Association of negative fluid balance during the de-escalation phase of sepsis management with mortality: A cohort study.

PURPOSE: We aimed to evaluate the impact of negative fluid balance during the fluid de-escalation phase of sepsis management. MATERIAL AND METHODS: This is a historical cohort study of adult intensive care units (ICU) patients with septic shock and severe sepsis in a quaternary medical center, from January 2007 through December 2009. We used regression modeling to assess the impact of negative volume balance on mortality after adjustments for age, comorbidities, and illness severity. RESULTS: Among 633 enrolled patients, 387 patients reached negative fluid balance who in comparison with others had a lower 90-day mortality rate (36% vs. 44%; P = .048), despite higher severity of illness. Each 1-L negative daily fluid balance was associated with reduced ICU, hospital, 90-day and 1-year mortality (hazard ratio [HR] 0.39 [95%CI, 0.28-0.57], 0.76 [95%CI, 0.63-0.94], 0.69 [95%CI, 0.59-0.81], 0.67 [0.58-0.78], respectively; P < .05). This protective effect of negative volume balance was maintained when cumulative ICU fluid balance was utilized. CONCLUSIONS: There is not only a significant association between outcomes of patients who were resuscitated for sepsis and achieving negative fluid balance, but also the amount of daily or cumulative negative fluid balance is associated with lower mortality of these patients. Prospective clinical trials are needed to validate this finding.

Risk of ESRD and Mortality in Kidney and Bladder Stone Formers.

RATIONALE & OBJECTIVES: Kidney stones have been associated with increased risk for end-stage renal disease (ESRD). However, it is unclear whether there is also an increased risk for mortality and if these risks are uniform across clinically distinct categories of stone formers. STUDY DESIGN: Historical matched-cohort study. SETTING & PARTICIPANTS: Stone formers in Olmsted County, MN, between 1984 and 2012 identified using International Classification of Diseases, Ninth Revision codes. Age- and sex-matched individuals who had no codes for stones were the comparison group. PREDICTOR: Stone formers were placed into 5 mutually exclusive categories after review of medical charts: incident symptomatic kidney, recurrent symptomatic kidney, asymptomatic kidney, bladder only, and miscoded (no stone). OUTCOMES: ESRD, mortality, cardiovascular mortality, and cancer mortality. ANALYTICAL APPROACH: Cox proportional hazards models with adjustment for baseline comorbid conditions. RESULTS: Overall, 65 of 6,984 (0.93%) stone formers and 102 of 28,044 (0.36%) non-stone formers developed ESRD over a mean follow-up of 12.0 years. After adjusting for baseline hypertension, diabetes mellitus, dyslipidemia, gout, obesity, and chronic kidney disease, risk for ESRD was higher in recurrent symptomatic kidney (HR, 2.34; 95% CI, 1.08-5.07), asymptomatic kidney (HR, 3.94; 95% CI, 1.65-9.43), and miscoded (HR, 6.18; 95% CI, 2.25-16.93) stone formers, but not in incident symptomatic kidney or bladder stone formers. The adjusted risk for all-cause mortality was higher in asymptomatic kidney (HR, 1.40; 95% CI, 1.18-1.67) and bladder (HR, 1.37; 95% CI, 1.12-1.69) stone formers. Chart review of asymptomatic and miscoded stone formers suggested increased risk for adverse outcomes related to diagnoses including urinary tract infection, cancer, and musculoskeletal or gastrointestinal pain. CONCLUSIONS: The higher risk for ESRD in recurrent symptomatic compared with incident symptomatic kidney stone formers suggests that stone events are associated with kidney injury. The clinical indication for imaging in asymptomatic stone formers, the correct diagnosis in miscoded stone formers, and the cause of a bladder outlet obstruction in bladder stone formers may explain the higher risk for ESRD or death in these groups.

The Changing Incidence and Presentation of Urinary Stones Over 3 Decades.

OBJECTIVE: To evaluate trends in the incidence of kidney stones and characteristics associated with changes in the incidence rate over 3 decades. PATIENTS AND METHODS: Adult stone formers in Olmsted County, Minnesota, from January 1, 1984, to December 31, 2012, were validated and characterized by age, sex, stone composition, and imaging modality. The incidence of kidney stones per 100,000 person-years was estimated. Characteristics associated with changes in the incidence rate over time were assessed using Poisson regression models. RESULTS: There were 3224 confirmed symptomatic (stone seen), 606 suspected symptomatic (no stone seen), and 617 incidental asymptomatic kidney stone formers. The incidence of confirmed symptomatic kidney stones increased from the year 1984 to 2012 in both men (145 to 299/100,000 person-years; incidence rate ratio per 5 years, 1.14, P<.001) and women (51 to 217/100,000 person-years; incidence rate ratio per 5 years, 1.29, P<.001). Overall, the incidence of suspected symptomatic kidney stones did not change, but that of asymptomatic kidney stones increased. Utilization of computed tomography for confirmed symptomatic stones increased from 1.8% in 1984 to 77% in 2012; there was a corresponding higher increased incidence of symptomatic small stones (≤3 mm) than of larger stones (>3 mm). Confirmed symptomatic kidney stones with documented spontaneous passage also increased. The incidence of kidney stones with unknown composition increased more than that of stones with known composition. CONCLUSION: The incidence of both symptomatic and asymptomatic kidney stones has increased dramatically. The increased utilization of computed tomography during this period may have improved stone detection and contributed to the increased kidney stone incidence.

Electrolyte and Acid-Base Disorders in Chronic Kidney Disease and End-Stage Kidney Failure.

The kidneys play a pivotal role in the regulation of electrolyte and acid-base balance. With progressive loss of kidney function, derangements in electrolytes and acid-base inevitably occur and contribute to poor patient outcomes. As chronic kidney disease (CKD) has become a worldwide epidemic, medical providers are increasingly confronted with such problems. Adequate diagnosis and treatment will minimize complications and can potentially be lifesaving. In this review, we discuss the current understanding of the disease process, clinical presentation, diagnosis and treatment strategies, integrating up-to-date knowledge in the field. Although electrolyte and acid-base derangements are significant causes of morbidity and mortality in CKD and end-stage renal disease patients, they can be effectively managed through a timely institution of combined preventive measures and pharmacological therapy. Exciting advances and several upcoming outcome trials will provide further information to guide treatment and improve patient outcomes.

Acid-Base and Electrolyte Disorders in Patients with and without Chronic Kidney Disease: An Update.

Kidneys play a pivotal role in the maintenance and regulation of acid-base and electrolyte homeostasis, which is the prerequisite for numerous metabolic processes and organ functions in the human body. Chronic kidney diseases compromise the regulatory functions, resulting in alterations in electrolyte and acid-base balance that can be life-threatening. In this review, we discuss the renal regulations of electrolyte and acid-base balance and several common disorders including metabolic acidosis, alkalosis, dysnatremia, dyskalemia, and dysmagnesemia. Common disorders in chronic kidney disease are also discussed. The most recent and relevant advances on pathophysiology, clinical characteristics, diagnosis, and management of these conditions have been incorporated.

Incidence of kidney stones in kidney transplant recipients: A systematic review and meta-analysis.

AIM: To evaluate the incidence and characteristics of kidney stones in kidney transplant recipients. METHODS: A literature search was performed using MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews from the inception of the databases through March 2016. Studies assessing the incidence of kidney stones in kidney transplant recipients were included. We applied a random-effects model to estimate the incidence of kidney stones. RESULTS: Twenty one studies with 64416 kidney transplant patients were included in the analyses to assess the incidence of kidney stones after kidney transplantation. The estimated incidence of kidney stones was 1.0% (95%CI: 0.6%-1.4%). The mean duration to diagnosis of kidney stones after kidney transplantation was 28 ± 22 mo. The mean age of patients with kidney stones was 42 ± 7 years. Within reported studies, approximately 50% of kidney transplant recipients with kidney stones were males. 67% of kidney stones were calcium-based stones (30% mixed CaOx/CaP, 27%CaOx and 10%CaP), followed by struvite stones (20%) and uric acid stones (13%). CONCLUSION: The estimated incidence of kidney stones in patients after kidney transplantation is 1.0%. Although calcium based stones are the most common kidney stones after transplantation, struvite stones (also known as "infection stones") are not uncommon in kidney transplant recipients. These findings may impact the prevention and clinical management of kidney stones after kidney transplantation.