Clinical Trial Comparing the Efficacy and Safety of Regional Citrate Anticoagulation Versus Heparin in CRRT.

Introduction: Heparin continues to be the most common modality of anticoagulation in CRRT. The increased risk of hemorrhagic complications associated with its use led to the emergence of regional citrate anticoagulation (RCA) as an alternative. However, the perceived complexities associated with its use and the risk of metabolic derangements have prevented it from being adopted on a larger scale. Thus, we conducted a prospective study to compare the efficacy and safety of RCA versus heparin. Methods: Adult patients admitted to our ICU (November 2018-November 2019) with renal insufficiency and requiring CRRT were included in the study. It was an open-label study with 25 patients each being allotted to the heparin and citrate groups. Our primary outcome was the filter life span. Secondary outcomes included metabolic derangements, bleeding episodes, and patient survival. The starting dose of citrate was 2.0 mmol/L. Results: The mean filter life span was 32.84 h in the citrate group and 30.40 h in the heparin group (p-value = 0.47). In a significant proportion of the cases, CRRT was terminated for non-filter clotting-related reasons (64% in citrate vs. 32% in heparin). Kaplan-Meir analysis was done to overcome this confounder; the filter lifespan was estimated to be 46.94 h in citrate and 40.05 h for the heparin group (p-value = 0.29). No significant metabolic derangements or bleeding episodes were noted in either group. Overall patient survival was higher in the citrate group at 52% versus 32% (p-value = 0.15) in the heparin group. Conclusion: No significant difference in filter lifespan or risk of metabolic derangements was noted. A trend toward higher patient survival rates in the citrate group was noted, which warrants further evaluation in future trials.

Abdominal aortic calcification as prognostic marker in continuous ambulatory peritoneal dialysis.

BACKGROUND: Patients with chronic kidney disease (CKD) on dialysis are at high risk of cardiovascular complications and mortality. We investigated the prognostic role of presence and severity of abdominal aortic calcification (AAC) detected by a simple lateral lumbar X-ray as a risk marker in CAPD. MATERIALS AND METHODS: A prospective study was undertaken in 45 patients on CAPD (continuous ambulatory peritoneal dialysis). Lateral lumbar films of consented patients were checked for the presence of AAC at the level of L1 - L4 lumbar vertebrae. The severity of aortic calcification was graded as per Antero-Posterior Severity Score (APSS). These APSS grades were correlated with the patient's demographic, biochemical, and echocardiographic findings. The patients were followed up prospectively for one year. RESULTS: 45 patients formed the study group. Mean standard deviation (SD) age and body mass index (BMI) were 57.2 (11.9) years and 25.8 (4.7) kg/m2, respectively. Males constituted 62% of the cohort. Average duration of dialysis was 34.3 months. Diabetic kidney disease was seen in 75%. The prevalence of AAC was 47%. AAC was positively correlated with age of patient (r = 0.378; p = 0.01). No correlation with BMI, diabetes, hypertension, dialysis vintage, serum calcium, phosphorus, and PTH was seen; whereas a trend towards negative correlation with alkaline phosphatase was seen. Mitral valve calcification had a significant association with APSS severity. Patients with severe APSS (≥ 4) had poor survival, with an average survival of 37 months (Log-rank test p = 0.026). ROC analysis showed that APSS 3 predicted 1-year mortality with a specificity of 89% and sensitivity of 62% (AUC = 0.73) (p = 0.007). CONCLUSION: Abdominal aortic calcification was present in 47% of our CAPD patients. A simple lateral pelvic skiagram can be utilized as a cost-effective tool in prediction of All-cause mortality and cardiac valvular calcification.

Incidence, Risk Factors and Outcome of COVID-19 Associated AKI- A Study from South India.

BACKGROUND: Acute Kidney Injury (AKI) is a dreaded complication of Covid-19 infection with high morbidity and mortality. Limited data exists on Indian experience. In a tertiary care hospital situated in South India, we analysed the incidence, clinical profile and outcomes of patients diagnosed with AKI due to COVID-19. METHODS: Retrospective data of Adult cases admitted with COVID-19 over a 8 month period from April - November 2020 was collected. Incidence, Demographics, Clinical profile, Management and Outcomes of COVID-19 associated AKI were analysed. Primary outcome was In- hospital mortality. Secondary outcomes were Dialysis Requirement and Renal Recovery. RESULTS: 52 (7%) out of a total 718 patients with COVID-19 developed AKI. Mean Age was 58 years (IQR 51-69) with a striking male predominance of 92%.(Male:Female -9.4:1) (P< 0.001). Co morbidities seen were Diabetes in 38 (73%) and Hypertension in 31(59%) and Coronary Artery Disease in 17(32%). Fever with myalgia was seen in 29 (46%), Respiratory symptoms in 31(59%), Oliguria in 26(50%) and Diarrhea in 2 (3%) patients. At admission, Hypoxemia and Hypotension were seen in 27 (51%) and 16 (30%) patients respectively. Urinalysis revealed > 2+ dipstick Proteinuria in 24 (46%) and Microscopic hematuria in 16(34%) patients. 25 (48%) were admitted in Stage 3 AKI with a mean S.Creatinine level of 4.4 + 3.4 mg/dl. CT chest showed > 50% lung involvement in 23 patients (44%). Mechanical ventilation was required in 20(38%). Hemodialysis was required in 12 (23%). The median duration of hospitalisation was 10 + 5 days. Primary Outcome of Mortality occurred in 44% of AKI cohort in comparison to 7% in Non AKI cohort (Relative Risk[RR]6.2; 95% Confidence Interval[CI], 4.1 to 9.4) (P= 0.001). Hypoxemia [RR,3.76;95% CI,1.4-9.5], Hypotension [RR 2.54; CI,1.5-4 ], Low Serum albumin [RR1.6;CI,1.1 - 2.3] and Requirement for mechanical ventilation [RR,11.3; CI, 2.9 - 23 ] were significant risk factors for mortality. All 5 patients who required both mechanical ventilation and Dialysis died. 31 patients (59%) were treated with Remdesivir therapy without survival benefit. Significantly higher C-Reactive Protein, Interleukin -6, D-Dimer levels and lower serum albumin levels were seen in those who died. Among the 29 patients who survived, the estimated GFR (e GFR) had recovered in 12 (41%) at discharge. After further followup of 4-6 weeks, the total number of patients who recovered renal function rose to 21 (72%). CONCLUSION: Mortality in COVID associated AKI stood at 44%. Multiple factors contributed to high mortality such as Severe disease with hypotension and extensive pulmonary involvement, High Neutrophil to Lymphocyte Ratio, Absolute Monocyte Count, inflammatory markers, d-Dimer and low serum albumin. It was encouraging to note that 72% of survivors recovered renal function by 4-6 weeks after discharge from hospital which means that it is worth the struggle to treat AKI in COVID-19.