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Mortality and associated risk factors in perioperative acute kidney injury treated with continuous renal replacement therapy.

ABSTRACT: BACKGROUND:Perioperative acute kidney injury (AKI) is associated with multiple postoperative complications leading to prolonged hospital stay and higher costs. AKI requiring continuous renal replacement therapy (CRRT) after surgery has an incidence of 2-6% and mortality approximates 40-60%. Previous studies examining mortality in perioperative AKI patients managed with CRRT have concentrated on cardiac surgery patients and there are very limited data on broad surgical patient populations requiring CRRT. We examined long-term mortality and factors associated with poor outcome in a broad surgical population requiring CRRT for perioperative AKI during a 10-year period. METHODS:Surgical patients admitted to the intensive care unit (ICU) of academic tertiary hospital requiring CRRT between years 2010-2019 were included. CRRT was performed using regional citrate-calcium-anticoagulation. Extracted data included patient demographics, comorbidities, and clinical parameters at ICU admission and at the initiation of CRRT. Creatinine and estimated glomerular filtration rate (eGFR) were measured at 1 year after ICU admission. RESULTS:A total of 157 patients were included in the study. ICU mortality was 42.7%, 90-day mortality 58.0% and 1-year mortality 62.4%. Blood lactate at ICU admission and CRRT initiation were independently associated with mortality in the multivariate models. Patients with lactate > 4 mmol/l had higher mortality than patients with normal lactate (77% vs. 21%) (p < 0.001). Creatinine (p = 0.004) and eGFR (p < 0.001) remained significantly altered at 1 year of follow-up compared to baseline. CONCLUSIONS:Patients undergoing surgery and requiring perioperative CRRT in the ICU have a high risk of mortality. Mortality appears to be independently associated with lactate levels.

SUBMITTER: Uusalo P

PROVIDER: S-EPMC8670067 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Background: Dialysis-dependent acute kidney injury (AKI) can be treated using continuous (CRRT) or intermittent renal replacement therapies (IRRT). Although some studies suggest that CRRT may have advantages over IRRT, study findings are inconsistent. This study assessed differences between CRRT and IRRT regarding important clinical outcomes (such as mortality and renal recovery) and cost-effectiveness. Additionally, ethical aspects that are linked to renal replacement therapies in the intensive care setting are considered. Methods: Systematic searches in MEDLINE, EMBASE, and Cochrane Library including RCTs, observational studies, and cost-effectiveness studies were performed. Results were pooled using a random effects-model. Results: Forty-nine studies were included. Findings show a higher rate of renal recovery among survivors who initially received CRRT as compared with IRRT. This advantage applies to the analysis of all studies with different observation periods (Relative Risk (RR) 1.10; 95% Confidence Interval (CI) [1.05, 1.16]) and to a selection of studies with observation periods of 90 days (RR 1.07; 95% CI [1.04, 1.09]). Regarding observation periods beyond there are no differences when only two identified studies were analyzed. Patients initially receiving CRRT have higher mortality as compared to IRRT (RR 1.17; 95% CI [1.06, 1.28]). This difference is attributable to observational studies and may have been caused by allocation bias since seriously ill patients more often initially receive CRRT instead of IRRT. CRRT do not significantly differ from IRRT with respect to change of mean arterial pressure, hypotensive episodes, hemodynamic instability, and length of stay. Data on cost-effectiveness is inconsistent. Recent analyzes indicate that initial CRRT is cost-effective compared to initial IRRT due to a reduction of the rate of long-term dialysis dependence. As regards a short time horizon, this cost benefit has not been shown. Conclusion: Findings of the conducted assessment show that initial CRRT is associated with higher rates of renal recovery. Potential long-term effects on clinical outcomes for more than three months could not be analyzed and should be investigated in further studies. Economical analyzes indicate that initial CRRT is cost-effective when costs of long-term dialysis dependence are considered. However, transferability of the economic analyzes to the German health care system is limited and the conduction of economical analyzes using national cost data should be considered.

Project description:Introduction: Although low serum albumin (ALB) may worsen acute kidney injury (AKI), additional study is needed to establish the connection between ALB and the prognosis of critically ill patients with AKI and treated with continuous renal replacement therapy (CRRT). Methods:A secondary analysis of a bi-center, retrospective, and observational study, such as critically ill patients with AKI and treated with CRRT from January 2009 to September 2016. The univariate analysis, multi-factor regression analysis, sensitivity analysis, and curve-fitting analysis were applied to explore the association of ALB with the 28 and 90 days mortality of critically ill patients with AKI and treated with CRRT, and the removal efficiency of serum phosphorus. Results: From January 2009 to September 2016, 1,132 cases with AKI and treated with CRRT met the inclusion criteria and enrolled in this study. We found that the higher ALB before CRRT, the lower the 28- and 90-day mortality of patients with AKI and treated with CRRT, the higher removal efficiency of serum phosphorus, the adjusted hazard ratio (HR) value for 28-day mortality in the four models were separately 0.92 (0.90, 0.95), 0.91 (0.89, 0.94), 0.92 (0.89, 0.95), and 0.92 (0.89, 0.95); the adjusted HR value for 90 day mortality in the four models were 0.91 (0.89, 0.94), 0.92 (0.89, 0.95), 0.92 (0.89, 0.95), and 0.92 (0.89, 0.96); the adjusted OR value for the removal efficiency of serum phosphorus in the four models were separately -0.04 (-0.07, -0.01), -0.05 (-0.08, -0.01), -0.04 (-0.08, -0.01), and -0.04 (-0.08, -0.01). The sensitivity analysis and curve-fitting analysis also showed that ALB before CRRT was correlated with the 28 and 90 days mortality of critically ill patients with AKI and treated with CRRT and the removal efficiency of serum phosphorus. Conclusion: The higher the serum ALB before CRRT, the lower the mortality of critically ill patients with AKI and treated with CRRT, and the higher the clearance efficiency of serum phosphorus.

Project description:IntroductionThe optimal dialysis dose for the treatment of acute kidney injury (AKI) is controversial. We sought to evaluate the relationship between renal replacement therapy (RRT) dose and outcome.MethodsWe performed a prospective multicentre observational study in 30 intensive care units (ICUs) in eight countries from June 2005 to December 2007. Delivered RRT dose was calculated in patients treated exclusively with either continuous RRT (CRRT) or intermittent RRT (IRRT) during their ICU stay. Dose was categorised into more-intensive (CRRT >or= 35 ml/kg/hour, IRRT >or= 6 sessions/week) or less-intensive (CRRT < 35 ml/kg/hour, IRRT < 6 sessions/week). The main outcome measures were ICU mortality, ICU length of stay and duration of mechanical ventilation.ResultsOf 15,200 critically ill patients admitted during the study period, 553 AKI patients were treated with RRT, including 338 who received CRRT only and 87 who received IRRT only. For CRRT, the median delivered dose was 27.1 ml/kg/hour (interquartile range (IQR) = 22.1 to 33.9). For IRRT, the median dose was 7 sessions/week (IQR = 5 to 7). Only 22% of CRRT patients and 64% of IRRT patients received a more-intensive dose. Crude ICU mortality among CRRT patients were 60.8% vs. 52.5% (more-intensive vs. less-intensive groups, respectively). In IRRT, this was 23.6 vs. 19.4%, respectively. On multivariable analysis, there was no significant association between RRT dose and ICU mortality (Odds ratio (OR) more-intensive vs. less-intensive: CRRT OR = 1.21, 95% confidence interval (CI) = 0.66 to 2.21; IRRT OR = 1.50, 95% CI = 0.48 to 4.67). Among survivors, shorter ICU stay and duration of mechanical ventilation were observed in the more-intensive RRT groups (more-intensive vs. less-intensive for all: CRRT (median): 15 (IQR = 8 to 26) vs. 19.5 (IQR = 12 to 33.5) ICU days, P = 0.063; 7 (IQR = 4 to 17) vs. 14 (IQR = 5 to 24) ventilation days, P = 0.031; IRRT: 8 (IQR = 5.5 to 14) vs. 18 (IQR = 13 to 35) ICU days, P = 0.008; 2.5 (IQR = 0 to 10) vs. 12 (IQR = 3 to 24) ventilation days, P = 0.026).ConclusionsAfter adjustment for multiple variables, these data provide no evidence for a survival benefit afforded by higher dose RRT. However, more-intensive RRT was associated with a favourable effect on ICU stay and duration of mechanical ventilation among survivors. This result warrants further exploration.Trial registrationCochrane Renal Group (CRG110600093).

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Mortality and associated risk factors in perioperative acute kidney injury treated with continuous renal replacement therapy.

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