Temporal trends of dialysis requiring acute kidney injury after orthotopic cardiac and liver transplant hospitalizations.

BACKGROUND: The epidemiology and outcomes of acute kidney injury (AKI) in prevalent non-renal solid organ transplant recipients is unknown. METHODS: We assessed the epidemiology of trends in acute kidney injury (AKI) in orthotopic cardiac and liver transplant recipients in the United States. We used the Nationwide Inpatient Sample to evaluate the yearly incidence trends (2002 to 2013) of the primary outcome, defined as AKI requiring dialysis (AKI-D) in hospitalizations after cardiac and liver transplantation. We also evaluated the trend and impact of AKI-D on hospital mortality and adverse discharge using adjusted odds ratios (aOR). RESULTS: The proportion of hospitalizations with AKI (9.7 to 32.7% in cardiac and 8.5 to 28.1% in liver transplant hospitalizations; ptrend<0.01) and AKI-D (1.63 to 2.33% in cardiac and 1.32 to 2.65% in liver transplant hospitalizations; ptrend<0.01) increased from 2002-2013. This increase in AKI-D was explained by changes in race and increase in age and comorbidity burden of transplant hospitalizations. AKI-D was associated with increased odds of in hospital mortality (aOR 2.85; 95% CI 2.11-3.80 in cardiac and aOR 2.00; 95% CI 1.55-2.59 in liver transplant hospitalizations) and adverse discharge [discharge other than home] (aOR 1.97; 95% CI 1.53-2.55 in cardiac and 1.91; 95% CI 1.57-2.30 in liver transplant hospitalizations). CONCLUSIONS: This study highlights the growing burden of AKI-D in non-renal solid organ transplant recipients and its devastating impact, and emphasizes the need to develop strategies to reduce the risk of AKI to improve health outcomes.

Dialysis Requiring Acute Kidney Injury in Acute Cerebrovascular Accident Hospitalizations.

BACKGROUND AND PURPOSE: The epidemiology of dialysis requiring acute kidney injury (AKI-D) in acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) admissions is poorly understood with previous studies being from a single center or year. METHODS: We used the Nationwide Inpatient Sample to evaluate the yearly incidence trends of AKI-D in hospitalizations with AIS and ICH from 2002 to 2011. We also evaluated the trend of impact of AKI-D on in-hospital mortality and adverse discharge using adjusted odds ratios (aOR) after adjusting for demographics and comorbidity indices. RESULTS: We extracted a total of 3,937,928 and 696,754 hospitalizations with AIS and ICH, respectively. AKI-D occurred in 1.5 and 3.5 per 1000 in AIS and ICH admissions, respectively. Incidence of admissions complicated by AKI-D doubled from 0.9/1000 to 1.7/1000 in AIS and from 2.1/1000 to 4.3/1000 in ICH admissions. In AIS admissions, AKI-D was associated with 30% higher odds of mortality (aOR, 1.30; 95% confidence interval, 1.12-1.48; P<0.001) and 18% higher odds of adverse discharge (aOR, 1.18; 95% confidence interval, 1.02-1.37; P<0.001). Similarly, in ICH admissions, AKI-D was associated with twice the odds of mortality (aOR, 1.95; 95% confidence interval, 1.61-2.36; P<0.01) and 74% higher odds of adverse discharge (aOR, 1.74; 95% confidence interval, 1.34-2.24; P<0.01). Attributable risk percent of mortality was high with AKI-D (98%-99%) and did not change significantly over the study period. CONCLUSIONS: Incidence of AKI-D complicating hospitalizations with cerebrovascular accident continues to grow and is associated with increased mortality and adverse discharge. This highlights the need for early diagnosis, better risk stratification, and preparedness for need for complex long-term care in this vulnerable population.

Characteristics and Outcomes of Ethics Consultations in an Oncologic Intensive Care Unit.

OBJECTIVE: To evaluate the frequency, characteristics, and outcomes of ethics consultations in critically ill patients with cancer. DESIGN, SETTING, AND METHODS: This is a retrospective analysis of all adult patients with cancer who were admitted to the intensive care unit (ICU) of a comprehensive cancer center and had an ethics consultation between September 2007 and December 2011. Demographic and clinical variables were abstracted along with the details and contexts of the ethics consultations. MAIN RESULTS: Ethics consultations were obtained on 53 patients (representing 1% of all ICU admissions). The majority (90%) of patients had advanced-stage malignancies, had received oncologic therapies within the past 12 months, and required mechanical ventilation and/or vasopressor therapy for respiratory failure and/or severe sepsis. Two-thirds of the patients lacked decision-making capacity and nearly all had surrogates. The most common reasons for ethics consultations were disagreements between the patients/surrogates and the ICU team regarding end-of-life care. After ethics consultations, the surrogates agreed with the recommendations made by the ICU team on the goals of care in 85% of patients. Moreover, ethics consultations facilitated the provision of palliative medicine and chaplaincy services to several patients who did not have these services offered to them prior to the ethics consultations. CONCLUSION: Our study showed that ethics consultations were helpful in resolving seemingly irreconcilable differences between the ICU team and the patients' surrogates in the majority of cases. Additionally, these consultations identified the need for an increased provision of palliative care and chaplaincy visits for patients and their surrogates at the end of life.

National trends of acute kidney injury requiring dialysis in decompensated cirrhosis hospitalizations in the United States.

BACKGROUND AND AIMS: Cirrhosis affects 5.5 million patients with estimated costs of US$4 billion. Previous studies about dialysis requiring acute kidney injury (AKI-D) in decompensated cirrhosis (DC) are from a single center/year. We aimed to describe national trends of incidence and impact of AKI-D in DC hospitalizations. METHODS: We extracted our cohort from the Nationwide Inpatient Sample (NIS) from 2006-2012. We identified hospitalizations with DC and AKI-D by validated ICD9 codes. We analyzed temporal changes in DC hospitalizations complicated by AKI-D and utilized multivariable logistic regression models to estimate AKI-D impact on hospital mortality. RESULTS: We identified a total of 3,655,700 adult DC hospitalizations from 2006 to 2012 of which 78,015 (2.1 %) had AKI-D. The proportion with AKI-D increased from 1.5 % in 2006 to 2.23 % in 2012; it was stable between 2009 and 2012 despite an increase in absolute numbers from 6773 to 13,930. The overall hospital mortality was significantly higher in hospitalizations with AKI-D versus those without (40.87 vs. 6.96 %; p < 0.001). In an adjusted multivariable analysis, adjusted odds ratio for mortality was 2.17 (95 % CI 2.06-2.28; p < 0.01) with AKI-D, which was stable from 2006 to 2012. Changes in demographics and increases in acute/chronic comorbidities and procedures explained temporal changes in AKI-D. CONCLUSIONS: Proportion of DC hospitalizations with AKI-D increased from 2006 to 2009, and although this was stable from 2009 to 2012, there was an increase in absolute cases. These results elucidate the burden of AKI-D on DC hospitalizations and excess associated mortality, as well as highlight the importance of prevention, early diagnosis and testing of novel interventions in this vulnerable population.

Incidence, Risk Factors, and Outcome Trends of Acute Kidney Injury in Elective Total Hip and Knee Arthroplasty.

Over the past decade, there has been a marked increase in the number of primary and revision total hip and knee arthroplasties performed in the United States. Acute kidney injury (AKI) is a common complication of these procedures; however, little is known about its epidemiology in the elective arthroplasty population. We conducted a study to determine the incidence, risk factors, and outcomes of AKI after elective joint arthroplasty. Drawing on the Nationwide Inpatient Sample database, we found that the proportion of hospitalizations complicated by AKI increased rapidly from 0.5% in 2002 to 1.8% to 1.9% in 2012. Multivariate analysis revealed that the key risk factors for AKI were chronic kidney disease and the postoperative events of sepsis, acute myocardial infarction, and blood transfusion. Moreover, codiagnosis with chronic kidney disease increased the risk for AKI associated with all 3 postoperative events. After adjusting for confounders, we found an association between AKI and a significantly increased risk for in-hospital mortality and discharge to long-term facilities. AKI serves as an important quality indicator in elective hip and knee surgeries. With elective arthroplasties expected to rise, carefully planned approach to interdisciplinary perioperative care is essential to reduce both the risk and consequences of AKI.

An analysis of patients transferred to a tertiary oncological intensive care unit for defined procedures.

BACKGROUND: Up to 50 000 intensive care unit interhospital transfers occur annually in the United States. OBJECTIVE: To determine the prevalence, characteristics, and outcomes of cancer patients transferred from an intensive care unit in one hospital to another intensive care unit at an oncological center and to evaluate whether interventions planned before transfer were performed. METHODS: Data on transfers for planned interventions from January 2008 through December 2012 were identified retrospectively. Demographic and clinical variables, receipt of planned interventions, and outcome data were analyzed. RESULTS: Of 4625 admissions to an intensive care unit at the oncological center, 143 (3%) were transfers from intensive care units of other hospitals. Of these, 47 (33%) were transfers for planned interventions. Patients' mean age was 57 years, and 68% were men. At the time of intensive care unit transfer, 20 (43%) were receiving mechanical ventilation. Interventions included management of airway (n = 19) or gastrointestinal (n = 2) obstruction, treatment of tumor bleeding (n = 12), chemotherapy (n = 10), and other (n = 4). A total of 37 patients (79%) received the planned interventions within 48 hours of intensive care unit arrival; 10 (21%) did not because their signs and symptoms abated. Median intensive care unit and hospital lengths of stay at the oncological center were 4 and 13 days, respectively. Intensive care unit and hospital mortality rates were 11% and 19%, respectively. Deaths occurred only in patients who received interventions. CONCLUSIONS: Interhospital transfers of cancer patients to an intensive care unit at an oncological center are infrequent but are most commonly done for direct interventional care. Most patients received planned interventions soon after transfer.

The burden of dialysis-requiring acute kidney injury among hospitalized adults with HIV infection: a nationwide inpatient sample analysis.

OBJECTIVE: The objective of this study was to describe the incidence of acute kidney injury (AKI) requiring renal replacement therapy ('dialysis-requiring AKI') and the impact on in-hospital mortality among hospitalized adults with HIV infection. DESIGN: A longitudinal analysis of a nationally representative administrative database. METHODS: We reviewed the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample Database, a large, nationally representative sample of inpatient hospital admissions, to identify all adult hospitalizations with an associated diagnosis of HIV infection from 2002 to 2010. We analysed temporal trends in the incidence of dialysis-requiring AKI and the associated odds of in-hospital mortality. We also explored potential reasons behind temporal changes. RESULTS: Among 183 0041 hospitalizations with an associated diagnosis of HIV infection, the proportion complicated by dialysis-requiring AKI increased from 0.7% in 2002 to 1.35% in 2010. This temporal rise was completely explained by changes in demographics and an increase in concurrent comorbidities and procedure utilization. The adjusted odds of in-hospital mortality associated with dialysis-requiring AKI also increased over the study period, from 1.45 [95% confidence interval (95% CI) 0.97-2.12] in 2002 to 2.64 (95% CI 2.04-3.42) in 2010. CONCLUSION: These data suggest that the incidence of dialysis-requiring AKI among hospitalized adults with HIV infection continues to increase, and that severe AKI remains a significant predictor of in-hospital mortality in this population. The increased incidence of dialysis-requiring AKI was largely explained by ageing of the HIV population and increasing prevalence of chronic non-AIDS comorbidities, suggesting that these trends will continue.

Systematic oral hydration with water is similar to parenteral hydration for prevention of contrast-induced nephropathy: an updated meta-analysis of randomised clinical data.

BACKGROUND: Contrast-induced nephropathy (CIN) is the third most common cause of hospital-acquired kidney injury and is related to increased long-term morbidity and mortality. Adequate intravenous (IV) hydration has been demonstrated to lessen its occurrence. Oral (PO) hydration with water is inexpensive and readily available but its role for CIN prevention is yet to be determined. METHODS: PubMed, EMBASE and the Cochrane Central register of controlled trials (CENTRAL) databases were searched until April 2015 and studies were selected using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. All randomised clinical trials with head-to-head comparison between PO and IV hydration were included. RESULTS: A total of 5 studies with 477 patients were included in the analysis, 255 of those receiving PO water. The incidence of CIN was statistically similar in the IV and PO arms (7.7% and 8.2%, respectively; relative risk 0.97; 95% CI 0.36 to 2.94; p=0.95). The incidence of CIN was statistically similar in the IV and PO arms in patients with chronic kidney disease and with normal renal function. Rise in creatinine at 48-72 h was lower in the PO hydration group compared with IV hydration (pooled standard mean difference 0.04; 95% CI 0.03 to 0.06; p<0.001; I(2)=62%). CONCLUSIONS: Our meta-analysis shows that systematic PO hydration with water is at least as effective as IV hydration with saline to prevent CIN. PO hydration is cheaper and more easily administered than IV hydration, thus making it more attractive and just as effective.