Long-term kidney follow-up after pediatric acute kidney support therapy for children less than 15 kg.

BACKGROUND: In small children, acute dialysis (pediatric acute kidney support therapy (paKST)) is increasingly used; however, it is challenging for many reasons. We compared clinical characteristics and predictors of long-term outcomes of patients < 15 kg on peritoneal dialysis (PD), hemodialysis (HD), and continuous kidney replacement therapy (CKRT). METHODS: Patients with history of paKST (CKRT, HD, PD) weighing < 15 kg and ≥ 6 months of follow-up at Hacettepe University were included. Surviving patients were evaluated at last visit. RESULTS: 109 patients (57 females) were included. Median age at paKST was 10.1 months (IQR: 2-27 months). In total, 43 (39.4%) patients received HD, 37 (34%) PD, and 29 (26.6%) CKRT. 64 (58.7%) patients died a median 3 days (IQR: 2-9.5 days) after paKST. Percentages of patients using vasopressor agents, with sepsis, and undergoing mechanical ventilation were lower in those who survived. After mean follow-up of 2.9 ± 2.1 years, 34 patients were evaluated at mean age 4.7 ± 2.4 years. Median spot urine protein/creatinine was 0.19 (IQR: 0.13-0.37) and 12 patients (35.3%) had non-nephrotic proteinuria. Three patients had estimated glomerular filtration rate (eGFR) < 90 mL/min/1.73m2 and 2 (6%) had hyperfiltration. In total 22 patients (64.7%) had ≥ 1 kidney risk factor (elevated blood pressure/hypertension, hyperfiltration, eGFR < 90 ml/min/1.73m2, and/or proteinuria) at last visit. Among 28 patients on paKST < 32 months, 21 had ≥ 1 risk factor (75%), whereas among 6 patients who had paKST ≥ 32 months, one patient had ≥ 1 risk factor (16.7%), (p = 0.014). CONCLUSIONS: Patients on paKST who undergo mechanical ventilation and vasopressor treatment should be followed-up more closely. After surviving the acute period, patients on paKST need to be followed-up closely during the chronic stage. A higher resolution version of the Graphical abstract is available as Supplementary information.

Promoting Patient and Nurse Safety in Acute Dialysis Units Through Advocacy and Collaboration.

Hospitals face the increasing challenge of balancing the need to provide quality care with that of being cost-effective. While guidelines and benchmarks for quality care exist in many areas within the hospital, those guidelines can be lacking for the acute (inpatient) dialysis setting. Nephrology nurses working in this setting may provide hemodialysis, peritoneal dialysis, continuous kidney replacement therapy, and apheresis treatments at the patient's bedside and in an acute dialysis unit. This article discusses the need to promote patient and nurse safety in acute dialysis settings through advocacy and collaboration.

Offering Patients Therapy Options in Unplanned Start (OPTiONS): Implementation of an educational program is feasible and effective.

BACKGROUND: Patients with unplanned dialysis start (UPS) have worse clinical outcomes than non-UPS patients, and receive peritoneal dialysis (PD) less frequently. In the OPTiONS study of UPS patients, an educational programme (UPS-EP) aiming at improving care of UPS patients by facilitating care pathways and enabling informed choice of dialysis modality was implemented. We here report on impact of UPS-EP on modality choice and clinical outcomes in UPS patients. METHODS: This non-interventional, prospective, multi-center, observational study included 270 UPS patients from 26 centers in 6 European countries (Austria, Germany, Denmark, France, United Kingdom and Sweden) who prior to inclusion presented acutely, or were being followed by nephrologists but required urgent dialysis commencement by an acutely placed CVC or PD catheter. Effects of UPS-EP on choice and final decision of dialysis therapy and outcomes within 12 months of follow up were analysed. RESULTS: Among 270 UPS patients who had an unplanned start to dialysis, 214 were able to receive and 203 complete UPS-EP while 56 patients - who were older (p = 0.01) and had higher Charlson comorbidity index (CCI; p < 0.01) - did not receive UPS-EP. Among 177 patients who chose dialysis modality after UPS-EP, 103 (58%) chose PD (but only 86% of them received PD) and 74 (42%) chose HD (95% received HD). Logistic regression analysis showed that diabetes 1.88 (1.05 - 3.37) and receiving UPS-EP, OR = 4.74 (CI, 2.05 - 10.98) predicted receipt of PD. Patients choosing PD had higher CCI (p = 0.01), higher prevalence of congestive heart failure (p < 0.01) and myocardial infarction (p = 0.02), and were more likely in-patients (p = 0.02) or referred from primary care (p = 0.02). One year survival did not differ significantly between PD and HD patients. Peritonitis and bacteraemia rates were better than international guideline standards. CONCLUSIONS: UPS-EP predicted patient use of PD but 14% of those choosing PD after UPS-EP still did not receive the modality they preferred. Patient survival in patients choosing and/or receiving PD was similar to HD despite age and comorbidity disadvantages of the PD groups.

Laparoscopic versus open peritoneal dialysis catheter insertion for the management of pediatric acute kidney injury.

BACKGROUND: Acute pediatric dialysis is provided by a single center in New Zealand. Most acute dialysis in our center is performed in the under 5 age group. The advantage of using peritoneal dialysis (PD) in these children is the ability to perform continuous renal replacement therapy without always requiring an ICU setting, avoiding central venous access and promoting greater cardiovascular stability. The disadvantage of PD in the acute setting includes the requirement for immediate use and the potential for early leaks due to peritoneal disruption with resulting delayed use and restricted volumes. There is a growing trend toward minimally invasive surgery and the laparoscopic method allows this. Surgeons at this center have been using a laparoscopic technique since 2005. METHODS: We performed a 10-year review of acute PD at the Starship Hospital from 2003 to 2013. Data on 102 children who met the criteria were collected. RESULTS: These 102 children had 113 acute PD catheters. The two groups were comparable in terms of age and reason for presentation. The median age of the laparoscopic group was 2 years (interquartile range [IQR] 6) and the open group was 3 years (IQR 3.2). The predominant diagnosis for both groups was hemolytic uremic syndrome (HUS) accounting for 71% of laparoscopic cases, and 72% of open cases. The incidence of infection was 0% versus 7% in the laparoscopic versus open approach. Ten percent of patients required further manipulation of the catheter after initial insertion in the laparoscopic group, compared with 11% in the open approach. Conversion to hemodialysis (HD) due to catheter-related complications was seen in 10% of laparoscopic cases and 9% of the open cases. Dialysate fluid leak was noted in 26% in the laparoscopic group compared with 11% in the open group (p = 0.08). Anesthesia time is longer in the laparoscopic group (p = 0.008). CONCLUSION: We found no significant differences in complication rates between laparoscopic and open surgical approaches regarding acute PD catheter insertion. We saw a trend in increased leakage with laparoscopic procedures and a significantly longer operative time. We concluded that the laparoscopic approach in the acute situation for emergency dialysis is safe and effective.

New consensus definition of acute kidney injury accurately predicts 30-day mortality in patients with cirrhosis and infection.

BACKGROUND & AIMS: Participants at a consensus conference proposed defining cirrhosis-associated acute kidney injury (AKI) based on a >50% increase in serum creatinine level from the stable baseline value in <6 months or an increase of ≥ 0.3 mg/dL in <48 hours. We performed a prospective study to evaluate the ability of these criteria to predict mortality within 30 days of hospitalization among patients with cirrhosis and infection. METHODS: We followed up 337 patients with cirrhosis who were admitted to the hospital with an infection or developed an infection during hospitalization (56% men; 56 ± 10 years of age; Model for End-Stage Liver Disease [MELD] score, 20 ± 8) at 12 centers in North America. We compared data on 30-day mortality, length of stay in the hospital, and organ failure between patients with and without AKI. RESULTS: In total, based on the consensus criteria, 166 patients (49%) developed AKI during hospitalization. Patients who developed AKI were admitted with higher Child-Pugh scores than those who did not develop AKI (11.0 ± 2.1 vs 9.6 ± 2.1; P < .0001) as well as higher MELD scores (23 ± 8 vs 17 ± 7; P < .0001) and lower mean arterial pressure (81 ± 16 vs 85 ± 15 mm Hg; P < .01). Higher percentages of patients with AKI died within 30 days of hospitalization (34% vs 7%), were transferred to the intensive care unit (46% vs 20%), required ventilation (27% vs 6%), or went into shock (31% vs 8%); patients with AKI also had longer stays in the hospital (17.8 ± 19.8 vs 13.3 ± 31.8 days) (all P < .001). Of the AKI episodes, 56% were transient, 28% were persistent, and 16% resulted in dialysis. Mortality was higher among those without renal recovery (80%) compared with partial (40%) or complete recovery (15%) or those who did not develop AKI (7%; P < .0001). CONCLUSIONS: Among patients with cirrhosis, 30-day mortality is 10-fold higher among those with irreversible AKI than those without AKI. The consensus definition of AKI accurately predicts 30-day mortality, length of hospital stay, and organ failure.

Laboratory predictors of acute dialysis in hemolytic uremic syndrome.

BACKGROUND: Strict guidelines on use of dialysis in children with post-diarrheal hemolytic uremic syndrome (D + HUS) are lacking. This study investigated laboratory predictors of acute dialysis because they are more objective than clinical features. Added to this, given that urine output is also an objective parameter, its ability to predict dialysis requirements was also investigated. METHODS: Out of 153 D + HUS children reviewed, 88 received dialysis and 65 did not. Initial laboratory parameters and diuresis between both groups were analyzed. RESULTS: Dialyzed patients had higher creatinine, urea, alanine aminotransferase, hematocrit and leukocyte count; and lower sodium, bicarbonate, and pH compared to non-dialyzed ones. Serum creatinine was the only independent predictor (P = 0.003) of dialysis; therefore, its ability to predict dialysis was estimated on receiver operating characteristic (ROC) curve analysis and using the Acute Kidney Injury Network (AKIN) staging system. Area under the ROC curve was 0.92 (95% confidence interval [95%CI]: 0.83-1) with a creatinine cut-off of 1.25 mg/dL (sensitivity, 100%; specificity, 76.5%) for children <1 year, and 0.93 (95%CI: 0.88-0.98) with a threshold of 2 mg/dL (sensitivity, 91%; specificity, 87.5%) for older children. AKIN stage 3 at admission predicted dialysis with a sensitivity of 92% and specificity of 84.2%. Urine output had the highest accuracy for dialysis prediction (sensitivity, 100%; specificity, 95.3%). CONCLUSIONS: Initial serum creatinine concentration was the best laboratory predictor of dialysis, but the first 24 h diuresis was even better for this purpose. But, given that serum creatinine is an immediate available parameter, the cut-offs identified may label D + HUS children who will probably need dialysis, prompting early referral to centers able to provide dialysis.

Temporal Trends in the Initiation of Dialysis Among Patients With Heart Failure With or Without Diabetes: A Nationwide Study From 2002 to 2016.

BACKGROUND: The incidence and distribution of acute and chronic dialysis among patients with heart failure (HF), stratified by diabetes, remain uncertain. We hypothesized that with improved survival and rising comorbidities, the demand for dialysis would increase over time. METHODS AND RESULTS: Patients with incident HF, aged 18 to 100 years, between 2002 and 2016, were identified using Danish nationwide registers. Primary outcomes included acute and chronic dialysis initiation, HF-related hospitalization, and all-cause mortality. These outcomes were assessed in 2002 to 2006, 2007 to 2011, and 2012 to 2016, stratified by diabetes. We calculated incidence rates (IRs) per 1000 person-years and hazard ratios (HR) using multivariable Cox regression. Of 115 533 patients with HF, 2734 patients received acute dialysis and 1193 patients received chronic dialysis. The IR was 8.0 per 1000 and 3.5 per 1000 person-years for acute and chronic dialysis, respectively. Acute dialysis rates increased significantly among patients with diabetes over time, while no significant changes occurred in those without diabetes, chronic dialysis, HF-related hospitalization, or overall mortality. Diabetes was associated with significantly higher HRs of acute and chronic dialysis, respectively, compared with patients without diabetes (HR, 2.07 [95% CI, 1.80-2.39] and 2.93 [95% CI, 2.40-3.58] in 2002 to 2006; HR, 2.45 [95% CI, 2.14-2.80] and 2.86 [95% CI, 2.32-3.52] in 2007 to 2011; and 2.69 [95% CI, 2.33-3.10] and 3.30 [95% CI, 2.69-4.06] in 2012 to 2016). CONCLUSIONS: The IR of acute and chronic dialysis remained low compared with HF-related hospitalizations and mortality. Acute dialysis rates increased significantly over time, contrasting no significant trends in other outcomes. Diabetes exhibited over 2-fold increased rates of the outcomes. These findings emphasize the importance of continued monitoring and renal care in patients with HF, especially with diabetes, to optimize outcomes and prevent adverse events.

Evaluation of the Acute Kidney Injury Network criteria in hospitalized patients with cirrhosis and ascites.

BACKGROUND & AIMS: For several years hepatologists have defined acute renal failure in patients with cirrhosis as an increase in serum creatinine (sCr) ≥ 50% to a final value of sCr>1.5mg/dl (conventional criterion). Recently, the Acute Kidney Injury Network (AKIN) defined acute renal failure as acute kidney injury (AKI) on the basis of an absolute increase in sCr of 0.3mg/dl or a percentage increase in sCr ≥ 50% providing also a staging from 1 to 3. AKIN stage 1 was defined as an increase in sCr ≥ 0.3mg/dl or increase in sCr ≥ 1.5-fold to 2-fold from baseline. AKI diagnosed with the two different criteria was evaluated for the prediction of in-hospital mortality. METHODS: Consecutive hospitalized patients with cirrhosis and ascites were included in the study and evaluated for the development of AKI. RESULTS: Conventional criterion was found to be more accurate than AKIN criteria in improving the prediction of in-hospital mortality in a model including age and Child-Turcotte-Pugh score. The addition of either progression of AKIN stage or a threshold value for sCr of 1.5mg/dl further improves the value of AKIN criteria in this model. More in detail, patients with AKIN stage 1 and sCr<1.5mg/dl had a lower mortality rate (p=0.03), a lower progression rate (p=0.01), and a higher improvement rate (p=0.025) than patients with AKIN stage 1 and sCr ≥ 1.5mg/dl. CONCLUSIONS: Conventional criterion is more accurate than AKIN criteria in the prediction of in-hospital mortality in patients with cirrhosis and ascites. The addition of either the progression of AKIN stage or the cut-off of sCr ≥ 1.5mg/dl to the AKIN criteria improves their prognostic accuracy.

Acute Kidney Injury and Renal Replacement Therapy: A Review and Update for the Perioperative Physician.

Post-operative acute kidney injury is a devastating complication with significant morbidity and mortality associated with it. The perioperative anesthesiologist is in a unique position to potentially mitigate the risk of postoperative AKI, however, understanding the pathophysiology, risk factors and preventative strategies is paramount. There are also certain clinical scenarios, where renal replacement therapy may be indicated intraoperatively including severe electrolyte abnormalities, metabolic acidosis and massive volume overload. A multidisciplinary approach including the nephrologist, critical care physician, surgeon and anesthesiologist is necessary to determine the optimal management of these critically ill patients.

Specificity of severe AKI aetiology and care in the elderly. The IRACIBLE prospective cohort study.

INTRODUCTION: Acute Kidney Injury (AKI) is increasingly common in people over 65 years of age, but its causes and management are poorly described. The purpose of this study was to describe the causes, management and prognosis of patients over 65 hospitalised for severe acute kidney injury (AKI) in all departments of a tertiary centre. METHOD: The prospective IRACIBLE (IRA: AKI in French; CIBLE: target in French) cohort included 480 patients hospitalised at a university hospital over 18 months for severe AKI or subgroup of AKIN3 (Acute Kidney Injury Network classification) defined by an acute creatinine increase > 354 µmol/L or managed with acute renal replacement therapy (RRT). The history, aetiology of AKI, management, and prognosis were compared in three age groups: < 65, 65-75, and > 75 years. RESULTS: The study population included 480 subjects (73% men) with a median body mass index (BMI) of 26.6 kg/m2 [23.3, 30.9], 176 (37%) diabetic patients, 124 (26%) patients < 65 years, 150 (31%) 65-75 years and 206 (43%) > 75 years. Increasing age class was associated with more comorbidities, a significantly lower median estimated glomerular filtration rate (eGFR) 6 months before inclusion (82; 62; 46 ml/min/1.73 m2, p < 0.05) and aetiology of AKI, which was more often obstructive (12%; 15%; 23%, p = 0.03) or part of a cardio-renal syndrome (6%; 9%; /15%, p = 0.04). Older patients were less often managed in the intensive care unit  (54%; 47%; 24%, p < 0.0001), were less frequently treated by RRT (52%; 43%; 31%, p < 0.001) and received fewer invasive treatments  (6%; 9%; 22%, p < 0.0001). Older survivors returned home less often (80%; 73%; 62%, p = 0.05) in favour of transfers to rehabilitation services (10%; 13%; 22%) with higher mortality at 3 months (35%; 32%; 50%, p < 0.0001). CONCLUSION: Older patients hospitalised for severe AKI have a specific profile with more comorbidities, lower baseline renal function, an aetiology of AKI of mainly extra-parenchymal causes and a complex pathway of care with an overall poor prognosis.

Acute intermittent renal replacement therapy in a rural Scottish intensive care unit - a review of patient and renal outcomes.

In this study we report 5-year outcomes for patients who received intermittent haemodiafiltration for Acute Kidney Injury (AKI) between 2010 and 2014 in a small Scottish Intensive Care Unit (ICU). Dialysis independence and mortality at ICU discharge, 30 and 90 days, one and five years were determined. There were 1496 admissions to ICU during the study period. 12% of patient admissions required Renal Replacement Therapy (RRT). 56.3% of patients survived to ICU discharge and all were RRT independent at ICU discharge. 30 day, 90 day, 1 year and 5 year survival was 52.3%, 50.6%, 46.6% and 30.7% respectively. By 5 years, 2 patients had developed end stage kidney disease.

Acute kidney injury requiring renal replacement therapy in people with COVID-19 disease in Ontario, Canada: a prospective analysis of risk factors and outcomes.

BACKGROUND: Severely ill people with coronavirus disease 2019 (COVID-19) are at risk of acute kidney injury treated with renal replacement therapy (AKI-RRT). The understanding of the risk factors and outcomes for AKI-RRT is incomplete. METHODS: We prospectively collected data on the incidence, demographics, area of residence, time course, outcomes and associated risk factors for all COVID-19 AKI-RRT cases during the first two waves of the pandemic in Ontario, Canada. RESULTS: There were 271 people with AKI-RRT, representing 0.1% of all diagnosed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases. These included 10% of SARS-CoV-2 admissions to intensive care units (ICU). Median age was 65 years, with 11% <50 years, 76% were male, 47% non-White and 48% had diabetes. Overall, 59% resided in the quintile of Ontario neighborhoods with the greatest ethnocultural composition and 51% in the two lowest income quintile neighborhoods. Mortality was 58% at 30 days after RRT initiation, and 64% at 90 days. By 90 days, 20% of survivors remained RRT-dependent and 31% were still hospitalized. On multivariable analysis, people aged >70 years had higher mortality (odds ratio 2.4, 95% confidence interval 1.3, 4.6). Cases from the second versus the first COVID-19 wave were older, had more baseline comorbidity and were more likely to initiate RRT  >2 weeks after SARS-CoV-2 diagnosis (34% versus 14%; P < 0.001). CONCLUSIONS: AKI-RRT is common in COVID-19 ICU admissions. Residency in areas with high ethnocultural composition and lower socioeconomic status are strong risk factors. Late-onset AKI-RRT was more common in the second wave. Mortality is high and 90-day survivors have persisting high morbidity.

Alerting to acute kidney injury - Challenges, benefits, and strategies.

Acute Kidney Injury (AKI) is a complex heterogeneous syndrome that often can go unrecognized and is encountered in multiple clinical settings. One strategy for proactive identification of AKI has been through electronic alerts (e-alerts) to improve clinical outcomes. The two traditional criteria for AKI diagnosis and staging have been urinary output and serum creatinine. The latter has dominated in aiding identification and prediction of AKI by alert models. While creatinine can provide information to estimate glomerular filtration rate, the utility to depict real-time change in rapidly declining kidney function is paradoxical. Alerts for AKI have recently been popularized by several studies in the UK showcasing the various use cases for detection and management by simply relying on creatinine changes. Predictive models for real-time alerting to AKI have also gone beyond simple delta checks of creatinine as reviewed here, and hold promise to leverage data contained beyond the laboratory domain. However, laboratory data still remains vital to e-alerts in AKI. Here, we highlight a select number of approaches for real-time alerting to AKI built on traditional consensus definitions, evaluate impact on clinical outcomes from e-alerts, and offer critiques on new and expanded definitions of AKI.

Continuous Renal Replacement Therapy in the Critically Ill Patient: From Garage Technology to Artificial Intelligence.

The history of continuous renal replacement therapy (CRRT) is marked by technological advances linked to improvements in the knowledge of the mechanisms and kinetics of extracorporeal removal of solutes, and the pathophysiology of acute kidney injury (AKI) and other critical illnesses. In the present article, we review the main steps in the history of CRRT, from the discovery of continuous arteriovenous hemofiltration to its evolution into the current treatments and its early use in the treatment of AKI, to the novel sequential extracorporeal therapy. Beyond the technological advances, we describe the development of new medical specialties and a shared nomenclature to support clinicians and researchers in the broad and still evolving field of CRRT.

Discharge Documentation and Follow-Up of Critically Ill Patients With Acute Kidney Injury Treated With Kidney Replacement Therapy: A Retrospective Cohort Study.

Leading organisations recommend follow-up of acute kidney injury (AKI) survivors, as these patients are at risk of long-term complications and increased mortality. Information transfer between specialties and from tertiary to primary care is essential to ensure timely and appropriate follow-up. Our aim was to examine the association between completeness of discharge documentation and subsequent follow-up of AKI survivors who received kidney replacement therapy (KRT) in the Intensive Care Unit (ICU). We retrospectively analysed the data of 433 patients who had KRT for AKI during ICU admission in a tertiary care centre in the UK between June 2017 and May 2018 and identified patients who were discharged from hospital alive. Patients with pre-existing end-stage kidney disease and patients who were transferred from hospitals outside the catchment area were excluded. The primary objective was to assess the completeness of discharge documentation from critical care and hospital; secondary objectives were to determine cardiovascular medications reconciliation after AKI, and to investigate kidney care and outcomes at 1 year. The development of AKI and the need for KRT were mentioned in 85 and 82% of critical care discharge letters, respectively. Monitoring of kidney function post-discharge was recommended in 51.6% of critical care and 36.3% of hospital discharge summaries. Among 35 patients who were prescribed renin-angiotensin-aldosterone system inhibitors before hospitalisation, 15 (42.9%) were not re-started before discharge from hospital. At 3 months, creatinine and urine protein were measured in 88.2 and 11.8% of survivors, respectively. The prevalence of chronic kidney disease stage III or worse increased from 27.2% pre-hospitalisation to 54.9% at 1 year (p < 0.001). Our data demonstrate that discharge summaries of patients with AKI who received KRT lacked essential information. Furthermore, even in patients with appropriate documentation, renal follow-up was poor suggesting the need for more education and streamlined care pathways.

Novel Use of Premixed Dialysate Bags during Water Supply Interruption in Acute Hospital Setting.

Patients on dialysis are exposed to large amounts of water during conventional intermittent hemodialysis; hence, there are strict regulations regarding the quality of water used to prepare dialysate. Occasionally, water systems fail due to natural disasters or structural supply issues, such as water-main breaks or unplanned changes in municipal or facility water quality. It is critical to regularly monitor and immediately recognize such a failure and take steps to avoid exposing the patients to contaminants. In addition to the recognition of the problem, the ability to pivot and continue to provide safe treatment to inpatients who are dependent on dialysis is essential, both from an ultrafiltration and a clearance standpoint. At our hospital, an unforeseen water disruption occurred and we were able to continue to provide KRT with premade, bagged dialysate to mitigate the effect on our patients on dialysis. This is a novel method using available machines and dialysate, which we normally stock for continuous KRT, for short dialysis sessions. The methodology is similar to that which has been widely used for short daily home hemodialysis with low dialysate flow rate. Because this situation occurred in the midst of the SARS-CoV-2 pandemic, we had to be mindful of dialysate volumes and staffing time. Here, we present our investigation into the cause of the water-system failure and how we quickly implemented the alternative dialysis method. Short dialysis with low-flow dialysate will not deliver the same Kt/V per session as standard dialysis; however, this method was successfully implemented and tailored with adjustments for patients requiring higher clearance for specific indications, such as severe hyperkalemia.

Acute Renal Replacement Therapy in Intensive Care Units versus Outside Intensive Care Units: Are They Different?

INTRODUCTION: Acute renal replacement therapy (RRT) is indicated when metabolic and fluid demands exceed total kidney capacity, and demand for kidney function is determined by non-renal comorbidities, severity of acute disease and solute and fluid burden; therefore, the criteria for commencing RRT and dialysis in intensive care units (ICUs) may be different to those outside ICUs. OBJECTIVE: We investigated whether criteria for commencing acute RRT and dialysis outside ICU were different to those in ICU and whether these differences affected patient mortality in either setting. METHODS: We performed a retrospective observational study evaluating acute kidney injury (AKI), Kidney Disease Improving Global Outcome 3 (KDIGO3) in adult patients undergoing RRT "in and outside" ICU from 2012 to 2018, in a Brazilian teaching hospital. RESULTS: We evaluated 913 adults with AKI KDIGO3 undergoing RRT; 629 (68.9%) outside ICU and 284 (31.1%) in ICU. Infections were the main cause of hospitalisation (34.4%). Septic and ischaemic AKI were the main aetiologies of AKI (50.8% and 32.9%, respectively), metabolic and fluid demand to capacity imbalance were the main indications for dialysis (69.7%), and intermittent haemodialysis (IHD) was the primary dialysis method (59.2%). The general mortality rate after 30 days was 59%. There were no differences in gender, age and main diagnosis between groups. Both groups were different in acute tubular necrosis index specific scores (ATN-ISS), AKI aetiology, elderly population, indications for dialysis, dialysis methods and mortality rates. In ICU, patients older than 65 years old, with septic AKI were more prevalent (49.1 versus 41.4%, and 55.1 versus 37.5%, respectively), while ischaemic and nephrotoxic AKI were less frequent (24.3 versus 37 and 10.2 versus 16.3%, respectively), and ATN-ISS was higher (0.74 ± 0.31 versus 0.58 ± 0.16). Similarly, metabolic and fluid demand to capacity imbalance as an indication for acute RRT, prolonged intermittent haemodialysis (PIRRT) and continuous renal replacement therapy (CRRT) were more frequent, while peritoneal dialysis (PD) was less frequent (74.6 versus 69.7%, 31.6 versus 22.4%, and 5.3 versus 17.8%, respectively), and mortality was higher (69 versus 54.7%, respectively). Logistic regression revealed that age, septic AKI and being "in" ICU were factors associated with death. CONCLUSION: The criteria for commencing RRT and dialysis in ICU were different to those outside ICU; however, they did not impact on patient outcomes.

Causes and risk factors for acute dialysis initiation among patients with end-stage kidney disease-a large retrospective observational cohort study.

BACKGROUND: Patients who require acute initiation of dialysis have higher mortality rates when compared with patients with planned starts. Our primary objective was to explore the reasons and risk factors for acute initiation of renal replacement therapy (RRT) among patients with end-stage kidney disease (ESKD). Our secondary objective was to determine the difference in glomerular filtration rate (GFR) change in the year preceding RRT between elective and acute dialysis starts. METHODS: We conducted a single-centre retrospective observational study. ESKD patients either started dialysis electively (planned starters) or acutely and were known to renal services for >90 (unplanned starters) or <90 days (urgent starters). RESULTS: In all, 825 consecutive patients initiated dialysis between January 2013 and December 2015. Of these, 410 (49.7%) patients had a planned start. A total of 415 (50.3%) patients had an acute start on dialysis: 244 (58.8%) unplanned and 171 (41.2%) urgent. The reasons for acute dialysis initiation included acute illness (58%) and unexplained decline to ESKD (33%). Cardiovascular disease [n = 30 (22%)] and sepsis [n = 65 (48%)] accounted for the majority of acute systemic illness. Age and premorbid cardiovascular disease were independent risk factors for acute systemic illness among unplanned starts, whereas autoimmune disease accounted for the majority of urgent starts. The rate of decline in GFR was greater in the month preceding RRT among acute dialysis starters compared with planned starters (P < 0.001). CONCLUSIONS: Cardiovascular disease and advancing age were independent risk factors for emergency dialysis initiation among patients known to renal services for >3 months. The rapid and often unpredictable loss of renal function in the context of acute systemic illness poses a challenge to averting emergency dialysis start.

Optimizing Ambulance Transport of Hemodialysis Patients to the Emergency Department: A Cohort Study.

BACKGROUND: Dialysis patients who require ambulance transport to the emergency department ("ambulance-ED") may subsequently require timely dialysis in a monitored setting ("urgent dialysis"). OBJECTIVE: The purpose of this study was to develop and internally validate a risk prediction model for urgent dialysis based on patient characteristics at the time of paramedic assessment before ambulance-ED. DESIGN: Cohort Study. SETTING: Region of Nova Scotia, Canada, covered by a single emergency medical services provider. PATIENTS: Thrice-weekly hemodialysis patients who initiated dialysis between 2009 and 2013 (follow-up to 2015) and experienced one or more ambulance-ED events. MEASUREMENTS: The primary outcome ("urgent dialysis") was defined as dialysis within 24 hours of an ambulance-ED in a monitored setting or dialysis within 24 hours of an ambulance-ED with an initial ED potassium of >6.5 mmol/L. Predictors of urgent dialysis based on paramedic assessment before ambulance-ED included presenting complaint, vital signs and time from last dialysis to ambulance dispatch. METHODS: Associations with urgent dialysis were analyzed using logistic regression from which a risk prediction model was created. The model was internally validated using bootstrapping and model performance was assessed by discrimination and calibration. RESULTS: Among 197 patients, there were 624 ambulance-ED events and 87 episodes of urgent dialysis. Weakness as a presenting complaint (odds ratio [OR]: 4.62, 95% confidence interval [CI]: 1.23-17.29), >24 hours since last dialysis (OR: 2.09, 95% CI: 1.15-3.81), and vital signs, including heart rate <60 beats/minute (OR: 3.06, 95% CI: 1.09-8.61), oxygen saturation <90% (OR: 3.04, 95% CI: 1.55-5.94), elevated respiratory rate (≥20 breaths/min), and systolic blood pressure>160 mmHg, were associated with urgent dialysis after ambulance-ED. A risk prediction model incorporating these variables had very good discrimination (C-statistic: 0.81, 95% CI: 0.76-0.86). The negative predictive value was 93.6% using the optimal cut point. Of patients who were predicted to need urgent dialysis but were transported to a facility incapable of providing it, 31% were re-transported for urgent dialysis. LIMITATIONS: Findings of our study may not be generalizable to other centers where the practice of ambulance transfer and availability of monitored dialysis may differ, and data were lacking for potential missed dialysis sessions or changes in routine dialysis scheduling. CONCLUSIONS: Patient characteristics at the time of paramedic assessment are associated with urgent dialysis after ambulance-ED. This risk prediction model has the potential to guide dialysis patient transport to dialysis-capable facilities when needed.

CONTEXTE: Les patients dialysés transportés à l'urgence en ambulance (« transports en ambulance ¼) pourraient par la suite nécessiter une dialyse urgente dans un environnement monitoré (« dialyse d'urgence ¼). OBJECTIFS: On visait à élaborer et à valider à l'interne un modèle de prédiction du risque pour une dialyse d'urgence basé sur les caractéristiques des patients recueillies par les ambulanciers pendant le transport. TYPE D'ÉTUDE: Étude de cohorte. CADRE: Une région de la Nouvelle-Écosse (Canada) desservie par un seul établissement fournissant des soins médicaux d'urgence. SUJETS: Des patients hémodialysés trois fois par semaine ayant amorcé leur traitement entre 2009 et 2013 (suivi jusqu'en 2015) et ayant été transportés au moins une fois à l'urgence en ambulance. MESURES: Le critère de jugement principal (« dialyse d'urgence ¼) a été défini par une dialyse amorcée dans un environnement monitoré dans les 24 heures suivant l'arrivée en ambulance, ou par une dialyse amorcée dans les 24 heures suivant l'arrivée en ambulance et en présence d'un taux de potassium supérieur à 6,5 mmol/L. Les plaintes formulées par le patient, les signes vitaux et le temps entre la dernière dialyse et l'envoi de l'ambulance ont constitué les facteurs prédictifs d'une dialyse d'urgence s'appuyant sur l'évaluation des ambulanciers. MÉTHODOLOGIE: La régression logistique a été utilisée pour analyser les associations avec une dialyse urgente et cette analyse a servi à la création d'un modèle de prédiction du risque. Ce dernier a été validé à l'interne par la méthode du bootstrapping, et sa performance a été confirmée par discrimination et calibration. RÉSULTATS: Parmi les 197 patients recrutés, 624 transports en ambulance et 87 épisodes de dialyse urgente ont été répertoriés. Une dialyse urgente après un transport en ambulance a été justifiée par les facteurs suivants: des plaintes de faiblesse générale (RC: 4,62; IC 95 %: 1,23-17,29), une période de plus de 24 heures depuis la dernière dialyse (RC: 2,09; IC 95 %: 1,15-3,81) et les signes vitaux (notamment une fréquence cardiaque <60 battements/minute [RC: 3,06; IC 95 %: 1,09-8,61], une saturation en oxygène <90 % [RC: 3,04; IC 95 %: 1,55 − 5,94], une fréquence respiratoire élevée [≥20 respirations/min] et une pression artérielle systolique >160 mmHg). Un modèle de prédiction du risque incorporant ces variables a montré une bonne discrimination (statistique c: 0,81; IC 95 %: 0,76-0,86). Le coefficient de prévision d'un test négatif s'est établi à 93,6 % en utilisant un seuil optimal. Parmi les patients pour qui on avait prévu qu'ils nécessiteraient une dialyse urgente, mais qui avaient été transportés dans un établissement n'étant pas en mesure de la fournir, 31 % ont dû être transportés à nouveau pour une dialyse urgente. LIMITES: Ces résultats pourraient ne pas être généralisables aux établissements où diffèrent les pratiques de transfert par ambulance et la disponibilité de la dialyse urgente en environnement monitoré. De plus, des données quant aux séances de dialyse manquées ou aux changements apportés dans la routine de la dialyse étaient non disponibles. CONCLUSION: Certaines caractéristiques des patients, recueillies par les ambulanciers pendant le transport à l'hôpital, ont été associées au besoin de procéder à une dialyse urgente après un transport en ambulance. Ce modèle de prédiction du risque pourrait, lorsque nécessaire, guider le transport en ambulance des patients dialysés vers des établissements en mesure de les prendre en charge.

Acute Kidney Injury and Septic Shock-Defined by Updated Sepsis-3 Criteria in Critically Ill Patients.

Sepsis is commonly associated with acute kidney injury (AKI), particularly in those requiring dialysis (AKI-D). To date, Sepsis-3 criteria have not been applied to AKI-D patients. We investigated sepsis prevalence defined by Sepsis-3 criteria and evaluated the outcomes of septic-associated AKI-D among critically ill patients. Using the data collected from a prospective multi-center observational study, we applied the Sepsis-3 criteria to critically ill AKI-D patients treated in intensive care units (ICUs) in 30 hospitals between September 2014 and December 2015. We described the prevalence, outcomes, and characteristics of sepsis as defined by the screening Sepsis-3 criteria among AKI-D patients, and compared the outcomes of AKI-D patients with or without sepsis using the Sepsis-3 criteria. A total of 1078 patients (median 70 years; 673 (62.4%) men) with AKI-D were analyzed. The main etiology of AKI was sepsis (71.43%) and the most frequent indication for acute dialysis was oliguria (64.4%). A total of 577 (53.3% of 1078 patients) met the Sepsis-3 criteria, and 206 among the 577 patients (19.1%) had septic shock. Having sepsis and septic shock were independently associated with 90-day mortality among these ICU AKI-D patients (hazard ratio (HR) 1.23 (p = 0.027) and 1.39 (p = 0.004), respectively). Taking mortality as a competing risk factor, AKI-D patients with septic shock had a significantly reduced chance of weaning from dialysis at 90 days than those without sepsis (HR 0.65, p = 0.026). The combination of the Sepsis-3 criteria with the AKI risk score led to better performance in forecasting 90-day mortality. Sepsis affects more than 50% of ICU AKI patients requiring dialysis, and one-fifth of these patients had septic shock. In AKI-D patients, coexistent with or induced by sepsis (as screened by the Sepsis-3 criteria), there is a significantly higher mortality and reduced chance of recovering sufficient renal function, when compared to those without sepsis.