Medium Cut-Off versus Low-Flux Dialyzers in Hemodialysis Patients with COVID-19: Clinical Outcomes and Reduction in Interleukin-6.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has caused extensive morbidity and mortality worldwide. Hemodialysis (HD) patients are both vulnerable to COVID-19 infection and tend to suffer greater disease severity and mortality. This retrospective study aimed to compare medium cut-off (MCO) and low-flux (LF) membrane dialyzers in terms of interleukin-6 (IL-6) reduction, change in inflammatory state, intradialytic complications, and mortality in chronic HD patients with COVID-19. METHOD: HD patients with a confirmed COVID-19 infection were admitted to the hospital for 10-14 days and underwent HD at the COVID-HD unit. Choice of dialyzer membrane used (MCO vs. LF) depended on the primary nephrologist(s). We collected data on demographics, baseline characteristics, laboratory results, diagnosis, treatments, HD prescription, hemodynamic status during HD, and mortality at 14 and 28 days after. RESULTS: IL-6 reduction ratio (RR) in the MCO group was 9.7 (interquartile range, 71.1) percent, which was significantly higher than that of the LF group (RR, -45.7 [interquartile range, 70.2] percent). The incidence rate of intradialytic hypotension in the MCO group was 3.846 events per 100 dialysis hours (95% confidence interval [CI], 1.954-6.856), which was significantly lower than that of the LF group (9.057; 95% CI, 5.592-13.170). Overall, mortality was not significantly different between the two groups. CONCLUSION: The MCO membrane was more effective in removing IL-6 and was better tolerated than the LF membrane. Large, randomized controlled trials are required to confirm the relative benefits of the MCO membrane, especially mortality. However, due to the COVID-19 pandemic, our results suggest that the MCO membrane may be beneficial in chronic HD patients with COVID-19.

Therapeutic plasma exchange with standard hemodialysis machine as an alternative to dedicated apheresis device: A 5-year experience.

Patients suffering from various diseases have been shown to benefit from therapeutic plasma exchange (TPE). However, in developing countries, there are many obstacles hindering the establishment and initiation of TPE programs. These include inadequate funding and lack of government healthcare coverage. Our center in Thailand practices a unique membrane plasma separator technique using a hemodialysis machine incorporated with a plasma separator. Over a 5 year period, there were 130 such sessions conducted in 24 patients. The indications for TPE treatment included neurological, hematological, and nephrological diseases. Overall, response to TPE was good. Some TPE-related adverse events did occur, but none were life-threatening. Unfortunately, infection remained a problem and was sometimes a cause of death. Future challenges include minimization of infection rates and making TPE treatment readily accessible to patients.

The Effect of Citrate on Clot Formation, Dialyzer Reuse, and Anemia in Hemodialysis Patients.

BACKGROUND: Citrate anticoagulation is increasingly favored for preventing extracorporeal circuit clotting during renal replacement therapy. This study tested the effect of citrate compared with acetate on heparin avoidance and other parameters. METHODS: Sixty-one chronic hemodialysis (HD) patients were switched from conventional dialysis fluid (acetate) to citrate dialysis fluid and were treated in 3 phases, each lasting 4 weeks: 50%, 25%, and no heparin. Visual clotting score, erythropoiesis stimulating agent (ESA) dose, and laboratory parameters were measured. RESULTS: Except for 2 episodes of clotting, the same dialyzers were used throughout each citrate phase. The mean visual clotting scores were comparable across study periods. Hemoglobin decreased slightly in phase 2 despite the constant ESA dose. The ionized calcium levels rose after HD in most sessions. No adverse events occurred during citrate dialysis. CONCLUSION: During citrate dialysis in chronic HD patients, heparin can be completely avoided. The electrolyte levels, the adequacy of dialysis, and hemoglobin can be maintained without significant adverse events.

Acute kidney injury in critically ill surgical patients: Epidemiology, risk factors and outcomes.

AIM: Acute kidney injury (AKI) is one of the most serious complications seen in intensive care units (ICUs). However, its epidemiology, risk factors and clinical outcomes in surgical critically ill patients remains unclear. METHODS: A prospective cohort study was conducted in surgical intensive care unit (ICU) of the university hospital in Bangkok, Thailand. AKI was diagnosed according to the KDIGO 2012 criteria. RESULTS: A total of 189 of the 400 patients enrolled in our study developed AKI (47.3%). The severity was: stage 1 = 29.6% of all AKI (56 cases), stage 2 = 30.7% (58 cases), and stage 3 = 39.7% (75 cases). Risk factors of AKI development included a higher BMI, a greater APACHE-II score, septic shock, use of mechanical ventilation, acute medical complications during surgical admission, and pre-existing chronic kidney disease. After adjustment for covariates, only the most severe stage of AKI (stage 3) was associated with increasing 28-day ICU mortality compared with no AKI stage, HR = 7.75 (95% CI, 1.46-41.20, P = 0.02). CONCLUSION: Acute kidney injury is common and is associated with an increase in mortality in surgical ICU patients. There should be more focus on patients with AKI risk factors to prevent this deleterious event.

Intra-abdominal hypertension among medical septic patients associated with worsening kidney outcomes (IAH-WK study).

High intra-abdominal pressure (IAP) is associated with acute kidney injury (AKI). However, the relationship between intra-abdominal hypertension (IAH) and AKI in medical septic patients is still inconclusive. This prospective cohort study enrolled patients admitted in the Medical Intensive Care Unit from April 2020 to February 2021. Demographic, therapeutic, and laboratory data were obtained upon admission. The evaluation of IAP was performed via the intra-vesical method during the first and second 24 hours of admission. Kidney function was evaluated on the first 3 days and at least on the 7th day of enrollment. Among 79 patients, 30 (38%) developed IAH, while 50 (63.3%) developed AKI within 7 days. On the first day, the mean IAP was 15.4 (interquartile range [IQR], 4) and 7.0 (IQR, 3.7) mm Hg in the IAH and non-IAH groups, respectively. A total of 52 patients (65.8%) developed the primary outcome (i.e., a composite outcome including AKI, treatment with kidney replacement therapy, or death). On Cox proportional-hazards model between IAH and outcomes, after adjustment for multiple covariates, IAH was associated with a composite outcome (hazard ratio [HR], 6.5; 95% confidence interval [CI], 2.3-18.6; P < .005) and the development of AKI (HR, 6.5; 95% CI, 2.3-18.8; P < .005). IAH was associated with a composite outcome of AKI, treatment with kidney replacement therapy, or death in medical septic patients. thaiclinicaltrial.org, Identifier: TCTR20200531001, Registered May 24, 2020.

Cranial versus Caudal Direction Technique of Native Percutaneous Kidney Biopsy: A Randomized Controlled Trial.

Background: Percutaneous kidney biopsy (PKB) is the gold standard for diagnosing various kidney diseases, but it can result in potential complications. This study aimed to compare kidney tissue adequacy and safety between the two biopsy techniques, including cranial direction (CN) and caudal direction (CD), of needle biopsy under real-time ultrasonogram guidance. Methods: This single-center, prospective, single-blinded, randomized trial included patients undergoing native PKB from July 5, 2017, to June 30, 2019. Patients were randomized to the CN and CD groups. Adequacy and complications between the two groups were analyzed. All PKBs were performed under real-time ultrasonogram guidance with a 16-gauge kidney biopsy needle. Results: A total of 107 participants were enrolled (53 in the CD group and 54 in the CN group). The CD group has more glomeruli than the CN group but with no statistical significance (16 versus 11, p = 0.0865). The CD group obtained more adequate kidney tissue samples than the CN group (69.8% versus 59.3%, p = 0.348). The number of inadequate glomeruli tissue sampling is similar in both groups (14 versus 15, respectively). Furthermore, the CN group had more adverse events, including Hb decline ≥10% after kidney biopsy, perinephric hematoma size ≥1 cm, hematuria, and the need for blood transfusion, than the CD group. Conclusion: The CD technique of the percutaneous kidney biopsy in the native kidney has fewer complications and was possibly more effective than the CN technique.

Curcuminoids can prevent post-contrast acute kidney injury in chronic kidney disease patients: A randomized controlled trial.

BACKGROUND: Post contrast acute kidney injury (PC-AKI) following coronary procedures is a common cause of renal impairment in hospitalized patients, curcuminoids exert anti-inflammatory and antioxidant actions and have shown positive effects on renal hemodynamic protection The objective of this study was to evaluate the role of curcuminoids in the prevention of PC-AKI in chronic kidney disease (CKD) patients. METHODS: This study was a single-center, prospective, double-blind, randomized, placebo-controlled trial in patients with CKD undergoing elective coronary angiography (CAG) at Vajira Hospital from October 2018 to March 2019. Patients were randomized to receive curcuminoids at 1500 mg per day 3 days before and 2 days after the procedure or placebo. The primary outcome was the development of PC-AKI, and the secondary outcomes were overall acute kidney injury (AKI) incidence within 7 days after CAG, changes in estimated glomerular filtration rate (eGFR), interleukin-6 (IL-6), high sensitivity C-reactive protein (hs-CRP), and other adverse events. RESULTS: Sixty patients were enrolled in this study (30 in the curcuminoid group and 30 in the control group). AKI developed in 5 patients in the control group but not in the curcuminoid group (16.67% vs 0%, P = .052). that curcuminoids could preserve changes in eGFR compared to the placebo group (-1.5 vs 2.5 mL/min/1.73 m2, P value <.001 within 48 hours and -4 vs 1 mL/min/1.73 m2, P value 0.002 within 7 days). However, the hs-CRP and IL-6 levels did not differ between the groups. No serious adverse events were observed in either of the groups. CONCLUSION: Prophylactic administration of curcuminoids, in addition to standard treatment, reduces the incidence of PC-AKI in patients with CKD undergoing elective CAG.

External Validation of the Acute Kidney Injury Risk Prediction Score for Critically Ill Surgical Patients Who Underwent Major Non-Cardiothoracic Surgery.

BACKGROUND: Acute kidney injury (AKI) is a common complication encountered in an intensive care unit (ICU). In 2020, the AKI prediction score was developed specifically for critically ill surgical patients who underwent major non-cardiothoracic surgeries. This study aimed to externally validate the AKI prediction score in terms of performance and clinical utility. METHODS: External validation was carried out in a prospective cohort of patients admitted to the ICU of the Faculty of Medicine Vajira Hospital between September 2014 and September 2015. The endpoint was AKI within seven days following ICU admission. Discriminative ability was based on the area under the receiver operating characteristic curves (AuROC). Calibration and clinical usefulness were evaluated. RESULTS: A total of 201 patients were included in the analysis. AKI occurred in 37 (18.4%) patients. The discriminative ability dropped from good in the derivation cohort, to acceptable in the validation cohort (0.839 (95%CI 0.825-0.852) vs. 0.745 (95%CI 0.652-0.838)). No evidence of lack-of-fit was identified (p = 0.754). The score had potential clinical usefulness across the range of threshold probability from 10 to 50%. CONCLUSIONS: The AKI prediction score showed an acceptable discriminative performance and calibration with potential clinical usefulness for predicting AKI risk in surgical patients who underwent major non-cardiothoracic surgery.

Effect of high dose ergocalciferol in chronic kidney disease patients with 25-hydroxyvitamin D deficiency.

OBJECTIVE: To evaluate 25 hydroxyvitamin D (25-OH-D) deficiency in a cohort ofpredialysis CKD patients and the treatment effect and safety of high dose ergocalciferol supplement in predialysis CKD. MATERIAL AND METHOD: Fifty-six predialysis CKD patients who came for a regular visit at a single hospital with calculated glomerular filtration rate < or =60 mL/min/1.73 m2 were screened for 25-OH-D levels. Forty-four patients with 25-OH-D deficiency were recruited into this prospective observational study that examined the effect of high dose oral ergocalciferol supplementation. After eight weeks, 37 patients completed the follow-up and biochemical parameters were reevaluated and analyzed. RESULTS: The mean 25-OH-D level of 56 patients was 25.6 +/- 8 ng/mL. Forty-four (78.5%) patients had 25-OH-D levels less than 30 ng/mL and four (7.1%) had severe deficiency with the level less than 15 ng/mL. High dose ergocalciferol supplement successively increased 25-OH-D levels in 35 (95%) patients. 25-OH-D levels increased significantly from 22 +/- 4.8 to 34.5 +/- 10.8 ng/mL after eight weeks (p < 0.001). During the study period, there were no changes in serum calcium, phosphate, and PTH. There was no other side effect associated with the treatment. CONCLUSION: 25-OH-D deficiency were found in this cohort of predialysis CKD patients. Ergocalciferol was a safe and effective supplement for the 25-OH-D in predialysis CKD.

Acute Kidney Injury Outcomes of Elderly and Nonelderly Patients in the Medical Intensive Care Unit of a University Hospital in a Developing Country.

BACKGROUND: Aging is associated with a high risk of acute kidney injury (AKI), and the elderly with AKI show a higher mortality rate than those without AKI. In this study, we compared AKI outcomes between elderly and nonelderly patients in a university hospital in a developing country. MATERIALS AND METHODS: This retrospective cohort study included patients with AKI who were admitted to the medical intensive care unit (ICU) between January 1, 2012, and December 31, 2017. The patients were divided into the elderly (eAKI; age ≥65 years; n = 158) and nonelderly (nAKI; n = 142) groups. Baseline characteristics, comorbidities, principle diagnosis, renal replacement therapy (RRT) requirement, hospital course, and in-hospital mortality were recorded. The primary outcome was in-hospital mortality. RESULTS: The eAKI group included more females, patients with higher Acute Physiology and Chronic Health Evaluation II scores, and patients with more comorbidities than the nAKI group. The etiology and staging of AKI were similar between the two groups. There were no significant differences in in-hospital mortality (p=0.338) and RRT requirement (p=0.802) between the two groups. After adjusting for covariates, the 28-day mortality rate was similar between the two groups (p=0.654), but the 28-day RRT requirement was higher in the eAKI group than in the nAKI group (p=0.042). CONCLUSION: Elderly and nonelderly ICU patients showed similar survival outcomes of AKI, although the elderly were at a higher risk of requiring RRT.

The efficacy of blind versus real-time ultrasound-guided percutaneous renal biopsy in developing country.

INTRODUCTION: Renal biopsy is a useful diagnostic procedure. In developing countries, two techniques of renal biopsy, blind percutaneous renal biopsy and real-time ultrasound-guided percutaneous renal biopsy, have been performed. The majority of studies compared these using different types and sizes of biopsy needle. The aim of this study was to compare both techniques in resource constraint country. METHOD: We reviewed renal biopsy database, between 1 January 2014 to 30 June 2017. The primary outcome was the total number of glomeruli. The other outcomes were tissue adequacy and bleeding complications. We also analyzed multivariable logistic regression to find factors associated with tissue adequacy and bleeding complications. RESULT: Of the 204 renal biopsies, 100 were blind percutaneous renal biopsy and 104 real-time ultrasound-guided percutaneous renal biopsy. The number of native renal biopsies was 169 (82.8%). Baseline characteristics of two groups were comparable. The mean number of total glomeruli from real-time ultrasound-guided percutaneous renal biopsy was significantly more than blind percutaneous renal biopsy (20.8 ± 12.1 vs 16.0 ± 13.0, p = 0.001). The real-time ultrasound-guided percutaneous renal biopsy obtained more adequate tissues than blind percutaneous renal biopsy (45.2% vs 16%, p < 0.001) and was the only factor associated with adequate tissue. Moreover, 16 renal biopsies from blind percutaneous renal biopsy obtained inadequate tissue. The overall bleeding complications were not statistically different. We found being female, lower eGFR and lower hematocrit were associated with bleeding complications. CONCLUSION: In comparison with blind percutaneous renal biopsy, real-time ultrasound-guided percutaneous renal biopsy obtained more adequate tissue and number of glomeruli. While the complications of both were comparable. We encourage to practice and perform real-time ultrasound-guided percutaneous renal biopsy in resource constraint countries.