Successful Liberation from Acute Kidney Replacement Therapy in Critically Ill Patients: A Prospective Cohort Study.

INTRODUCTION: Recovery of kidney function to liberate patients from acute kidney replacement therapy (AKRT) is recognized as a vital patient-centered outcome. The lack of specific guidelines providing specific recommendations on therapy interruption is an important obstacle. We aimed to determine the prevalence of successful discontinuation of AKRT and its predictive factors after the elaboration of clinical protocol with these recommendations. METHODOLOGY: A prospective cohort study was performed with 156 patients at a public Brazilian university hospital between July 2020 and July 2021. RESULTS: Success and hospital discharge were achieved for most patients (84.6% and 89%, respectively). Multivariable logistic regression analysis showed that C-reactive protein (CRP), urine output, and creatinine clearance at the time of interruption were variables associated with discontinuation success (OR: 0.943, CI: 0.905-0.983, p = 0.006; OR: 1.078, CI: 1.008-1.173, p = 0.009 and OR: 1.091, CI: 1.012-1.213, p = 0.004; respectively). The areas under the curve for CRP, urine output, and creatinine clearance at the time of interruption were 0.78, 0.62, and 0.82, respectively. Both CRP and creatinine clearance were good predictors of successful liberation of AKRT. The optimal cutoff value of them had sensitivity and specificity of 0.88 and 0.87, 0.91 and 0.90, respectively. The use of noradrenalin at the time of interruption (OR: 0.143, CI: 0.047-0.441, p = 0.001) and successful discontinuation (OR: 3.745, CI: 1.047-13.393, p = 0.042) were identified as variables associated with hospital discharge. CONCLUSION: Our results show the factors related to success in discontinuing AKRT are the CRP, creatinine clearances, and urinary output at the time of AKRT interruption and it was associated with lower mortality.

Factors predicting successful discontinuation of acute kidney replacement therapy: A retrospective cohort study.

BACKGROUND: Treatment for severe acute kidney injury (AKI) typically involves the use of acute kidney replacement therapy (AKRT) to prevent or reverse complications. METHODOLOGY: We aimed to determine the prevalence of successful discontinuation of AKRT and its predictive factors. A retrospective cohort study was performed with 316 patients hospitalized at a public Brazilian university hospital between January 2011 and June 2020. RESULTS: Success and hospital discharge were achieved for most patients (85% and 74%, respectively). Multivariable logistic regression analysis showed that C-reactive protein (CRP), urine output, and need mechanical ventilation at the time of interruption were variable associated with discontinuation success (OR 0.969, CI 0.918-0.998, p = 0.031; OR 1.008, CI 1.001-1.012, p = 0.041 and OR 0.919, CI 0.901-0.991, p = 0.030; respectively), while the absence of comorbidities such as chronic kidney disease (OR 0.234, CI 0.08-0.683, p = 0.008), cardiovascular disease (OR 0.353, CI 0.134-0.929, p = 0.035) and hypertension (OR 0.278, CI 0.003-0.882, p = 0.009), as well as pH values at the time of AKRT indication (OR 1.273, CI 1.003-1.882, p = 0.041), mechanical ventilation at the time of interruption (OR 0.19, CI 0.19-0.954, p = 0.038) and successful discontinuation (OR 8.657, CI 3.135-23.906, p < 0.001) were identified as variables associated with hospital discharge. CONCLUSION: These results show that clinical conditions such as comorbidities, urine output, and mechanical ventilation, and laboratory variables such as pH and CRP are factors associated with hospital discharge and AKRT discontinuation success, requiring larger studies for confirmation.

Advances in Peritoneal Dialysis in Acute Kidney Injury.

UNASSIGNED: In the 1970s, acute peritoneal dialysis (PD) was widely accepted for the treatment of acute kidney injury (AKI), but this practice has declined in favor of extracorporeal therapies, mainly in developed world. The lack of familiarity with the use of PD in critically ill patients has also led to a lack of use even among those receiving maintenance PD. Renewed interest in the use of PD for AKI therapy has emerged due to its increasing use in low- and middle-income countries due to its lower cost and minimal infrastructural requirements. In high-income countries, the coronavirus disease 2019 pandemic saw PD for AKI used early on, where many critical care units were in crisis and relied on PD use when resources for other AKI therapy modalities were limited. In this review, we highlight the advantages and disadvantages of PD in AKI patients and indications and contraindications for its use. We also provide an overview of advances to support PD treatment during AKI, discussing PD access, PD prescription, complications related to PD, and its use in particular clinical conditions. (Rev Invest Clin. 2023;75(6):327-36).

Vancomycin dosing, monitoring and toxicity: Critical review of the clinical practice.

Vancomycin is an antibiotic used in the treatment of infections caused by multidrug-resistant Gram-positive bacteria, especially methicillin-resistant Staphylococcus aureus. In the last decades, vancomycin has been widely used in hospital environments due to the increasing incidence of sepsis and septic shock. Sepsis may lead to multiple organ failure; it is considered a risk factor for the development of acute kidney injury (AKI), with an overall mortality rate of around 45%, which can reach the surprising rate of 70% with the combination of AKI and sepsis. Considering the high mortality rate of sepsis and its related costs of hospitalization and treatment, specific measures should be adopted, such as early-goal treatment protocols: proper and early administration of antimicrobials, fluids, vasoactive drugs and transfusion support. Besides the careful selection of the antimicrobial, another concern related to critically ill patients is the proper dose of the antimicrobial, since pharmacokinetic changes are observed due to drug absorption, distribution, metabolism and elimination. Gram-positive pathogens are very common in hospitalized patients with septic shock, so vancomycin has been the antimicrobial of choice for more than 60 years. However, discussions about its dosage, administration and monitoring are extremely important, considering the risk of nephrotoxicity and the emergence of resistant S. aureus. This narrative review aims to discuss controversial aspects related to the efficacy and safety of vancomycin, correlating them with data available in the literature and identifying knowledge gaps in guide future lines of research.

Urgent start peritoneal dialysis.

PURPOSE OF REVIEW: Although historically peritoneal dialysis was widely used in nephrology, it has been underutilized in recent years. In this review, we present several key opportunities and strategies for revitalization of urgent start peritoneal dialysis use, and discuss the recent literature on clinical experience with peritoneal dialysis use in the acute and unplanned setting. RECENT FINDINGS: Interest in using urgent start peritoneal dialysis to manage acute kidney injury (AKI) and unplanned chronic kidney disease (CKD) stage 5 patients has been increasing. To overcome some of the classic limitations of peritoneal dialysis use in AKI, such as a high chance of infectious and mechanical complications, and no control of urea, the use of cycles, flexible catheters, and a high volume of dialysis fluid has been proposed. This knowledge can be used in the case of an unplanned start on chronic peritoneal dialysis, and may be a tool to increase the peritoneal dialysis penetration rate among incident patients starting chronic dialysis therapy. SUMMARY: Peritoneal dialysis should be offered in an unbiased way to all patients starting unplanned dialysis, and without contraindications to peritoneal dialysis. It may be a feasible, well tolerated, and complementary alternative to hemodialysis, not only in the chronic setting, but also in the acute.

Effect of peritoneal dialysis vs. haemodialysis on respiratory mechanics in acute kidney injury patients.

BACKGROUND: Peritoneal dialysis (PD) and hemodialysis (HD) are options for the treatment of acute kidney injury (AKI) patients. The aim of this study was to compare the effects of PD and daily HD on respiratory mechanics of AKI patients undergoing invasive mechanical ventilation (IMV). METHODS: A prospective cohort study evaluated 154 patients, 37 on continuous PD and 94 on HD. Respiratory mechanics parameters such as pulmonary static compliance (Psc) and resistance of the respiratory system (Rsr) and oxygenation index (OI) were assessed for 3 days. Patients were evaluated at moments 1, 2 and 3 (pre- and post-dialysis). RESULTS: The initial clinical parameters were similar in the two groups, except the age that was higher in continuous PD group (70.8 ± 11.6 vs. 60 ± 15.8; p < 0.0001). In both groups, Psc increased significantly, with no difference between the two groups-pre-dialysis (continuous PD 40 ± 17.4, 42.8 ± 17.2, 48 ± 19; HD 39.1 ± 21.3, 39. 5 ± 18.9, 45.2 ± 21) and post-dialysis (continuous PD 42.8 ± 7.2, 48 ± 19, 57.1 ± 18.3; HD 42 ± 19, 45 ± 18.5, 56 ± 24.8). Rsr remained stable among patients on continuous PD (pre-dialysis 10.4 ± 5.1, 13.3 ± 7.7, 13.5 ± 10.3, post-dialysis 13.3 ± 7.7, 13.5 ± 10.3, 11.1 ± 5.9) and decreased among HD patients (pre-dialysis 10.4 ± 5.1, 10.4 ± 5.1, 10.4 ± 5, 1, post-dialysis 10.5 ± 6.8, 10 ± 4.9, 8.9 ± 4.2). There was difference in Rsr between the two groups at the post-dialysis moments 1 and 2 (p = 0.03). OI increased in both groups (continuous PD 260.7 ± 119, 252.7 ± 87.1, 287.3 ± 88.4; HD 228 ± 85, 257 ± 84, 312.1 ± 111.5, p > 0.05), although there was no difference between them. CONCLUSION: AKI patients undergoing IMV and HD or PD had improvement in the mechanical ventilation and oxygenation, with no difference between the two groups.

Peritoneal Dialysis Treatment Modality Option in Acute Kidney Injury.

BACKGROUND: Peritoneal dialysis (PD) may be a feasible and safe alternative to haemodialysis not only in the chronic but also in the acute setting. It was previously widely accepted as a modality for acute kidney injury (AKI) treatment, but its practice declined in favor of other types of extracorporeal therapies. SUMMARY: The interest in PD to manage AKI patients has been increased and PD is now frequently used in developing countries because of its lower cost and minimal infrastructural requirements. Studies from these countries have shown that, with careful thought and planning, critically ill patients can be successfully treated using PD. Some of the classic limitations of PD use in AKI, such as infectious and mechanical complications and poor metabolic control, have been decreased with the use of cyclers, flexible catheters, and a high volume of dialysate. The recent publication of the International Society of Peritoneal Dialysis guidelines for PD in AKI has tried to address these issues and provide an evidence-based standard by which to initiate therapy. Key Message: In this review, advances in technical aspects and the advantages and limitations of PD were discussed; it clearly showed that PD is a simple, safe, and efficient way to correct metabolic, electrolyte, acid - base, and volume disturbances generated by AKI and it can be used as a renal replacement therapy modality to treat AKI, both in and out of the intensive care unit setting.

Estimating Catabolism: A Possible Tool for Nutritional Monitoring of Patients With Acute Kidney Injury.

Hypercatabolism has been described as the main nutritional change in acute kidney injury. Catabolism may be defined as the excessive release of amino acids from skeletal muscle. Conditions such as fasting, inadequate nutritional support, renal replacement therapy, metabolic acidosis, and secretion of catabolic hormones are the main factors that affect protein catabolism. Given the imprecision of the methods conventionally used to assess and monitor the nutritional status of hospitalized patients, the parameters of protein catabolism, such as nitrogen balance, urea nitrogen appearance, and protein catabolic rate appear to be the main measures in this population. Considering the high prevalence of malnutrition in this population and important limitations in this clinical condition, such as the inflammatory state and altered fluid, catabolism parameters are accurate and reliable methods that could contribute to minimize adverse prognosis in this population.

Long-term outcome of severe acute kidney injury survivors followed by nephrologists in a developing country.

AIM: This study aimed to evaluate the long-term outcome of patients after a severe episode of acute kidney injury (AKI) on survival and progression to chronic kidney disease (CKD) and to identify risk factors associated with these outcomes. METHODS: We performed a prospective study that evaluated the long-term outcome of 509 AKI stage 3 patients who were followed by nephrologists in a Brazilian University Hospital from 2004 to 2013. RESULTS: Age was 60.2 years (47.5-71) and the follow-up time was 25 months (12-44). The late mortality was 38.1% and age (HR 2.89, 95% CI=1.88 to 4.46, P < 0.0001), diabetes (HR 1.46, 95% CI=1 0.02 to 2.16, P < 0.047), liver disease (HR 2.95, 95% CI=1.19 to 7.3, P = 0.02) and creatinine (Cr) at the time of hospital discharge (HR 1.21, 95% CI=1.04 to 1.41, P = 0.01) were associated with poor long-term survival. At the moment of hospital discharge, 52.1% of patients had complete recovery of renal function, 39.7% had partial recovery and 8.3% had not recovered renal function. After 36 months, 43.5% of patients progressed to CKD, and 5.3% needed for chronic dialysis. Factors associated with progression to CKD were age (HR 1.02, 95% CI=1.008 to 1.035, P = 0.009), CKD (HR 1.05 95% CI=1.007 to 1.09, P = 0.04), diabetes (HR 1.12, CI 1.008-1.035, P = 0.009) and number of AKI episodes (HR 1.65, 95% CI=1.19 to 2.2, P = 0.0023). CONCLUSION: This study showed that AKI patients have high mortality after hospital discharge and age, diabetes, liver disease, and Cr value at the time of discharge were factors associated with long-term mortality. The risk factors for this progression to CKD were age, the presence of diabetes and the number of AKI episodes.

Dialysis complications in acute kidney injury patients treated with prolonged intermittent renal replacement therapy sessions lasting 10 versus 6 hours: results of a randomized clinical trial.

Prolonged intermittent renal replacement therapy (PIRRT) has emerged as an alternative to continuous renal replacement therapy in the management of acute kidney injury (AKI) patients. This trial aimed to compare the dialysis complications occurring during different durations of PIRRT sessions in critically ill AKI patients. We included patients older than 18 years with AKI associated with sepsis admitted to the intensive care unit and using noradrenaline doses ranging from 0.3 to 0.7 µg/kg/min. Patients were divided into two groups randomly: in G1, 6-h sessions were performed, and in G2, 10-h sessions were performed. Seventy-five patients were treated with 195 PIRRT sessions for 18 consecutive months. The prevalence of hypotension, filter clotting, hypokalemia, and hypophosphatemia was 82.6, 25.3, 20, and 10.6%, respectively. G1 was composed of 38 patients treated with 100 sessions, whereas G2 consisted of 37 patients treated with 95 sessions. G1 and G2 were similar in male predominance (65.7 vs. 75.6%, P = 0.34), age (63.6 ± 14 vs. 59.9 ± 15.5 years, P = 0.28) and Sequential Organ Failure Assessment score (SOFA; 13.1 ± 2.4 vs. 14.2 ± 3.0, P = 0.2). There was no significant difference between the two groups in hypotension (81.5 vs. 83.7%, P = 0.8), filter clotting (23.6 vs. 27%, P = 0.73), hypokalemia (13.1 vs. 8.1%, P = 0.71), and hypophosphatemia (18.4 vs. 21.6%, P = 0.72). However, the group treated with sessions of 10 h were refractory to clinical measures for hypotension, and dialysis sessions were interrupted more often (9.5 vs. 30.1%, P = 0.03). Metabolic control and fluid balance were similar between G1 and G2 (blood urea nitrogen [BUN]: 81 ± 30 vs. 73 ± 33 mg/dL, P = 1.0; delivered Kt/V: 1.09 ± 0.24 vs. 1.26 ± 0.26, P = 0.09; actual ultrafiltration: 1731 ± 818 vs. 2332 ± 947 mL, P = 0.13) and fluid balance (-731 ± 125 vs. -652 ± 141 mL, respectively) . In conclusion, intradialysis hypotension was common in AKI patients treated with PIRRT. There was no difference in the prevalence of dialysis complications in patients undergoing different durations of PIRRT.

The role of peritoneal dialysis in the treatment of acute kidney injury in neurocritical patients: a retrospective Brazilian study.

BACKGROUND: Acute kidney injury (AKI) occurs frequently in the neurocritical intensive care unit and is associated with greater morbidity and mortality. AKI and its treatment, including acute kidney replacement therapy, can expose patients to a secondary greater brain injury. This study aimed to explore the role of peritoneal dialysis (PD) in neurocritical AKI patients in relation to metabolic and fluid control, complications related to PD and outcome. METHODS: Neurocritical AKI patients were treated by PD (prescribed Kt/V = 0.40/session) using a flexible catheter and a cycler and lactate as a buffer. RESULTS: A total of 58 patients were included. The mean age was 61.8 ± 13.2 years, 65.5% were in the intensive care unit, 68.5% needed intravenous inotropic agents, 72.4% were on mechanical ventilation, APACHE II was 16 ± 6.67 and the main neurological diagnoses were stroke (25.9%) and intracerebral haemorrhage (31%). Ischaemic acute tubular necrosis (iATN) was the most common cause of AKI (51.7%), followed by nephrotoxic ATN AKI (25.8%). The main dialysis indications were uraemia and hypervolemia. Blood urea and creatinine levels stabilised after four sessions at around 48 ± 11 mg/dL and 2.9 ± 0.4 mg/dL, respectively. Negative fluid balance and ultrafiltration increased progressively and stabilised around 2.1 ± 0.4 L /day. Weekly delivered Kt/V was 2.6 ± 0.31. The median number of high-volume PD sessions was 6 (4-10). Peritonitis and mechanical complications were not frequent (8.6% and 10.3%, respectively). Mortality rate was 58.6%. Logistic regression identified as factors associated with death in neurocritical AKI patients: age (odds ratio (OR) = 1.14, 95% confidence interval (CI) = 1.09-2.16, p = 0.001), nephrotoxic AKI (OR = 0.78, 95% CI = 0.69- 0.95, p = 0.03), mechanical ventilation (OR = 1.54, 95% CI = 1.17-2.46, p = 0.01), intracerebral haemorrhage as main neurological diagnoses (OR = 1.15, 95% CI = 1.09-2.11, p = 0.03) and negative fluid balance after two PD sessions (OR = 0.94, 95% CI = 0.74-0.97, p = 0.009). CONCLUSION: Our study suggests that careful prescription may contribute to providing adequate treatment for most neurocritical AKI patients without contraindications for PD use, allowing adequate metabolic and fluid control, with no increase in the number of infectious, mechanical and metabolic complications. Mechanical ventilation, positive fluid balance and intracerebral haemorrhage were factors associated with mortality, while patients with nephrotoxic AKI had lower odds of mortality compared to those with septic and ischaemic AKI. Further studies are needed to investigate better the role of PD in neurocritical patients with AKI.

Comparison between FRAIL Scale and Clinical Frailty Scale in predicting hospitalization in hemodialysis patients.

BACKGROUND: To assess the prevalence of frailty by the Clinical Frailty Scale (CFS) and the 5-item FRAIL scale and their association with hospitalization in hemodialysis (HD) patients. METHODS: This was a prospective observational study. We included patients of both genders ≥ 18 years old in HD treatment for at least 3 months. Demographic, clinical, and routine laboratory data were retrieved from the medical charts. Two different frailty assessment tools were used, the CFS and the FRAIL scale. Participants were followed up for 9 months and hospitalizations for all causes were evaluated. A Venn diagram was constructed to show the overlap of possible frailty and pre-frailty. Cox regression was used to identify the association between frailty and hospitalization. The significance level was 5%. RESULTS: A total of 137 subjects were included in the analysis. The median age was 61 (52-67) years and 60% were male. The hospitalization rate and mortality in 9 months were 22.6% and 7.29%, respectively. Regarding frailty, the overall prevalence was 13.8% assessed by CFS and 36.5% according to the FRAIL scale. In the Cox regression, frailty by FRAIL scale was associated with a 2.8-fold increase in the risk of hospitalization (OR = 2.880; 95% CI = 1.361-6.096; p = 0.006), but frailty assessed by the CFS was not associated with the need for hospitalization. CONCLUSION: In HD patients, the FRAIL scale proved to be an easy-to-apply tool, identifying a high prevalence of frailty and being a predictor of hospital admission.

Advances in peritoneal dialysis in acute kidney injury.

Peritoneal dialysis (PD) is a simple, safe, cheap, and efficient renal replacement therapy method. It can correct metabolic disorders and fluid overload in acute kidney injury (AKI) patients both in and out of the intensive care unit. Use of PD in AKI is enhanced by placement of a Tenckhoff catheter, which can be safely accomplished at the bedside. Some PD modalities, such as high-volume PD and continuous-flow PD, can provide dialysis doses and efficiency comparable to extracorporeal blood purification methods. PD is particularly suitable for neonates, children, and patients with refractory heart failure or who are otherwise hemodynamically unstable. PD should be considered in situations where systemic anticoagulation and/or vascular access are problematic. PD is limited by a lower efficiency that may produce inadequate renal replacement in larger and/or severely hypercatabolic patients. Fluid removal can be unpredictable, there is a risk of infection, and possible issues with mechanical ventilation. In this article, we discuss the use of PD in AKI, with emphasis on recent advances.

Can delivery dialysis dose affect survival of acute kidney injury patients?

UNLABELLED: Intensity of dialysis dose in acute kidney injury (AKI) might benefit critically ill patients. The aim of this study was to evaluate the effect of intermittent hemodialysis (IHD) dose on mortality in patients with AKI. METHODS: Prospective observational study was performed on AKI patients treated with IHD. The delivered dialysis dose per session was calculated based on single-pool Kt/V urea. Patients were allocated in two groups according to the weekly delivered median Kt/V: higher intensity dialysis dose (HID: Kt/V higher than median) and lower intensity dialysis dose (LID: Kt/V lower than median). Thereafter, AKI patients were divided according to the presence or absence of sepsis and urine output. Clinical and lab characteristics and survival of AKI patients were compared. RESULTS: A total of 121 AKI patients were evaluated. Forty-two patients did not present with sepsis and 45 did not present with oliguria. Mortality rate after 30 days was lower in the HID group without sepsis (14.3% × 47.6%; p = 0.045) and without oliguria (31.8% × 69.5%; p = 0.025). Survival curves also showed that the HID group had higher survival rate when compared with the LID group in non-septic and non-oliguric patients (p = 0.007 and p = 0.003, respectively). CONCLUSION: Higher dialysis doses can be associated with better survival of less seriously ill AKI patients.

The Serum Concentration of Vancomycin as a Diagnostic Predictor of Nephrotoxic Acute Kidney Injury in Critically Ill Patients.

The impact of serum concentrations of vancomycin is a controversial topic. RESULTS: 182 critically ill patients were evaluated using vancomycin and 63 patients were included in the study. AKI occurred in 44.4% of patients on the sixth day of vancomycin use. Vancomycin higher than 17.53 mg/L between the second and the fourth days of use was a predictor of AKI, preceding AKI diagnosis for at least two days, with an area under the curve of 0.806 (IC 95% 0.624-0.987, p = 0.011). Altogether, 46.03% of patients died, and in the Cox analysis, the associated factors were age, estimated GFR, CPR, and vancomycin between the second and the fourth days. DISCUSSION: The current 2020 guidelines recommend using Bayesian-derived AUC monitoring rather than trough concentrations. However, due to the higher number of laboratory analyses and the need for an application to calculate the AUC, many centers still use therapeutic trough levels between 15 and 20 mg/L. CONCLUSION: The results of this study suggest that a narrower range of serum concentration of vancomycin was a predictor of AKI in critically ill septic patients, preceding the diagnosis of AKI by at least 48 h, and it can be a useful monitoring tool when AUC cannot be used.

Acute Kidney Injury in Elderly Patients With Coronavirus Infectious Disease: A Study of Incidence, Risk Factors, and Prognosis in Brazil.

Introduction: Elderly patients with COVID-19 are at a higher risk of severity and death as not only several comorbidities but also aging itself has been considered a relevant risk factor. Acute kidney injury (AKI), one of the worst complications of SARS-CoV-2 infection, is associated with worse outcomes. Studies on AKI with COVID-19 in Latin-American patients of older age remain scarce. Objectives: To determine AKI incidence and the risk factors associated with its development, as well as to compare outcome of elderly patients with or without AKI associated with SARS-CoV-2 infection. Methods: This retrospective cohort study evaluated patients with SARS-CoV2 infection admitted to a Public Tertiary Referral Hospital from 03/01/2020 to 12/31/2020, from admission to resolution (hospital discharge or death). Demographic, clinical, and laboratory data were collected from patients during hospitalization. Daily kidney function assessment was performed by measuring serum creatinine and urine output. AKI was diagnosed according to KDIGO 2012 criteria. Results: Of the 347 patients with COVID-19 admitted to our hospital during the study period, 52.16% were elderly, with a median age of 72 years (65- 80 years). In this age group, most patients were males (56.91%), hypertensive (73.48%), and required ICU care (55.25%). AKI overall incidence in the elderly was 56.9%, with higher frequency in ICU patients (p < 0.001). There was a predominance of KDIGO 3 (50.48%), and acute kidney replacement therapy (AKRT) was required by 47.57% of the patients. The risk factors associated with AKI development were higher baseline creatinine level (OR 10.54, CI 1.22 -90.61, p = 0.032) and need for mechanical ventilation (OR 9.26, CI 1.08-79.26, p = 0.042). Mortality was also more frequent among patients with AKI (46.41%vs24.7%, p < 0.0001), with death being associated with CPK level (OR 1.009, CI 1.001-1.017, p = 0.042), need for mechanical ventilation (OR 17.71, CI 1.13-277.62, p = 0.002) and KDIGO 3 (OR 2.017 CI 1.039 -3.917, p = 0.038). Conclusion: AKI was frequent among the elderly hospitalized with COVID-19 and its risk factors were higher baseline creatinine and need for mechanical ventilation. AKI was independently associated with a higher risk of death.

Early nephrology consultation can have an impact on outcome of acute kidney injury patients.

BACKGROUND: Patients who develop acute kidney injury (AKI) in the intensive care unit (ICU) have extremely high rates of mortality and morbidity. The objectives of this study were to compare clinical and laboratory characteristics of AKI patients evaluated and not evaluated by nephrologists in ICU and generate the hypothesis of the relationship between timing of nephrology consultation and outcome. METHODS: We explored associations among presence and timing of nephrology consultation with ICU stay and in-ICU mortality in 148 ICU patients with AKI at a Brazilian teaching hospital from July 2008 to May 2010. Multivariable logistic regression was used to adjust confounding and selection bias. RESULTS: AKI incidence was 30% and 52% of these AKI patients were evaluated by nephrologists. At multivariable analysis, AKI patients evaluated by nephrologists showed higher Acute Tubular Necrosis-Index Specific Score and creatinine level, more dialysis indications, lower urine output and longer ICU stay. The mortality rate was similar to AKI patients who were not evaluated. Nephrology consultation was delayed (≥ 48 h) in 62.3% (median time to consultation, 4.7 days). Lower serum creatinine levels (P = 0.009) and higher urine output (P = 0.002) were associated with delayed consultation. Delayed consultation was associated with increased ICU mortality (65.4 versus 88.2%, P < 0.001). CONCLUSIONS: In AKI, patients evaluated by nephrologists seem to be more seriously ill than those not evaluated and present similar mortality rate. The delayed nephrology consultation can be associated with increased ICU mortality.

Pharmacokinetics of Intraperitoneal Vancomycin and Amikacin in Automated Peritoneal Dialysis Patients With Peritonitis.

Objective: The study aimed to evaluate the vancomycin and amikacin concentrations in serum and dialysate for automatic peritoneal dialysis (APD) patients. Methods: A total of 558 serum and dialysate samples of 12 episodes of gram-positive and 18 episodes of gram-negative peritonitis were included to investigate the relationship between vancomycin and amikacin concentrations in serum and dialysate on the first and third days of treatment. Samples were analysed 30, 120 min, and 48 h after intraperitoneal administration of vancomycin in peritonitis caused by gram-positive agents and 30, 120 min, and 24 h after intraperitoneal administration of amikacin in peritonitis caused by gram-negative agents. Vancomycin was administered every 72 h and amikacin once a day. The target therapeutic concentration of amikacin was 25-35 mg/l at the peak moment and 4-8 mg/l at the trough moment; and after 48 h for vancomycin, 15-20 mg/l at the trough moment. Results: For peritonitis caused by gram-negative agents, at the peak moment, therapeutic levels of amikacin were reached in dialysate in 80.7% of patients with evolution to cure and in 50% of patients evaluated as non-cure (p = 0.05). At the trough moment, only 38% were in therapeutic concentrations in the dialysate in the cure group and 42.8% in the non-cure group (p = 1). Peak plasma concentrations were subtherapeutic in 98.4% of the samples in the cure group and in 100% of the non-cure group. At the trough moment, therapeutic concentrations were present in 74.4% of the cure group and 71.4% of the non-cure group (p = 1). Regarding vancomycin and among gram-positive agents, therapeutic levels were reached at the peak moment in 94% of the cure group and 6% of the non-cure group (p = 0.007). After 48 h, 56.8% of the cure group had a therapeutic serum concentration whereas for the non-cure group it was only 33.3% (p = 0.39). Conclusion: Despite a small sample size, we demonstrated peak dialysate amikacin level and peak serum vancomycin level correlates well with Gram-negative and Gram positve peritonitis cure, respectively. It is suggested to study the antibiotics pharmacodynamics for a better understanding of therapeutic success in a larger sample.

The Role of Peritoneal Dialysis in the Treatment of Acute Kidney Injury in Patients With Acute-on-Chronic Liver Failure: A Prospective Brazilian Study.

This study aimed to explore the role of peritoneal dialysis (PD) in acute-on-chronic liver disease (ACLD) in relation to metabolic and fluid control and outcome. Fifty-three patients were treated by PD (prescribed Kt/V = 0.40/session), with a flexible catheter, tidal modality, using a cycler and lactate as a buffer. The mean age was 64.8 ± 13.4 years, model of end stage liver disease (MELD) was 31 ± 6, 58.5% were in the intensive care unit, 58.5% needed intravenous inotropic agents including terlipressin, 69.5% were on mechanical ventilation, alcoholic liver disease was the main cause of cirrhosis and the main dialysis indications were uremia and hypervolemia. Blood urea and creatinine levels stabilized after four sessions at around 50 and 2.5 mg/dL, respectively. Negative fluid balance (FB) and ultrafiltration (UF) increased progressively and stabilized around 3.0 L and -2.7 L/day, respectively. Weekly-delivered Kt/V was 2.7 ± 0.37, and 71.7% of patients died. Five factors met the criteria for inclusion in the multivariable analysis. Logistic regression identified as risk factors associated with Acute Kidney Injury (AKI) in ACLD patients: MELD (OR = 1.14, CI 95% = 1.09-2.16, p = 0.001), nephrotoxic AKI (OR = 0.79, CI 95% = 0.61-0.93, p = 0.02), mechanical ventilation (OR = 1.49, CI 95% = 1.14-2.97, p < 0.001), and positive fluid balance (FB) after two PD sessions (OR = 1.08, CI 95% = 1.03-1.91, p = 0.007). These factors were significantly associated with death. In conclusion, our study suggests that careful prescription may contribute to providing adequate treatment for most Acute-on-Chronic Liver Failure (ACLF) patients without contraindications for PD use, allowing adequate metabolic and fluid control, with no increase in the number of infectious or mechanical complications. MELD, mechanical complications and FB were factors associated with mortality, while nephrotoxic AKI was a protective factor. Further studies are needed to better investigate the role of PD in ACLF patients with AKI.

Acute Kidney Injury in COVID-19: 90 Days of the Pandemic in a Brazilian Public Hospital.

Renal involvement is frequent in COVID-19 (4-37%). This study evaluated the incidence and risk factors of acute kidney injury (AKI) in hospitalized patients with COVID-19. Methodology: This study represents a prospective cohort in a public and tertiary university hospital in São Paulo, Brazil, during the first 90 days of the COVID-19 pandemic, with patients followed up until the clinical outcome (discharge or death). Results: There were 101 patients hospitalized with COVID-19, of which 51.9% were admitted to the intensive care unit (ICU). The overall AKI incidence was 50%; 36.8% had hematuria or proteinuria (66.6% of those with AKI), 10.2% had rhabdomyolysis, and mortality was 36.6%. Of the ICU patients, AKI occurred in 77.3% and the mortality was 65.4%. The mean time for the AKI diagnosis was 6 ± 2 days, and Kidney Disease Improving Global Outcomes (KDIGO) stage 3 AKI was the most frequent (58.9%). Acute renal replacement therapy was indicated in 61.5% of patients. The factors associated with AKI were obesity [odds ratio (OR) 1.98, 95% confidence interval (CI) 1.04-2.76, p < 0.05] and the APACHE II score (OR 1.97, 95% CI 1.08-2.64, p < 0.05). Mortality was higher in the elderly (OR 1.03, 95% CI 1.01-1.66, p < 0.05), in those with the highest APACHE II score (OR 1.08, 95% CI 1.02-1.98, p < 0.05), and in the presence of KDIGO stage 3 AKI (OR 1.11, 95% CI 1.05-2.57, p < 0.05). Conclusion: AKI associated with severe COVID-19 in this Brazilian cohort was more frequent than Chinese, European, and North American data, and the risk factors associated with its development were obesity and higher APACHE II scores. Mortality was high, mainly in elderly patients, in those with a more severe disease manifestation, and in those who developed KDIGO stage 3 AKI.