, relative risks with 95% confidence intervals were calculated for binary outcomes (renal recovery status or mortality). The present study indicated no significant differences in renal recovery, in-hospital mortality, and in-ICU mortality between AKI patients given CRRT and those given sustained low-efficiency dialysis (SLED). Additionally, the study showed no significant difference in in-hospital mortality between AKI patients given CRRT and those given intermittent hemodialysis (IHD), whereas elevated in-ICU mortality was detected in AKI patients given CRRT, compared to those given IHD. The three modalities (CRRT, IHD, and SLED) have their own advantages and disadvantages. More rigorous trials design with large cohort should be made to explore the differences in renal recovery, in-hospital, and in-ICU mortalities between different kinds of RRTs.     

心血管手术相关急性肾损伤患者行连续性肾脏替代治疗后的预后因素分析

目的探讨心血管手术相关急性肾损伤患者行连续性肾脏替代治疗后不同预后的相关因素。 方法本研究纳入2015年1月至2018年12月在南京医科大学第一附属医院住院行心血管手术治疗且接受连续性肾脏替代治疗的患者,按90 d是否死亡和90 d内RRT治疗天数(≤14 d,15～90 d,>90 d)将患者分为4组,分析90 d死亡、90 d透析依赖、90 d延迟摆脱透析的相关影响因素。 结果本研究共纳入210例患者,平均随访400 d。其中90 d死亡114例,90 d生存且14 d内摆脱透析37例,90 d生存15～90 d内摆脱透析46例,90 d生存且透析依赖13例。多因素Cox回归显示：90 d死亡的独立危险因素包括高龄(HR＝1.029,95%CI: 1.013～1.045,P<0.001)、术前血清肌酐低(HR＝0.993,95%CI: 0.987～0.998,P＝0.008)、CRRT前APACHE Ⅱ高评分(HR＝1.043, 95%CI: 1.004～1.084,P＝0.028)、CRRT前SOFA评分高(HR＝1.130, 95%CI: 1.052～1.213,P<0.001)、CRRT前脓毒症(HR＝2.327, 95%CI: 1.591～3.403,P<0.001)、CRRT前过低的舒张压(HR＝0.979,95%CI: 0.963～0.996,P＝0.013)。90 d存活患者透析依赖的独立危险因素包括术前较低的eGFR(HR＝0.962,95%CI: 0.940～0.984,P<0.001)。90 d存活患者中延迟摆脱透析的危险因素有血清白蛋白低(OR＝0.837,95%CI: 0.717～0.977,P＝0.024)、机械通气时间长(OR＝1.434,95%CI: 1.175～1.749,P<0.001)、CRRT前尿量少(OR＝0.739,95%CI: 0.623～0.876,P<0.001)。 结论心血管手术相关急性肾损伤并行连续性肾脏替代治疗患者中,90 d死亡与高龄、CRRT前疾病的严重程度、脓毒症和过低的舒张压有关;90 d存活患者透析依赖与患者术前较差的肾功能有关;90 d存活患者延迟摆脱透析与血清白蛋白低、机械通气时间长、CRRT前尿量少有关。     

Effect of ionized serum calcium on outcomes in acute kidney injury needing renal replacement therapy: secondary analysis of the acute renal failure trial network study

Abstract

Background: Hypocalcemia is very common in critically ill patients. While the effect of ionized calcium (iCa) on outcome is not well understood, manipulation of iCa in critically ill patients is a common practice. We analyzed all-cause mortality and several secondary outcomes in patients with acute kidney injury (AKI) by categories of serum iCa among participants in the Acute Renal Failure Trial Network (ATN) Study. Methods: This is a post hoc secondary analysis of the ATN Study which was not preplanned in the original trial. Risk of mortality and renal recovery by categories of iCa were compared using multiple fixed and adjusted time-varying Cox regression models. Multiple linear regression models were used to explore the impact of baseline iCa on days free from ICU and hospital. Results: A total of 685 patients were included in the analysis. Mean age was 60 (SD?=?15) years. There were 502 male patients (73.3%). Sixty-day all-cause mortality was 57.0%, 54.8%, and 54.4%, in patients with an iCa <1, 1–1.14, and ≥1.15?mmol/L, respectively (p?=?0.87). Mean of days free from ICU or hospital in all patients and the 28-day renal recovery in survivors to Day 28 were not significantly different by categories of iCa. The hazard for death in a fully adjusted time-varying Cox regression survival model was 1.7 (95% CI: 1.3–2.4) comparing iCa <1 to iCa?≥?1.15?mmol/L. No outcome was different for levels of iCa?>?1?mmol/L. Conclusion: Severe hypocalcemia with iCa?<?1?mmol/L independently predicted mortality in patients with AKI needing renal replacement therapy.     

Role of B-type natriuretic peptide as a marker of mortality in acute kidney injury patients treated with continuous renal replacement therapy

Abstract

Objectives: Acute kidney injury (AKI) treated with continuous renal replacement therapy (CRRT) is associated with poor outcome. Plasma B-type natriuretic peptide (BNP) is a biomarker related to fluid volume overload, and is elevated in AKI patients. The purpose of the study was to assess whether BNP levels at the time of starting CRRT could be used as a predictor of mortality in patients with AKI receiving CRRT. Methods: We conducted a prospective observational cohort study enrolling 149 patients with AKI receiving CRRT. The primary outcome was mortality during CRRT. Results: The median BNP level of 84 (56.3%) patients who expired was significantly higher than that of those who survived (1812.5 vs. 475.0?pg/mL; p?=?0.01). Receiver operating characteristic curves demonstrated BNP levels as a predictor of mortality during CRRT with an area under the curve of 0.77 (p?=?0.000), and the optimal threshold for BNP was 1054?pg/mL. Patients with BNP levels above 1054?pg/mL had a significantly higher mortality (76.6 vs. 34.7%; p?=?0.01). Conclusion: Elevated BNP level is associated with mortality in patients with AKI receiving CRRT.     

Clinical characteristics of sepsis-induced acute kidney injury in patients undergoing continuous renal replacement therapy

Objective: The aim of this study was to investigate the clinical characteristics of sepsis-induced acute kidney injury (AKI) in patients undergoing continuous renal replacement therapy (CRRT).

Methods: From 2011 to 2015, we enrolled 340 patients who were treated with CRRT for sepsis at the Presbyterian Medical Center. In all patients, CRRT was performed using the PRISMA platform. We divided these patients into two groups (survivors and non-survivors) according to the 28-day all-cause mortality. We compared clinical characteristics and analyzed the predictors of mortality.

Results: The 28-day all-cause mortality was 62%. Survivors were younger than non-survivors and had higher platelet counts (178?±?101?×?10³/mL vs. 134?±?84?×?10³/mL, p?p?p?p?0.05?mL/kg/h (66% vs. 86%, p?=?.001) in the first day. In a multivariate logistic regression analysis, age, platelet count, RDW score, APACHE II score, serum creatinine level, and a urine output of <0.05?mL/kg/h the first day were prognostic factors for the 28-day all-cause mortality.

Conclusion: Age, platelet count, APACHE II score, RDW score, serum creatinine level, and urine output the first day are useful predictors for the 28-day all-cause mortality in sepsis patients requiring CRRT.     

Effect of preoperative statin therapy on postoperative acute kidney injury in patients undergoing major surgery: Systemic review and meta‐analysis

We aimed to examine the association between preoperative use of statins and postoperative acute kidney injury (AKI) in patients undergoing major surgery by performing a systemic review and meta‐analysis. MEDLINE and EMBASE, from inception to April 2013, and the reference lists of related articles were searched for relevant studies. Trials comparing preoperative statin therapy with no preoperative statin in patients undergoing major surgery were included. Outcome measures of interest were the risk of cumulative postoperative AKI and postoperative AKI requiring renal replacement therapy (RRT). Fixed or random effect meta‐analysis was performed to derive summary effect estimates. In five randomized controlled trials (RCTs) and 19 observational studies, comprising a total of 989 173 patients undergoing major surgery, 112 840 patients (11.41%) received preoperative statin therapy. The specific type, dosage, and duration of statin therapy were not available in most studies. Preoperative statin therapy was associated with a significant risk reduction for cumulative postoperative AKI (weighted summary odds ratio (OR) 0.87, 95% CI 0.79 to 0.95). The effect of risk reduction was also significant when considering postoperative AKI requiring RRT (OR 0.80, 95% CI 0.72 to 0.90). When restricting the analysis to the five RCTs, preoperative statin therapy did not show significant protective effect on postoperative AKI (OR 0.49, 95% CI 0.22 to 1.09). In patients undergoing major surgery, preoperative statin therapy could associate with a reduced risk for postoperative AKI. However, considerable heterogeneity existed among included studies. Future randomized trials were warranted for this critical clinical question.     

Association between CRT(D)/ICD and renal insufficiency: A systematic review and meta‐analysis

Cardiac resynchronization therapy with or without a defibrillator (CRT(D)) and implantable cardioverter defibrillator (ICD) may reduce the risk of arrhythmia or heart failure‐specific mortality and improves the prognosis of patients with chronic kidney disease (CKD) or dialysis. The aim of this study was to perform a meta‐analysis investigating the relationship between CRT(D)/ICD and renal insufficiency. Cochrane Library, Web of Science, Embase, and Pubmed were systematically searched from inception to 29 October 2019. We included studies that report all‐cause mortality of patients with renal insufficiency who received CRT(D)/ICD therapy. Twenty‐six studies (n = 119,263) were included, exploring the relationship between CRT(D)/ICD and renal insufficiency from two aspects: (1) Compared with ICD‐only, CRT(D) was associated with lower risk of all‐cause mortality in CKD patients (odds ratios (OR) = 0.67; 95% confidence interval (CI), 0.60 to 0.75). For non‐primary prevention (secondary prevention or both), the analysis revealed a lower risk of all‐cause mortality in the ICD group than in the no‐ICD group (OR = 0.47; 95% CI, 0.40 to 0.55). (2) CKD increased all‐cause mortality in comparison with control group (OR = 2.12; 95% CI, 1.85 to 2.44), and so did dialysis (OR = 2.53; 95% CI, 2.34 to 2.73). Furthermore, compared with CKD3 (eGFR: 30‐59 ml/min/1.73 m²), CKD4/5 (eGFR <30 ml/min/1.73 m²) was observed to have a significantly higher risk of all‐cause mortality (OR = 2.70; 95% CI, 1.93 to 3.80). This review shows a clear association between CRT(D)/ICD and renal insufficiency in the aspect of all‐cause mortality, and may provide a reference for the clinical application of CRT(D)/ICD.     

A systematic review of continuous renal replacement therapy and intermittent haemodialysis in management of patients with acute renal failure

Background: Acute renal failure (ARF) still bears a poor prognosis with mortality rates up to 70% and the ideal form of renal replacement therapy (RRT) remains controversial. The purpose of this study was to conduct a systematic review and meta-analysis of all randomized controlled trials (RCT) to examine the effect of dialysis modality (IHD: Intermittent haemodialysis; CRRT: continuous renal replacement therapy) on survival of patients with ARF and to also study the effect of each modality on dialysis dependence (DD). Methods: Using and combining two comprehensive search themes (ARF and RRT), we searched electronic databases from 1969 through September of 2007, supplemented by a manual review of abstracts from nephrology meetings and reference lists of review articles. All RCT comparing IHD with CRRT in adult patients with ARF and with explicit reporting of mortality were included. The primary outcome was the pooled estimate of the odds ratio (OR) of mortality for patients with ARF treated with CRRT versus IHD. The secondary outcome was OR of DD at time of discharge for surviving patients. Results: A total of 587 studies were identified, 554 of which were excluded on initial screening. Analysis of the nine RCT (1635 patients) showed an OR of 0.89 (0.63–1.24) for survival in patients on CRRT. Limiting the analysis to the seven RCT published after the year 2000, revealed an OR of 0.72 (0.58–0.90). The OR of all the studies before 2000 was 1.06 (95% CI 0.67–1.68), as compared with OR of 0.61 (95% CI 0.50–0.74) for studies post-2000. Four studies showed a significantly lower risk of DD among the CRRT group and none showed higher OR for DD. When analysis was limited to the RCT, the OR for DD was 1.07 (0.47–2.39), suggesting no difference in DD between the modalities. Conclusions: Similar to previously reported meta-analyses, we did not find a significant effect of CRRT on the OR of survival. The progressive reduction in the OR of survival with CRRT relative to IHD might reflect progressive improvements in IHD. The OR of DD was not affected by mode of RRT. In conclusion, compared with IHD, CRRT does not offer an advantage with regards to survival or DD in ARF. Considering its cost and potential disadvantages, it is imperative to identify the subset of patients with ARF that would potentially derive maximum benefit from CRRT. This will require large, adequately powered studies with sufficient follow-up.     

Optimizing the timing of renal replacement therapy in burn patients with acute kidney injury

Acute kidney injury is a common complication in burn ICU patients and is associated with a high mortality rate. The optimal timing for starting renal replacement therapy (RRT) remains unknown; there is no established universal definition for early and late RRT initiation. The aims of the present narrative review are to briefly analyze the available recently published data on the timing of initiation of RRT in critically ill patients and to discuss the optimal timing of RRT in critically ill burn patients with acute kidney injury. When considering renal replacement therapy for acute kidney injury patients, physicians face the dilemma of balancing the hazards of starting too early, exposing patient to an unnecessary therapy with possible complications and costs related to treatment, and preventing a significant proportion of patients from spontaneous recovery of their renal function against the potential life-threatening harm of initiating RRT) too late. Evidence suggests that with appropriate care up to 80% of burn patients experience recovery of kidney function and the need for RRT seems to be very rare after hospital discharge. In the absence of life-threatening complications, the optimal time and thresholds for starting RRT in burn patients are uncertain. High heterogeneity exists between studies on RRT timing in burn patients.     

Surgical therapy vs conservative therapy for patients with acute injury of lateral ankle ligament: A meta‐analysis and systematic review

The goal of this meta‐analysis was to explore the overall safety and efficacy of surgical therapy vs conservative therapy for acute injury of the lateral ankle ligament based on eligible studies. Eligible studies were identified by searching PubMed, Cochrane, and Embase databases using appropriate updated index words to January 2018. We also searched relevant publication sources. Eligible studies included randomised controlled trials and comparative studies. Mean difference or relative risk (RR), along with 95% confidence interval (CI), was used to analyse the main outcomes. A total of 13 studies were eligible for this meta‐analysis, with 834 patients in the surgical therapy group and 930 patients in the conservative therapy group. Compared with patients receiving conservative treatment, patients undergoing surgical treatment had a significant higher American Orthopedic Foot And Ankle Society (AOFAS) score (weighted mean difference(WMD): 10.33, 95% CI: 6.83‐13.83) and an effective rate (RR: 1.15, 95% CI: 1.04‐1.28). No significant differences were observed in the incidence of recurrent ankle injury (RR: 1.01, 95% CI: 0.62‐1.65), limited range of motion (RR: 1.44, 95% CI: 0.83‐2.50), deep vein thrombosis (RR: 1.33, 95% CI: 0.73‐2.41), and wound infection or necrosis (RR: 3.99, 95% CI: 0.45‐35.34). However, compared with patients receiving conservative treatment, patients undergoing surgical therapy had significantly increased rates of complications (RR: 3.31, 95% CI: 2.55‐4.28), ankylosis (RR: 3.63, 95% CI: 2.16‐6.08), scare tenderness (RR: 10.16, 95% CI: 3.89‐26.52) and sensory loss (RR: 5.66, 95% CI: 2.76‐11.59). The results demonstrated that surgical treatment increased the AOFAS score and effective rate compared with conservative treatment. Besides, surgical treatment increased the rate of complications. Nevertheless, more high‐quality randomised controlled trials with a larger sample size conducted at multiple centres with a long‐term follow up are needed to confirm our conclusions.