Characteristics of and Outcomes After Dialysis-Treated Acute Kidney Injury, 2009-2018: A Taiwanese Multicenter Study.

RATIONALE & OBJECTIVE: Dialysis-treated acute kidney injury (AKI) is increasingly common in intensive care units (ICUs) and is associated with poor outcomes. Few studies have explored the temporal trends in severity of acute illness at dialysis initiation, indications for dialysis, and their association with patient outcomes. STUDY DESIGN: Multicenter retrospective cohort study. SETTING & PARTICIPANTS: 9,535 adult patients admitted to the ICU who received their first dialysis treatment from Chang Gung Memorial Hospital system in Taiwan from 2009 through 2018. EXPOSURE: Calendar year. OUTCOMES: ICU mortality and dialysis treatment at discharge among hospital survivors. ANALYTICAL APPROACH: The temporal trends during the study period were investigated using test statistics suited for continuous or categorical data. The association between the study year and the risk of mortality was analyzed using multivariable Cox regression with adjustment for relevant clinical variables, including the severity of acute illness, defined by Sequential Organ Failure Assessment (SOFA) score. RESULTS: The mean SOFA score at dialysis initiation decreased slightly from 14.0 in 2009 to 13.6 in 2018. There was no significant trend in the number of indications for dialysis initiation that were fulfilled over time. Observed ICU mortality decreased over time, and the curve appeared to be reverse J-shaped, with a substantial decrease from 56.1% in 2009 to 46.3% in 2015 and a slight increase afterward. The risk of mortality was significantly reduced from 2013 to 2018 compared with 2009 in adjusted models. The decreasing trend in ICU mortality over time remained significant. There was an increase in dialysis treatment at discharge among survivors, mainly in patients with estimated glomerular filtration rate<60mL/min/1.73m2, from 36.8% in 2009 to 43.9% in 2018. LIMITATIONS: Residual confounding from unmeasured factors over time such as severity of comorbidities, detailed medication interventions, and delivered dialysis dose. CONCLUSIONS: We observed reductions in mortality among ICU patients with dialysis-treated acute kidney injury between 2009 and 2018, even after adjusting for dialysis indication and severity of illness at dialysis initiation. However, dialysis treatment at discharge among survivors has increased over time, mainly in patients with preexisting kidney disease. PLAIN-LANGUAGE SUMMARY: The current medical management of severe acute kidney injury (AKI) is primarily limited to supportive care and kidney replacement therapy if indicated, leading to perceptions that outcomes among intensive care unit (ICU) patients with dialysis-treated AKI have not improved. In this multicenter retrospective study of ICU patients with dialysis-treated AKI between 2009 and 2018 in Taiwan, patient mortality decreased over time despite increasing comorbidities. Moreover, the decreasing linear trends remained significant even when considering severity of acute illness at dialysis initiation, which was based on physiologic and laboratory measurements seldom evaluated in previous studies. Further research should explore the basis for these improvements.

The Nutritional Risk Index as a Predictor of 90-Day Dialysis Dependence After Acute Renal Failure: A Pilot Study.

OBJECTIVE: Return of sufficient renal function to discontinue dialysis following acute renal failure is an important clinical and patient-oriented outcome. Our study sought to develop a model using the Nutritional Risk Index (NRI) to predict 90-day dialysis dependence. METHODS: We retrospectively analyzed 77 patients with acute renal failure admitted to a single university medical center's intensive care units between January 2015 and January 2019 with the need for continuous renal replacement therapy. We assessed the predictive ability of the NRI for 90-day dialysis dependence using age, serum total protein, number of vasopressor days, baseline predialysis estimated glomerular filtration rate (eGFR), and Sequential Organ Failure Assessment (SOFA) score as covariates. RESULTS: Of the analytic group, 20 (25.9%) had severe nutritional risk, and 16 (20.8%) recovered from acute renal failure at 90 days. The mean age was 57.1 years. The clinical model comprising the NRI, age, serum total protein, number of vasopressor days, SOFA score, and baseline predialysis eGFR had an area under the curve (AUC) of 0.89 (95% confidence interval [CI], 0.81-0.97), sensitivity 56.3%, and specificity 95%. Exclusion of baseline predialysis eGFR and SOFA score did not significantly decrease model discrimination, AUC 0.87 (95% CI, 0.78-0.97). The AUC was least when serum total protein was dropped from the final model, 0.79 (95% CI, 0.66-0.92). CONCLUSIONS: The NRI when used together with other clinical parameters, including serum total protein, may improve the accuracy of predicting renal recovery and independence from dialysis at 90 days.

Renal outcomes according to renal replacement therapy modality and treatment protocol in the ATN and RENAL trials.

BACKGROUND: In critically ill patients with acute kidney injury, renal replacement therapy (RRT) modality and treatment protocols may affect kidney recovery. This study explored whether RRT modality and treatment protocol affected RRT dependence in the 'Randomized Evaluation of Normal versus Augmented Level of RRT' and the 'Acute Renal Failure Trial Network' (ATN) trials. METHODS: Primary outcome was 28-day RRT dependence. Secondary outcomes included RRT dependence among survivors and in different SOFA-based treatment protocol groups. We used the Fine-Gray competing-risk model sub-distribution hazard ratio (SHR) to assess the primary outcome. Analyses were adjusted for confounders. RESULTS: Of 2542 patients, 2175 (85.5%) received continuous RRT (CRRT) and 367 (14.4%) received intermittent hemodialysis (IHD) as first RRT modality. CRRT-first patients had greater illness severity. After adjustment, there was no between-group difference in 28-day RRT dependence (SHR, 0.96 [95% CI 0.84-1.10]; p = 0.570) or hospital mortality (odds ratio [OR], 1.14 [95% CI 0.86-1.52]; p = 0.361) However, among survivors, CRRT-first was associated with decreased 28-day RRT dependence (OR, 0.54 [95% CI 0.37-0.80]; p = 0.002) and more RRT-free days (common OR: 1.38 [95% CI 1.11-1.71]). Moreover, among CRRT-first patient, the ATN treatment protocol was associated with fewer RRT-free days, greater mortality, and a fourfold increase in RRT dependence at day 28. CONCLUSIONS: There was no difference in RRT dependence at day 28 between IHD and CRRT. However, among survivors and after adjustment, both IHD-first and the ATN treatment protocol were strongly associated with greater risk of RRT dependence at 28 days after randomization. Trial registration NCT00221013 registered September 22, 2005, and NCT00076219 registered January 19, 2004.

Characteristics and outcomes of Aboriginal and Torres Strait Islander patients with dialysis-dependent kidney disease in Australian intensive care units.

BACKGROUND: In Australia, 531 people per million population have dialysis-dependent chronic kidney disease (CKD5D). The incidence is four times higher for Aboriginal and Torres Strait Islander (indigenous) people compared with non-Indigenous Australians. CKD5D increases the risk of hospitalisation, admission to the intensive care unit (ICU) and mortality compared with patients without CKD5D. There is limited literature describing short-term outcomes of patients with CKD5D who are admitted to the ICU, comparing indigenous and non-indigenous patients. AIMS: This registry-based retrospective cohort analysis compared demographic and clinical data between indigenous and non-indigenous patients with CKD5D and tested whether indigenous status predicted short-term outcomes independently of other contributing factors. Adjusted hospital mortality was the primary outcome measure. METHODS: Data were from the Australian and New Zealand Intensive Care Society's Centre for Outcome and Resource Evaluation Adult Patient Database. Australian ICU admissions between 2010 and 2017 were included. Data from 173 ICU (2136 beds) include 1 051 697 ICU admissions, of which 23 793 had a pre-existing diagnosis of CKD5D. RESULTS: Indigenous patients comprised 11.9% of CKD5D patients in ICU. CKD5D was prevalent among 4.9% of indigenous and 2.9% of non-indigenous ICU admissions. Indigenous patients were 13.5 years younger, had fewer comorbidities and lower crude mortality despite equivalent calculated mortality risk. After adjusting for age, remoteness and severity of illness, indigenous status did not predict mortality. CONCLUSIONS: Socioeconomic disadvantage contributes to earlier development of CKD5D and the overrepresentation in ICU of indigenous people. Mortality is equivalent once correcting for confounders, but addressing inequality requires strengthening preventative care.

Accelerated versus standard initiation of renal replacement therapy for critically ill patients with acute kidney injury: a systematic review and meta-analysis of RCT studies.

BACKGROUND: Acute kidney injury (AKI) is a common yet possibly fatal complication among critically ill patients in intensive care units (ICU). Although renal replacement therapy (RRT) is an important supportive management for severe AKI patients, the optimal timing of RRT initiation for these patients is still unclear. METHODS: In this systematic review, we searched all relevant randomized controlled trials (RCTs) that directly compared accelerated with standard initiation of RRT from PUBMED, MEDLINE, EMBASE, and Cnki.net published prior to July, 20, 2020. We extracted study characteristics and outcomes of being free of dialysis, dialysis dependence and mortality. We rated the certainty of evidence according to Cochrane methods and the GRADE approach. RESULTS: We identified 56 published relevant studies from 1071 screened abstracts. Ten RCTs with 4753 critically ill AKI patients in intensive care unit (ICU) were included in this meta-analysis. In our study, accelerated and standard RRT group were not associated with all-cause mortality (log odds-ratio [OR]: - 0.04, 95% confidence intervals [CI] - 0.16 to 0.07, p = 0.46) and free of dialysis (log OR: - 0.03, 95% CI - 0.14 to 0.09, p = 0.65). In the subgroup analyses, accelerated RRT group was significantly associated with lower risk of all-cause mortality in the surgical ICU and for those who received continuous renal replacement therapy (CRRT). In addition, patients in these two subgroups had higher chances of being eventually dialysis-free. However, accelerated initiation of RRT augmented the risk of dialysis dependence in the subgroups of patients treated with non-CRRT modality and whose Sequential Organ Failure Assessment (SOFA) score were more than 11. CONCLUSIONS: In this meta-analysis, critically ill patients with severe AKI would benefit from accelerated RRT initiation regarding all-cause mortality and being eventually free of dialysis only if they were surgical ICU patients or if they underwent CRRT treatment. However, the risk of dialysis dependence was increased in the accelerated RRT group when those patients used non-CRRT modality or had high SOFA scores. All the literatures reviewed in this study were highly heterogeneous and potentially subject to biases. Trial registration CRD42020201466, Sep 07, 2020. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=201466 .

Stem cell mobilization in patients with dialysis-dependent multiple myeloma: Report of the Polish Myeloma Study Group.

INTRODUCTION: High-dose chemotherapy with autologous hematopoietic stem cell transplantation (auto-HSCT) improves the outcome of patients with multiple myeloma (MM). It seems that auto-HSCT is also a feasible therapeutic option in MM dialysis-dependent (MMDD) patients. However, to perform transplantation, a sufficient number of stem cells must be collected. MATERIALS AND METHODS: Given that data on mobilization of auto-HSC efficacy and safety in dialysis-dependent patients are limited, we report data from all Polish Centers belonging to the Polish Myeloma Study Group. Twenty-eight dialysis-dependent MM-patients were enrolled into this retrospective analysis. The study population comprised patients diagnosed between 2004 and 2015 in whom an attempt to collect auto-HSC was made (68%: women, median age: 56). Patients received granulocyte-colony stimulating factor (G-CSF) alone or in combination with chemotherapy and autologous peripheral blood stem cells (auto-PBSCs) were collected by leukapheresis. RESULTS AND CONCLUSIONS: The success rate in terms of obtaining sufficient number of CD34(+) cells/kg for an auto-HSCT (≥2 × 106 cells/kg body weight) during the first mobilization attempt was 92% (26/28 patients), and for 2 auto-HSCTs (≥4 × 106 cells/kg) - was 75% (21/28 patients). After the second mobilization attempt (undertaken in 8 patients), a sufficient number of CD34(+)/kg cells for an auto-HSCT was obtained for all patients and the number of CD34(+)/kg collected cells was sufficient for 2 auto-HSCT in 6 additional patients. Hematologic toxicity and infections were the most frequent complications. Higher doses of cytarabine (>1.6 g/m2 ) and cyclophosphamide (> 2 g/m2 ) should be avoided in MMDD patients due to toxicity. Further studies are needed to establish mobilization regimens, confirm their safety, and dosing in MMDD patients.

Changing incidence and outcomes following dialysis-requiring acute kidney injury among critically ill adults: a population-based cohort study.

BACKGROUND: Dialysis-requiring acute kidney injury (AKI) is common among critically ill patients, but little is known about trends in the incidence and outcomes of this condition over time. STUDY DESIGN: Population-based cohort study. SETTING & PARTICIPANTS: All adult patients admitted to an intensive care unit in Ontario, Canada, 1996 to 2010. PREDICTOR: Year and era (1996-2000, 2001-2005, and 2006-2010) of cohort entry. OUTCOMES: Mortality and dialysis dependence, each evaluated at 90 and 365 days after initiation of dialysis therapy for AKI. MEASUREMENTS: The annual incidence proportion of dialysis-requiring AKI was evaluated and patients with this condition were characterized by era. Associations between era and the outcomes of interest were evaluated with Cox proportional hazards (for time to death) and logistic regression (for dialysis dependence), with adjustment for relevant demographic and clinical variables. RESULTS: The annual incidence of dialysis-requiring AKI among critically ill patients increased from 0.8% in 1996 to 3.0% in 2010 (P for trend < 0.001). 90-day mortality declined from 50% in 1996 to 2000 to 45% in 2006 to 2010 (adjusted HR, 0.83 [95% CI, 0.79-0.87] compared to 1996-2000). Dialysis dependence among surviving patients at 90 days was marginally lower in 2006 to 2010 (25.1%) compared to 1996 to 2000 (27.2%), but after adjustment for confounding factors, was not significantly different (adjusted OR, 0.91; 95% CI, 0.80-1.03). LIMITATIONS: Unmeasured confounding by factors that may have changed in patients with dialysis-requiring AKI during the different eras; data set does not allow for mechanistic explanation for the findings; and lack of access to laboratory investigations after hospital discharge. CONCLUSIONS: The incidence proportion of dialysis-requiring AKI among critically ill patients increased by almost 4-fold between 1996 and 2010. This was accompanied by a significant decline in mortality, but the risk of long-term dialysis dependence continues to affect a substantial minority of surviving patients with no clear evidence of improvement over time.

Economics of dialysis dependence following renal replacement therapy for critically ill acute kidney injury patients.

BACKGROUND: The obective of this study was to perform a cost-effectiveness analysis comparing intermittent with continuous renal replacement therapy (IRRT versus CRRT) as initial therapy for acute kidney injury (AKI) in the intensive care unit (ICU). METHODS: Assuming some patients would potentially be eligible for either modality, we modeled life year gained, the quality-adjusted life years (QALYs) and healthcare costs for a cohort of 1000 IRRT patients and a cohort of 1000 CRRT patients. We used a 1-year, 5-year and a lifetime horizon. A Markov model with two health states for AKI survivors was designed: dialysis dependence and dialysis independence. We applied Weibull regression from published estimates to fit survival curves for CRRT and IRRT patients and to fit the proportion of dialysis dependence among CRRT and IRRT survivors. We then applied a risk ratio reported in a large retrospective cohort study to the fitted CRRT estimates in order to determine the proportion of dialysis dependence for IRRT survivors. We conducted sensitivity analyses based on a range of differences for daily implementation cost between CRRT and IRRT (base case: CRRT day $632 more expensive than IRRT day; range from $200 to $1000) and a range of risk ratios for dialysis dependence for CRRT as compared with IRRT (from 0.65 to 0.95; base case: 0.80). RESULTS: Continuous renal replacement therapy was associated with a marginally greater gain in QALY as compared with IRRT (1.093 versus 1.078). Despite higher upfront costs for CRRT in the ICU ($4046 for CRRT versus $1423 for IRRT in average), the 5-year total cost including the cost of dialysis dependence was lower for CRRT ($37 780 for CRRT versus $39 448 for IRRT on average). The base case incremental cost-effectiveness analysis showed that CRRT dominated IRRT. This dominance was confirmed by extensive sensitivity analysis. CONCLUSIONS: Initial CRRT is cost-effective compared with initial IRRT by reducing the rate of long-term dialysis dependence among critically ill AKI survivors.

Heterogeneity in the definition of major adverse kidney events: a scoping review.

Acute kidney injury (AKI) is associated with persistent renal dysfunction, the receipt of dialysis, dialysis dependence, and mortality. Accordingly, the concept of major adverse kidney events (MAKE) has been adopted as an endpoint for assessing the impact of AKI. However, applied criteria or observation periods for operationalizing MAKE appear to vary across studies. To evaluate this heterogeneity for MAKE evaluation, we performed a systematic scoping review of studies that employed MAKE as an AKI endpoint. Four major academic databases were searched, and we identified 122 studies with increasing numbers over time. We found marked heterogeneity in applied criteria and observation periods for MAKE across these studies, with some even lacking a description of criteria. Moreover, 13 different observation periods were employed, with 30 days and 90 days as the most common. Persistent renal dysfunction was evaluated by estimated glomerular filtration rate (34%) or serum creatinine concentration (48%); however, 37 different definitions for this component were employed in terms of parameters, cut-off criteria, and assessment periods. The definition for the dialysis component also showed significant heterogeneity regarding assessment periods and duration of dialysis requirement (chronic vs temporary). Finally, MAKE rates could vary by 7% [interquartile range: 1.7-16.7%] with different observation periods or by 36.4% with different dialysis component definitions. Our findings revealed marked heterogeneity in MAKE definitions, particularly regarding component assessment and observation periods. Dedicated discussion is needed to establish uniform and acceptable standards to operationalize MAKE in terms of selection and applied criteria of components, observation period, and reporting criteria for future trials on AKI and related conditions.

Earlier-start versus usual-start dialysis in patients with community-acquired acute kidney injury: a randomized controlled trial.

BACKGROUND: Optimum timing of the initiation of dialysis therapy in acute kidney injury is not clear. STUDY DESIGN: Prospective, open label, 2-arm, randomized, controlled trial. SETTING & PARTICIPANTS: 208 adults with acute kidney injury with progressively worsening azotemia at the artificial kidney dialysis unit of a tertiary-care referral center in western India. INTERVENTION: Earlier-start dialysis was initiated when serum urea nitrogen and/or creatinine levels increased to 70 and 7 mg/dL, respectively, whereas the usual-start dialysis patients (control group) received dialysis when clinically indicated as judged by treating nephrologists. OUTCOMES: Primary outcome was in-hospital mortality and dialysis dependence at 3 months. Secondary outcome in patients receiving dialysis was time to recovery of kidney function, computed from time of enrollment to the last dialysis session. RESULTS: Of 585 screened patients, 102 were assigned to earlier-start dialysis, and 106 to usual-start dialysis. Baseline characteristics were similar between randomized groups. 93 (91.1%) and 88 (83.1%) participants received dialysis in the intervention and control groups, respectively. Mean serum urea nitrogen and serum creatinine levels at dialysis therapy initiation were 71.7 ± 21.7 (SD) and 7.4 ± 5.3 mg/dL, respectively, in the intervention group versus 100.9 ± 32.6 and 10.41 ± 3.3 mg/dL in the control group. Data on primary outcome were available for all patients. In-hospital mortality was 20.5% and 12.2% in the intervention and control groups, respectively (relative risk, 1.67; 95% CI, 0.88-3.17; P = 0.2). 4.9% and 4.7% of patients in the intervention and control groups, respectively, were dialysis dependent at 3 months (relative risk, 1.04; 95% CI, 0.29-3.7; P = 0.9). LIMITATIONS: Study was not double blind, event rate (ie, mortality) was less than predicted, wide CIs preclude definitive findings. CONCLUSIONS: Our data do not support the earlier initiation of dialysis therapy in community-acquired acute kidney injury.

Impact of dialysis dependence on survival for multiple myeloma with renal impairment: a multicenter study in China.

Renal impairment (RI) is a very common complication of multiple myeloma (MM) with a negative impact on survival. Herein we retrospectively analyzed 334 MM patients with renal impairment at diagnosis from three hospitals in China. All 334 patients were divided into three groups, including dialysis dependence (n=43), dialysis independence (n=42), and without dialysis (n=249). Compared with dialysis independence and without dialysis groups, dialysis dependence group had the lowest overall hematologic response (48.8% vs. 97.6% vs. 77.1%, P<0.001) and overall renal response (0.0% vs. 97.6% vs. 72.7%, P<0.001), as well as the highest early mortality within 24 months (50.0% vs. 24.4% vs. 26.3%, P=0.006). Dialysis dependence group had similar progression-free survival (24 vs. 26 vs. 27 months, P=0.231) and significantly shorter overall survival (25 vs. 69 vs. 45 months, P=0.001). Dialysis dependence was independently associated with high mortality within 24 months and shorter overall survival. In conclusion, MM patients with dialysis dependence still tend to suffer a dismal disease course, including a high probability to suffer early mortality, worse hematological and renal response, as well as shorter survival. Dialysis independence could be very promising for survival improvement.

Relationship between metformin use and lactic acidosis in advanced chronic kidney disease: The REMIND-TMU study.

BACKGROUND: Evidence of metformin-associated lactic acidosis (MALA) in advanced chronic kidney disease (CKD) has been limited due to high mortality rate but rare incidence rate. The mechanism of increased MALA in advanced CKD is mainly based on the hypothesis of decreased drug elimination, which might also be confounded by increased comorbidities as CKD progresses. The goal of the study is to analyze the incidence and associated factors of lactic acidosis between metformin user and non-user with advanced CKD. METHODS: This study used a three million population-based, propensity score-matched cohort from 2008 to 2016. The primary outcome was laboratory-defined lactic acidosis. Relationships between the probability of lactic acidosis and various estimated glomerular filtration rate (eGFR) values in advanced CKD patients were also presented in regression analysis. RESULTS: Adults with type 2 diabetes whose eGFR was <30 mL/min/1.73 m2 were enrolled in this study. After the process of propensity score matching, 7707 patients were divided into metformin and non-metformin groups. In linear regression model, metformin significantly increased the risk of lactic acidosis (p=0.0204) as the eGFR declined in advanced CKD over a mean follow up of over 600 days even after confounder adjustment with age, sex and comorbidities. CONCLUSIONS: Metformin was associated with a significant increased risk of laboratory-defined lactic acidosis (p=0.0204) even after adjusting confounder such as age, sex and underlying comorbidities. This "REMIND" study reminds us that metformin-associated lactic acidosis is mainly caused by decreased drug renal elimination other than underlying comorbidities in advanced CKD patients.

Hospital case volume and clinical outcomes in critically ill patients with acute kidney injury treated with dialysis.

PURPOSE: To determine whether patients with severe acute kidney injury who receive dialysis (AKI-D) experience better outcomes at centres that care for more patients with AKI-D. MATERIALS AND METHODS: Linked administrative datasets where used to perform a retrospective cohort study of all critically ill patients in Ontario, Canada, who had a first episode of AKI-D between 2002 and 2011. Centre volume for a given year, was designated by calculating the mean number of patients treated with acute dialysis at that centre during that year and the one preceding it. Patients treated at that centre were then assigned to a centre volume quartile for that year. RESULTS: We identified 19,658 critically ill patients with AKI-D treated at 54 Ontario hospitals. Mortality and dialysis dependence at 90-days were 46% and 31%, respectively. Centre volume was not associated with mortality at 90 days (with quartile 1 as the reference, adjusted odds ratio (aOR) 1.16 (95% CI, 0.87 - 1.54) in quartile 2, aOR 1.17 (95% CI, 0.91 - 1.50) in quartile 3, and aOR 1.06 (95% CI, 0.81 - 1.41) in quartile 4). CONCLUSIONS: There are no Centre volume survival associations in the management of AKI-D despite high mortality and dependence rate.

Short- and long-term outcomes after postsurgical acute kidney injury requiring dialysis.

OBJECTIVE: Prompt assessment of perioperative complications is critical for the comprehensive care of surgical patients. Acute kidney injury requiring dialysis (AKI-D) is associated with high mortality, yet little is known about how long-term outcomes of patients have evolved. The association of AKI-D with postsurgical outcomes has not been well studied. METHODS: We investigated patients from the National Health Insurance Research Database and validated by the multicenter Clinical Trial Consortium for Renal Diseases cohort. All patients with AKI-D 18 years or older undergoing four major surgeries (cardiothoracic, esophagus, intestine, and liver) were retrospectively investigated (N=106,573). Patient demographics, surgery type, comorbidities before admission, and postsurgical outcomes, including the in-hospital, 30-day, and long-term mortality together with dialysis dependence were collected. RESULTS: AKI-D is the top risk factor for 30-day and long-term mortality after major surgery. Of 1,664 individuals with AKI-D and 6,656 matched controls, AKI-D during the hospital stay was associated with in-hospital (adjusted hazard ratio [aHR]=3.04, 95% CI 2.79-3.31), 30-day (aHR=3.65, 95% CI 3.37-3.94), and long-term (aHR=3.22, 95% CI 3.01-3.44) mortality. Patients undergoing cardiothoracic surgery (CTS) showed less in-hospital (aHR=0.85, 95% CI 0.75-0.97), 30-day (aHR=0.79, 95% CI 0.70-0.89), and long-term (aHR=0.80, 95% CI 0.72-0.90) mortality compared with non-CTS patients with AKI-D. CTS patients had a high risk of 30-day dialysis dependence (subhazard ratio [sHR]=1.67, 95% CI 1.18-2.38), but the risk of long-term dialysis dependence was similar (sHR=1.38, 95% CI 0.96-2.00) after AKI-D by taking mortality as a competing risk. Non-CTS patients had more comorbidities of sepsis, azotemia, hypoalbuminemia, and metabolic acidosis compared with CTS patients. CONCLUSION: AKI exhibits paramount effects on postsurgical outcomes that extend well beyond discharge from the hospital. The goal of the perioperative assessment should include the reassurance of enhancing renal function recovery among different surgeries, and optimized follow-up is warranted in attenuating the complications after postsurgical AKI has occurred.

Acute renal failure due to small cell neuroendocrine carcinoma of the left kidney: A case report.

The majority of small cell carcinoma (SCC) cases originate from the lungs. SCC of the kidneys is rare. Among genitourinary tumors, renal cell carcinoma is the most common type of tumor to be associated with paraneoplastic syndromes. The majority of paraneoplastic syndromes disappear following nephrectomy in renal cell carcinoma cases. The present case involved the assessment of a female patient with SCC of the left kidney. The patient was diagnosed with acute renal failure and underwent a laparoscopic left radical nephrectomy. Surgical intervention removed the need for dialysis; the patient was under follow-up observation every week without any requirement for dialysis for 8 months and received adjuvant carboplatin-etoposide chemotherapy. Surgery is an option for dialysis-dependent patients with a renal tumor. The removal of the tumor burden may restore renal function and eliminate paraneoplastic syndromes.

Obstetric acute kidney injury; a three year experience at a medical college hospital in north karnataka, India.

INTRODUCTION: Acute kidney injury is a rare and sometimes fatal complication of pregnancy, the incidence of which has been declining worldwide, though still high in developing countries. There are recent observations of increasing incidence in some developed countries attributed to hypertensive disorders of pregnancy. MATERIALS AND METHODS: In this study, we have analysed the records of all patients referred to the dialysis unit of a medical college hospital in Karnataka for acute kidney injury related to pregnancy. AKIN (Acute Kidney Injury Network) criteria for the diagnosis of acute kidney injury were adapted. Age, parity, gestational age, causative factors for acute kidney injury, mode of delivery, access to antenatal care, operative procedures, blood component transfusions, number of haemodialysis, time for initiation of haemodialysis, duration of hospital stay and mortality were analysed by finding mean, standard deviation and standard error. RESULTS: Fifteen patients out of 21563 who delivered in our hospital developed acute kidney injury. These (n=15) were out of 149 patients of acute kidney injury of various aetiologies who underwent haemodialysis between 2012 and 2014. Of these two were unregistered for antenatal care. Ten were multiparous, Eleven were from rural background, one had home delivery, six had vaginal delivery, seven had caesarean section and two had second trimester abortion. Placental abruption with intrauterine death was the commonest Cause in 9 out of 15 cases. All had severe anaemia. Patients received a mean of 3.9 (SD+/- 2.4) sessions of haemodialysis. Eleven patients recovered completely, two died and two left against medical advice. CONCLUSION: Obstetric acute kidney injury is associated with poor access to antenatal care, multiparity and rural background. Placental abruption is the commonest cause of obstetric acute kidney injury. Blood component transfusions, avoidance of nephrotoxic drugs and early initiation of haemodialysis are associated with better outcome.

Primer estudio epidemiológico de injuria renal aguda con requerimiento de terapia de reemplazo renal en argentina. sobrevida general y renal a mediano plazo / First epidemiological study of acute kidney injury with requirement of renal replacement therapy in argentina. intermediate general and renal survival

Resumen Introducción: La injuria renal aguda es un trastorno complejo, multicausal, asociado con alta mortalidad y ocasional dependencia de diálisis crónica. Se desconoce la evolución de los pacientes que requieren terapia de reemplazo renal por injuria renal aguda en Argentina. Material y métodos: Estudio prospectivo, observacional, longitudinal y multicéntrico, en mayores de 14 años, ingresados en hospitales públicos de la provincia de Santa Fe, con diagnóstico de injuria renal aguda y necesidad de terapia de reemplazo renal, durante dos años (2017 y 2018). Resultados: Total 255 pacientes. Frecuencia 164 ppm/año, 1.85/1000 internaciones por año, varones 70,98%, edad 46-66 años, comorbilidades en 71,37%, internación en unidad de cuidados críticos 89.02%, compromiso extrarrenal 82.52%. Causas más frecuentes: hipotensión arterial 62.35%, infecciones 52.73%, nefrotóxicos 17.65%. Terapia de reemplazo renal: hemodiálisis intermitente 74.51%, diálisis lenta 11.76%, terapia continua 13.73%. Evolución: vivos a 30 días 116 (45.49%), dependencia de diálisis crónica 12 (10.34%). Mortalidad: 54.51% a 30 días, progresando al 65.88% a los 420 días. Sin diferencia significativa en mortalidad a 30 días según edad, sexo, terapia de reemplazo renal, comorbilidades ni creatininemia en primera diálisis. Hubo diferencia significativa (p <0.05) en mortalidad en injuria renal aguda aislada versus compromiso extrarrenal (RR: 1.55), Unidad de Cuidados Críticos versus Sala (RR: 3.31) e hipotensión arterial (RR: 1.79) como causa. Los pacientes con dependencia de diálisis crónica presentaron mayor mortalidad a 420 días que aquellos que recuperaron función renal (50% vs 22%, RR: 2.26). Conclusiones: Este es el primer estudio epidemiológico de injuria renal aguda, con seguimiento de la población que requirió terapia de reemplazo renal en Argentina. Está compuesto por pacientes jóvenes, graves y con alta proporción de compromiso de órganos extrarrenales. La mortalidad es elevada y se prolonga más allá del inicio de la terapia de reemplazo renal, la dependencia de diálisis crónica conlleva un peor pronóstico vital.

Abstract Introduction: Acute kidney injury is a complex, multicausal disorder associated with high mortality and chronic dialysis dependence. The evolution of patients who required renal replacement therapy due to acute kidney injury in Argentina is unknown. Methods: Prospective, observational, longitudinal, multicentric study in individuals over 14 years of age admitted to public hospitals (Province of Santa Fe) with a diagnosis of acute kidney injury and need for renal replacement therapy; study duration: two years (2017 and 2018). Results: Total 255 patients. Frequency 164 ppm/year, 1.85/1000 hospitalizations/year, males 70.98%, age 46.66 years, comorbidities present in 71.37%, hospitalization in critical care 89.02%, extra renal involvement 82.52%. Most frequent causes: arterial hypotension 62.35%, infections 52.73%, nephrotoxic 17.65%. Renal replacement therapy: intermittent hemodialysis 74.51%, sustained low-efficiency dialysis 11.76%, continuous: 13.73%. Evolution: alive at 30 days 116 (45.49%), chronic dialysis dependence 12 (10.34%). Mortality: at 30 days 54.51%, progressing to 65.88% at 420 days. No significant difference in mortality at 30 days according to age, sex, renal replacement therapy, comorbidities or creatinine in first dialysis. There was a significant difference (p <0.05) in mortality in isolated acute renal injury extra renal involvement (RR: 1.55), Critical Care Unit vs Ward (RR: 3.31) and arterial hypotension as cause (RR: 1.79). Patients with chronic dialysis dependence presented higher mortality than those who recovered renal function (50% vs 22%, RR: 2.26). Conclusions: This is the first epidemiological study with follow-up of the population that required renal replacement therapy in Argentina. It is composed of young, severe patients with a high proportion of extra renal organ involvement. Mortality is high and continues beyond the onset of renal replacement therapy, chronic dialysis dependence leads to a worse vital prognosis.