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1.
Medicina (Kaunas) ; 57(6)2021 May 22.
Artigo em Inglês | MEDLINE | ID: mdl-34067299

RESUMO

Background and Objectives: Fluid disbalance is associated with adverse outcomes in critically ill patients with acute kidney injury (AKI). In this study, we intended to assess fluid status using bioimpedance analysis (BIA) and central venous pressure (CVP) measurement and to evaluate the association between hyperhydration and hypervolemia with the outcomes of severe AKI. Materials and Methods: A prospective study was conducted in the Hospital of the Lithuanian University of Health Sciences Kauno Klinikos. Forty-seven patients treated at the Intensive Care Unit (ICU) with severe AKI and a need for renal replacement therapy (RRT) were examined. The hydration level was evaluated according to the ratio of extracellular water to total body water (ECW/TBW) of bioimpedance analysis and volemia was measured according to CVP. All of the patients were tested before the first hemodialysis (HD) procedure. Hyperhydration was defined as ECW/TBW > 0.39 and hypervolemia as CVP > 12 cm H2O. Results: According to bioimpedance analysis, 72.3% (n = 34) of patients were hyperhydrated. According to CVP, only 51.1% (n = 24) of the patients were hypervolemic. Interestingly, 69.6% of hypovolemic/normovolemic patients were also hyperhydrated. Of all study patients, 57.4% (n = 27) died, in 29.8% (n = 14) the kidney function improved, and in 12.8% (n = 6) the demand for RRT remained after in-patient treatment. A tendency of higher mortality in hyperhydrated patients was observed, but no association between hypervolemia and outcomes of severe AKI was established. Conclusions: Three-fourths of the patients with severe AKI were hyperhydrated based on bioimpedance analysis. However, according to CVP, only half of these patients were hypervolemic. A tendency of higher mortality in hyperhydrated patients was observed.


Assuntos
Lesão Renal Aguda , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/terapia , Pressão Venosa Central , Humanos , Unidades de Terapia Intensiva , Estudos Prospectivos , Terapia de Substituição Renal
2.
PLoS One ; 16(5): e0251932, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34015009

RESUMO

INTRODUCTION: There is evidence that SARS-CoV2 has a particular affinity for kidney tissue and is often associated with kidney failure. METHODS: We assessed whether proteinuria can be predictive of kidney failure, the development of chronic kidney disease, and mortality in 37 critically ill COVID-19 patients. We used machine learning (ML) methods as decision trees and cut-off points created by the OneR package to add new aspects, even in smaller cohorts. RESULTS: Among a total of 37 patients, 24 suffered higher-grade renal failure, 20 of whom required kidney replacement therapy. More than 40% of patients remained on hemodialysis after intensive care unit discharge or died (27%). Due to frequent anuria proteinuria measured in two-thirds of the patients, it was not predictive for the investigated endpoints; albuminuria was higher in patients with AKI 3, but the difference was not significant. ML found cut-off points of >31.4 kg/m2 for BMI and >69 years for age, constructed decision trees with great accuracy, and identified highly predictive variables for outcome and remaining chronic kidney disease. CONCLUSIONS: Different ML methods and their clinical application, especially decision trees, can provide valuable support for clinical decisions. Presence of proteinuria was not predictive of CKD or AKI and should be confirmed in a larger cohort.


Assuntos
/complicações , Estado Terminal/mortalidade , Aprendizado de Máquina , Proteinúria/etiologia , Insuficiência Renal Crônica/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Proteinúria/mortalidade , Insuficiência Renal Crônica/mortalidade , Terapia de Substituição Renal , Estudos Retrospectivos
3.
Semin Dial ; 34(3): 257-262, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33969909

RESUMO

The COVID-19 pandemic significates an enormous number of patients with pneumonia that get complicated with severe acute respiratory distress syndrome (ARDS), some of them with refractory hypercapnia and hypoxemia that need mechanical ventilation (MV). Those patients who are not candidate to extracorporeal membrane oxygenation (ECMO), the extracorporeal removal of CO2 (ECCO2 R) can allow ultra protective MV to limit the transpulmonary pressures and avoid ventilatory induced lung injury (VILI). We report a first case of prolonged ECCO2 R support in 38 year male with severe COVID-19 pneumonia refractory to conventional support. He was admitted tachypneic and oxygen saturation 71% without supplementary oxygen. The patient's clinical condition worsens with severe respiratory failure, increasing the oxygen requirement and initiating MV in the prone position. After 21 days of protective MV, PaCO2 rise to 96.8 mmHg, making it necessary to connect to an ECCO2 R system coupled continuous veno-venous hemodialysis (CVVHD). However, due to the lack of availability of equipment in the context of the pandemic, a pediatric gas exchange membrane adapted to CVVHD allowed to maintain the removal of CO2 until completing 27 days, being finally disconnected from the system without complications and with a satisfactory evolution.


Assuntos
/terapia , Dióxido de Carbono/metabolismo , Pneumonia Viral/terapia , Pneumonia Viral/virologia , Terapia de Substituição Renal , Insuficiência Respiratória/terapia , Insuficiência Respiratória/virologia , Adulto , Humanos , Masculino , Pandemias
4.
Int J Biol Sci ; 17(6): 1497-1506, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33907513

RESUMO

Increasing clinical evidence shows that acute kidney injury (AKI) is a common and severe complication in critically ill COVID-19 patients. The older age, the severity of COVID-19 infection, the ethnicity, and the history of smoking, diabetes, hypertension, and cardiovascular disease are the risk factor for AKI in COVID-19 patients. Of them, inflammation may be a key player in the pathogenesis of AKI in patients with COVID-19. It is highly possible that SARS-COV-2 infection may trigger the activation of multiple inflammatory pathways including angiotensin II, cytokine storm such as interleukin-6 (IL-6), C-reactive protein (CRP), TGF-ß signaling, complement activation, and lung-kidney crosstalk to cause AKI. Thus, treatments by targeting these inflammatory molecules and pathways with a monoclonal antibody against IL-6 (Tocilizumab), C3 inhibitor AMY-101, anti-C5 antibody, anti-TGF-ß OT-101, and the use of CRRT in critically ill patients may represent as novel and specific therapies for AKI in COVID-19 patients.


Assuntos
Lesão Renal Aguda/etiologia , Inflamação/etiologia , Estresse Fisiológico , Lesão Renal Aguda/epidemiologia , Lesão Renal Aguda/terapia , Ativação do Complemento , Síndrome da Liberação de Citocina , Complicações do Diabetes/metabolismo , Humanos , Terapia de Substituição Renal
5.
Lancet ; 397(10281): 1293-1300, 2021 04 03.
Artigo em Inglês | MEDLINE | ID: mdl-33812488

RESUMO

BACKGROUND: Delaying renal replacement therapy (RRT) for some time in critically ill patients with severe acute kidney injury and no severe complication is safe and allows optimisation of the use of medical devices. Major uncertainty remains concerning the duration for which RRT can be postponed without risk. Our aim was to test the hypothesis that a more-delayed initiation strategy would result in more RRT-free days, compared with a delayed strategy. METHODS: This was an unmasked, multicentre, prospective, open-label, randomised, controlled trial done in 39 intensive care units in France. We monitored critically ill patients with severe acute kidney injury (defined as Kidney Disease: Improving Global Outcomes stage 3) until they had oliguria for more than 72 h or a blood urea nitrogen concentration higher than 112 mg/dL. Patients were then randomly assigned (1:1) to either a strategy (delayed strategy) in which RRT was started just after randomisation or to a more-delayed strategy. With the more-delayed strategy, RRT initiation was postponed until mandatory indication (noticeable hyperkalaemia or metabolic acidosis or pulmonary oedema) or until blood urea nitrogen concentration reached 140 mg/dL. The primary outcome was the number of days alive and free of RRT between randomisation and day 28 and was done in the intention-to-treat population. The study is registered with ClinicalTrial.gov, NCT03396757 and is completed. FINDINGS: Between May 7, 2018, and Oct 11, 2019, of 5336 patients assessed, 278 patients underwent randomisation; 137 were assigned to the delayed strategy and 141 to the more-delayed strategy. The number of complications potentially related to acute kidney injury or to RRT were similar between groups. The median number of RRT-free days was 12 days (IQR 0-25) in the delayed strategy and 10 days (IQR 0-24) in the more-delayed strategy (p=0·93). In a multivariable analysis, the hazard ratio for death at 60 days was 1·65 (95% CI 1·09-2·50, p=0·018) with the more-delayed versus the delayed strategy. The number of complications potentially related to acute kidney injury or renal replacement therapy did not differ between groups. INTERPRETATION: In severe acute kidney injury patients with oliguria for more than 72 h or blood urea nitrogen concentration higher than 112 mg/dL and no severe complication that would mandate immediate RRT, longer postponing of RRT initiation did not confer additional benefit and was associated with potential harm. FUNDING: Programme Hospitalier de Recherche Clinique.


Assuntos
Lesão Renal Aguda/terapia , Terapia de Substituição Renal/métodos , Tempo para o Tratamento , Lesão Renal Aguda/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , França , Humanos , Unidades de Terapia Intensiva/organização & administração , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Terapia de Substituição Renal/estatística & dados numéricos , Índice de Gravidade de Doença
6.
Pol Merkur Lekarski ; 49(290): 143-145, 2021 Apr 18.
Artigo em Inglês | MEDLINE | ID: mdl-33895762

RESUMO

Hemodialysis is the dominant method of renal replacement therapy. The condition of its effectiveness is obtaining adequate vascular access, among others, central catheters. Central venous catheterization is a routine procedure, but it carries a risk of complications. An extremely rare but completely avoidable complication is the loss of the guidewire during the central venous catheterization procedure. A CASE REPORT: A 79-year-old patient, chronically hemodialyzed was admitted to the hospital to create vascular access. Previous vascular access, femoral central venous catheter was removed due to thrombosis. During hospitalization, angio-CT scan was performed, which showed the presence of a foreign body in the venous system, from the inguinal canal to the brachiocephalic vein. This structure turned out to be a guide, remaining after vein catheterization in the past. Complications during the procedure have never been reported. While bending her torso, the patient has been complaining of nonspecific pains in the neck area for 2 years. Part of the guide was extravascular in the upper mediastinum. The patient was consulted by a vascular surgeon, who due to the presence of the guidewire for a long time, recommended conservative treatment and regular follow-ups. CONCLUSIONS: An extremely rare complication, which is the loss of the guide during insertion of a vascular catheter, can be avoided by strict adherence to procedures, mindfulness, occupational hygiene and by appropriate supervision of specialists over young doctors. The presented case of the patient proves that the guidewire left in the venous system may remain unnoticed for several years. In the described case, removal of a foreign body would be associated with extensive surgery and a high risk of vascular damage, therefore conservative treatment and regular check-ups were recommended.


Assuntos
Cateterismo Venoso Central , Cateteres Venosos Centrais , Trombose , Idoso , Cateterismo Venoso Central/efeitos adversos , Cateteres Venosos Centrais/efeitos adversos , Feminino , Humanos , Diálise Renal/efeitos adversos , Terapia de Substituição Renal
7.
Nephrol Nurs J ; 48(2): 147-167, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33886245

RESUMO

Depression is undertreated in patients with chronic kidney disease (CKD) stage 4 without kidney replacement therapy (KRT), despite evidence showing its association with an increase in morbidity and mortality. Earlier and more adequate identification of patients with depression is needed. A quasi-experimental evidence-based project included 33 patients with CKD stage 4 not on KRT from a local nephrology office. The patients, who had previously been screened with the Patient Health Questionnaire-2 (PHQ-2), were screened with the Beck Depression Inventory. Nine patients (27%) had Beck Depression Inventory scores suggesting the need for a mental health referral compared to none having the need for a mental health referral captured by the PHQ-2. Results of this study indicate that screening with the Beck Depression Inventory should be considered to more accurately identify patients with depressive symptoms so interventions can occur earlier.


Assuntos
Nefrologia , Insuficiência Renal Crônica , Depressão/diagnóstico , Depressão/etiologia , Humanos , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/terapia , Terapia de Substituição Renal
8.
Medicine (Baltimore) ; 100(15): e25255, 2021 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-33847623

RESUMO

RATIONALE: Fibrinolysis shutdown associated with severe thrombotic complications is a recently recognized syndrome that was previously seldom investigated in patients with severe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. It presents a unique therapeutic dilemma, as anticoagulation with heparin alone is insufficient to address the imbalance in fibrinolysis. And while the use of fibrinolytic agents could limit the disease severity, it is often associated with bleeding complications. There is a need for biomarkers that will guide the timely stratification of patients into those who may benefit from both anticoagulant and fibrinolytic therapies. PATIENT CONCERNS: All 3 patients presented with shortness of breath along with comorbidities predisposing them to severe SARS-CoV-2 infection. One patient (Patient 3) also suffered from bilateral deep venous thrombosis. DIAGNOSES: All 3 patients tested positive for SARS-CoV-2 RNA by reverse transcription polymerase chain reaction (RT-PCR) and were eventually diagnosed with respiratory failure necessitating intubation. INTERVENTIONS: All 3 patients required mechanical ventilation support, 2 of which also required renal replacement therapy. All 3 patients were also placed on anticoagulation therapy. OUTCOMES: In Patients 1 and 2, the initial D-dimer levels of 0.97 µg/ml fibrinogen equivalent units (FEU) and 0.83 µg/ml FEU were only slightly elevated (normal <0.50 µg/ml FEU). They developed rising D-dimer levels to a peak of 13.21 µg/ml FEU and >20.0 µg/ml FEU, respectively, which dropped to 1.34 µg/ml FEU 8 days later in Patient 1 and to 2.94 µg/ml on hospital day 13 in Patient 2. In Patient 3, the D-dimer level on admission was found to be elevated to >20.00 µg/ml FEU together with imaging evidence of thrombosis. And although he received therapeutic heparin infusion, he still developed pulmonary embolism (PE) and his D-dimer level declined to 5.91 µg/ml FEU. Despite "improvement" in their D-dimer levels, all 3 patients succumbed to multi-system organ failure. On postmortem examination, numerous arterial and venous thromboses of varying ages, many consisting primarily of fibrin, were identified in the lungs of all patients. LESSONS: High D-dimer levels, with subsequent downtrend correlating with clinical deterioration, seems to be an indicator of fibrinolysis suppression. These findings can help form a hypothesis, as larger cohorts are necessary to demonstrate their reproducibility.


Assuntos
Anticoagulantes/uso terapêutico , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Insuficiência de Múltiplos Órgãos , Terapia Trombolítica/métodos , Autopsia/métodos , /complicações , /terapia , Deterioração Clínica , Feminino , Fibrinólise , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/sangue , Insuficiência de Múltiplos Órgãos/diagnóstico , Insuficiência de Múltiplos Órgãos/etiologia , Valor Preditivo dos Testes , Prognóstico , Terapia de Substituição Renal/métodos , Respiração Artificial/métodos , Índice de Gravidade de Doença , Trombose Venosa/sangue , Trombose Venosa/complicações , Trombose Venosa/diagnóstico
9.
Int J Infect Dis ; 106: 281-288, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33823283

RESUMO

BACKGROUND: The spatiotemporal trend of renal involvement in coronavirus disease 2019 (COVID-19) patients is still unclear. Therefore, the aim of this study was to reveal the dynamics of renal involvement superimposed COVID-19 according to time and space. METHODS: COVID-19 patients reporting renal involvement were included in this study. The following information was collected from relevant articles: first author, patient demographics, patient enrollment period, location, definition of acute kidney injury (AKI), prevalence of AKI, and use of renal replacement therapy (RRT). RESULTS: A total of 17 134 patients were finally included. The overall prevalence of AKI in COVID-19 patients was 19%, with 7% of them undergoing RRT. The overall risk of AKI in patients enrolled before March 1, 2020 (9%) was significantly lower than that after March 1, 2020 (36%) (P < 0.00001). Moreover, the overall risk of AKI outside Asia (35%) was significantly higher than that in Asia (10%) (P < 0.00001). Additionally, similar to patients requiring RRT, AKI patients were more likely to become seriously ill or even to die (P < 0.00001). CONCLUSIONS: This study found that renal involvement superimposed COVID-19, a comorbidity portending a poor prognosis, has become an increasingly serious problem over time and is more common outside Asia. Thus, more attention should be paid to the management of this specific group of patients.


Assuntos
Lesão Renal Aguda/complicações , /complicações , Lesão Renal Aguda/terapia , Adulto , Comorbidade , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Terapia de Substituição Renal , Estudos Retrospectivos , Fatores de Risco
12.
J Cardiothorac Surg ; 16(1): 59, 2021 Mar 29.
Artigo em Inglês | MEDLINE | ID: mdl-33781312

RESUMO

This letter to the editor has made several comments regarding possible statistical issues in recent article by Wang et al. determining the risk factors of continuous renal replacement treatment after emergency surgery for type A acute aortic dissection, which is published in Journal of Cardiothoracic Surgery. 2020; 15(1):100. Our comments were involved in the issues of using the propensity score matched cohorts to adjust the covariates that can potentially confound the primary outcomes, process of establishing multivariate model and application of Kaplan-Meier curve analysis in this retrospective study. We would like to remind readers to pay special attention to these issues and invite the authors to comment on these.


Assuntos
Lesão Renal Aguda/prevenção & controle , Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Pontuação de Propensão , Terapia de Substituição Renal/métodos , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Lesão Renal Aguda/etiologia , Humanos , Fatores de Risco
13.
Oxid Med Cell Longev ; 2021: 8873581, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33763177

RESUMO

Recent studies have recognized several risk factors for cardiopulmonary bypass- (CPB-) associated acute kidney injury (AKI). However, the lack of early biomarkers for AKI prevents practitioners from intervening in a timely manner. We reviewed the literature with the aim of improving our understanding of the risk factors for CPB-associated AKI, which may increase our ability to prevent or improve this condition. Some novel early biomarkers for AKI have been introduced. In particular, a combinational use of these biomarkers would be helpful to improve clinical outcomes. Furthermore, we discuss several interventions that are aimed at managing CPB-associated AKI, may increase the effect of renal replacement therapy (RRT), and may contribute to preventing CPB-associated AKI. Collectively, the conclusions of this paper are limited by the availability of clinical trial evidence and conflicting definitions of AKI. A guideline is urgently needed for CPB-associated AKI.


Assuntos
Lesão Renal Aguda/etiologia , Ponte Cardiopulmonar/efeitos adversos , Lesão Renal Aguda/fisiopatologia , Lesão Renal Aguda/terapia , Lesão Renal Aguda/urina , Biomarcadores/sangue , Biomarcadores/urina , Humanos , Polimorfismo Genético , Terapia de Substituição Renal , Fatores de Risco
14.
BMC Nephrol ; 22(1): 100, 2021 03 19.
Artigo em Inglês | MEDLINE | ID: mdl-33740915

RESUMO

BACKGROUND: We aimed to present the demographic characteristics, clinical presentation, and outcomes of our multicenter cohort of adult KTx recipients with COVID-19. METHODS: We conducted a multicenter, retrospective study using data of patients hospitalized for COVID-19 collected from 34 centers in Turkey. Demographic characteristics, clinical findings, laboratory parameters (hemogram, CRP, AST, ALT, LDH, and ferritin) at admission and follow-up, and treatment strategies were reviewed. Predictors of poor clinical outcomes were analyzed. The primary outcomes were in-hospital mortality and the need for ICU admission. The secondary outcome was composite in-hospital mortality and/or ICU admission. RESULTS: One hundred nine patients (male/female: 63/46, mean age: 48.4 ± 12.4 years) were included in the study. Acute kidney injury (AKI) developed in 46 (42.2%) patients, and 4 (3.7%) of the patients required renal replacement therapy (RRT). A total of 22 (20.2%) patients were admitted in the ICU, and 19 (17.4%) patients required invasive mechanical ventilation. 14 (12.8%) of the patients died. Patients who were admitted in the ICU were significantly older (age over 60 years) (38.1% vs 14.9%, p = 0.016). 23 (21.1%) patients reached to composite outcome and these patients were significantly older (age over 60 years) (39.1% vs. 13.9%; p = 0.004), and had lower serum albumin (3.4 g/dl [2.9-3.8] vs. 3.8 g/dl [3.5-4.1], p = 0.002), higher serum ferritin (679 µg/L [184-2260] vs. 331 µg/L [128-839], p = 0.048), and lower lymphocyte counts (700/µl [460-950] vs. 860 /µl [545-1385], p = 0.018). Multivariable analysis identified presence of ischemic heart disease and initial serum creatinine levels as independent risk factors for mortality, whereas age over 60 years and initial serum creatinine levels were independently associated with ICU admission. On analysis for predicting secondary outcome, age above 60 and initial lymphocyte count were found to be independent variables in multivariable analysis. CONCLUSION: Over the age of 60, ischemic heart disease, lymphopenia, poor graft function were independent risk factors for severe COVID-19 in this patient group. Whereas presence of ischemic heart disease and poor graft function were independently associated with mortality.


Assuntos
/complicações , Transplante de Rim , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/terapia , Adulto , Fatores Etários , /mortalidade , Creatinina/sangue , Cuidados Críticos , Feminino , Sobrevivência de Enxerto/fisiologia , Mortalidade Hospitalar , Humanos , Tempo de Internação , Contagem de Linfócitos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/complicações , Terapia de Substituição Renal , Respiração Artificial , Estudos Retrospectivos , Fatores de Risco , Albumina Sérica/metabolismo , Transplantados , Resultado do Tratamento , Turquia/epidemiologia
15.
BMC Nephrol ; 22(1): 92, 2021 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-33722189

RESUMO

BACKGROUND: Acute kidney injury (AKI) is a common manifestation among patients critically ill with SARS-CoV-2 infection (Coronavirus 2019) and is associated with significant morbidity and mortality. The pathophysiology of renal failure in this context is not fully understood, but likely to be multifactorial. The intensive care unit outcomes of patients following COVID-19 acute critical illness with associated AKI have not been fully explored. We conducted a cohort study to investigate the risk factors for acute kidney injury in patients admitted to and intensive care unit with COVID-19, its incidence and associated outcomes. METHODS: We reviewed the medical records of all patients admitted to our adult intensive care unit suffering from SARS-CoV-2 infection from 14th March 2020 until 12th May 2020. Acute kidney injury was defined using the Kidney Disease Improving Global Outcome (KDIGO) criteria. The outcome analysis was assessed up to date as 3rd of September 2020. RESULTS: A total of 81 patients admitted during this period. All patients had acute hypoxic respiratory failure and needed either noninvasive or invasive mechanical ventilatory support. Thirty-six patients (44%) had evidence of AKI (Stage I-33%, Stage II-22%, Renal Replacement Therapy (RRT)-44%). All patients with AKI stage III had RRT. Age, diabetes mellitus, immunosuppression, lymphopenia, high D-Dimer levels, increased APACHE II and SOFA scores, invasive mechanical ventilation and use of inotropic or vasopressor support were significantly associated with AKI. The peak AKI was at day 4 and mean duration of RRT was 12.5 days. The mortality was 25% for the AKI group compared to 6.7% in those without AKI. Among those received RRT and survived their illness, the renal function recovery is complete and back to baseline in all patients. CONCLUSION: Acute kidney injury and renal replacement therapy is common in critically ill patients presenting with COVID-19. It is associated with increased severity of illness on admission to ICU, increased mortality and prolonged ICU and hospital length of stay. Recovery of renal function was complete in all survived patients.


Assuntos
Lesão Renal Aguda/etiologia , /complicações , APACHE , Lesão Renal Aguda/epidemiologia , Lesão Renal Aguda/mortalidade , Lesão Renal Aguda/terapia , Estudos de Coortes , Estado Terminal , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Recuperação de Função Fisiológica , Terapia de Substituição Renal/estatística & dados numéricos , Respiração Artificial/efeitos adversos , Fatores de Risco , Equilíbrio Hidroeletrolítico
16.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 33(2): 211-215, 2021 Feb.
Artigo em Chinês | MEDLINE | ID: mdl-33729142

RESUMO

OBJECTIVE: To investigate the risk factors of citrate accumulation in patients with liver failure treated with regional citrate anticoagulated continuous renal replacement therapy (RCA-CRRT). METHODS: The clinical data of liver failure patients with RCA-CRRT admitted to department of intensive care unit (ICU) of Nantong Third People's Hospital from January 2017 to June 2020 were retrospectively analyzed. The selected patients were divided into citrate accumulation group and control group according to whether there was citrate accumulation (serum total calcium/free calcium ratio ≥ 2.4) during CRRT. The age, acute physiology and chronic health evaluation II (APACHE II), mean arterial pressure (MAP), norepinephrine (NE) dose, blood lactic acid (Lac) concentration, liver function status, citrate dose, filter time and prognosis of the patients were compared between the two groups. Unconditional Logistic regression was used to analyze the risk factors for citrate accumulation. RESULTS: Among 48 patients with RCA-CRRT and liver failure, 20 patients had citrate accumulation (accumulation group), and a total of 96 CRRTs were performed; the remaining 28 patients did not have citrate accumulation (control group), a total of 106 CRRTs were performed. There were no significant differences in age and APACHE II score between the two groups. Compared with the control group, the MAP in the accumulation group was lower [mmHg (1 mmHg = 0.133 kPa): 66.9±13.6 vs. 86.4±8.3, P = 0.032], and the dosage of NE (µg/min: 16.3±8.4 vs. 5.9±2.8, P = 0.015) and lactic acid level (mmol/L: 4.89±1.45 vs. 2.98±0.87, P = 0.004) were higher, the damage of liver function was more serious [total bilirubin (TBil, µmol/L): 220.4±45.2 vs. 163.4±43.8, P = 0.012; Child-Pugh score: 12.0±2.5 vs. 8.8±1.4, P = 0.029; model for end-stage liver disease (MELD) score: 31.30±8.22 vs. 21.78±6.40, P = 0.041], hourly citric acid dosage (mmol/h: 27.4±6.9 vs. 19.3±4.9, P = 0.032) and total citric acid dosage (mmol: 3 393±809 vs. 1 819±502, P = 0.039) were higher. Although there were no significant differences in the length of ICU stay, total length of hospitalization stay and cost of hospitalization between the two groups, the 28-day mortality of the accumulation group was higher than that of the control group (60.0% vs. 28.6%, P = 0.039). Unconditional Logistic regression analysis showed that MAP [odds ratio (OR) = 2.901, 95% confidence interval (95%CI) was 0.921-19.493, P = 0.019], NE dosage (OR = 2.098, 95%CI was 1.923-12.342, P = 0.002), Lac level (OR = 5.201, 95%CI was 3.211-9.433, P = 0.012), Child-Pugh score (OR = 1.843, 95%CI was 0.437-7.420, P = 0.018), MELD score (OR = 3.012, 95%CI was 0.384-12.843, P = 0.031), hourly citric acid dosage (OR = 4.254, 95%CI was 1.734-11.839, P = 0.011) and total citric acid dosage (OR = 4.109, 95%CI was 1.283-18.343, P = 0.001) were risk factors for citrate accumulation. CONCLUSIONS: In patients with tissue hypoperfusion and severe liver function damage, citrate anticoagulation should be avoided or the dosage of citric acid should be reduced, in order to avoid citrate accumulation.


Assuntos
Terapia de Substituição Renal Contínua , Doença Hepática Terminal , Anticoagulantes/uso terapêutico , Citratos , Ácido Cítrico , Humanos , Prognóstico , Terapia de Substituição Renal , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença
17.
Pol Merkur Lekarski ; 49(289): 13-18, 2021 Feb 24.
Artigo em Inglês | MEDLINE | ID: mdl-33713086

RESUMO

Introduction of the definition and classification of chronic kidney disease (CKD) according to the KDOQI guidelines in 2002 served as a turning point in nephrology. On one hand, the new definition has allowed for the standardization of terminology, on the other hand, however, it has led to a rapid growth in CKD diagnoses. Another issue is the strengthening of the assumption, that diagnosis of CKD is associated with further progressive kidney dysfunction until reaching the end stage renal disease (ESRD). Clinical practice, however, provides evidence that not all patients diagnosed with CKD reach ESRD and eventually require renal replacement therapy (RRT), and in many cases CKD does not progress. AIM: The aim of the study was to assess practical information for a clinician provided by eGFR and its changes during the follow-up of a patient as regards the RRT prognosis and mortality risk. MATERIALS AND METHODS: The study group consisted of patients with CKD treated in the regional outpatient clinic. Progression was assessed by determining a linear trend line for eGFR results. Based on its course and the value of the coefficient of determination R2, four types of eGFR trajectories were identified: linear progression type (G2), nonlinear progression type (G1), improvement type (G3), undetermined eGFR change type (G4). RESULTS: The study group consisted of 65 patients 58.5% females, age mean 69 ± 12.8 years. The mean annual eGFR change in the entire group was -1.67±11.7 ml/min/1.73m2/year. During the study, 6.2% of patients began RRT (hemodialysis), and 9.2% died. Despite the evident tendency towards higher mortality in the group characterized by progression (G1+G2) as compared to the group without progression (G3+G4), the difference did not reach statistical significance (p=0.617). However, the comparison of groups with the baseline eGFR value above and below 45 ml/min/1.73 m2 differentiated the two groups that statistically differed in mortality (p=0.044). CONCLUSIONS: The baseline eGFR was not a significant predictor of future renal outcomes (ESRD, RRT). However, eGFR below 45 ml/min/ 1.73m2 was associated with a significantly higher mortality risk (p=0.036). Moreover, the groups with the fastest and with improved eGFR were characterized by the highest mortality.


Assuntos
Falência Renal Crônica , Insuficiência Renal Crônica , Idoso , Idoso de 80 Anos ou mais , Progressão da Doença , Receptores ErbB , Feminino , Taxa de Filtração Glomerular , Humanos , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Prognóstico , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/terapia , Terapia de Substituição Renal
18.
N Engl J Med ; 384(9): 818-828, 2021 03 04.
Artigo em Inglês | MEDLINE | ID: mdl-33657294

RESUMO

BACKGROUND: The vasoconstrictor terlipressin is used for type 1 hepatorenal syndrome (HRS-1) in many parts of the world and is part of the clinical practice guidelines in Europe. METHODS: We conducted a phase 3 trial to confirm the efficacy and safety of terlipressin plus albumin in adults with HRS-1. The patients were randomly assigned in a 2:1 ratio to receive terlipressin or placebo for up to 14 days; in both groups, concomitant use of albumin was strongly recommended. The primary end point was verified reversal of HRS, defined as two consecutive serum creatinine measurements of 1.5 mg per deciliter or less at least 2 hours apart and survival without renal-replacement therapy for at least 10 days after the completion of treatment. Four prespecified secondary end points were analyzed with the Hochberg procedure to account for multiple comparisons. RESULTS: A total of 300 patients underwent randomization - 199 were assigned to the terlipressin group and 101 to the placebo group. Verified reversal of HRS was reported in 63 patients (32%) in the terlipressin group and 17 patients (17%) in the placebo group (P = 0.006). With respect to the prespecified secondary end points, HRS reversal, defined as any serum creatinine level of 1.5 mg per deciliter or less during the first 14 days, was reported in 78 patients (39%) in the terlipressin group and 18 (18%) in the placebo group (P<0.001); HRS reversal without renal-replacement therapy by day 30, in 68 (34%) and 17 (17%), respectively (P = 0.001); HRS reversal among patients with systemic inflammatory response syndrome (84 patients in the terlipressin group and 48 patients in the placebo group), in 31 (37%) and 3 (6%), respectively (P<0.001); and verified reversal of HRS without recurrence by day 30, in 52 (26%) and 17 (17%), respectively (P = 0.08). At day 90, liver transplantations had been performed in 46 patients (23%) in the terlipressin group and 29 patients (29%) in the placebo group, and death occurred in 101 (51%) and 45 (45%), respectively. More adverse events, including abdominal pain, nausea, diarrhea, and respiratory failure, occurred with terlipressin than with placebo. Death within 90 days due to respiratory disorders occurred in 22 patients (11%) in the terlipressin group and 2 patients (2%) in the placebo group. CONCLUSIONS: In this trial involving adults with cirrhosis and HRS-1, terlipressin was more effective than placebo in improving renal function but was associated with serious adverse events, including respiratory failure. (Funded by Mallinckrodt Pharmaceuticals; CONFIRM ClinicalTrials.gov number, NCT02770716.).


Assuntos
Síndrome Hepatorrenal/tratamento farmacológico , Terlipressina/uso terapêutico , Vasoconstritores/uso terapêutico , Albuminas/uso terapêutico , Terapia Combinada , Método Duplo-Cego , Feminino , Síndrome Hepatorrenal/etiologia , Síndrome Hepatorrenal/mortalidade , Humanos , Infusões Intravenosas , Cirrose Hepática/complicações , Transplante de Fígado , Masculino , Pessoa de Meia-Idade , Terapia de Substituição Renal , Insuficiência Respiratória/induzido quimicamente , Terlipressina/efeitos adversos , Resultado do Tratamento , Vasoconstritores/efeitos adversos
19.
Am J Nephrol ; 52(2): 161-172, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33765681

RESUMO

INTRODUCTION: Renal involvement in COVID-19 is less well characterized in settings with vigilant public health surveillance, including mass screening and early hospitalization. We assessed kidney complications among COVID-19 patients in Hong Kong, including the association with risk factors, length of hospitalization, critical presentation, and mortality. METHODS: Linked electronic records of all patients with confirmed COVID-19 from 5 major designated hospitals were extracted. Duplicated records due to interhospital transferal were removed. Primary outcome was the incidence of in-hospital acute kidney injury (AKI). Secondary outcomes were AKI-associated mortality, incident renal replacement therapy (RRT), intensive care admission, prolonged hospitalization and disease course (defined as >90th percentile of hospitalization duration [35 days] and duration from symptom onset to discharge [43 days], respectively), and change of estimated glomerular filtration rate (GFR). Patients were further stratified into being symptomatic or asymptomatic. RESULTS: Patients were characterized by young age (median: 38.4, IQR: 28.4-55.8 years) and short time (median: 5, IQR: 2-9 days) from symptom onset to admission. Among the 591 patients, 22 (3.72%) developed AKI and 4 (0.68%) required RRT. The median time from symptom onset to in-hospital AKI was 15 days. AKI increased the odds of prolonged hospitalization and disease course by 2.0- and 3.5-folds, respectively. Estimated GFR 24 weeks post-discharge reduced by 7.51 and 1.06 mL/min/1.73 m2 versus baseline (upon admission) in the AKI and non-AKI groups, respectively. The incidence of AKI was comparable between asymptomatic (4.8%, n = 3/62) and symptomatic (3.7%, n = 19/519) patients. CONCLUSION: The overall rate of AKI among COVID-19 patients in Hong Kong is low, which could be attributable to a vigilant screening program and early hospitalization. Among patients who developed in-hospital AKI, the duration of hospitalization is prolonged and kidney function impairment can persist for up to 6 months post-discharge. Mass surveillance for COVID-19 is warranted in identifying asymptomatic subjects for earlier AKI management.


Assuntos
Lesão Renal Aguda/epidemiologia , Programas de Rastreamento/organização & administração , Terapia de Substituição Renal/estatística & dados numéricos , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/imunologia , Lesão Renal Aguda/terapia , Adulto , Fatores Etários , Idoso , /imunologia , Cuidados Críticos/estatística & dados numéricos , Diagnóstico Precoce , Feminino , Taxa de Filtração Glomerular/imunologia , Hong Kong/epidemiologia , Mortalidade Hospitalar , Humanos , Incidência , Tempo de Internação , Masculino , Programas de Rastreamento/estatística & dados numéricos , Pessoa de Meia-Idade , Alta do Paciente , Estudos Retrospectivos , Fatores de Risco , /isolamento & purificação , Índice de Gravidade de Doença
20.
BMJ Case Rep ; 14(3)2021 Mar 29.
Artigo em Inglês | MEDLINE | ID: mdl-33782066

RESUMO

Emerging data suggest that patients with certain comorbidities requiring intensive care unit (ICU) admission for COVID-19 have a poor prognosis. This report describes a case of a patient with multiple comorbidities who contracted COVID-19 pneumonitis but was successfully weaned off invasive mechanical ventilation after 118 days, despite his admission being complicated by recurrent septic episodes and requirement for advanced cardiovascular support and renal replacement therapy. Of note, our patient received three courses of steroids in total during his ICU stay,and current literature strongly supports the use of steroids in critically unwell patients with COVID-19. To the best of our knowledge, this is the longest reported ventilated time and intensive care/hospital stay for a surviving patient with COVID-19 and highlights the importance of allowing sufficient time for clinical interventions to take effect, even when the prognosis appears bleak.


Assuntos
/terapia , Pneumonia/terapia , Respiração Artificial , Anti-Infecciosos/uso terapêutico , Comorbidade , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia/virologia , Terapia de Substituição Renal , Sepse/complicações , Sepse/tratamento farmacológico , Esteroides/uso terapêutico , Reino Unido , Desmame do Respirador , Ventiladores Mecânicos
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