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%.
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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.
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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

Increased risk of dementia in patients hospitalized with acute kidney injury

Tsai, H. et al. (2017) PloS one. 12(2) p. e0171671

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Purpose: To determine whether acute kidney injury (AKI) is a risk factor for dementia.

Conclusions: We found that patients with AKI exhibited a significantly increased risk of developing dementia. This study provides evidence on the association between AKI and long-term adverse outcomes. Additional clinical studies investigating the related pathways are warranted.

Read the full abstract and article here

Sodium Bicarbonate Versus Sodium Chloride for Preventing Contrast-Associated Acute Kidney Injury in Critically Ill Patients: A Randomized Controlled Trial

This paper by Valette and colleagues was published in Critical Care Medicine in February 2017.  The full text of the article is available to subscribers to this journal via this link.  The Library and Knowledge Service can obtain the full text of the article for registered members by requesting it via the library website document request form.

Objectives:  To test whether hydration with bicarbonate rather than isotonic sodium chloride reduces the risk of contrast-associated acute kidney injury in critically ill patients.

Design:  Prospective, double-blind, multicentre, randomized controlled study

Setting:  Three French ICUs.  Patients:  Critically ill patients with stable renal function (n = 307) who received intravascular contrast media.  Interventions:  Hydration with 0.9% sodium chloride or 1.4% sodium bicarbonate administered with the same infusion protocol: 3 mL/kg during 1 hour before and 1 mL/kg/hr during 6 hours after contrast medium exposure.

Measurements and Main Results:  The primary endpoint was the development of contrast-associated acute kidney injury, as defined by the Acute Kidney Injury Network criteria, 72 hours after contrast exposure. Patients randomized to the bicarbonate group (n = 151) showed a higher urinary pH at the end of the infusion than patients randomized to the saline group (n = 156) (6.7 ± 2.1 vs 6.2 ± 1.8, respectively; p < 0.0001). The frequency of contrast-associated acute kidney injury was similar in both groups: 52 patients (33.3%) in the saline group and 53 patients (35.1%) in the bicarbonate group (absolute risk difference, -1.8%; 95% CI [-12.3% to 8.9%]; p = 0.81). The need for renal replacement therapy (five [3.2%] and six [3.9%] patients; p = 0.77), ICU length of stay (24.7 ± 22.9 and 23 ± 23.8 d; p = 0.52), and mortality (25 [16.0%] and 24 [15.9%] patients; p > 0.99) were also similar between the saline and bicarbonate groups, respectively.

Conclusions: Except for urinary pH, none of the outcomes differed between the two groups. Among ICU patients with stable renal function, the benefit of using sodium bicarbonate rather than isotonic sodium chloride for preventing contrast-associated acute kidney injury is marginal, if any.