Global Scientific Trends in Continuous Renal Replacement Therapy from 2000 to 2023: A Bibliometric and Visual Analysis.

INTRODUCTION: Continuous renal replacement therapy (CRRT) is one of the most widely used blood purification and organ support methods in the ICU. However, the development process, the current status, hotspots, and future trends of CRRT remain unclear. METHOD: The WoSCC database was used to analyze CRRT research evolution and theme trends. VOSviewer was used to construct coauthorship, co-occurrence, co-citation, and network visualizations. CiteSpace is used to detect bursts for co-occurrence items. Several important subtopics were reviewed and discussed in more detail. RESULTS: Global publications increased from 56 in 2000 to 398 in 2023, a 710.71% increase. Blood Purification published the most manuscripts, followed by the International Journal of Artificial Organs. The USA, the San Bortolo Hospital, and Bellomo were the most productive and impactful institution, country, and author, respectively. Based on co-occurrence cluster analysis, five clusters emerged: (1) clinical applications and management of CRRT; (2) sepsis and CRRT; (3) CRRT anticoagulant management; (4) CRRT and antibiotic pharmacokinetics and pharmacodynamics; and (5) comparison of CRRT and intermittent hemodialysis. COVID-19, initiation, ECOMO, cefepime, guidelines, cardiogenic shock, biomarker, and outcome were the latest high-frequency keywords or strongest bursts, indicating the emerging frontiers of CRRT. CONCLUSIONS: There has been widespread publication and citation of CRRT research in the past 2 decades. We provide an overview of current trends, global collaboration patterns, basic knowledge, research hotspots, and emerging frontiers.

Comparison of Different Prediction Models for Unplanned Interruption of Continuous Renal Replacement Treatment: A Systematic Review of Qualitative Analyses.

INTRODUCTION: This study will systematically search and evaluate the prediction models for unplanned interruption of continuous renal replacement treatment (CRRT) and to provide a reference for building a higher quality prediction model for unplanned interruption of CRRT. METHODS: PubMed, Embase, Cochrane Library, CINAHL, China National Knowledge Infrastructure (CNKI), SinoMed, and Wanfang Database were systematically searched for studies on prediction models for unexpected interruption of CRRT. The languages were limited to Chinese and English. The search time limit was from the establishment of the database to June 30, 2023. Two researchers screened the literature and extracted the data independently, and the risk of bias and applicability of the included literature were analyzed using the risk of bias assessment tool for predictive model studies. RESULTS: A total of nine studies were included, and the area under the receiver operating characteristic curve ranged from 0.679 to 0.997. The applicability of the prediction model in seven studies was good and in two studies was poor. CONCLUSION: More attention should be paid to the effectiveness of different risk assessment methods in future construction, so as to obtain better risk prediction models with high accuracy and provide certain reference and basis for formulating relevant prevention strategies.

[Acute kidney injury - Update 2021]. / Akute Nierenschädigung ­ Update 2021.

One in five hospitalized patients suffers acute kidney injury (AKI). Depending on its severity, AKI is associated with an up to 15-fold increased risk of mortality and constitutes a major risk factor for subsequent cardiovascular events and for the development of chronic kidney disease. This concise review summarizes recently published studies, focusing on 1.) automated AKI detection using electronic health records-based AKI alert systems, 2.) renal replacement therapy and its optimal timing and anticoagulation regimen, and 3.) coronavirus disease-2019 (COVID-19) associated AKI.

Una visión nefrológica del tratamiento sustitutivo renal en el paciente crítico con fracaso renal agudo: horizonte 2020 / Renal replacement therapy in critically ill patients with acute kidney injury: 2020 nephrologist's perspective

Las terapias de reemplazo renal (TRR) para el abordaje del fracaso renal agudo (FRA) de los pacientes inestables en la unidad de cuidados intensivos (UCI) se han convertido en una medida rutinaria e imprescindible para su manejo de tal manera que, tanto la hemodiálisis intermitente (HD), como las formas híbridas (HD extendida) o continuas (TRR continua) pueden emplearse indistintamente en estos enfermos. Con esta revisión pretendemos resumir de forma ordenada la evidencia disponible en cuanto a indicación, selección de modalidad, momento de inicio, dosificación y aspectos técnicos de las TRR. Hemos realizado una revisión narrativa a partir de las guías vigentes, documentos de consenso de los principales grupos de trabajo y últimos ensayos clínicos relevantes sobre la TRR. En nuestra revisión no hemos encontrado evidencia de que ninguna modalidad de TRR prescrita en pacientes en UCI obtenga beneficios tangibles en términos de supervivencia, estancia en UCI/hospitalización ni recuperación de la función renal; a pesar de su optimización en cuanto a indicaciones, selección de modalidad, momento y/o intensidad de inicio de la técnica. Es más, en la literatura actual todavía existe controversia sobre la superioridad de una modalidad de TRR sobre otra ya que, sólo en los pacientes post- quirúrgicos hemodinámicamente inestables se ha podido demostrar un beneficio al emplearse una TRR continua de alto flujo e inicio precoz frente a una HD. Con la evidencia actual pormenorizada en nuestra revisión pretendemos poner de manifiesto la tendencia actual al manejo multidisciplinar por intensivistas y nefrólogos de estas terapias en UCI, lo cual podría reportar beneficios en la evolución clínica de los enfermos críticos y dar cabida a que el punto de vista del nefrólogo se tuviera en cuenta de manera rutinaria en la toma de decisiones sobre el estado hemodinámico, las condiciones médicas coexistentes, la disponibilidad recursos y el posible efecto sobre la función renal a largo plazo a la hora de seleccionar y gestionar los problemas de cada modalidad de TRR seleccionada

Renal replacement therapies (RRT) as support for acute kidney injury in critically ill patients have become a routine and essential practice in their management, resulting in the widespread use of various techniques among these patients, such as intermittent hemodialysis (IHD), extended hemodialysis and continuous RRT (CRRT). In this review we aim to summarize current evidence of indication, choice of modality, timing of initiation, dosing and technical aspects of RRT. We carried out a narrative review based on guidelines, consensus documents by main working groups and the latest relevant clinical trials on RRT in the critically ill. We did not find enough evidence of any RRT modality having superior benefits in terms of patient survival, length of intensive care unit/hospital stay or renal outcomes among critically ill patients, in spite of optimization of clinical indication, modality, timing of initiation and intensity of initial therapy. This is still a controverted matter, since only early start of high-flux CRRT has been proven beneficial over IHD among hemodynamically unstable postoperative patients. Our objective is to portrait current RRT practices in multidisciplinary management of critically ill patients by intensive care and nephrology professionals. Implication of a nephrologist in the assessment of hemodynamic status, coexisting medical conditions, renal outcome expectations and management of resources could potentially have benefits at the time of RRT selection and troubleshooting

Accelerated versus standard initiation of renal replacement therapy for critically ill patients with acute kidney injury: a systematic review and meta-analysis of RCT studies.

BACKGROUND: Acute kidney injury (AKI) is a common yet possibly fatal complication among critically ill patients in intensive care units (ICU). Although renal replacement therapy (RRT) is an important supportive management for severe AKI patients, the optimal timing of RRT initiation for these patients is still unclear. METHODS: In this systematic review, we searched all relevant randomized controlled trials (RCTs) that directly compared accelerated with standard initiation of RRT from PUBMED, MEDLINE, EMBASE, and Cnki.net published prior to July, 20, 2020. We extracted study characteristics and outcomes of being free of dialysis, dialysis dependence and mortality. We rated the certainty of evidence according to Cochrane methods and the GRADE approach. RESULTS: We identified 56 published relevant studies from 1071 screened abstracts. Ten RCTs with 4753 critically ill AKI patients in intensive care unit (ICU) were included in this meta-analysis. In our study, accelerated and standard RRT group were not associated with all-cause mortality (log odds-ratio [OR]: - 0.04, 95% confidence intervals [CI] - 0.16 to 0.07, p = 0.46) and free of dialysis (log OR: - 0.03, 95% CI - 0.14 to 0.09, p = 0.65). In the subgroup analyses, accelerated RRT group was significantly associated with lower risk of all-cause mortality in the surgical ICU and for those who received continuous renal replacement therapy (CRRT). In addition, patients in these two subgroups had higher chances of being eventually dialysis-free. However, accelerated initiation of RRT augmented the risk of dialysis dependence in the subgroups of patients treated with non-CRRT modality and whose Sequential Organ Failure Assessment (SOFA) score were more than 11. CONCLUSIONS: In this meta-analysis, critically ill patients with severe AKI would benefit from accelerated RRT initiation regarding all-cause mortality and being eventually free of dialysis only if they were surgical ICU patients or if they underwent CRRT treatment. However, the risk of dialysis dependence was increased in the accelerated RRT group when those patients used non-CRRT modality or had high SOFA scores. All the literatures reviewed in this study were highly heterogeneous and potentially subject to biases. Trial registration CRD42020201466, Sep 07, 2020. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=201466 .

Trends in Procedures to Initiate Renal Replacement Therapy among People Living with Spina Bifida.

PURPOSE: Given the increasing prevalence of chronic kidney disease in people with spina bifida, we sought to determine if this is associated with an increase in end stage kidney disease. We examined population based data to measure the frequency of procedures to establish renal replacement therapy-a marker for end stage kidney disease-among patients with spina bifida. MATERIALS AND METHODS: We used the Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery and Services Database from Florida, Kentucky, Maryland and New York (2000 to 2014), which include encounter level data. With a diagnosis code based algorithm we identified all procedural encounters made by patients with spina bifida. We determined the percentage of these encounters that were for facilitating renal replacement therapy (ie arteriovenous anastomosis, renal transplantation). We assessed for changes over time in this percentage with the Cochran-Armitage trend test. Bivariate analysis was performed using chi-square test. RESULTS: Of all procedures performed on patients with spina bifida over this time the proportion of procedures performed to establish renal replacement therapy significantly decreased in both the inpatient and outpatient settings (p=0.042 and p <0.001, respectively). People with spina bifida undergoing procedures to establish renal replacement therapy were, on average, young adults (mean age 34.5 and 36.0 years) with a high prevalence hypertension (75.8% of inpatients, 68.6% of outpatients). CONCLUSIONS: The frequency of surgeries to initiate renal replacement therapy among people with spina bifida undergoing procedures is low and is not increasing. This highlights the importance of consistent care throughout adolescence and young adulthood, and hypertension screening.

Probing expert opinions on the future of kidney replacement therapies.

Patients with kidney failure can only survive with some form of kidney replacement (transplant or dialysis). Unfortunately, innovations in kidney replacement therapy lag behind many other medical fields. This study compiles expert opinions on candidate technologies for future kidney replacement therapies. A worldwide web-based survey was conducted with 1566 responding experts, identified from scientific publications on kidney (renal) replacement therapy, indexed in the Web of Science Core Collection (period 2014-2019). Candidate innovative approaches were categorized in line with the Kidney Health Initiative roadmap for innovative kidney replacement therapies. Most respondents expected a revolution in kidney replacement therapies: 68.59% before 2040 and 24.85% after 2040, while 6.56% expected none. Approaches anticipated as most likely were implantable artificial kidneys (38.6%) and wearable artificial kidneys (32.4%). A majority of experts expect that kidney replacement therapies can be significantly improved by innovative technologies.

Subclinical Hypothyroidism Increases the Requirement of Renal Replacement Therapy After Cardiac Surgery.

BACKGROUND: Subclinical or biochemically diagnosed hypothyroidism (SCH) is defined as an elevated serum thyroid-stimulating hormone (TSH) with normal free thyroxine (FT4) levels. Thyroid hormones play a major role in the normal function of the heart and vascular physiology. Atherosclerosis, increased systemic vascular resistance, and decreased arterial compliance are common pathophysiological changes that may occur in hypothyroidism. Acute kidney injury (AKI) is one of the devastating complications after cardiac surgery. Age, diabetes mellitus (DM), preexisting renal dysfunction, hypertension, impaired left ventricular function, and severe arteriosclerosis are the major risk factors for the development of AKI. The purpose of the current study was to analyze the influence of SCH on AKI and the requirement of renal replacement therapy (RRT) after isolated coronary artery bypass graft surgery (CABG). METHODS: We retrospectively reviewed the prospectively collected data of 336 adult patients who underwent isolated CABG surgery with normal renal function (baseline serum creatinine value <1.4 mg/dL) from January 2017 to January 2019. The patients were divided into two groups either having the diagnosis of SCH (Group I, N = 47) or not (Group II, N = 289). SCH was diagnosed based on preoperative serum TSH and FT4 levels. Kidney injury was interpreted, according to RIFLE classification. The effect of SCH on AKI and the need for RRT after CABG was determined using logistic regression analysis and the results were expressed as odds ratio (OR) with a 95% confidence interval (CI). A P value < .05 was considered statistically significant. RESULTS: Subclinical hypothyroidism was diagnosed in 14% of all patients. Postoperative AKI occurred in 15 patients (31.9%) in Group I, whereas there were 42 patients (14.5%) in Group II. On logistic regression analysis, the presence of SCH was shown to be associated with an increased incidence of postoperative AKI (OR, 0.363; 95% CI, 0.181-0.727; P = .004). RRT was used in 2.97% of patients (seven patients in Group I and three patients in Group II, P < .001). The 30-day mortality was 2.1%. CONCLUSION: The presence of SCH seems to be associated with an increased incidence of AKI and increased requirement for RRT after cardiac surgery.

Variability in the incidence of renal replacement therapy over time in Western industrialized countries: A retrospective registry analysis.

INTRODUCTION: A growing number of patients started renal replacement therapy (RRT) in Western industrialized countries between 1980 an early 2000s. Thereafter reports from national and international registries suggest a trend towards stabilization and sometimes a decrease in the incidence rate. AIM: To investigate the differences in overall and age-specific incidence rates between industrialized countries from 1998 until 2013. Secondly, to investigate changes in incidence rates over time and their association with specific age categories. METHOD: We extracted the unadjusted overall incidence of RRT and age-specific incidence rates from renal registry reports in Europe, the United States, Canada, Australia and New Zealand. Time trends in the incidence rate by country and age categories were analyzed by Joinpoint regression analysis. RESULTS: The incidence rate in 2013 ranged from 89 per million population (pmp) in Finland to 363 pmp in the US. Incidence rates in the lower age categories (20-64 year) were similar between countries and remained stable over time. Higher incidence countries were characterized by higher numbers of patients in both the 65-74 and ≥75 year categories starting RRT. Joinpoint analysis confirmed that most countries had significant reductions in the incidence rate at the end of the study period. These reductions were explained by lower numbers of older patients starting RRT and were observed also in countries with lower overall incidence rates. CONCLUSION: This study confirmed different incidence rates of RRT between industrialized countries worldwide. Countries with the highest overall incidence rates also had the highest incidence rates in the oldest age categories. Since the early 2000's the number of older patients starting RRT is either stabilizing or even decreasing in most countries. This reduction is universal and is also observed in countries with previously low incidence rates.

The clinical relevance of oliguria in the critically ill patient: analysis of a large observational database.

BACKGROUND: Urine output is widely used as one of the criteria for the diagnosis and staging of acute renal failure, but few studies have specifically assessed the role of oliguria as a marker of acute renal failure or outcomes in general intensive care unit (ICU) patients. Using a large multinational database, we therefore evaluated the occurrence of oliguria (defined as a urine output < 0.5 ml/kg/h) in acutely ill patients and its association with the need for renal replacement therapy (RRT) and outcome. METHODS: International observational study. All adult (> 16 years) patients in the ICON audit who had a urine output measurement on the day of admission were included. To investigate the association between oliguria and mortality, we used a multilevel analysis. RESULTS: Of the 8292 patients included, 2050 (24.7%) were oliguric during the first 24 h of admission. Patients with oliguria on admission who had at least one additional 24-h urine output recorded during their ICU stay (n = 1349) were divided into three groups: transient-oliguria resolved within 48 h after the admission day (n = 390 [28.9%]), prolonged-oliguria resolved > 48 h after the admission day (n = 141 [10.5%]), and permanent-oliguria persisting for the whole ICU stay or again present at the end of the ICU stay (n = 818 [60.6%]). ICU and hospital mortality rates were higher in patients with oliguria than in those without, except for patients with transient oliguria who had significantly lower mortality rates than non-oliguric patients. In multilevel analysis, the need for RRT was associated with a significantly higher risk of death (OR = 1.51 [95% CI 1.19-1.91], p = 0.001), but the presence of oliguria on admission was not (OR = 1.14 [95% CI 0.97-1.34], p = 0.103). CONCLUSIONS: Oliguria is common in ICU patients and may have a relatively benign nature if only transient. The duration of oliguria and need for RRT are associated with worse outcome.

Clinical characteristics at the renal replacement therapy initiation of Japanese pediatric patients: a nationwide cross-sectional study.

BACKGROUND: Although there is debate regarding the timing of initiation of renal replacement therapy (RRT) in adults with end-stage renal disease, there is a paucity of reliable epidemiological data on pediatric patients. The present study was performed to investigate current practice in Japan with regard to the timing of initiation of RRT in children based on estimated glomerular filtration rate (eGFR). METHODS: A total of 649 pediatric patients < 20 years old with eGFR at the initiation of RRT between 1 January 2006 and 31 December 2013 were included in the study. Baseline eGFR was calculated for each patient using the Schwartz formula. RESULTS: eGFR at the start of RRT was 12.1 mL/min/1.73 m2 [interquartile range (IQR) 8.4-16.3]. A total of 209 children (32.2%) had high eGFR (eGFR > 15 mL/min/1.73 m2) at the initiation of RRT. Initiation of RRT was more likely in those undergoing preemptive transplantation (PEKT) with high eGFR [odds ratio (OR) 4.16; 95% confidence interval (CI) 1.95-8.90, P < 0.001]. There were 31 deaths of various causes during follow-up, with infections representing the leading causes of death. CONCLUSIONS: The median eGFR at the initiation of RRT in children showed a wide range of variation. Further studies are needed to investigate the impact of the decision regarding when to initiate RRT in individual pediatric patients.

The changing patterns of access overtime to the renal replacement therapy programme in Thailand.

Based on projected numbers, approximately only 50% of those requiring renal replacement therapy (RRT) receive it. Many patients who require RRT live in low- and middle-income countries. The objective of this study was to examine the changing pattern over time of entry into the RRT programme in Thailand following RRT's inclusion in the Universal Coverage Scheme. This study was an ecological study using the age-period-cohort analysis to look at dialysis registration and kidney transplant trends during RRT programme implementation. Data from 2008 to 2016 of patients diagnosed with end-stage renal disease (ESRD) were obtained from the National Health Security Office. The study found that the numbers of new patients with ESRD, aged 20-69, registered with the dialysis programme increased over time. For patients aged 20-40 years, the dialysis programme took up to 400 new patients for every 1000 new ESRD diagnoses. For kidney transplant, the rates increased slowly. The kidney transplant programme could at best treat only around 50 cases for every 1000 new ESRD diagnoses in patients aged 20-30 years. Findings of this study highlighted the importance of promoting strategies to reduce the increasing number of patients with kidney disease, to consider conservative therapy for older/frail patients, and to improve access to kidney transplantation and live-donation.

Epidemiology of acute kidney injury in intensive care units in Beijing: the multi-center BAKIT study.

BACKGROUND: Acute kidney injury (AKI) commonly occurs in intensive care units (ICUs), leading to adverse clinical outcomes and increasing costs. However, there are limited epidemiological data of AKI in the critically ill in Beijing, China. METHODS: In this prospective cohort study in 30 ICUs, we screened the patients up to 10 days after ICU admission. Characteristics and outcomes were compared between AKI and non-AKI, renal replacement therapy (RRT) and non-RRT patients. Nomograms of logistic regression and Cox regression were performed to examine potential risk factors for AKI and mortality. RESULTS: A total of 3107 patients were included in the final analysis. The incidence of AKI was 51.0%; stages 1 to 3 accounted for 23.1, 11.8, and 15.7%, respectively. The majority (87.6%) of patients with AKI developed AKI on the first 4 days after admission to the ICU. A total of 281 patients were treated with RRT. Continuous RRT with predilution, citrate for anticoagulation and femoral vein for vascular access was the most common RRT pattern (29.9%, 84 of 281). Patients with AKI were associated with longer ICU-LOS and higher mortality and costs (P<0.001). In patients treated with RRT, 78.6 and 28.5% of RRTs were dependent on the 7th and 28th days, respectively. The 28 day mortalities of non-AKI, AKI stages 1-3, and septic shock patients were 6.83, 15.04, 27.99, 45.18 and 36.5%, respectively. CONCLUSIONS: Approximately half of our ICU patients experienced AKI. The majority of patients with AKI developed AKI during the first 4 days after admission to the ICU. Continuous RRT with predilution, citrate for anticoagulation and femoral vein for vascular access was the most common RRT pattern in our ICUs. AKI was associated with a higher mortality and costs, incomplete kidney recovery and s series of adverse outcomes.

The Predictive Factor for Future Renal Replacement Therapy among the Working Generation.

OBJECTIVE: Many patients undergoing renal replacement therapy (RRT) have had the cause since the working generation, but it has often been unnoticed. To reduce RRT patients, early detection of high-risk subjects, lifestyle modification, and appropriate treatment are desired. We aimed to reveal the situation about highrisk cases for future RRT and rapid estimated glomerular filtration rate (eGFR) decline cases (over -3 mL/ min/1.73m2/year) among the working generation, and detect predictive factors for both groups. METHODS: We prospectively observed five-year consecutive health checkup data of the employees at a steelworks in Japan. The risk for future RRT was estimated using annual change of eGFR (ΔeGFR) and expected remaining lifetime for each subject. RESULTS: Among 959 subjects, we identified 75 high-risk cases for RRT (7.8%) and 46 rapid eGFR decline cases (4.8%). In logistic regression analyses, urine protein level by dipstick test was an independent predictive factor for both high-risk cases for RRT (odds ratio 2.04) and rapid eGFR decline cases (odds ratio 2.23). CONCLUSION: A considerable number of high-risk subjects were latent even in active workers. It was suggested that urine protein level was a predictive factor for RRT risk regardless of whether eGFR was preserved among the working generation.

Why physiology will continue to guide the choice between balanced crystalloids and normal saline: a systematic review and meta-analysis.

BACKGROUND: Crystalloids are the most frequently prescribed drugs in intensive care medicine and emergency medicine. Thus, even small differences in outcome may have major implications, and therefore, the choice between balanced crystalloids versus normal saline continues to be debated. We examined to what extent the currently accrued information size from completed and ongoing trials on the subject allow intensivists and emergency physicians to choose the right fluid for their patients. METHODS: Systematic review and meta-analysis with random effects inverse variance model. Published randomized controlled trials enrolling adult patients to compare balanced crystalloids versus normal saline in the setting of intensive care medicine or emergency medicine were included. The main outcome was mortality at the longest follow-up, and secondary outcomes were moderate to severe acute kidney injury (AKI) and initiation of renal replacement therapy (RRT). Trial sequential analyses (TSA) were performed, and risk of bias and overall quality of evidence were assessed. Additionally, previously published meta-analyses, trial sequential analyses and ongoing large trials were analysed for included studies, required information size calculations and the assumptions underlying those calculations. RESULTS: Nine studies (n = 32,777) were included. Of those, eight had data available on mortality, seven on AKI and six on RRT. Meta-analysis showed no significant differences between balanced crystalloids versus normal saline for mortality (P = 0.33), the incidence of moderate to severe AKI (P = 0.37) or initiation of RRT (P = 0.29). Quality of evidence was low to very low. Analysis of previous meta-analyses and ongoing trials showed large differences in calculated required versus accrued information sizes and assumptions underlying those. TSA revealed the need for extremely large trials based on our realistic and clinically relevant assumptions on relative risk reduction and baseline mortality. CONCLUSIONS: Our meta-analysis could not find significant differences between balanced crystalloids and normal saline on mortality at the longest follow-up, moderate to severe AKI or new RRT. Currently accrued information size is smaller, and the required information size is larger than previously anticipated. Therefore, completed and ongoing trials on the topic may fail to provide adequate guidance for choosing the right crystalloid. Thus, physiology will continue to play an important role for individualizing this choice.

Temporal validation of the CT-PIRP prognostic model for mortality and renal replacement therapy initiation in chronic kidney disease patients.

BACKGROUND: A classification tree model (CT-PIRP) was developed in 2013 to predict the annual renal function decline of patients with chronic kidney disease (CKD) participating in the PIRP (Progetto Insufficienza Renale Progressiva) project, which involves thirteen Nephrology Hospital Units in Emilia-Romagna (Italy). This model identified seven subgroups with specific combinations of baseline characteristics that were associated with a differential estimated glomerular filtration rate (eGFR) annual decline, but the model's ability to predict mortality and renal replacement therapy (RRT) has not been established yet. METHODS: Survival analysis was used to determine whether CT-PIRP subgroups identified in the derivation cohort (n = 2265) had different mortality and RRT risks. Temporal validation was performed in a matched cohort (n = 2051) of subsequently enrolled PIRP patients, in which discrimination and calibration were assessed using Kaplan-Meier survival curves, Cox regression and Fine & Gray competing risk modeling. RESULTS: In both cohorts mortality risk was higher for subgroups 3 (proteinuric, low eGFR, high serum phosphate) and lower for subgroups 1 (proteinuric, high eGFR), 4 (non-proteinuric, younger, non-diabetic) and 5 (non-proteinuric, younger, diabetic). Risk of RRT was higher for subgroups 3 and 2 (proteinuric, low eGFR, low serum phosphate), while subgroups 1, 6 (non-proteinuric, old females) and 7 (non-proteinuric, old males) showed lower risk. Calibration was excellent for mortality in all subgroups while for RRT it was overall good except in subgroups 4 and 5. CONCLUSIONS: The CT-PIRP model is a temporally validated prediction tool for mortality and RRT, based on variables routinely collected, that could assist decision-making regarding the treatment of incident CKD patients. External validation in other CKD populations is needed to determine its generalizability.

Implementation of a Renal Replacement Therapy Simulation to Strengthen Essential Pharmacist Skills.

Objective. To assess third-year pharmacy students' knowledge and application of renal pharmacotherapy using a renal replacement therapy (RRT) simulation. Methods. A simulation was developed that involved three stations related to RRT: peritoneal dialysis, continuous renal replacement therapy (CRRT), and hemodialysis. Stations involved demonstration of each modality, literature searches for drug information questions related to renal dosing with written recommendations, and utilization of an electronic medical record (EMR) to develop a verbal Situation, Background, Assessment, Recommendation (SBAR) for a patient with chronic kidney disease (CKD). Pre- and post-simulation assessments regarding therapeutic knowledge of RRT was used. Results. All 174 students completed the pre- and post-simulation assessments over the course of two years. Student performance indicated significant improvement in overall knowledge based on the assessments with significant overall differences in questions relating to indications for RRT, type of RRT indicated for hemodynamic instability, and agents used to maintain circuit patency. Overall inter-class differences were also identified at baseline and specifically for the questions regarding indications for RRT and agents used to maintain circuit patency. Both classes showed significant improvement in overall knowledge based on the post-simulation assessments. Debrief sessions and course evaluations indicated student satisfaction with the simulation experience. Students reported that the experience met the simulation objectives. Conclusion. Participation in an RRT simulation allowed pharmacy students to apply knowledge and skills learned didactically related to renal pharmacotherapy.