Outcome assessment of pregnancy-related acute kidney injury in Morocco: A national prospective study.

Acute kidney injury (AKI) is a rare but life-threatening complication of pregnancy. The aim of this paper is to study the characteristics of acute AKI in pregnancy and to emphasize on its management modalities in Moroccan hospitals. This is a national prospective study performed over six months from July 1 to December 31 2010 on AKI developing in pregnant patients, both preand post-partum period. Patients with pre-existing kidney disease were excluded from the study. Outcome was considered unfavorable when complete recovery of renal function was not achieved and/or maternal death occurred. Forty-four patients were included in this study. They were 29.6 ± 6 years old and mostly illiterate (70.6%). Most AKI occurred in the post-partum period, with 66% of the cases occurring in those who did not receive antenatal care. The main etiologies were pre-eclampsia (28 cases), hemorrhagic shock (six cases) and septic events (five cases). We noted three cases of acute fatty liver, one case of obstructive kidney injury and one case of lupus nephritis. Hemodialysis was necessary in 17 (38.6%) cases. The outcome was favorable in 29 patients. The maternal mortality rate was 11.4%. Two poor prognostic factors were identified: Age over 38 years and sepsis. AKI is a severe complication of pregnancy in developing countries. Its prevention necessitates the improvement of the sanitary infrastructure and the establishment of the obligatory antenatal care.

The Cost-Effectiveness of Continuous Erythropoiesis Receptor Activator Once Monthly versus Epoetin Thrice Weekly for Anaemia Management in Chronic Haemodialysis Patients.

Introduction. The aim of this study was to compare the cost-effectiveness of continuous erythropoietin receptor activator (CERA) once monthly to epoetin beta (EpoB) thrice weekly to maintain haemoglobin (Hb) within the range 10.5-12 g/dL. Methods. Prospective cohort study and cost-effectiveness analysis. Chronic haemodialysis patients (CHP), being treated with EpoB, were selected for two periods of follow-up: period 1, maintaining prior treatment with EpoB, and period 2, conversion to CERA once monthly. Hb concentrations and costs were measured monthly. Health care payer perspective for one year was adopted. Results. 75 CHP completed the study, with a mean age of 52.9 ± 14.3 years. Baseline Hb was 11.14 ± 1.18 g/dL in EpoB phase and 11.46 ± 0.79 g/dL in CERA phase; we observed a significant increase in the proportion of patients successfully treated (Hb within the recommended range), 65.3% versus 70.7%, p: 0.008, and in the average effectiveness by 4% (0.55 versus 0.59). Average cost-effectiveness ratios were 6013.86 and 5173.64$, with an ICER CERA to EpoB at -6457.5$. Conclusion. Our health economic evaluation of ESA use in haemodialysis patients suggests that the use of CERA is cost-effective compared with EpoB.

Commentary: the practice of dialysis in the intensive care unit in a developing country.

INTRODUCTION AND AIMS: In developing countries, little is known about renal replacement therapy (RRT) for acute kidney injury (AKI) in critically ill patients. The aim of this study is to describe characteristics of patients, clinical practice of renal support and outcomes in intensive care units (ICU) in a developing country. METHODS: Patients who underwent RRT for AKI from May 2003 to July 2008, in four ICUs in our institution were included in this retrospective study. Patients with end stage renal disease or younger than aged 18 years were exclueded. We have considered: patient demographics, indications of RRT, number of dialysis session, comorbidities, APACH II score for illness severity, mechanical ventilation, use of vasoactive drugs, and mortality rate. RESULTS: 105 critically ill patients admitted during the study period were treated with RRT, with a mean age of 56.13 +/- 16.8 (19-85) years. Sixty five were male and 40 female; all received intermittent hemodialysis. The total number of dialysis sessions was 284, and the mean number was 3.7 +/- 2.9; mean length of session was 225.22 +/- 75.16 (60-290) min. The majority of the cases (67%) were from medical ICU, followed by 30.2% from surgical ICUs (including cardiothoracic surgery ICU) and 2.8% were from burn ICU. The most common comorbidities were type 2 diabetes mellitus in 46 (44%) and hypertension in 35 (33.4%). Sepsis was a contributing factor to AKI in 60 patients (57.14%), hypovolemia in 30 (28.5%), and cardiogenic shock in 9 (8.5%). The APACHE II score was 25.86 +/- 11.8; the majority of patients (66.7%) were ventilated; 63 (60%) were under vasoactive drugs and 88 (83.8%) were oliguric. The most common indication for initiation of dialysis was hyperkalemia in 51 (48.5%) of the cases, followed by severe acidosis in 35 (33.3%) and acute pulmonary edema for 20 (19%). ICU mortality was 68.5% and increased to 95.2% when more than two organs were involved. CONCLUSIONS: Our experience suggests that indications for initiation of RRT in ICU are not greatly different from that in industrialized countries; yet, the big difference is in a high mortality rate among our patients.

Quantification of hemodialysis dose: what Kt/V to choose?

BACKGROUND: Quantification of hemodialysis became more accurate and easier after the advent of ionic dialysance and the use of methods for estimating urea distribution volume (V). The aim of this study was to compare different methods of hemodialysis dose assessment: Kt/VDau (Daugirdas 2nd generation), Kt/VOCM (Kt by OCM (Online Clearance Monitor) and V by Watson), and Kt/VBCM (Kt by OCM and V by bio-impedance); and to assess the dialysis adequacy, defined by a Kt/V>1.4. DESIGN: Prospective, observational study. METHODS: 35 hemodialysis sessions were evaluated in 35 chronic hemodialysis patients. During each session, we measured simultaneously, Kt/VOCM, Kt/VBCM and calculated Kt/VDau by performing blood samples before and after each session. RESULTS: 35 patients, gender (M/F: 19/16), mean age of 50.49 years, were evaluated. We noted a difference between the three methods of evaluating Kt/V index: Kt/VDau, Kt/VOCM and Kt/VBCM (1.82 ± 0.29; 1.45 ± 0.23; 1.8 ± 0.33, p<0.001). Comparison of Kt/VOCM with Kt/VDau and Kt/VBCM leads to a significant systematic underestimate of Kt/V by 22% and 20.5% respectively. Better agreement between Kt/VDau and Kt/VBCM was observed. The adequate hemodialysis was achieved, according to three methods: Kt/VDau, Kt/VOCM and Kt/VBCM respectively in 100%, 57,1% and 88.6% of the cases. CONCLUSIONS: The Kt/V index is different depending on the method used for its evaluation. The three methods can be used for quantification of hemodialysis with a better agreement between Kt/VDau and Kt/VBCM. In this study, Kt/VOCM results underestimate hemodialysis efficiency. This difference has to be considered when applying quantification of hemodialysis to clinical practice.

Parameters to assess nutritional status in a Moroccan hemodialysis cohort.

INTRODUCTION: Malnutrition is common in maintenance hemodialysis (HD) and is associated with increased mortality and morbidity in affected patients. The aim of this study was to determine the prevalence of malnutrition and correlate the methods of nutritional assessment. METHODS: We evaluated the nutritional status of 40 prevalent HD patients by subjective global assessment (SGA) score, anthropometrics [body mass index (BMI), arm circumference (AC), triceps skin-fold thicknesses (TSF), arm muscle circumference (AMC)], biochemical tests [normalized protein equivalent to total nitrogen appearance (nPNA), and pre-dialysis serum albumin and serum prealbumin levels] and bio-electrical impedance (BEI) analysis to estimate body composition [lean tissue index (LTI) and fat tissue index (FTI)]. RESULTS: The study assessed 40 patients (20 males and 20 females) with a mean age of 50.7±16.5 years. The prevalence of malnutrition according to the different methods ranged from 5 % to 65%. There were highly significant gender-specific differences in AMC (p<0.001) and TSF (p<0.001). The BEI revealed a highly significant difference in LTI (p<0.001) but no difference in FTI (p=0.14) according to gender. There was a positive correlation between LTI and both serum albumin (r=0.37; p=0.018) and serum prealbumin (r=0.53; p<0.001). Also, there was a significant positive correlation between FTI and BMI (r=0.59; p<0.001), AC (r=0.44; p=0.004) and TSF (r=0.61; p<0.001). CONCLUSION: Our data suggest that BEI analysis provides a useful means of assessing nutritional status and was correlated with anthropometrics and biochemical findings.