Timing of Initiation of Dialysis in Critically Ill Patients with Acute Kidney Injury (original) (raw)
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Survival by Dialysis Modality in Critically Ill Patients with Acute Kidney Injury
Journal of the American Society of Nephrology, 2006
Among critically ill patients, acute kidney injury (AKI) requiring dialysis is associated with mortality rates generally in excess of 50%. Continuous renal replacement therapies (CRRT) often are recommended and widely used, although data to support its superiority over intermittent hemodialysis (IHD) are lacking. Data from the Program to Improve Care in Acute Renal Disease (PICARD), a multicenter observational study of AKI, were analyzed. Among 398 patients who required dialysis, the risk for death within 60 d was examined by assigned initial dialysis modality (CRRT [n ؍ 206] versus IHD [n ؍ 192]) using standard Kaplan-Meier product limit estimates, proportional hazards ("Cox") regression methods, and a propensity score approach to account for selection effects. Crude survival rates were lower for patients who were treated with CRRT than IHD (survival at 30 d 45 versus 58%; P ؍ 0.006). Adjusted for age, hepatic failure, sepsis, thrombocytopenia, blood urea nitrogen, and serum creatinine and stratified by site, the relative risk for death associated with CRRT was 1.82 (95% confidence interval 1.26 to 2.62). Further adjustment for the propensity score did not materially alter the association (relative risk 1.92; 95% confidence interval 1.28 to 2.89). Among critically ill patients with AKI, CRRT was associated with increased mortality. Although the results could reflect residual confounding by severity of illness, these data provide no evidence for a survival benefit afforded by CRRT. Larger, prospective, randomized clinical trials to compare CRRT and IHD in severe AKI are needed.
Kidney360, 2022
BackgroundMortality of patients who are critically ill with AKI initiated on RRT is very high. Identifying modifiable and unmodifiable clinical variables at dialysis start that are associated with hospital survival can help, not only in prognostication, but also in clinical triaging.MethodsA retrospective observational study was conducted on patients with AKI-D who were initiated on RRT in the medical and surgical intensive care units (ICUs) of a high-acuity academic medical center from January 2010 through December 2015. We excluded patients with suspected poisoning, ESKD, stage 5 CKD not on dialysis, or patients with AKI-D initiated on RRT outside of the ICU setting. The primary outcome was in-hospital mortality.ResultsOf the 416 patients who were critically ill with AKI-D admitted to the medical (38%), surgical (41%), and cardiac (21%) ICUs, with nearly 75% on artificial organ support, the mean age 62.1±14.8 years, mean SOFA score was 11.8±4.3, dialysis was initiated using contin...
Severity of Acute Kidney Injury and Two-Year Outcomes in Critically Ill Patients
CHEST Journal, 2013
P atients in whom acute kidney injury (AKI) develops while in the ICU have increased risks of death in the ICU, in the hospital, and in the short term. 1-12 This increased risk has been found to be proportional to the stage of AKI. 1-3,6 However, most studies that have linked AKI to mortality have examined in-hospital mortality but not long-term outcomes. In 2002, the Acute Dialysis Quality Initiative defi ned universal AKI criteria, 13 and in 2005, these were revised by the Acute Kidney Injury Network (AKIN), using updated serum creatinine and urine output criteria Background: The association between levels of acute kidney injury (AKI) during ICU admission and long-term mortality are not well defi ned. Methods: We examined medical records of adult patients admitted to a large tertiary medical center with no history of end-stage renal disease who survived 60 days from ICU admission between 2001 and 2007. Demographic, clinical, physiologic, and date of death data were extracted. Results: Among 15,048 patients, 12,399 (82.4%) survived 60 days from ICU admission and comprised the study population. AKI did not develop in 5,663 (45.7%) during ICU admission, whereas progressively severe levels of AKI as defi ned by Acute Kidney Injury Network (AKIN) criteria AKIN 1, AKIN 2, and AKIN 3 developed in 4,589 (37.0%), 1,613 (13.0%), and 534 (4.3%), respectively. Only 42.5% of patients with AKIN 3 survived 2 years from ICU admission. Patients with AKIN 3 had a 61% higher mortality risk 2 years from ICU discharge compared with patients in whom AKI did not develop. Patients with AKIN 1 and AKIN 2 had similar increased mortality risk 2 years from ICU admission (hazard ratio, 1.26 and 1.28, respectively). The level of estimated glomerular fi ltration rate on ICU discharge and chronic kidney disease were associated with long-term mortality. Conclusions: Patients in whom AKI develops during ICU admission have signifi cantly increased risks of death that extend beyond their high ICU mortality rates. These increased risks of death continue for at least 2 years after the index ICU admission.
PLoS Medicine, 2014
Background: The incidence of acute kidney injury (AKI) is increasing globally and it is much more common than end-stage kidney disease. AKI is associated with high mortality and cost of hospitalisation. Studies of treatments to reduce this high mortality have used differing renal replacement therapy (RRT) modalities and have not shown improvement in the short term. The reported long-term outcomes of AKI are variable and the effect of differing RRT modalities upon them is not clear. We used the prolonged follow-up of a large clinical trial to prospectively examine the long-term outcomes and effect of RRT dosing in patients with AKI.
Journal of Critical …, 2010
This research aims to apply the definition proposed by the Acute Kidney Injury Network (AKIN) research group to assess the incidence, risk factors, and outcomes in acute kidney injury (AKI) patients admitted at the intensive care unit (ICU). Design: This is a retrospective cohort study. Patients who were admitted to the ICU from January 1, 2003 to December 31, 2004 were studied. Interventions: Medical records of all patients were reviewed. Demographic information, diagnoses, risk factors for AKI, laboratory data, urinary output, frequency and days of exposure to mechanical ventilation, ICU and hospital stay, and outcomes were recorded. Measurements and Main Results: A total of 794 patients were studied. There were 39.8% of patients who presented AKI (stage 1: 13.9%, stage 2: 12%, stage 3: 13.9%). The variables that were associated with the presence of AKI in the multivariable analysis were as follows: sepsis (odds ratio [OR], 5.29; 95% confidence interval [CI], 3.36-8.33), heart failure (OR, 3.01; 95% CI, 1.59-5.67), vasopressor use (OR, 1.89; 95% CI, 1.26-2.83), and age (β = 1.02; 95% CI, 1.01-1.03). The mean hospital stay increased with renal commitment: patients without AKI, 10.9 days; AKIN stage 1, 17.8; AKIN stage 2, 21.1; and AKIN stage 3, 22.1 days (P b .0001). Mortality rate increased as more advanced the AKI stage was (no AKI,
Clinical Acute Kidney Injury 2
Nephrology Dialysis Transplantation, 2014
Introduction and Aims: Acute peritoneal dialysis (PD) is one of the treatments of choice for acute kidney injury (AKI) patients. Acute PD can be performed both in and out of the intensive care unit (ICU). Furthermore, acute PD need less sophisticated equipment and more available than the continuous venovenous hemodialysis (CVVH). However, the large outcome series of acute PD in AKI have never been documented. Methods: We retrospectively reviewed the data in the tertiary teaching-based hospital in the northeastern part of Thailand. During October 2011 to September 2012, 167 AKI patients had been received the acute PD treatment. Baseline characteristic data, time to start acute PD and clinical outcomes were collected. Results: Nighty-four acute PD patients were analyzed. Mean age of patients was 56 ± 16 years. Median BUN and Cr at start acute PD were 70.5 and 6.28 mg/dl. Most of patients (86%) required inotropic drugs and ventilator support (90.4%) at the starting acute PD. About 73.4% of patients were monitored in ICU. About 28.7% of patients were performed acute PD during the nighttime (6 P.M. to 6 A.M.). Overall mortality was 67%. There was no difference in mortality rate between the time to starting acute PD (daytime and nighttime, 64.1% vs 74.1%, P=0.35 respectively). Twenty-five percentages of patients had PD peritonitis. Conclusions: Acute PD is the one of the dialysis support in AKI patients especially in the hemodynamically unstable patients and unavailable CVVH. However, the mortality rate of AKI patients was still high despite acute PD support.
BMC Nephrology, 2017
Background: Acute kidney injury (AKI) is a serious complication of critical illness with both attributed morbidity and mortality at short-term and long-term. The incidence of AKI reported in critically ill patients varies substantially with the population evaluated and the definitions used. We aimed to assess which of the AKI definitions (RIFLE, AKIN or KDIGO) with or without urine output criteria recognizes AKI most frequently and quickest. Additionally, we conducted a review on the comparison of incidence proportions of varying AKI definitions in populations of critically ill patients. Methods: We included all patients with index admissions to our intensive care unit (ICU) from January 1 st , 2014 until June 11 th , 2014 to determine the incidence and onset of AKI by RIFLE, AKIN and KDIGO during the first 7 days of ICU admission. We conducted a sensitive search using PubMed evaluating the comparison of RIFLE, AKIN and KDIGO in critically ill patients Results: AKI incidence proportions were 15, 21 and 20% respectively using serum creatinine criteria of RIFLE, AKIN and KDIGO. Adding urine output criteria increased AKI incidence proportions to 35, 38 and 38% using RIFLE, AKIN and KDIGO definitions. Urine output criteria detected AKI in patients without AKI at ICU admission in a median of 13 h (IQR 7-22 h; using RIFLE definition) after admission compared to a median of 24 h using serum creatinine criteria (IQR24-48 h). In the literature a large heterogeneity exists in patients included, AKI definition used, reference or baseline serum creatinine used, and whether urine output in the staging of AKI is used. Conclusion: AKIN and KDIGO criteria detect more patients with AKI compared to RIFLE criteria. Addition of urine output criteria detect patients with AKI 11 h earlier than serum creatinine criteria and may double AKI incidences in critically ill patients. This could explain the large heterogeneity observed in literature.
CLINICAL ACUTE KIDNEY INJURY 1
Nephrology Dialysis Transplantation, 2014
Introduction and Aims: Acute kidney injury (AKI) is an important public health problem. AKI is a risk factor for progression of kidney disease, incidence of chronic kidney disease (CKD) and mortality. The aim of the study was to assess characteristics, renal survival and mortality of patients who developed AKI stage 3, according to KDIGO guidelines, and needed renal replacement therapy (RRT), not in intensive care unit. Methods: All patients who required RRT due to AKI stage 3 along two years were included, excluding patients in intensive care unit. Demographic and personal history data, previous renal function, cause of AKI, renal function, renal survival, and mortality at one, three, six and twelve months after AKI were recorded. Results: A total of 107 patients were enrolled (incidence 134 patients/106 population/ year). Mean age 72.2±13.9 (range 25-92), 57.9% men. Patient's characteristics: 77.6% were hypertensive, 40.2% were diabetics, 45.8% were dyslipemics, 41.1% were obese, 27.1% were smokers, and 61.2% with chronic renal failure (eFG<60mil/min) of which 54% stage 3, 36.5% stage 4, and 9.5% stage 5. Cause of AKI: renal disease 63.6%, prerrenal 28.9% and obstructive causes 7.5%.Renal function: Serum creatinine before AKI 1.78±1.12 mg/dL; maximum serum creatinine during AKI hospitalization 7.39 ±4.43mg/dL; at discharge, 2.64±1.62mg/dL; one month later, 2.07±1.36mg/dL; three months later, 2.35±1.60mg/dL; six months later, 2.25±1.85mg/dL and one year later, 1.95±1.14 mg/dL.During hospitalization, 24.3% died, 16.8% kept on RRT at discharge, and 58.9% recovered partial or completely renal function. One month after AKI, 31.7% had died, 15.8% kept on RRT, and 52.5% preserved renal function, 5.6% was missing. Three months later, 45.7% died, 10.9% kept on RRT, and 43.5% preserved renal function, 14% was missing. Six months later, 48.3% had die, 10% kept on RRT, and 33.3% preserved renal function, 8.3% were missing. Finally, one year after AKI, 71.8% of patients had died, 9.9% needed RRT, 18.3% recovered partial or completely renal function and 33.6% missing. AKI in diabetic or dyslipemic patients has an increased mortality ( p=0.03 and p=0.06 respectively). CKD before AKI is not associated with increased mortality.Renal function according to KDOQI classification of patients who had AKI stage 3 was: at discharge: stage 1 1.6%, 2 16.1%, 3 24.2%, 4 37.1% and 5 21.0%; three months after AKI : stage 1 2.5%, 2 15%, 3 30%, 4 32.5% and 5 17.5%; six months after AKI: 1 6.5%, 2 12.9%, 3 38.7%, 4 19.4% and 5 19.4% and one year after AKI, renal function was: 2 25%, 3 41.7%, 4 25% and 5 8.3%. Conclusions: In our health area AKI stage 3 requiring RRT have a incidence similar to other studies. Mortality in AKI patients exceeds 70% one year after AKI episode and renal survival decreases in this period. Nephrology follow-up must be established in patients who survive AKI. The develop of tools to identify high-risk patients and to promote renal recovery is important to reduce burden of CKD and mortality.
Early initiation of dialysis: mortality and renal function recovery in acute kidney injury patient
Jornal Brasileiro de Nefrologia, 2012
Introduction: The decision of when to start dialysis in Acute Kidney Injury (AKI) patients with overt uremia is strongly established, however, when blood urea nitrogen (BUN) levels is < 100 mg/dL the timing of initiation of dialysis remains uncertain. Purpose: The aim of this study was to assess mortality and renal function recovery AKI patients started on dialysis at different BUN levels. Methods: This was a retrospective study performed at Medical School Hospital, São Paulo, Brazil, enrolling 86 patients underwent to dialysis. Results: Dialysis was started when BUN ≤ 75 mg/dl in 23 patients (Group I) and BUN > 75 mg/dl in 63 patients (Group II). Hypervolemia and mortality were higher in Group I than in Group II (65.2% vs. 14.3%-p < 0.05, 39.1% vs. 68.9%-p < 0.05, respectively). Among survivors, the rate of renal function recovery was higher in Group I (71.4% and 36.8%, respectively-p < 0.05). Multivariate analysis showed that sepsis, age > 60 years, peritoneal dialysis and BUN > 75 mg/dl at dialysis initiation were independently related with mortality. Conclusions: Lower mortality and higher renal function recovery rates were associated with early dialysis initiated at lower BUN leves in AKI patients. Início precoce da diálise: mortalidade e recuperação da função renal em pacientes com lesão renal aguda Early initiation of dialysis: mortality and renal function recovery in acute kidney injury patients