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1.
Medicine (Baltimore) ; 99(1): e18519, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31895786

RESUMO

Urinary obstruction may be a complicating factor in critically ill patients with urinary tract infections (UTIs) and requires efforts for identifying and controlling the infection source. However, its significance in clinical practice is uncertain. This retrospective study investigated the overall hospital courses of patients in the intensive care unit (ICU) with UTIs from the emergency department.Baseline severity was assessed by the sequential organ failure assessment (SOFA) score; outcomes included probability and inotropic-, ventilator-, renal replacement therapy (RRT)-, and ICU-free days and 28-day mortality.Of 122 patients with UTIs, 99 had abdominal computed tomography scans. Patients without computed tomography scans more frequently had quadriplegia and a urinary catheter than those without scans (P = .001 and .01). Urinary obstruction was identified in 40 patients who had higher SOFA scores and lactate levels (P = .01 and P < .001). The use and free days of inotropic drugs and ventilator did not differ between the groups. However, patients with obstruction were more likely to require RRT and had shorter durations of RRT-free days (odds ratio 3.8; P = .06 and estimate -3.0; P = .04). Durations of ICU-free days were shorter, but it disappeared after adjustment for initial SOFA scores (estimate -2.3; P = .15). Impact of the timing of urinary drainage on outcomes was evaluated, demonstrating that an intervention within 72 hours lengthened the duration of RRT-free days compared with that after 72 hours (estimate -6.0 days; P = .03). On the other hand, the study did not find the association between other outcomes including 28-day mortality and the timing of urinary drainage.Urinary obstruction can be a complicating factor, resulting in a higher probability of RRT implementation and shorter durations of RRT- and ICU-free days in critically ill patients with UTIs. Furthermore, delayed intervention for urinary drainage may result in longer durations of RRT. Efforts should be warranted to find the presence of urinary obstruction and to control infection source in critically ill patients with UTIs.


Assuntos
Estado Terminal/mortalidade , Terapia de Substituição Renal/mortalidade , Infecções Urinárias/mortalidade , Doenças Urológicas/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Razão de Chances , Escores de Disfunção Orgânica , Estudos Retrospectivos , Fatores de Tempo , Infecções Urinárias/etiologia , Infecções Urinárias/terapia , Doenças Urológicas/complicações , Doenças Urológicas/terapia
2.
Yonsei Med J ; 60(10): 984-991, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31538434

RESUMO

PURPOSE: Despite the increasing use of continuous renal replacement therapy (CRRT) in the neonatal intensive care unit (NICU), few studies have investigated its use in preterm infants. This study evaluated the prognosis of preterm infants after CRRT and identified risk factors of mortality after CRRT. MATERIALS AND METHODS: A retrospective review was performed in 33 preterm infants who underwent CRRT at the NICU of Samsung Medical Center between 2008 and 2017. Data of the demographic characteristics, predisposing morbidity, cardiopulmonary function, and CRRT were collected and compared between surviving and non-surviving preterm infants treated with CRRT. Univariable and multivariable analyses were performed to identify factors affecting mortality. RESULTS: Compared with the survivors, the non-survivors showed younger gestational age (29.3 vs. 33.6 weeks), lower birth weight (1359 vs. 2174 g), and lower Apgar scores at 1 minute (4.4 vs. 6.6) and 5 minutes (6.5 vs. 8.6). At the initiation of CRRT, the non-survivors showed a higher incidence of inotropic use (93% vs. 40%, p=0.017) and fluid overload (16.8% vs. 4.0%, p=0.031). Multivariable analysis revealed that fluid overload >10% at CRRT initiation was the primary determinant of mortality after CRRT in premature infants, with an adjusted odds ratio of 14.6 and a 95% confidence interval of 1.10-211.29. CONCLUSION: Our data suggest that the degree of immaturity, cardiopulmonary instability, and fluid overload affect the prognosis of preterm infants after CRRT. Preventing fluid overload and earlier initiation of CRRT may improve treatment outcomes.


Assuntos
Recém-Nascido Prematuro/fisiologia , Terapia de Substituição Renal , Feminino , Mortalidade Hospitalar , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Masculino , Análise Multivariada , Terapia de Substituição Renal/mortalidade , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
3.
Medicine (Baltimore) ; 98(33): e16800, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31415389

RESUMO

BACKGROUND: The effects of early continuous renal replacement therapy (CRRT) on mortality in patients with septic acute kidney injury (AKI) remain controversial. A systematic review and meta-analysis was performed to investigate the impact of timing of CRRT on clinical outcomes in patients with septic AKI. METHODS: The PubMed, Cochrane, and Embase databases were searched from inception to the 31st of March 2019, to identify trials that assessed the timing of initiation of CRRT in patients with septic AKI. RESULTS: Five trials including 900 patients were included. The results of this meta-analysis showed that there was no significant difference between 28-day mortality (odds ratio = 0.76;95% CI, 0.58-1.00; P = .05) and 90-day mortality(odds ratio = 0.79;95% CI, 0.59-1.06; P = .12)of early and late initiation of CRRT group. In addition, compared with late initiation strategy, early initiation showed no significant advantage in length of stay in ICU (Mean difference = -0.9;95% CI, -2.37 to 0.57; P = .23) and length of stay in hospital (Mean difference = -1.43;95% CI, -5.28 to 2.41; P = .47). CONCLUSION: Our meta-analysis revealed that early initiation of CRRT could not reduce mortality in patients with septic AKI. The study also showed no significant difference in ICU length of stay or hospital length of stay between early and late CRRT group. To achieve optimal timing of CRRT for septic AKI, large multicenter randomized trials with better design are still needed.


Assuntos
Lesão Renal Aguda/mortalidade , Lesão Renal Aguda/terapia , Terapia de Substituição Renal/mortalidade , Sepse/mortalidade , Tempo para o Tratamento/estatística & dados numéricos , Lesão Renal Aguda/complicações , Adulto , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Fatores de Risco , Sepse/etiologia , Fatores de Tempo
4.
Einstein (Sao Paulo) ; 17(3): eAO4399, 2019 May 30.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31166482

RESUMO

OBJECTIVE: To determine whether pre-hospital statin use is associated with lower renal replacement therapy requirement and/or death during intensive care unit stay. METHODS: Prospective cohort analysis. We analyzed 670 patients consecutively admitted to the intensive care unit of an academic tertiary-care hospital. Patients with ages ranging from 18 to 80 years admitted to the intensive care unit within the last 48 hours were included in the study. RESULTS: Mean age was 66±16.1 years old, mean body mass index 26.6±4/9kg/m2 and mean abdominal circumference was of 97±22cm. The statin group comprised 18.2% of patients and had lower renal replacement therapy requirement and/or mortality (OR: 0.41; 95%CI: 0.18-0.93; p=0.03). The statin group also had lower risk of developing sepsis during intensive care unit stay (OR: 0.42; 95%CI: 0.22-0.77; p=0.006) and had a reduction in hospital length-of-stay (14.7±17.5 days versus 22.3±48 days; p=0.006). Statin therapy was associated with a protective role in critical care setting independently of confounding variables, such as gender, age, C-reactive protein, need of mechanical ventilation, use of pressor agents and presence of diabetes and/or coronary disease. CONCLUSION: Statin therapy prior to hospital admission was associated with lower mortality, lower renal replacement therapy requirement and sepsis rates.


Assuntos
Lesão Renal Aguda/terapia , HDL-Colesterol/efeitos dos fármacos , LDL-Colesterol/efeitos dos fármacos , Colesterol , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Terapia de Substituição Renal/estatística & dados numéricos , Triglicerídeos , APACHE , Lesão Renal Aguda/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Proteína C-Reativa/análise , Colesterol/sangue , HDL-Colesterol/sangue , LDL-Colesterol/sangue , Creatinina/sangue , Cuidados Críticos/métodos , Feminino , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Curva ROC , Valores de Referência , Terapia de Substituição Renal/mortalidade , Reprodutibilidade dos Testes , Fatores de Risco , Resultado do Tratamento , Triglicerídeos/sangue , Adulto Jovem
5.
Transplant Proc ; 51(5): 1520-1521, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31155186

RESUMO

BACKGROUND: For most patients with liver failure receiving maintenance renal replacement therapy (RRT), treatment with living-donor liver transplantation (LDLT) alone is indicated in Japan. MATERIAL AND METHODS: We retrospectively reviewed patients who underwent LDLT while receiving RRT in our hospital. RESULTS: Three of the 5 patients who underwent LDLT while on RRT died during the first year after transplantation. CONCLUSIONS: The indications for liver transplantation in patients on RRT require careful examination.


Assuntos
Falência Hepática/complicações , Transplante de Fígado/métodos , Insuficiência Renal/complicações , Terapia de Substituição Renal , Adulto , Feminino , Humanos , Japão , Falência Hepática/cirurgia , Transplante de Fígado/mortalidade , Doadores Vivos , Masculino , Pessoa de Meia-Idade , Insuficiência Renal/terapia , Terapia de Substituição Renal/mortalidade , Estudos Retrospectivos
6.
Indian J Pediatr ; 86(4): 360-364, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30741388

RESUMO

OBJECTIVES: To identify prognostic factors and indications in patients receiving continuous renal replacement therapy (CRRT) in the pediatric intensive care unit (PICU), and to demonstrate their effect on mortality. METHODS: A total of 63 patients admitted between 2011 and 2014 were included in the study. The demographic information, pediatric risk of mortality (PRISM) scores, vasoactive-inotropic score, indication for CRRT, time of starting CRRT, presence of fluid overload, durations of CRRT, and pediatric intensive care unit (PICU) stay were compared between survivors and non-survivors. RESULTS: The overall rate of survival was 69,8%. The most common indication for CRRT was fluid overload (31.7%) followed by acute attacks of metabolic diseases (15.9%), and resistant metabolic acidosis (15.9%). The median duration of CRRT was 58 (IQR 24-96) h. The most common CRRT modality was continuous venovenous hemodiafiltration. The CRRT modality was not different between survivors and nonsurvivors. Sepsis, as the diagnosis for admission to intensive care unit was significantly related to decreased survival when compared to acute kidney injury and acute attacks of metabolic diseases. Patients with fluid overload had significantly increased rate of death, CRRT duration, use of mechanical ventilation, and PICU stay. CONCLUSIONS: The CRRT, can be effectively used for removal of fluid overload, treatment of acute attacks of metabolic diseases, and other indications in critically ill pediatric patients. It has a positive effect on mortality in high-risk PICU patients. This treatment modality can be used more frequently in pediatric intensive care unit with improved patient outcomes, and should be focused on starting therapy in early stages of fluid overload.


Assuntos
Terapia de Substituição Renal/mortalidade , Lesão Renal Aguda/terapia , Adolescente , Fatores Etários , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Terapia de Substituição Renal/métodos , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Equilíbrio Hidroeletrolítico
7.
PLoS One ; 14(1): e0211429, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30703146

RESUMO

The long-term prognosis of patients with postoperative acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) after cardiovascular surgery is unclear. We aimed to investigate long-term renal outcomes and survival in these patients to determine the risk factors for negative outcomes. Long-term prognosis was examined in 144 hospital survivors. All patients were independent and on renal replacement therapy at hospital discharge. The median age at operation was 72.0 years, and the median pre-operative estimated glomerular filtration rate (eGFR) was 39.5 mL/min/1.73 m2. The median follow-up duration was 1075 days. The endpoints were death, chronic maintenance dialysis dependence, and a composite of death and chronic dialysis. Predictors for death and dialysis were evaluated using Fine and Gray's competing risk analysis. The cumulative incidence of death was 34.9%, and the chronic dialysis rate was 13.3% during the observation period. In the multivariate proportional hazards analysis, eGFR <30 mL/min/1.73 m2 at discharge was associated with the composite endpoint of death and dialysis [hazard ratio (HR), 2.1; 95% confidence interval (CI), 1.1-3.8; P = 0.02]. Hypertension (HR 8.7, 95% CI, 2.2-35.4; P = 0.002) and eGFR <30 mL/min/1.73 m2 at discharge (HR 26.4, 95% CI, 2.6-267.1; P = 0.006) were associated with dialysis. Advanced age (≥75 years) was predictive of death. Patients with severe CRRT-requiring AKI after cardiovascular surgery have increased risks of chronic dialysis and death. Patients with eGFR <30 mL/min/1.73 m2 at discharge should be monitored especially carefully by nephrologists due to the risk of chronic dialysis and death.


Assuntos
Lesão Renal Aguda/mortalidade , Doenças Cardiovasculares/cirurgia , Procedimentos Cirúrgicos Cardiovasculares/efeitos adversos , Complicações Pós-Operatórias/mortalidade , Diálise Renal/mortalidade , Terapia de Substituição Renal/mortalidade , Sobreviventes/estatística & dados numéricos , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/terapia , Idoso , Feminino , Seguimentos , Taxa de Filtração Glomerular , Humanos , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida
8.
Clin Res Cardiol ; 108(6): 669-682, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30578436

RESUMO

BACKGROUND: The study sought to assess the prognostic impact of chronic kidney disease (CKD) and renal replacement therapy (RRT) in patients with ventricular tachyarrhythmias and sudden cardiac arrest (SCA) on admission. METHODS: A large retrospective registry was used including all consecutive patients presenting with ventricular tachycardia (VT), fibrillation (VF) and SCA on admission from 2002 to 2016. Non-CKD vs. "CKD without RRT", and "CKD without RRT" vs. "CKD with RRT" were compared applying multivariable Cox regression models and propensity-score matching for evaluation of the primary prognostic endpoint defined as long-term all-cause mortality at 2 years. Secondary prognostic endpoints were cardiac death at 24 h, in-hospital death at index and the composite endpoint of recurrent ventricular tachyarrhythmias, appropriate ICD therapies and cardiac death at 24 h. RESULTS: In 2686 unmatched high-risk patients with ventricular tachyarrhythmias and SCA, non-CKD was present in 46%, "CKD without RRT" in 46% and "CKD with RRT" in 8%. Each, VT and VF occurred in about one-third of CKD patients. Multivariable Cox regression models revealed that "CKD without RRT" (HR = 2.118; p = 0.001) and "CKD with RRT" (HR = 3.043; p = 0.001) patients were associated with the primary endpoint of long-term mortality at 2 years, which was also proven after propensity-score matching (non-CKD vs. "CKD without RRT": 43% vs. 27%, log rank p = 0.001; HR = 1.847; "CKD without RRT" vs. "CKD with RRT": 74% vs. 51%, log rank p = 0.001; HR = 2.129). The rates of secondary endpoints were higher for cardiac death at 24 h, in-hospital death at index and the composite of recurrent ventricular tachyarrhythmias, appropriate ICD therapies and  cardiac death at 24 h, respectively, for "CKD without RRT" and "CKD with RRT" patients.  CONCLUSION: In patients presenting with ventricular tachyarrhythmias and aborted SCA on admission, the presence of CKD, especially combined with RRT, is independently associated with an increase of long-term all-cause mortality at 2 years, cardiac death at 24 h, in-hospital death and the composite of recurrent ventricular tachyarrhythmias, appropriate ICD therapies and  cardiac death at 24 h.


Assuntos
Morte Súbita Cardíaca/prevenção & controle , Cardioversão Elétrica , Insuficiência Renal Crônica/terapia , Terapia de Substituição Renal , Taquicardia Ventricular/terapia , Fibrilação Ventricular/terapia , Idoso , Causas de Morte , Desfibriladores Implantáveis , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/instrumentação , Cardioversão Elétrica/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Recidiva , Sistema de Registros , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/mortalidade , Insuficiência Renal Crônica/fisiopatologia , Terapia de Substituição Renal/efeitos adversos , Terapia de Substituição Renal/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/mortalidade , Taquicardia Ventricular/fisiopatologia , Fatores de Tempo , Fibrilação Ventricular/diagnóstico , Fibrilação Ventricular/mortalidade , Fibrilação Ventricular/fisiopatologia
9.
Arthritis Rheumatol ; 71(3): 411-419, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30225865

RESUMO

OBJECTIVE: End points currently used in lupus nephritis (LN) clinical trials lack uniformity and questionably reflect long-term kidney survival. This study was undertaken to identify short-term end points that predict long-term kidney outcomes for use in clinical trials. METHODS: A database of 944 patients with LN was assembled from 3 clinical trials and 12 longitudinal cohorts. Variables from the first 12 months of treatment after diagnosis of active LN (prediction period) were assessed as potential predictors of long-term outcomes in a 36-month follow-up period. The long-term outcomes examined were new or progressive chronic kidney disease (CKD), severe kidney injury (SKI), and the need for permanent renal replacement therapy (RRT). To predict the risk for each outcome, hazard index tools (HITs) were derived using multivariable analysis with Cox proportional hazards regression. RESULTS: Among 550 eligible subjects, 54 CKD, 55 SKI, and 22 RRT events occurred. Variables in the final CKD HIT were prediction-period CKD status, 12-month proteinuria, and 12-month serum creatinine level. The SKI HIT variables included prediction-period CKD status, International Society of Nephrology (ISN)/Renal Pathology Society (RPS) class, 12-month proteinuria, 12-month serum creatinine level, race, and an interaction between ISN/RPS class and 12-month proteinuria. The RRT HIT included age at diagnosis, 12-month proteinuria, and 12-month serum creatinine level. Each HIT validated well internally (c-indices 0.84-0.92) and in an independent LN cohort (c-indices 0.89-0.92). CONCLUSION: HITs, derived from short-term kidney responses to treatment, correlate with long-term kidney outcomes, and now must be validated as surrogate end points for LN clinical trials.


Assuntos
Biomarcadores/análise , Nefrite Lúpica/mortalidade , Insuficiência Renal Crônica/mortalidade , Terapia de Substituição Renal/mortalidade , Índice de Gravidade de Doença , Lesão Renal Aguda/mortalidade , Lesão Renal Aguda/terapia , Adulto , Fatores Etários , Ensaios Clínicos como Assunto , Creatinina/sangue , Bases de Dados Factuais , Feminino , Humanos , Estudos Longitudinais , Nefrite Lúpica/terapia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Proteinúria/urina , Insuficiência Renal Crônica/terapia , Reprodutibilidade dos Testes
10.
Adv Clin Exp Med ; 28(5): 615-623, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30462382

RESUMO

BACKGROUND: Acute kidney injury (AKI) occurs in up to 30% of pediatric intensive care unit (PICU) patients and is associated with a high mortality rate. OBJECTIVES: The objective of the study was to evaluate factors associated with the outcome and to identify the prognostic factors in children receiving continuous renal replacement therapy (CRRT). MATERIAL AND METHODS: This was a retrospective, single-center study, including 46 patients. RESULTS: Logistic regression analysis demonstrated significant effects on patient survival exerted by the percentage of fluid overload (FO%) (odds ratio (OR): 1.030; p = 0.044). In the group of patients with FO% < 25%, the mortality was 33.3%, and in the FO% ≥ 25% group, the mortality was 67.9% (p < 0.001). The probability of death without multi-organ failure (MOF) was 13%, while with MOF it was 74%. There was no difference in the duration of hospitalization between the CRRT patients (mean: 21.9 days) and the general population of children hospitalized in PICU in the same period (n = 3,255; mean: 25.4 days); however, a significant difference was noted in mortality between the 2 groups of patients (54% vs 6.5%; p < 0.001). CONCLUSIONS: The mortality of PICU CRRT patients is more than 8-fold higher than the mortality of the total PICU population. Coexisting MOF increases the mortality almost 6 times. The mortality of children with FO% ≥ 25% was more than 2-fold higher than the mortality of children with FO% < 25%.


Assuntos
Lesão Renal Aguda/terapia , Unidades de Terapia Intensiva Pediátrica , Terapia de Substituição Renal/mortalidade , Desequilíbrio Hidroeletrolítico , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/mortalidade , Criança , Pré-Escolar , Estado Terminal , Feminino , Humanos , Masculino , Terapia de Substituição Renal/métodos , Estudos Retrospectivos , Resultado do Tratamento
11.
Am J Kidney Dis ; 73(2): 184-193, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30122544

RESUMO

RATIONALE & OBJECTIVE: Data for outcomes of patients with end-stage renal disease (ESRD) secondary to systemic sclerosis (scleroderma) requiring renal replacement therapy (RRT) are limited. We examined the incidence and prevalence of ESRD due to scleroderma in Europe and the outcomes among these patients following initiation of RRT. STUDY DESIGN: Registry study of incidence and prevalence and a matched cohort study of clinical outcomes. SETTING & PARTICIPANTS: Patients represented in any of 19 renal registries that provided data to the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry between 2002 and 2013. PREDICTOR: Scleroderma as the identified cause of ESRD. OUTCOMES: Incidence and prevalence of ESRD from scleroderma. Recovery from RRT dependence, patient survival after ESRD, and graft survival after kidney transplantation. ANALYTICAL APPROACH: Incidence and prevalence were calculated using population data from the European Union and standardized to population characteristics in 2005. Patient and graft survival were compared with 2 age- and sex-matched control groups without scleroderma: (1) diabetes mellitus as the cause of ESRD and (2) conditions other than diabetes mellitus as the cause of ESRD. Survival analyses were performed using Kaplan-Meier analysis and Cox regression. RESULTS: 342 patients with scleroderma (0.14% of all incident RRT patients) were included. Between 2002 and 2013, the range of adjusted annual incidence and prevalence rates of RRT for ESRD due to scleroderma were 0.11 to 0.26 and 0.73 to 0.95 per million population, respectively. Recovery of independent kidney function was greatest in the scleroderma group (7.6% vs 0.7% in diabetes mellitus and 2.0% in other primary kidney diseases control group patients, both P<0.001), though time required to achieve recovery was longer. The 5-year survival probability from day 91 of RRT among patients with scleroderma was 38.9% (95% CI, 32.0%-45.8%), whereas 5-year posttransplantation patient survival and 5-year allograft survival were 88.2% (95% CI, 75.3%-94.6%) and 72.4% (95% CI, 55.0%-84.0%), respectively. Adjusted mortality from day 91 on RRT was higher among patients with scleroderma than observed in both control groups (HRs of 1.25 [95% CI, 1.05-1.48] and 2.00 [95% CI, 1.69-2.39]). In contrast, patient and graft survival after kidney transplantation did not differ between patients with scleroderma and control groups. LIMITATIONS: No data for extrarenal manifestations, treatment, or recurrence. CONCLUSIONS: Survival of patients with scleroderma who receive dialysis for more than 90 days was worse than for those with other causes of ESRD. Patient survival after transplantation was similar to that observed among patients with ESRD due to other conditions. Patients with scleroderma had a higher rate of recovery from RRT dependence than controls.


Assuntos
Causas de Morte , Falência Renal Crônica/mortalidade , Falência Renal Crônica/terapia , Sistema de Registros , Terapia de Substituição Renal/mortalidade , Escleroderma Sistêmico/complicações , Adulto , Idoso , Estudos de Casos e Controles , Europa (Continente) , Feminino , Humanos , Internacionalidade , Estimativa de Kaplan-Meier , Falência Renal Crônica/etiologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Modelos de Riscos Proporcionais , Terapia de Substituição Renal/métodos , Estudos Retrospectivos , Medição de Risco , Escleroderma Sistêmico/diagnóstico , Escleroderma Sistêmico/terapia , Análise de Sobrevida , Resultado do Tratamento , Adulto Jovem
12.
Nephrology (Carlton) ; 24(2): 181-187, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29485220

RESUMO

AIM: Acute kidney injury (AKI) is an important clinical condition that is associated with increased mortality and morbidity. This study was performed to identify the factors that influence AKI stage, undergoing renal replacement therapy (RRT) and mortality. METHODS: This study was retrospectively conducted on 219 children with AKI who had been referred to the paediatric nephrology division of Dr Sami Ulus Teaching Hospital during their inpatient treatment from 2008 to 2012. AKI was defined using pRIFLE criteria. RESULTS: From the 219 enrolled patients, 131 were identified as having AKI at the time of hospital admission. Infant age group was the largest group. RRT was performed in 68 patients. Median RRT initiation time was 1.5 day (0-2) and the mortality increased significantly when RRT initiation time was >1 day. The likelihood of undergoing RRT was higher for patients who were younger, who were managed in PICU and who had intrinsic type of AKI. pRIFLE stage and AKI place did not influence the likelihood of undergoing RRT. Overall mortality was 26.9%. In log-rank tests, factors influencing survival were younger age, being treated in PICU, developing AKI during inpatient treatment, having a comorbid condition and undergoing RRT. pRIFLE stage did not influence survival. In the logistic regression model, factors associated with mortality included younger age, undergoing RRT and having AKI during inpatient treatment. Having underlying disease and being managed in PICU did not influence the likelihood of death. CONCLUSION: Acute kidney injury is an important condition in all hospitalized patients. More studies and interventions are needed on this topic to identify, treat and prevent AKI.


Assuntos
Lesão Renal Aguda/terapia , Terapia de Substituição Renal , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/mortalidade , Fatores Etários , Criança , Pré-Escolar , Mortalidade Hospitalar , Humanos , Lactente , Admissão do Paciente , Terapia de Substituição Renal/efeitos adversos , Terapia de Substituição Renal/mortalidade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Turquia
13.
Crit Care Med ; 47(4): e325-e331, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30585829

RESUMO

OBJECTIVES: Thrombocytopenia is common in critically ill patients with severe acute kidney injury and may be worsened by the use of renal replacement therapy. In this study, we evaluate the effects of renal replacement therapy on subsequent platelet values, the prognostic significance of a decrease in platelets, and potential risk factors for platelet decreases. DESIGN: Post hoc analysis of the Acute Renal Failure Trial Network Study. SETTING: The Acute Renal Failure Trial Network study was a multicenter, prospective, randomized, parallel-group trial of two strategies for renal replacement therapy in critically ill patients with acute kidney injury conducted between November 2003 and July 2007 at 27 Veterans Affairs and university-affiliated medical centers. SUBJECTS: The Acute Renal Failure Trial Network study evaluated 1,124 patients with severe acute kidney injury requiring renal replacement therapy. INTERVENTIONS: Predictor variables were thrombocytopenia at initiation of renal replacement therapy and platelet decrease following renal replacement therapy initiation. MEASUREMENTS AND MAIN RESULTS: Outcomes were mortality at 28 days, 60 days, and 1 year, renal recovery, renal replacement therapy free days, ICU-free days, and hospital-free days. Baseline thrombocytopenia in patients requiring renal replacement therapy was associated with increased mortality and was also associated with lower rates of renal recovery. A decrease in platelet values following renal replacement therapy initiation was associated with increased mortality. Continuous renal replacement therapy was not an independent predictor of worsening thrombocytopenia compared with those treated with intermittent hemodialysis. CONCLUSIONS: Baseline thrombocytopenia and platelet decrease following renal replacement therapy initiation were associated with increased mortality, and baseline thrombocytopenia was associated with decreased rates of renal recovery. Continuous renal replacement therapy did not decrease platelets compared with hemodialysis.


Assuntos
Lesão Renal Aguda/mortalidade , Estado Terminal/mortalidade , Terapia de Substituição Renal/mortalidade , Trombocitopenia/mortalidade , Lesão Renal Aguda/terapia , Estado Terminal/terapia , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Terapia de Substituição Renal/efeitos adversos , Fatores de Risco
14.
Cochrane Database Syst Rev ; 12: CD010612, 2018 12 18.
Artigo em Inglês | MEDLINE | ID: mdl-30560582

RESUMO

BACKGROUND: Acute kidney injury (AKI) is a common condition among patients in intensive care units (ICUs), and is associated with high death. Renal replacement therapy (RRT) is a blood purification technique used to treat the most severe forms of AKI. The optimal time to initiate RRT so as to improve clinical outcomes remains uncertain.This review complements another Cochrane review by the same authors: Intensity of continuous renal replacement therapy for acute kidney injury. OBJECTIVES: To assess the effects of different timing (early and standard) of RRT initiation on death and recovery of kidney function in critically ill patients with AKI. SEARCH METHODS: We searched the Cochrane Kidney and Transplant's Specialised Register to 23 August 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched LILACS to 11 September 2017. SELECTION CRITERIA: We included all randomised controlled trials (RCTs). We included all patients with AKI in ICU regardless of age, comparing early versus standard RRT initiation. For safety and cost outcomes we planned to include cohort studies and non-RCTs. DATA COLLECTION AND ANALYSIS: Data were extracted independently by two authors. The random-effects model was used and results were reported as risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS: We included five studies enrolling 1084 participants. Overall, most domains were assessed as being at low or unclear risk of bias. Compared to standard treatment, early initiation may reduce the risk of death at day 30, although the 95% CI does not rule out an increased risk (5 studies, 1084 participants: RR 0.83, 95% CI 0.61 to 1.13; I2 = 52%; low certainty evidence); and probably reduces the death after 30 days post randomisation (4 studies, 1056 participants: RR 0.92, 95% CI 0.76 to 1.10; I2= 29%; moderate certainty evidence); however in both results the CIs included a reduction and an increase of death. Earlier start may reduce the risk of death or non-recovery kidney function (5 studies, 1076 participants: RR 0.83, 95% CI 0.66 to 1.05; I2= 54%; low certainty evidence). Early strategy may increase the number of patients who were free of RRT after RRT discontinuation (5 studies, 1084 participants: RR 1.13, 95% CI 0.91 to 1.40; I2= 58%; low certainty evidence) and probably slightly increases the recovery of kidney function among survivors who discontinued RRT after day 30 (5 studies, 572 participants: RR 1.03, 95% CI 1.00 to 1.06; I2= 0%; moderate certainty evidence) compared to standard; however the lower limit of CI includes the null effect. Early RRT initiation increased the number of patients who experienced adverse events (4 studies, 899 participants: RR 1.10, 95% CI 1.03 to 1.16; I2 = 0%; high certainty evidence). Compared to standard, earlier RRT start may reduce the number of days in ICU (4 studies, 1056 participants: MD -1.78 days, 95% CI -3.70 to 0.13; I2 = 90%; low certainty evidence), but the CI included benefit and harm. AUTHORS' CONCLUSIONS: Based mainly on low quality of evidence identified, early RRT may reduce the risk of death and may improve the recovery of kidney function in critically patients with AKI, however the 95% CI indicates that early RRT might worsen these outcomes. There was an increased risk of adverse events with early RRT. Further adequate-powered RCTs using appropriate criteria to define the optimal time of RRT are needed to reduce the imprecision of the results.


Assuntos
Lesão Renal Aguda/terapia , Terapia de Substituição Renal/métodos , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/mortalidade , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Terapia de Substituição Renal/efeitos adversos , Terapia de Substituição Renal/mortalidade , Fatores de Tempo , Suspensão de Tratamento/estatística & dados numéricos
15.
Kidney Blood Press Res ; 43(5): 1539-1553, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30286463

RESUMO

BACKGROUND/AIMS: Mounting clinical experience and evidence from scale observational studies have suggested that polycystic kidney disease (PKD) was not a contraindication for peritoneal dialysis (PD). Recent studies have reported that PD may be associated with a better prognosis in PKD than that of non-PKD patients. To solve the problem, we performed a systematic review and comprehensive meta-analysis to compare the outcomes between PKD and non-PKD patients on PD and the all-cause mortality between patients with PKD on PD and hemodialysis (HD). METHODS: We conducted a systematic literature using electronic databases (PubMed, Ovid, Embase and Web of Science) to identify the studies reporting the endpoint events of PKD/non-PKD patients with PD and the all-cause mortality between patients with PKD on PD and HD, such as dialysis adequacy, technique failure, PD-related complications, the mode of RRT change, and all-cause mortality. We searched the literature published February 2018 or earlier. We used both fix-effects and random-effects models to calculate the overall effect estimate. A sensitivity analysis and subgroup analysis were performed to find the origin of heterogeneity. RESULTS: 12 studies with a total of 17,040 patients reported the endpoint events of PKD/non-PKD patients with PD. No significant difference was observed on dialysis adequacy (Kt/V, SMD: -0.02, 95%CI: -0.12-0.08; D: Pcr (4h), SMD: -0.10, 95% CI: -0.26-0.06), technique failure (RR: 0.97, 95%CI: 0.78-1.20), RRT change (RR: 0.96, 95%CI: 0.77-1.19), total PD-associated complications (RR: 1.0, 95%CI: 0.91-1.09) and all-cause mortality (RR: 0.40, 95%CI: 0.33-0.47) in PKD patients, compared with non-PKD subjects undergoing PD. However, the proportion of renal transplantation in PKD patients was higher than that of non-PKD patients (RR: 2.04, 95%CI: 1.88-2.20) with significant heterogeneity (I2 =82.7%, P=0.000). 4 studies with a total of 5,762 patients reported that the all-cause mortality did not differ between the PKD patients on PD and HD (RR: 0.87, 95%CI: 0.72-1.06). CONCLUSION: Our meta-analysis found that the outcomes of given population of PKD patients on PD were at least not inferior as compared to those with other primary kidney diseases, and suggested that PKD might be not absolutely a contraindication for PD. Given the limitations of the proposed, it needs further large-scale studies to assess whether PD is a suitable RRT option for end-stage renal disease (ESRD) patients with PKD.


Assuntos
Diálise Peritoneal/normas , Doenças Renais Policísticas/terapia , Humanos , Diálise Peritoneal/mortalidade , Doenças Renais Policísticas/mortalidade , Terapia de Substituição Renal/métodos , Terapia de Substituição Renal/mortalidade , Terapia de Substituição Renal/normas , Resultado do Tratamento
16.
Rev Bras Ter Intensiva ; 30(3): 376-384, 2018.
Artigo em Português, Inglês | MEDLINE | ID: mdl-30328991

RESUMO

OBJECTIVE: To evaluate whether early initiation of renal replacement therapy is associated with lower mortality in patients with acute kidney injury compared to delayed initiation. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials comparing early versus delayed initiation of renal replacement therapy in patients with acute kidney injury without the life-threatening acute kidney injury-related symptoms of fluid overload or metabolic disorders. Two investigators extracted the data from the selected studies. The Cochrane Risk of Bias Tool was used to assess the quality of the studies, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to test the overall quality of the evidence. RESULTS: Six randomized controlled trials (1,292 patients) were included. There was no statistically significant difference between early and delayed initiation of renal replacement therapy regarding the primary outcome (OR 0.82; 95%CI, 0.48 - 1.42; p = 0.488), but there was an increased risk of catheter-related bloodstream infection when renal replacement therapy was initiated early (OR 1.77; 95%CI, 1.01 - 3.11; p = 0.047). The quality of evidence generated by our meta-analysis for the primary outcome was considered low due to the risk of bias of the included studies and the heterogeneity among them. CONCLUSION: Early initiation of renal replacement therapy is not associated with improved survival. However, the quality of the current evidence is low, and the criteria used for -early- and -delayed- initiation of renal replacement therapy are too heterogeneous among studies.


Assuntos
Lesão Renal Aguda/terapia , Infecções Relacionadas a Cateter/epidemiologia , Terapia de Substituição Renal/métodos , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Análise de Regressão , Terapia de Substituição Renal/mortalidade , Fatores de Tempo , Resultado do Tratamento
17.
Scand Cardiovasc J ; 52(5): 238-243, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30182752

RESUMO

OBJECTIVES: Renal replacement therapy (RRT) is used to treat acute kidney injury as part of multi organ failure. Use and prognostic implications after out-of-hospital cardiac arrest (OHCA) is not well known. This study aims to assess incidence and use of RRT and whether RRT post-arrest was associated with 30-day mortality in Denmark in the years 2005-2013. METHODS: The Danish Cardiac Arrest Registry holds information on all OHCA patients in Denmark from 2005 to 2013. We identified 3,012 one-day survivors of OHCA ≥18 years, with presumed cardiac aetiology of arrest, admitted to ICU without previous RRT. Change in use of RRT during the study period was assessed using competing risk analysis. Mortality was assessed with Cox regression. RESULTS: On average, RRT was performed in 6% of the patient population with an average annual 1% increase, HR: 1.01, CI: 0.95-1.07, p = .69. Hazard of RRT was lower in patients receiving bystander cardiopulmonary resuscitation (CPR) (p < .001), patients with a shockable primary rhythm (p = .009) and elderly patients (p = .03). Socioeconomic factors did not influence hazard of RRT, but patients admitted to tertiary centres had higher hazard of RRT (p = .009). Use of RRT was associated with increased mortality in multivariate Cox regression (HR: 1.28, CI: 1.06-1.55, p = .01). CONCLUSION: Use of RRT as part of post resuscitation care following OHCA did not increase from 2005 to 2013; use was more common in tertiary centres and in patients with negative prehospital predictors (no bystander CPR, non-shockable rhythm). RRT was associated with increased mortality.


Assuntos
Lesão Renal Aguda/terapia , Parada Cardíaca Extra-Hospitalar/terapia , Padrões de Prática Médica/tendências , Terapia de Substituição Renal/tendências , Ressuscitação , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Dinamarca/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/diagnóstico , Parada Cardíaca Extra-Hospitalar/mortalidade , Sistema de Registros , Terapia de Substituição Renal/efeitos adversos , Terapia de Substituição Renal/mortalidade , Ressuscitação/efeitos adversos , Ressuscitação/mortalidade , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
18.
Clin Transplant ; 32(10): e13401, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30176069

RESUMO

BACKGROUND: Renal replacement therapy (RRT) after heart transplant (HT) is associated with worse prognosis. We aimed to identify predictors of RRT and the impact of this complication on long-term survival. METHODS: Cohort study of HT patients. Univariate and multivariate competing-risk regression was performed to identify independent predictors of RRT. The cumulative incidence function was plotted for RRT. The Kaplan-Meier method was used to compare long-term survival. RESULTS: We included 103 patients. At multivariate analysis, only the emergency status of HT (short-term mechanical circulatory support as a bridge to transplant), chronic kidney disease, and low oxygen delivery were independent predictors of RRT (subhazard ratio [SHR] 4.11, 95% CI 1.84-9.14; SHR 3.17, 95% CI 1.29-7.77; SHR 2.86, 95% CI 1.14-7.19, respectively). Elective HT patients that required RRT showed a significantly reduced survival comparable to patients with emergency HT and RRT (75% ± 13% vs. 67% ± 16%). The absence of RRT implied an excellent survival in patients with an emergency status of HT and elective HT (100% vs. 93% ± 4%). CONCLUSION: The emergency status of HT, chronic kidney disease, and low oxygen delivery were independent predictors of RRT. The occurrence of RRT increases the risk of death in elective HT as much as in patients with an emergency status.


Assuntos
Lesão Renal Aguda/mortalidade , Rejeição de Enxerto/mortalidade , Transplante de Coração/mortalidade , Complicações Pós-Operatórias , Terapia de Substituição Renal/mortalidade , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/etiologia , Idoso , Feminino , Seguimentos , Rejeição de Enxerto/diagnóstico , Rejeição de Enxerto/etiologia , Sobrevivência de Enxerto , Transplante de Coração/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida
19.
Am J Transplant ; 18(11): 2695-2707, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30203618

RESUMO

Our objectives were to evaluate kidney transplantation survival benefit in people aged ≥70 who were receiving renal replacement therapy (RRT) and to identify their risk factors for posttransplant mortality. This study included all patients in the national French Renal Epidemiology and Information Network registry who started RRT between 2002 and 2013 at age ≥70. Mortality risk was compared between patients with transplants; on the waiting list; and on dialysis matched for age, gender, comorbidities, and time on dialysis. Of the 41 716 elderly patients starting RRT, 1219 (2.9%) were on the waiting list and 877 (2.1%) underwent transplantation during the follow-up. Until month 3, transplant patients had a risk of death triple that of the wait-listed group. Although the risk was halved at month 9, the perioperative risk was still not offset by month 36. Compared with matched dialysis patients (n = 2183), transplant patients were not at significantly increased perioperative risk and had a lower mortality risk starting at month 3. Risk factors for posttransplant mortality were diabetes, cardiovascular comorbidities, and dialysis duration >2 years. Among older dialysis patients, 20% had neither cardiovascular comorbidity nor diabetes. Systematic early assessment of the eligibility of elderly patients for kidney transplantation is recommended to expand registration to patients with poor survival on dialysis and no cardiovascular comorbidity.


Assuntos
Rejeição de Enxerto/mortalidade , Falência Renal Crônica/mortalidade , Transplante de Rim/mortalidade , Complicações Pós-Operatórias , Diálise Renal/mortalidade , Terapia de Substituição Renal/mortalidade , Listas de Espera/mortalidade , Idoso , Estudos de Coortes , Comorbidade , Feminino , Seguimentos , Rejeição de Enxerto/etiologia , Sobrevivência de Enxerto , Humanos , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Masculino , Prognóstico , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo
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