Metformin-associated lactic acidosis and factors associated with 30-day mortality.

BACKGROUND: Metformin-associated lactic acidosis (MALA) is a rare event but underrecognition may lead to unfavorable outcomes in type 2 diabetes patients. While many risk factors of MALA have been identified, how to reduce mortality from MALA is a matter of debate. This study aimed to explore the factors associated with 30-day mortality amongst MALA patients. METHODS: An observational study enrolled patients diagnosed with MALA between January 2014 and December 2017. MALA was defined by a history of metformin administration, metabolic acidosis (arterial blood gas pH <7.35 or HCO3 <15 mmol/L), and elevated plasma lactate level (>5 mmol/L). We examined risk factors including age, sex, underlying diseases, current medications, blood tests, disease severity, and dialysis data. Mortality status was identified from medical records or report on telephone. RESULTS: We included 105 MALA patients. Most patients (95.2%) were diagnosed acute kidney injury stage 3 according to KDIGO 2012 definition. The 30-day mortality rate was 36.2% and dialysis rate was 85.7%. The survivors had higher proportions of underlying chronic kidney disease, presence of metabolic acidosis, receiving renal replacement therapy within 6 hours, and haemodialysis, whereas the non-survivors had higher percentage of hypertension and disease severity. Lower APACHE II score (HR = 0.95; 95%CI, 0.91-0.99; p = 0.038), time to dialysis < 6 hours (0.31; 0.14-0.69; 0.004), and haemodialysis (0.20;0.06-0.67; 0.010) were associated with lower 30-day mortality, using multivariate Cox-regression analysis. CONCLUSIONS: Mortality rate amongst patients with MALA was high. Early dialysis treatment within 6 hours after admission and haemodialysis were independently associated with lower 30-day mortality. The large scale, well-designed studies need to confirm these encouraging results.

Barriers to and constraints of acute peritoneal dialysis in acute kidney injury: A nationwide survey.

This national survey of barriers to and constraints of acute peritoneal dialysis (aPD) in acute kidney injury (AKI) was performed by distributing an online questionnaire to all medical directors of public dialysis units registered with the Nephrology Society of Thailand during September-November 2019. One hundred and thirteen adult facilities responded to the survey covering 75 from 76 provinces (99%) of Thailand. aPD was performed in 66 centres (58%). In facilities where aPD practice was available, the utilization rate was relatively low (<10 cases/year) and limited to specific conditions, including HIV seropositive patients, previous receiving dialysis education and plan and difficult vascular access creation. Only 9% of facilities performed aPD routinely, but interestingly all such units permitted bedside catheter insertion by the nephrologists or internists. The major constraints placed on aPD practice were PD catheter insertion competency, timely catheter insertion support and the medical supporting team's knowledge/competency deficits. aPD for AKI is underutilized in Thailand and limited by the inability to undertake timely PD catheter insertion and knowledge and competency deficits.

Outcomes after Acute Peritoneal Dialysis for Critical Cardiorenal Syndrome Type 1.

INTRODUCTION: The aim of the study was to demonstrate the outcomes of peritoneal dialysis (PD) in critically ill cardiorenal syndrome type 1 (CRS1). METHODS: A cohort of 147 patients with CRS1 who received PD from 2011 to 2019 in a referral hospital in Thailand was analyzed. The primary outcome was 30-day in-hospital mortality. Ultrafiltration and net fluid balance among survivors and nonsurvivors in the first 5 PD sessions were compared. RESULTS: The 30-day mortality rate was 73.4%. Most patients were critically ill CRS1 (all patients had a respiratory failure of which 68% had cardiogenic shock). Blood urea nitrogen and creatinine at the commencement of PD were 60.1 and 4.05 mg/dL. In multivariable analysis, increasing age, unstable hemodynamics, and positive fluid balance in the first 5 PD sessions were associated with the risk of in-hospital mortality. The change of fluid balance per day during the first 5 dialysis days was significantly different among survivor and nonsurvivor groups (-353 vs. 175 mL per day, p = 0.01). CONCLUSIONS: PD is a viable dialysis option in CRS1, especially in a resource-limited setting. PD can save up to 27% of lives among patients with critically ill CRS1.

Customized versus conventional video counseling for peritoneal dialysis decision-making in patients with stage 5 chronic kidney disease under a PD-first policy: a randomized controlled study.

BACKGROUND: Indecision regarding the start of peritoneal dialysis (PD) is a challenging problem in chronic kidney disease (CKD) stage 5 patients who receive conventional video counseling. This study aimed to evaluate the effect of video counseling customized to the local context versus conventional video counseling on PD decision-making in CKD stage 5 patients under PD-first policy. METHODS: We enrolled 120 patients with stage 5 CKD in Thailand who initiate PD between May 2016 to January 2017 in a randomized, open-label, controlled study. Patients were randomized to either a customized or conventional video counseling group. The primary outcome was PD acceptance rate with complete PD catheter insertion on schedule. The secondary outcomes were change in patient knowledge and confidence in PD and reasons for indecision PD. RESULTS: We analyzed 120 patients (customized, n = 60 vs. conventional, n = 60). The two groups were similar for age (55 vs. 56 years), blood urea nitrogen (89 vs. 86 mg/dL), creatinine (10.37 vs. 11.29 mg/dL), and eGFR (4.7 vs. 5.6 mL/min/1.73 m2). The PD acceptance rate along with PD catheter insertion on schedule in the customized video counseling group was not significantly different from that in the conventional video counseling group (66.6% vs. 63.3%, relative risk: 0.97, 95% confidence interval: 0.73 to 1.29; P = 0.86). Patient knowledge of and confidence in PD increased after counseling, but the difference was not significant. CONCLUSION: Among stage 5 CKD patients, counseling content customized to a local context did not differ in a rate of acceptance for beginning PD with PD catheter insertion on schedule compared with conventional video counseling.