Timing of Renal-Replacement Therapy in Patients with Acute Kidney Injury and Sepsis

This article by the IDEAL-ICU Trial Investigators and the CRICS TRIGGERSEP Network was published in the New England journal of medicine in October 2018.
Background:  Acute kidney injury is the most frequent complication in patients with septic shock and is an independent risk factor for death. Although renal-replacement therapy is the standard of care for severe acute kidney injury, the ideal time for initiation remains controversial.
Methods:  In a multicentre, randomized, controlled trial, we assigned patients with early-stage septic shock who had severe acute kidney injury at the failure stage of the risk, injury, failure, loss, and end-stage kidney disease (RIFLE) classification system but without life-threatening complications related to acute kidney injury to receive renal-replacement therapy either within 12 hours after documentation of failure-stage acute kidney injury (early strategy) or after a delay of 48 hours if renal recovery had not occurred (delayed strategy). The failure stage of the RIFLE classification system is characterized by a serum creatinine level 3 times the baseline level (or ≥4 mg per deciliter with a rapid increase of ≥0.5 mg per deciliter), urine output less than 0.3 ml per kilogram of body weight per hour for 24 hours or longer, or anuria for at least 12 hours. The primary outcome was death at 90 days.
Results:  The trial was stopped early for futility after the second planned interim analysis. A total of 488 patients underwent randomization; there were no significant between-group differences in the characteristics at baseline. Among the 477 patients for whom follow-up data at 90 days were available, 58% of the patients in the early-strategy group (138 of 239 patients) and 54% in the delayed-strategy group (128 of 238 patients) had died (P=0.38). In the delayed-strategy group, 38% (93 patients) did not receive renal-replacement therapy. Criteria for emergency renal-replacement therapy were met in 17% of the patients in the delayed-strategy group (41 patients).
Conclusions:  Among patients with septic shock who had severe acute kidney injury, there was no significant difference in overall mortality at 90 days between patients who were assigned to an early strategy for the initiation of renal-replacement therapy and those who were assigned to a delayed strategy.
The printed copy of the New England Journal of Medicine is available in the Health Care Library on D Level of Rotherham Hospital.

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Critical Care Reviews Newsletter 348 12th August 2018

The 348th Critical Care Reviews Newsletter, brings you the best critical care research and open access articles from across the medical literature during the last week.  “The highlights of this week’s edition are randomised controlled trials on terlipressin versus noradrenaline for AKI in acute-on-chronic liver failure, restricted fluid bolus volume in early paediatric septic shock & early CPAP in acute respiratory failure in children with impacritcal care reviewsired immunity; systematic reviews and meta analyses on complications and failures of central vascular access devices & laryngeal injury and upper airway symptoms after intubation during critical care; and guidelines and position statements on steroid therapy for sepsis, disorders of consciousness & spinal motion restriction in trauma.”

The full text of the newsletter can be accessed via this link.

Forced fluid removal in intensive care patients with acute kidney injury: The randomised FFAKI feasibility trial

This article by Berthelsen et al was published in the April 2018 issue of Acta Anaesthesiologica Scandinavica.
Background:  Accumulation of fluids is frequent in intensive care unit (ICU) patients with acute kidney injury and may be associated with increased mortality and decreased renal recovery. We present the results of a pilot trial assessing the feasibility of forced fluid removal in ICU patients with acute kidney injury and fluid accumulation of more than 10% ideal bodyweight.
Methods:  The FFAKI-trial was a pilot trial of forced fluid removal vs standard care in adult ICU patients with moderate to high risk acute kidney injury and 10% fluid accumulation. Fluid removal was done with furosemide and/or continuous renal replacement therapy aiming at net negative fluid balance > 1 mL/kg ideal body weight/hour until cumulative fluid balance calculated from ICU admission reached less than 1000 mL.
Results:  After 20 months, we stopped the trial prematurely due to a low inclusion rate with 23 (2%) included patients out of the 1144 screened. Despite the reduced sample size, we observed a marked reduction in cumulative fluid balance 5 days after randomisation (mean difference -5814 mL, 95% CI -2063 to -9565, P = .003) with forced fluid removal compared to standard care. While the trial was underpowered for clinical endpoints, no point estimates suggested harm from forced fluid removal.
Conclusions:  Forced fluid removal aiming at 1 mL/kg ideal body weight/hour may be an effective treatment of fluid accumulation in ICU patients with acute kidney injury. A definitive trial using our inclusion criteria seems less feasible based on our inclusion rate of only 2%.
To access the full text of these articles via the journal’s homepage you require a personal subscription to the journal.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Fluid accumulation during acute kidney injury in the intensive care unit

This research was published in Acta Anaesthesiologica Scandinavica in March 2018 by Berthelsen et al.
Introduction:  Fluid therapy is a ubiquitous intervention in patients admitted to the intensive care unit, but positive fluid balance may be associated with poor outcomes and particular in patients with acute kidney injury. Studies describing this have defined fluid overload either at specific time points or considered patients with a positive mean daily fluid balance as fluid overloaded. We wished to detail this further and performed joint model analyses of the association between daily fluid balance and outcome represented by mortality and renal recovery in patients admitted with acute kidney injury.
Method:  We did a retrospective cohort study of patients admitted to the intensive care unit with acute kidney injury during a 2-year observation period. We used serum creatinine measurements to identify patients with acute kidney injury and collected sequential daily fluid balance during the first 5 days of admission to the intensive care unit. We used joint modelling techniques to correlate the development of fluid overload with survival and renal recovery adjusted for age, gender and disease severity.
Results:  The cohort contained 863 patients with acute kidney injury of whom 460 (53%) and 254 (29%) developed 5% and 10% fluid overload, respectively. We found that both 5% and 10% fluid overload was correlated with reduced survival and renal recovery.
Conclusion:  Joint model analyses of fluid accumulation in patients admitted to the intensive care unit with acute kidney injury confirm that even a modest degree of fluid overload (5%) may be negatively associated with both survival and renal recovery.
Library members can order the full text of individual articles such as this one via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Acute kidney injury epidemiology, risk factors, and outcomes in critically ill patients 16-25 years of age treated in an adult intensive care unit

This research by Fuhrum et al was published in Annals of Intensive Care in February 2018
Background:  Most studies of acute kidney injury (AKI) have focused on older adults, and little is known about AKI in young adults (16-25 years) that are cared for in an adult intensive care unit (ICU). We analysed data from a large single-center ICU database and defined AKI using the Kidney Disease Improving Global Outcomes criteria. We stratified patients 16-55 years of age into four age groups for comparison and used multivariable logistic regression to identify associations of potential susceptibilities and exposures with AKI and mortality.
Results:  AKI developed in 52.6% (n = 8270) of the entire cohort and in 39.8% of the young adult age group (16-25 years). The AUCs for the age categories were similar at 0.754, 0.769, 0.772, and 0.770 for the 16-25-, 26-35-, 36-45-, and 45-55-year age groups, respectively. For the youngest age group, diabetes (OR 1.89; 95% CI 1.09-3.29), surgical reason for admission (OR 1.79; 95% CI 1.44-2.23), severity of illness (OR 1.02; 95% CI 1.02-1.03), hypotension (OR 1.13; 95% CI 1.04-1.24), and certain medications (vancomycin and calcineurin inhibitors) were all independently associated with AKI. AKI was a significant predictor for longer length of stay, ICU mortality, and mortality after discharge.
Conclusions:  AKI is a common event for young adults admitted to an adult tertiary care center ICU with an associated increased length of stay and risk of mortality. Potentially modifiable risk factors for AKI including medications were identified for all stratified age groups.
The full text of this article is available via the PDF that can be accessed via this link

Latest issue of “Journal of Critical Care” Volume 39 June 2017

This issue includes articles on the “Effect of ulinastatin combined with thymosin alpha 1 on sepsis: a systematic review and meta-analysis of Chinese and Indian patients”, “The accuracy of the bedside swallowing evaluation for detecting aspiratiojournal of critical care.pngn in survivors of acute respiratory failure” and “Acute kidney injury is an independent risk factor for myocardial injury after non cardiac surgery in critical patients”.

The contents page of this latest issue can be accessed via this link

To access the full text of these articles direct from the journal’s homepage you require a personal subscription to the journal.  Individual articles can be ordered via the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make article requests online via this link.

Acute kidney injury in the ICU: from injury to recovery

Reports from the 5th Paris International Conference | Annals of Intensive Care

The French Intensive Care Society organized its yearly Paris International Conference in intensive care on June 18–19, 2015. The main purpose of this meeting is to gather the best experts in the field in order to provide the highest quality update on a chosen topic. In 2015, the selected theme was: “Acute Renal Failure in the ICU: from injury to recovery.” The conference program covered multiple aspects of renal failure, including epidemiology, diagnosis, treatment and kidney support system, prognosis and recovery together with acute renal failure in specific settings. The present report provides a summary of every presentation including the key message and references and is structured in eight sections:

(a) diagnosis and evaluation,

(b) old and new diagnosis tools,

(c) old and new treatments,

(d) renal replacement therapy and management,

(e) acute renal failure witness of other conditions,

(f) prognosis and recovery,

(g) extracorporeal epuration beyond the kidney,

(h) the use of biomarkers in clinical practice

Find out more about the conference here