Potentially modifiable predictors for renal replacement therapy in patients with cardiac surgery associated-acute kidney injury: a propensity score-matched case-control study

Abstract Objective: To discover potentially modifiable perioperative predictors for renal replacement therapy (RRT) in patients with cardiac surgery-associated acute kidney injury (CSA-AKI). Methods: A cohort of 1773 consecutive cardiac surgery patients with postoperative acute kidney injury (AKI) from January 2013 to December 2015 were included retrospectively. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. The primary outcome was CSA-AKI requiring renal replacement therapy (AKI-RRT). The initiation of RRT was based on clinical judgment regarding severe volume overload, metabolic abnormality (e.g., acidosis, hyperkalemia), and oliguria. Patients with AKI-RRT were matched 1:1 with patients without AKI-RRT by a propensity score, to exclude the influence of patients' demographics, comorbidities, and baseline renal function. Multivariable regression was performed to identify the predictors in the matched sample. Results: AKI-RRT occurred in 4.4% of the entire cohort (n=78/1773), with 28.2% of in-hospital mortality (n=22/78). With the propensity score, 78 pairs of patients were matched 1:1 and the variables found to be predictors of AKI-RRT included the contrast exposure within 3 days before surgery (odds ratio [OR]=2.932), central venous pressure (CVP) >10 mmHg on intensive care unit (ICU) admission (OR=1.646 per mmHg increase), and erythrocyte transfusions on the 1st day of surgery (OR=1.742 per unit increase). Conclusion: AKI-RRT is associated with high mortality. The potentially modifiable predictors found in this study require concern and interventions to prevent CSA-AKI patients from worsening prognosis.

Lipid profile and statin use in critical care setting: implications for kidney outcome / Perfil lipídico e uso de estatina em terapia intensiva: implicações no desfecho renal

ABSTRACT 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.

RESUMO Objetivo: Determinar se o uso pré-admissão hospitalar de estatina está associado com menor necessidade de diálise e/ou óbito durante internação em unidade de terapia intensiva. Métodos: Análise de coorte prospectiva. Foram incluídos consecutivamente 670 pacientes admitidos na unidade de terapia intensiva de um hospital acadêmico de cuidados terciários. Os pacientes incluídos deveriam ter entre 18 e 80 anos e ter sido admitidos na unidade de terapia intensiva nas últimas 48 horas. Resultados: A média da idade dos pacientes foi de 66±16,1 anos. O índice de massa corporal foi de 26,6±4/9kg/m2 e a circunferência abdominal média foi de 97±22cm. O grupo que fez uso de estatina pré-admissão hospitalar (18,2% dos pacientes) necessitou menos de terapia de substituição renal e/ou evoluiu para óbito (OR: 0,41; IC95%: 0,18-0,93; p=0,03). O grupo que fez uso de estatina também apresentou menor risco de evoluir com sepse durante a internação na unidade de terapia intensiva (OR: 0,42; IC95%: 0,22-0,77; p=0,006) e teve menor duração da hospitalização (14,7±17,5 dias versus 22,3±48 dias; p=0,006). A terapia pré-admissão hospitalar com estatina foi associada a papel protetor no cenário da terapia intensiva independentemente de variáveis confundidoras, como sexo, idade, proteína C-reativa, necessidade de ventilação mecânica, uso de vasopressores e diagnóstico de diabetes e/ou coronariopatia. Conclusão: A terapia com estatina antes da admissão hospitalar foi associada a menor mortalidade, menor necessidade de terapia de substituição renal e taxa de ocorrência de sepse.

Tratamientos sustitutivos en enfermedad renal: diálisis peritoneal, hemodiálisis y trasplante renal / Substitute treatment and replacement in chronic kidney disease: peritoneal dialysis, hemodialysis and transplant

Los tratamientos sustitutivos de diálisis crónica o trasplante renal se inician cuando la filtración glomerular del paciente medida por la depuración de creatinina endógena en la orina de 24 horas es inferior a 15 o 10 ml/mm y cuando se presentan complicaciones. A los enfermos con indicaciones de trasplante se les debe buscar un donador vivo seleccionado o inscribirlos en la lista de espera nacional de donación cadavérica si no existen contraindicaciones. Aun cuando no hay un registro nacional mexicano de pacientes en diálisis crónica, solo datos indirectos de la Fundación Mexicana del Riñón y de la industria de diálisis, se estima que de 40 mil a 50 mil son sujetos a este tratamiento y que anualmente la cifra se incrementa 11 %. En términos generales se considera que por cada enfermo en diálisis crónica hay otro que fallece sin acceso al tratamiento. Las unidades de hemodiálisis deben cumplir con la norma oficialmexicana de hemodiálisis y la cédula de evaluación de la calidad de las unidades de hemodiálisis del Consejo de Salubridad General. Es aconsejable que los pacientes sean incorporados a diálisis crónica después de ser presentados al comité de diálisis, y que el tratamiento se aplique con la aceptación del enfermo o sus familiares y se registre en el censo nominal.

Chronic dialysis replacement treatments or renal transplants are instituted when the patient's glomerular filtration rate, measured by 24-h urine endogenous creatinine clearance, is <10-15 ml/mm and, as the The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI), European and Canadian guidelines point out, when one or two of the following complications occur: "uremic toxicity" symptoms, significant fluid retention that does not respond to loop diuretics, hyperkalemia, chronic anemia (hemoglobin <8 g), metabolic acidosis or acute pulmonary edema. In all patients for whom transplant is indicated, a selected live donor must be sought or, in the absence of contraindications, the patient should be registered with the national cadaver donation waiting list. While waiting for the transplant, patients will be on a chronic dialysis program. There is no national registry of patients undergoing chronic dialysis; only indirect data from the Mexican Kidney Foundation and the dialysis industry are available. However, it is estimated that 40,000-50,000 people are under this treatment and the numbers grow by 11% every year. Overall, it is thought that for every patient receiving chronic dialysis, there is one more patient who dies without access to therapy. Hemodialysis units must comply with the Official Hemodialysis Standard and the General Health Council Hemodialysis Unit Quality Assessment Form.