Outcome of Acute Kidney Injury in Sudanese Children — An Experience from a Sub-Saharan African Unit

♦ Background: Acute Kidney Injury (AKI) is an important cause of morbidity and mortality in developing countries. Although continuous renal replacement therapy is gaining more popularity worldwide, peritoneal dialysis (PD) in children remains an appropriate therapy for AKI in children for all age groups including neonates.♦ Methodology: We retrospectively reviewed all children who have been admitted with AKI at the pediatric nephrology unit, Soba University Hospital, Khartoum, during the period from January 2005 to December 2011.♦ Results: Over 7 years we recorded 659 children of whom 362 (54.9%) were male. The spectrum of age was variable with the majority being neonates, 178 (27.1%). The average patient admission rate was 94 patients per year, with an estimated incidence of 9.8 patients/million population/year. Common causes of AKI were sepsis 202 (30.8%), acute glomerulonephritis 75 (11.5%) and obstructive uropathy due to stones 56 (8.5%). The most common dialysis modality used was PD, 343 (52.4%), and peritonitis was reported in 53 (15.4%) patients. Recovery from AKI was achieved in 450 (68.9%) children, 37 (5.7%) went into chronic kidney disease (CKD), 33 (5.1%) referred to the pediatric surgery and 194 (29.7%) died.♦ Conclusion: In the setting of developing countries where AKI is a common cause of morbidity and mortality, reasonably equipped renal units with adequately trained medical staff may save many lives. International funding programs for communicable diseases and charity organizations should include AKI management in their programs. Acute PD remains the treatment modality of choice for AKI in developing countries.     

腹膜透析在急性肾损伤中的应用

急性肾损伤(acute kidney injury,AKI)发生率高.其肾脏替代治疗方式有血液透析(hemodialysis,HD)、连续肾脏替代治疗(tontinuou renal replacement therapy,CRRT)以及腹膜透析(PD),但PD在AKI中的作用常被忽略.与HD相比,PD更方便、经济、无需抗凝,尤其对血液动力学不稳定患者具有一定优势.近年一些研究显示PD治疗AKI存在潜力.本文将探讨PD在AKI应用的利弊,透析时机、剂量、模式的选择和透析处方的建立及在AKI中的应用.     

Year in review 2009: <Emphasis Type="Italic">Critical Care</Emphasis>- nephrology

We summarize original research in the field of critical care nephrology accepted or published in 2009 in Critical Care or, when considered relevant or directly linked to this research, in other journals. Four main topics have been identified for a rapid overview: (a) post-surgical acute kidney injury (AKI); (b) timing of renal replacement therapy (RRT): different authors examined this critical issue of RRT in different settings (post-surgical patients, burned patients, and intensive care unit patients); (c) DoReMi (Dose Response Multicentre International) and other important surveys on dialysis dose and management; and (d) pediatric AKI and RRT: interest in this last topic is increasing, and studies on biomarkers, complications of pediatric dialysis, and application of RRT to extracorporeal membrane oxygenation are discussed.     

佛山地区肾内科专业设置与血液净化设备登记报告

目的 了解佛山地区各医院肾内科专业设置、肾科医务人员和血液净化设备情况.方法 本地区所有开展透析的单位共17家医院参加了登记工作,填写<佛山市肾内科专业设置及血液净化情况调查表>,登记时间为2010年1月1日至12月31日,进行资料汇总和统计分析.结果 17家医院均开展了血液透析,同时开展血液透析和腹膜透析5家,单纯开展血液透析12家,无单纯开展腹膜透析者.17家医院中,拥有独立专科、专业组分别为6和11家,无单纯设专业医生者.全市共有肾科医师90名,其中正高、副高、中级和初级职称分别占14.8%、28.4%、27.3%和29.5%,博士、硕士、本科和专科学历分别占6.8%、28.4%、64.8%和0%.全市共有肾科护士180名,其中主任护师、副主任护师、主管护师、护师和护士分别占0.6%、3.3%、33.9%、41.7%和20.6%,本科、专科和中专学历分别占8.9%、61.7%和29.4%.全市肾科技术员中科室专有、医院共享和未配置分别占2、15和0家.全市共有血液透析机256台,血液透析滤过机12台,CRRT机7台,透析器复用机9台,全自动腹膜透析机3台.结论 本地区肾科专业、专科医生和护理队伍不断壮大.专科医师和护士职称、学历结构合理.本地区透析中心规模逐年扩大,血液净化机器增加迅速.开展透析的医院达17家,其中6家为镇级医院,同时开展了血液透析和腹膜透析.     

Impact of early nephrology referral on mortality and hospitalization in peritoneal dialysis patients.

OBJECTIVES: Several studies have examined the possible association between late referral to a nephrologist and mortality on maintenance hemodialysis. However, we lack information on the benefit of early nephrologist referral in patients receiving peritoneal dialysis (PD). PATIENTS AND METHODS: In an inception cohort of 102 consecutive PD patients identified in a single center between 2003 and 2004, we sought to determine whether late nephrologist referral was associated with poor outcomes. The primary end point was all-cause mortality. The effects of early referral to a multidisciplinary low clearance clinic on cardiovascular mortality and length of hospitalization were also evaluated. RESULTS: Of 102 incident PD patients, 61 subjects (59.8%) were referred early to the nephrologist (more than 3 months) before dialysis initiation. During the study period of 284.9 patient-years (median follow-up period 36.8 months), 25 patients died, 12 due to cardiovascular causes. Both cardiovascular and all-cause mortality were significantly increased among PD patients with late referral, but the relationship between late referral and all-cause mortality was mitigated substantially by adjusting for relevant factors. In univariate analysis, late nephrology referral was associated with increased cardiovascular mortality, with a hazard ratio of 5.43 (95% confidence interval 1.46 - 20.21, p = 0.012). Annual adjusted days of hospitalization were similar between the early and late nephrology referral groups. CONCLUSIONS: A comprehensive analysis of incident PD subjects confirmed the significant relationship between late nephrology referral and all-cause and cardiovascular mortality. A causal relationship remains to be established and validated.     

改良腹膜透析液双联系统的制作与应用

目的制作改良腹膜透析液双联系统,并探讨其在腹膜透析患者中的应用效果。方法选择2018年1月—2019年12月在某三级甲等医院肾内科随访的156例腹膜透析患者为研究对象,用随机数字表法将患者分为试验组和对照组,分别使用改良腹膜透析液双联系统和传统腹膜透析液双联系统进行换液操作,比较两组的换液时间、腹膜炎发生率、平均每次透析成本、患者满意度。结果与对照组相比,试验组腹膜透析换液操作时间缩短、腹膜炎发生率降低,平均每次透析成本减少,患者满意度得分高,差异具有统计学意义(P<0.05)。结论相对传统腹膜透析液双联系统,改良腹膜透析液双联系统方便操作、缩短了换液操作时间、降低了腹膜炎发生率和透析成本,可提高患者满意度。     

Peritoneal Dialysis for Children with Acute Kidney Injury in Lagos,Nigeria: Experience with Adaptations

♦ Introduction: International professional groups are supporting the training of physicians in developing countries in nephrology, including peritoneal dialysis (PD). This report documents the impact of such efforts in the provision of manual PD for children with acute kidney injury (AKI) in a public hospital in Lagos, Nigeria.♦ Methods: Medical records of all children with AKI managed with PD between July 2010 and March 2013 were reviewed.♦ Results: Seventeen children with a mean (SEM) age of 3.8 (0.8) years received PD for 0 - 18 days; about half were infants. PD was provided manually, frequently with intercostal drains as catheters. Blockage of catheters and peritonitis occurred in 4 (23.5%) and 2 (11.8%) children, respectively. Eight (47.1%) of the 17 children had resolution of AKI and were discharged from hospital. In 4 (57.1%) of the 7 children who died, PD was performed for ≤ 2 days.♦ Conclusion: PD for childhood AKI is feasible in resource-constrained regions with fairly good outcome. Blockage of catheter was the most common complication encountered.     

Modalities of renal replacement therapy and clinical outcomes of patients with acute kidney injury in a resource-limited setting: Results from a SEA-AKI study

PurposeTo determine the effects of modalities of renal replacement therapy (RRT) on the 30-d mortality and renal recovery in patients with acute kidney injury (AKI).Materials and methodsA multicenter cohort study was conducted in 17 hospitals from Thailand and Indonesia. We recruited patients who were admitted to the Intensive care unit and diagnosed with AKI. Relevant mode of RRT, as intermittent hemodialysis (IHD), continuous renal replacement therapy (CRRT), peritoneal dialysis (PD), or sustained low efficiency dialysis (SLED), was initiated as indicated.ResultsFrom 2844 patients with AKI, 449 cases (8.1%) received RRT. There were no significant differences in the 30-d mortality between those initially treated with CRRT, PD, and SLED compared to those treated with IHD. The renal recovery was similar for each RRT mode. The three independent factors of death were the primary diagnosis of kidney disease, higher APACHE II score, and non-renal SOFA score. Only 48 (10.7%) patients had been switched to another mode of RRT.ConclusionsAll four modes of RRT (IHD, CRRT, PD, and SLED) are acceptable treatments for severe AKI and gave a similar survival rate.     

急性肾损伤诊治进展

急性肾损伤(AKI)发病率逐年递增,其概念、诊断及分期日趋准确,寻找新的生物标志物的研究已成为热点,但仍无法完全替代血肌酐.AKI的预防在于早期发现并祛除危险因素;其治疗包括治疗原发病,防止多器官功能障碍,维持水、电解质、酸碱平衡以及肾脏替代治疗.早期透析可以改善患者预后,血液透析对小分子物质的清除及酸中毒的纠优于腹膜透析,小儿及血流动力学不稳定患者可选择腹膜透析.连续性肾脏替代治疗(CRRT)已被广泛应用于AKI的治疗,但其与间断性血液透析(IHD)互为补充,可随AKI的不同阶段和病情变化而转换,CRRT的治疗剂量仍然推荐传统剂量,对于某些特殊疾病高剂量CRRT可能有效.     

Biofilms in nephrology

Background: Biofilms are bacterial communities ubiquitous to moist environments. Biofilm formation is a factor in the development and persistence of infectious diseases. In clinical nephrology, biofilms influence the development of kidney stones and affect dialysis systems, including peritoneal and central venous catheters. Biofilms also play critical roles in persistent and resistant renal and urinary tract infections. Objective: To describe the physiology of biofilms and potential effects of biofilms upon infectious diseases, focusing on the role of biofilms in kidney stones, indwelling catheters and dialysis equipment. Methods: A literature search with Medline to identify pertinent English language articles published up to early 2008 using the keywords biofilm, nephrology, renal, calculi and infection. Results/conclusion: Biofilms are ubiquitous in clinical nephrology and play a role in the pathogenesis of resistant infections. Strategies for reducing the effects of biofilms in nephrology are described.     

Early vs late start of dialysis: it's all about timing

Acute kidney injury (AKI) is now well recognized as an independent risk factor for increased morbidity and mortality, particularly when dialysis is needed. The wide variation in dialysis utilization contributes to a lack of consensus on what parameters should guide the decision to start dialysis. While the association of early initiation of dialysis with survival benefit was first demonstrated four decades ago, few studies in the modern era of dialysis have addressed time of dialysis initiation. Though listed as one of the top priorities in research on AKI, timing of dialysis initiation has not been included as a factor in any of the large, randomized controlled trials in this area.     

Peritoneal dialysis in childhood acute kidney injury: experience in southwest Nigeria

♦ Background: The choices for renal replacement therapy (RRT) in childhood acute kidney injury (AKI) are limited in low-resource settings. Peritoneal dialysis (PD) appears to be the most practical modality for RRT in young children with AKI in such settings. Data from sub-Saharan Africa on the use of PD in childhood AKI are few.♦ Methods: We performed a retrospective study of children who underwent PD for AKI at a tertiary-care hospital in southwest Nigeria from February 2004 to March 2011 (85 months).♦ Results: The study included 27 children (55.6% female). Mean age was 3.1 ± 2.6 years, with the youngest being 7 days, and the oldest, 9 years. The causes of AKI were intravascular hemolysis (n = 11), septicemia (n = 8), acute glomerulonephritis (n = 3), gastroenteritis (n = 3), and hemolytic uremic syndrome (n = 2). Peritoneal dialysis was performed manually using percutaneous or adapted catheters. Duration of PD ranged from 6 hours to 12 days (mean: 5.0 ± 3.3 days). The main complications were peritonitis (n = 10), pericatheter leakage (n = 9), and catheter outflow obstruction (n = 5). Of the 27 patients, 19 (70%) survived till discharge.♦ Conclusions: In low-resource settings, PD can be successfully performed for the management of childhood AKI. In our hospital, the use of adapted catheters may have contributed to the high complication rates. Peritoneal dialysis should be promoted for the management of childhood AKI in low-resource settings, and access to percutaneous or Tenckhoff catheters, dialysis fluid, and automated PD should be increased.     

Early initiation of dialysis and late implantation of catheters adversely affect outcomes of patients on chronic peritoneal dialysis

OBJECTIVES: Predialysis nephrology care is thought to affect morbidity and mortality in hemodialysis patients. This study evaluated the impact of different patterns of predialysis care on outcomes of patients undergoing chronic peritoneal dialysis (PD). DESIGN: Retrospective cohort. SETTING AND PARTICIPANTS: 275 patients enrolled from January 1997 to March 2005 in a medical center in North Taiwan who recently initiated dialysis were classified according to early or late referral to nephrologists (> or =6 or <6 months of dialysis), planned or late implantation of Tenckhoff catheters (absence or presence of preceding emergent hemodialysis), and early or late start of dialysis [glomerular filtration rate (GFR) > or =5 or <5 mL/minute/1.73 m(2)]. MAIN OUTCOME MEASURES: All-cause mortality and hospitalization. RESULTS: During a median follow-up of 2.5 years, 41 deaths, 38 transfers to hemodialysis, and 26 renal transplantations occurred. Late start of dialysis was associated with a significant survival benefit (log rank, p = 0.012) and, along with planned implantation of catheters, exhibited a reduced risk for all-cause hospitalization (log rank, p = 0.025, 0.013). The predictors of overall mortality included baseline GFR [hazard ratio (HR) 1.18, p = 0.023], age (HR 1.07, p < 0.001), and diabetes (HR 3.64, p = 0.001); whereas the risk factors for all-cause hospitalization included age (HR 1.02, p = 0.012), late implantation of catheters (HR 1.78, p = 0.011), and diabetes (HR 1.92, p = 0.005). The timing of nephrology referral did not affect either death or hospitalization. CONCLUSIONS: Our data do not support earlier initiation of PD, but underscore the importance of planned implantation of catheters before commencement of chronic PD.     

Neutrophil gelatinase-associated lipocalin (NGAL) as biomarker of acute kidney injury: a review of the laboratory characteristics and clinical evidences

Abstract Acute kidney injury (AKI) is a common and serious condition, currently diagnosed by functional biomarkers, such as serum creatinine measurements. Unfortunately, creatinine increase is a delayed and unreliable indicator of AKI. The lack of early biomarkers of structural kidney injury has hampered our ability to translate promising experimental therapies to human AKI. The recent discovery, translation and validation of neutrophil gelatinase-associated lipocalin (NGAL), possibly the most promising novel AKI biomarker, is reviewed here. NGAL may be measured by several methods both in plasma and urine for the early diagnosis of AKI and for the prediction of clinical outcomes, such as dialysis requirement and mortality, in several common clinical scenarios, including in the intensive care unit, cardiac surgery and renal damage due the exposition to toxic agent and drugs, and renal transplantation. Furthermore, the predictive properties of NGAL, may play a critical role in expediting the drug development process. A systematic review of literature data indicates that further studies are necessary to establish accurate reference population values according to age, gender and ethnicity, as well as reliable and specific decisional values concerning the more common clinical settings related to AKI. Furthermore, proper randomized clinical trials on renal and systemic outcomes comparing the use of NGAL vs. standard clinical practice are still lacking and accurate cost-benefit and/or cost-utility analyses for NGAL as biomarker of AKI are also needed. However, it is important to note that NGAL, in the absence of diagnostic increases in serum creatinine, is able to detect some patients affected by subclinical AKI who have an increased risk of adverse outcomes. These results also suggest that the concept and definition of AKI might need to be reassessed.     

Epidemiology and outcomes of acute kidney injury in cardiac intensive care unit patients

PurposeTo describe the epidemiology and outcomes of acute kidney injury (AKI) among contemporary non-surgical cardiac intensive care unit (CICU) patients.Materials and methodsWe reviewed adult non-surgical CICU patients admitted from 2007 to 2015. The highest AKI stage during hospitalization was defined using modified Kidney Disease: Improving Global Outcomes (KDIGO) criteria, based on changes in serum creatinine. Hospital and 5-year mortality were examined using logistic regression and Cox proportional-hazards models, respectively.ResultsWe included 9311 patients with a mean age of 67.5 years, including 37% females. AKI was present in 51%: stage 1 AKI in 34%, stage 2 AKI in 9%, and stage 3 AKI in 8%. Hospital mortality was associated with AKI stage (adjusted OR for each AKI stage 1.17, 95% CI 1.04–1.31, p = 0.007). Five-year mortality was incrementally associated with AKI stage (adjusted HR per AKI stage 1.13, 95% CI 1.08–1.18; p < 0.001), particularly post-discharge mortality among hospital survivors (adjusted HR per AKI stage 1.20, 95% CI 1.15–1.25, p < 0.001). Patients with stage 3 AKI (especially requiring dialysis) had the highest adjusted hospital and five-year mortality.ConclusionAKI severity is incrementally associated with higher short-term and long-term mortality in CICU patients, especially severe AKI requiring dialysis.     

Recovery after AKI: Effects on outcomes over 15 years

PurposeTo examine the effect of kidney recovery on mortality, dialysis and kidney transplantation up to 15 years after AKI.Materials and methodsWe studied 29,726 survivors of critical illness and compared these outcomes stratified by AKI and recovery status at hospital discharge. Kidney recovery was defined as a return of serum creatinine to ≤150% of baseline without dialysis prior to hospital discharge.ResultsOverall AKI occurred in 59.2% in which two thirds developed stage 2–3 AKI. Recovery rate of AKI at hospital discharge was 80.8%. Patients who did not recover experienced the worst 15-year mortality compared to those who recovered and those without AKI (57.8% vs 45.2% vs 30.3%, p < 0.001). This pattern was also found in subgroups of patients with suspected sepsis-associated (57.1% vs 47.9% vs 36.5%, p < 0.001) and cardiac surgery-associated AKI (60.1% vs 41.8% vs 25.9%, p < 0.001). The rates of dialysis and transplantation at 15 years were low and not associated with recovery status.ConclusionsRecovery of AKI in critically ill patients at hospital discharge had an effect on long-term mortality for up to 15 years. These results have implications for acute care, follow-up and choice of endpoints for clinical trials.     

Diagnostic and interventional nephrology

The fragmented care of nephrology patients that results from referral to a radiologist for renal ultrasound (US) and biopsy, a surgeon for dialysis access placement, and an interventional radiologist for dialysis catheter placement and vascular access procedures often leads to delays in the treatment of these patients. Many specialists perform and interpret sonograms particular to their specialty rather than relying on technicians for performance and radiologists for interpretation, and nephrologists recently have begun to embrace this technology as an aid in the diagnosis and treatment of their patients. By combining an understanding of the pathophysiology of renal disease with the ability to perform clinical correlation and apply the laboratory data, the nephrologist is ideally suited to perform and interpret renal US and US guidance for percutaneous renal biopsies. Additionally, patients requiring peritoneal dialysis (PD) access have traditionally been referred to a general surgeon for catheter placement, which incurs additional delay in therapy and loss of decision-making control by the referring nephrologist. Recent data has emphasized that the peritoneal dialysis access procedure can be performed safely and effectively by a nephrologist trained in PD access procedures. Nephrologists also successfully perform tunneled hemodialysis catheter placement and vascular access procedures on an outpatient basis. The medical needs of patients with renal disease can be safely and efficiently delivered by a nephrologist trained in interventional nephrology (IN). This growing area of expertise will minimize delays, reduce cost, and allow physicians with training in the management of end-stage renal disease (ESRD) patients to be involved in the procedural aspects of their patients' care. An aggressive approach to the development of IN training programs at academic centers is warranted.     

Acute Kidney Injury in Adults: An Underdiagnosed Condition

Acute kidney injury (AKI) is a complex disease process that is increasingly common and has an increased rate of adverse outcomes and mortality. It is commonly underdiagnosed in inpatient and community settings by many providers. This article is a comprehensive review of AKI from risk factors to diagnosis to management and follow-up.