Prevention of intradialytic hypotension in patients with acute kidney injury submitted to sustained low-efficiency dialysis.

OBJECTIVES: This study evaluated the effects of a protocol aiming to reduce hypotension in acute kidney injury (AKI) patients submitted to sustained low-efficiency dialysis (SLED). METHODS: Patients were randomly assigned to two SLED prescriptions-control group, dialysate temperature was 37.0°C with a fixed sodium concentration [138 mEq/L] and ultrafiltration (UF) rate; and profiling group, dialysate temperature was 35.5°C with a variable sodium concentration [150-138 mEq/L] and UF rate. RESULTS: Sixty-two SLED sessions were evaluated (34 in profiling and 28 in control). Patients (n = 31) were similar in terms of gender, age, and Sequential Organ Failure Assessment (SOFA) score. Dialysis time, dialysis dose, and post-dialysis serum sodium were similar in both groups. The profiling group had significantly less hypotension episodes (23% vs. 57% in control, p = 0.009) and achieved higher UF volume (2.23 ± 1.25 L vs. 1.59 ± 1.03 L in control, p = 0.04) when compared with control group. CONCLUSIONS: SLED protocol with modulation of dialysate temperature, sodium, and UF profiling showed similar efficacy but less intradialytic hypotension when compared with a standard SLED prescription.

Low insulin-like growth factor-1 and hypocholesterolemia as mortality predictors in acute kidney injury in the intensive care unit.

OBJECTIVE: To assess the role of insulin-like growth factor-1 and cholesterol as predictors of acute kidney injury mortality in intensive care unit patients. DESIGN: Prospective cohort study. SETTING: Multidisciplinary adult intensive care unit (24 beds). PATIENTS: Adult patients with acute kidney injury at intensive care unit admission for an 11-month period were considered and a total of 56 patients were admitted in the study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: At intensive care unit admission serum insulin-like growth factor-1 (ng/mL), total cholesterol (mg/dL), albumin (g/dL), transferrin (mg/dL), total lymphocyte count, triceps skinfold thickness, arm muscle area, and Subjective Global Nutritional Assessment were evaluated. Insulin-like growth factor-1 was significantly lower in nonsurviving as compared with surviving patients (48.5 +/- 24.4 vs. 70.8 +/- 39.9; p = 0.044), as well as cholesterol (80.3 +/- 35.7 vs. 147.4 +/- 53.1; p < 0.001) and albumin (1.9 +/- 0.4 vs. 2.4 +/- 0.7; p = 0.018). Groups were similar regarding transferrin, lymphocyte, triceps skinfold thickness, arm muscle area, and subjective global nutritional assessment. A binary logistic regression model based on insulin-like growth factor-1 < or = median (50.6 ng/mL), presence of sepsis, oliguria, and cholesterol < or = median (96 mg/dL) identified insulin-like growth factor-1 (odds ratio = 7.73; 95% confidence interval 1.19-49.87; p = 0.032), sepsis (odds ratio = 7.28; 95% confidence interval 1.29-40.89; p = 0.024), oliguria (odds ratio = 8.7; 95% confidence interval 1.10-68.77; p = 0.040) and cholesterol (odds ratio = 10.94; 95% confidence interval 1.89-63.29; p = 0.008) as independent covariate for death. CONCLUSIONS: Decreased levels of insulin-like growth factor-1 and cholesterol were clearly related to higher mortality. The close correlation of insulin-like growth factor-1 with nutritional status, its serum stability, and short-half life makes it a suitable candidate for an early and sensitive marker for intensive care unit acute kidney injury mortality.

Viral hemorrhagic fever-induced acute kidney injury.

Viral hemorrhagic fevers (VHFs) are diseases caused by the RNA virus from 4 different families (Flaviridiae, Arenaviridae, Bunyaviridae, and Filoviridae) that are acquired through the bite of an infected arthropod or by the inhalation of particles of rodent excreta. Among the VHFs, dengue and yellow fever are the most prevalent in tropical regions worldwide. The clinical presentation is characterized by fever, malaise, increased vascular permeability, and coagulation defects that can result in bleeding. Acute kidney injury is an uncommon complication but renal dysfunction has been associated with various VHFs. In this article we review the renal manifestations of dengue and yellow fever infections.

Tetanus-induced acute kidney injury in a renal transplant recipient.

A 48-year-old renal transplant recipient who developed tetanus 6 years after transplantation is described. His immunosuppressive protocol was mofetil mycophenolate, sirolimus, and prednisone. The patient presented symptoms of severe tetanus with autonomic dysfunction, requiring ICU care and mechanical ventilation. His clinical course was marked by development of tetanus-induced acute kidney injury and sepsis. He was discharged after 37 days of hospitalization with recovered renal function. Tetanus is a preventable disease associated with a high fatality rate. Its treatment is difficult and requires specialized and intensive care. This case highlights the crucial importance of following adequate immunization guidelines in transplant recipients.

Avaliação da eficiência dialítica através da quantificação direta do dialisato em pacientes com insuficiência renal aguda submetidos à hemodiálise prolongada / Evaluation of dialysis efficiency by direct dialysate quantificationin acute renal failure patients submitted to extended hemodialysis

Introdução: A melhor forma de quantificar a dose de diálise em pacientes com insuficiência renal aguda (IRA) ainda não está estabelecida. O b j e t i v o s :Avaliar a dose de diálise recebida pela maneira tradicional (PRU e Kt/V) e através da quantificação direta do dialisato em pacientes com IRA. M é t o d o s :A dose de diálise foi quantificada pelo percentual de redução de uréia (PRU), Kt/V (spKt/V e eKt/V) e massa extraída de uréia no dialisato (coleta parcialpor dispositivo automatizado) em pacientes com IRA submetidos à hemodiálise prolongada em unidade de terapia intensiva (UTI). Pacientes cominsuficiência renal crônica (IRC) em programa de diálise serviram como grupo controle. Resultados: Foram realizadas 11 sessões de hemodiáliseprolongada em 8 pacientes com IRA e 8 sessões de hemodiálise convencional em 5 pacientes com IRC. O PRU foi maior nos pacientes com IRC (67%;62-74% v s 54%; 37-57%; P<0,01), assim como o spKt/V (1,31;1,15-1,62 vs 0,90;0,55-1,01; P<0,01) e o eKt/V (1,15; 1,03-1,44 vs 0,69;0,47-0,92; P<0,01).Não houve diferença com relação à massa extraída de uréia no dialisato entre as sessões de hemodiálise convencional (32,6 g; 24,4-56,1) e prolongada(31,8 g; 18,2-88,8). Conclusões: Apesar da maior dose de diálise recebida nos pacientes com IRC, quando avaliada pelo PRU e Kt/V, não houvediferença na massa extraída de uréia no dialisato. Possivelmente, os valores de normalidade definidos pelo método clássico de cinética de uréia parapacientes com IRC não se aplicam a pacientes com IRA e a aferição da dose de diálise pelo dialisato pode ser uma alternativa viável nestes pacientes.

Introduction: The best way for dialysis quantification in patients with acute renal failure (ARF) is not defined. Objectives: Evaluate the delivered dialysisdose by the traditional methods (URR and Kt/V) and by the direct dialysate quantification in patients with acute renal failure. Methods: The dialysis dosewas measured by urea reduction rate (URR), Kt/V (spKt/V, eKt/V) and urea extracted mass in the dialysate (partial dialysate collection by automatic device)in acute renal failure (ARF) patients submitted to extended dialysis in intensive care unit (ICU). Chronic renal failure (CRF) patients were the control group.Results: Eleven extended hemodialysis sessions in eight patients with ARF and eight conventional hemodialysis sessions in five CRF patients wereevaluated. The URR was higher in CRF patients (67%; 62-74% vs 54%; 37-57%; P<0.01) as the spKt/V (1.31;1.15-1.62 vs 0.90;0.55-1.01; P<0.01) andeKt/V (1.15; 1.03-1.44 vs 0.69;0.47-0.92; P<0.01). There was no difference regarding the urea extracted mass in the dialysate in the conventional (32.6 g;24.4-56.1) and extended hemodialysis (31.8 g; 18.2-88.8). Conclusions: In spite of CRF patients have received a higher dialysis dose when evaluated byURR and Kt/V, there was no difference in the urea extracted mass in the dialysate. The classical urea kinetic model may be not applicable for ARF patientsand the evaluation of the dialysate can be an alternative for measurement of dialysis dose in these patients.

Patients with ischaemic, mixed and nephrotoxic acute tubular necrosis in the intensive care unit--a homogeneous population?

INTRODUCTION: Acute tubular necrosis (ATN) is usually studied as a single entity, without distinguishing between ischaemic, nephrotoxic and mixed aetiologies. In the present study we evaluated the characteristics and outcomes of patients with ATN by aetiological group. METHOD: We conducted a retrospective comparison of clinical features, mortality rates and risk factors for mortality for the three types of ATN in patients admitted to the general intensive care unit of a university hospital between 1997 and 2000. RESULTS: Of 593 patients with acute renal failure, 524 (88%) were classified as having ATN. Their mean age was 58 years, 68% were male and 52% were surgical patients. The overall mortality rate was 62%. A total of 265 patients (51%) had ischaemic ATN, 201 (38%) had mixed ATN, and 58 (11%) had nephrotoxic ATN. There were no differences among groups in terms of age, sex, APACHE II score and reason for ICU admission. Multiple organ failure was more frequent among patients with ischaemic (46%) and mixed ATN (55%) than in those with nephrotoxic ATN (7%; P < 0.0001). The complications of acute renal failure (such as, gastrointestinal bleeding, acidosis, oliguria and hypervolaemia) were more prevalent in ischaemic and mixed ATN patients. Mortality was higher for ischaemic (66%; P = 0.001) and mixed ATN (63%; P = 0.0001) than for nephrotoxic ATN (38%). When ischaemic ATN patients, mixed ATN patients and all patients combined were analyzed by multivariate logistic regression, the independent factors for mortality identified were different except for oliguria, which was the only variable universally associated with death (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.64-5.49 [P = 0.0003] for ischaemic ATN; OR 1.96, 95% CI 1.04-3.68 [P = 0.036] for mixed ATN; and OR 2.53, 95% CI 1.60-3.76 [P < 0.001] for all patients combined]). CONCLUSION: The frequency of isolated nephrotoxic ATN was low, with ischaemic and mixed ATN accounting for almost 90% of cases. The three forms of ATN exhibited different clinical characteristics. Mortality was strikingly higher in ischaemic and mixed ATN than in nephrotoxic ATN. Although the type of ATN was not an independent predictor of death, the independent factors related to mortality were different for ischaemic, mixed and all patients combined. These data indicate that the three types of ATN represent different patient populations, which should be taken into consideration in future studies.

Risk factors for development of acute renal failure after liver transplantation.

BACKGROUND: Acute renal failure (ARF) is a common complication after liver transplantation (LTx). Identification of risk factors may prevent the development and attenuate the impact of ARF on patients outcome after LTX. METHODS: Retrospective analysis of variables in the pre, intra, and postoperative periods of 92 patients submitted to LTx was performed in order to identify risk factors for development of ARF after LTx. ARF was defined as serum creatinine > or = 2.0 mg/dL in the first 30 days after LTx. Univariate and multivariate analysis by logistic regression were performed. RESULTS: ARF group comprised 56 patients (61%). Preoperative serum creatinine was higher in ARF group. During the intraoperative period, ARF group required more blood transfusions, developed more episodes of hypotension and presented longer anesthesia time. In the postoperative period, ARF group presented higher serum bilirubin and more episodes of hypotension. Dialysis was required in 10 patients (11%). The identifled risk factors for development of ARF were: preoperative serum creatinine > 1.0 mg/dL. more than five blood transfusions in the intraoperative period, hypotension during intra and postoperative periods. The identified mortality risk factors were hypotension in the postoperative period and no recovery of renal function after 30 days. CONCLUSIONS: Several factors are involved in the pathogenesis of ARF after LTx and may influence patients outcome and mortality. Pretransplant renal function and hemodynamic conditions in the operative and postoperative periods were identified as risk factors for development of ARF after LTx. Nonrenal function recovery and postoperative hypotension were identified as mortality risk factors after LTx.