Urgent-Start Peritoneal Dialysis: Brazilian Experience.

INTRODUCTION: Unplanned peritoneal dialysis (PD) is an important option for chronic kidney disease (CKD) patients requiring kidney replacement therapy urgently as it offers the convenience of home-based therapy. The objective of this study was to assess the Brazilian urgent-start PD program in three different dialysis centers where there is shortage of hemodialysis (HD) beds. METHODS: This prospective, multicentric cohort study included incident patients with stage 5 CKD and no permanent vascular access established who started urgent PD between July 2014 and July 2020 in three different hospitals. Urgent-start PD was defined as initiation of treatment up to 72 h after catheter placement. Patients were followed up from catheter insertion and assessed according to mechanical and infectious complications related to PD, patients, and technique survival. RESULTS: Over 6 years, 370 patients were included in all three study centers. Mean patient age was 57.8 ± 16.32 years. Diabetic kidney disease was the main underlying condition (35.1%) and uremia was the main cause for dialysis indication (81.1%). Concerning complications related to PD, 24.3% had mechanical complications, 27.3% had peritonitis, 28.01% had technique failure, and 17.8% died. On logistic regression, hospitalization (p = 0.003) and exit site infection (p = 0.002) were identified as predictors of peritonitis, while mechanical complications (p = 0.004) and peritonitis (p < 0.001) were identified as predictors of technique failure and switching to HD. Age (p < 0.001), hospitalization (p = 0.012), and bacteremia (p = 0.021) were observed to predict death. The number of patients on PD increased at least 140% in all three participating centers. CONCLUSION: PD is a feasible option for patients starting dialysis in an unplanned manner and may be a useful tool for reducing shortage of HD beds.

The Role of Urinary Biomarkers as Diagnostic and Prognostic Predictors of Acute Kidney Injury Associated With Vancomycin.

Introduction: The incidence of acute kidney injury (AKI) related to vancomycin is variable, and several risk factors related to the treatment and patients may explain the nephrotoxicity. The role of urinary biomarkers in AKI related to vancomycin is unknown. Objective: The aim of this study was to evaluate the role of urinary IL-18, KIM-1, NGAL, TIMP-2, and IGFBP7 as diagnostic and prognostic predictors of AKI related to vancomycin. Methods: A prospective cohort study of patients receiving vancomycin and admitted to wards of a public university hospital from July 2019 to May 2020 was performed. We excluded patients that had AKI before starting vancomycin, hemodynamic instability, inability to collect urine, and chronic kidney disease stage 5. Results: Ninety-four patients were included, and the prevalence of AKI was 24.5%, while the general mortality was 8.7%. AKI occurred 11 ± 2 days after the first vancomycin dose. The most frequent KDIGO stage was 1 (61%). There was no difference between patients who developed and did not develop AKI due to gender, length of hospital stay, dose, and time of vancomycin use. Logistic regression identified age (OR 6.6, CI 1.16-38.22, p = 0.03), plasmatic vancomycin concentrations between 96 and 144 h (OR 1.18, CI 1.04-1.40, p = 0.04), and urinary NGAL levels between 96 and 144 h (OR 1.123, CI 1.096-1.290, p = 0.03) as predictors of AKI. The time of vancomycin use (OR 4.61, CI 1.11-22.02, p = 0.03), higher plasmatic vancomycin concentrations between 192 and 240 h (OR 1.02, CI 0.98-1.06, p = 0.26), and higher cell cycle arrest urinary biomarkers TIMP-2 multiplied by IGFBP-7 between 144 and 192 h (OR 1.33, CI 1.10-1.62, p = 0.02; OR 1.19, CI 1.09-1.39, p = 0.04, respectively) were identified as prognostic factors for non-recovery of kidney function at discharge. Conclusion: AKI related to vancomycin was frequent in patients hospitalized in wards. Age, plasmatic vancomycin concentrations, and NGAL between 96 and 144 h were identified as predictors of AKI related to vancomycin use. Plasmatic vancomycin concentrations and urinary NGAL were predictors of AKI diagnosis within the next 5 days. The urinary biomarkers of cell cycle arrest TIMP-2 and IGFBP-7 and the duration of vancomycin use were associated with non-recovery of kidney function at hospital discharge moment.

The use of antimicrobials in septic patients with acute kidney injury.

Sepsis is the most common cause of death in critically ill patients and it may be associated with multiorgan failure, including acute kidney injury (AKI). This situation can require acute renal support and increase mortality. Therefore, it is essential to administrate antimicrobials in dosis to achieve adequate serum levels, preventing overdosis and drug toxicity or underdosing and risk for resistance to antibiotics and higher mortality. To date, there aren't validated guidelines on antibiotic dosis adjustment in septic patients with AKI and the recommendations are extrapolated from studies conducted in non-critical patients with chronic kidney disease in end stage receiving chronic renal replacement therapy. This study aimed to review and discuss the complexity of that issue, considering the several factors related to the drugs removal: critically ill patient characteristics, antimicrobial properties and dialysis method.

Pharmacokinetics and pharmacodynamics of antibiotics in critically ill acute kidney injury patients.

Sepsis is the most common cause of death in critically ill patients and is associated with multiorgan failure, including acute kidney injury (AKI). This situation can require acute renal support and increase mortality. Therefore, it is essential to administer antimicrobials in doses that achieve adequate serum levels, avoiding both overdosing and drug toxicity as well as underdosing and the risk of antibiotic resistance and higher mortality. Currently, there are no validated guidelines on antibiotic dose adjustments in septic patients with AKI. The current recommendations were extrapolated from studies conducted in noncritical patients with end-stage chronic kidney disease receiving chronic renal replacement therapy. This study aimed to review and discuss the complexity of this issue, considering several factors related to drug metabolism, the characteristics of critically ill patients, the properties of antimicrobial drugs and dialysis methods.

The use of antimicrobials in septic patients with acute kidney injury / O uso de antimicrobianos em pacientes sépticos com lesão renal aguda

Abstract Sepsis is the most common cause of death in critically ill patients and it may be associated with multiorgan failure, including acute kidney injury (AKI). This situation can require acute renal support and increase mortality. Therefore, it is essential to administrate antimicrobials in dosis to achieve adequate serum levels, preventing overdosis and drug toxicity or underdosing and risk for resistance to antibiotics and higher mortality. To date, there aren't validated guidelines on antibiotic dosis adjustment in septic patients with AKI and the recommendations are extrapolated from studies conducted in non-critical patients with chronic kidney disease in end stage receiving chronic renal replacement therapy. This study aimed to review and discuss the complexity of that issue, considering the several factors related to the drugs removal: critically ill patient characteristics, antimicrobial properties and dialysis method.

Resumo A sepse é a principal causa de óbito em pacientes críticos e pode cursar com falência de vários órgãos, entre eles os rins, requerendo, com frequência, suporte renal agudo e elevando a mortalidade. Assim, torna-se imprescindível a administração de antimicrobianos em dose que garanta nível sérico adequado para evitar superdosagem e toxicidade medicamentosa ou ainda subdosagem e risco de resistência microbiana, ambas as situações contribuindo para maior mortalidade. Até o momento, não há diretrizes validadas para auxiliar no ajuste de dose de antibióticos nos pacientes sépticos com lesão renal aguda em suporte renal, sendo as recomendações extrapoladas de estudos realizados em pacientes não críticos e com doença renal em estádio final recebendo terapia renal substitutiva crônica. Esse estudo teve como objetivo revisar e discutir a complexidade desse assunto, levando em consideração os vários fatores relacionados à remoção de drogas: características do paciente crítico, propriedades dos antimicrobianos e método dialítico utilizado.