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BACKGROUND AND OBJECTIVES: AKI is frequent and is associated with poor outcomes. There is limited information on the epidemiology of AKI worldwide. This study compared patients with AKI in emerging and developed countries to determine the association of clinical factors and processes of care with outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This prospective observational study was conducted among intensive care unit patients from nine centers in developed countries and five centers in emerging countries. AKI was defined as an increase in creatinine of ≥0.3 mg/dl within 48 hours. RESULTS: Between 2008 and 2012, 6647 patients were screened, of whom 1275 (19.2%) developed AKI. A total of 745 (58% of those with AKI) agreed to participate and had complete data. Patients in developed countries had more sepsis (52.1% versus 38.0%) and higher Acute Physiology and Chronic Health Evaluation (APACHE) scores (mean±SD, 61.1±27.5 versus 51.1±25.2); those from emerging countries had more CKD (54.3% versus 38.3%), GN (6.3% versus 0.9%), and interstitial nephritis (7.0% versus 0.6%) (all P<0.05). Patients from developed countries were less often treated with dialysis (15.5% versus 30.2%; P<0.001) and started dialysis later after AKI diagnosis (2.0 [interquartile range, 0.75-5.0] days versus 0 [interquartile range, 0-5.0] days; P=0.02). Hospital mortality was 22.0%, and 13.3% of survivors were dialysis dependent at discharge. Independent risk factors associated with hospital mortality included older age, residence in an emerging country, use of vasopressors (emerging countries only), dialysis and mechanical ventilation, and higher APACHE score and cumulative fluid balance (developed countries only). A lower probability of renal recovery was associated with residence in an emerging country, higher APACHE score (emerging countries only) and dialysis, while mechanical ventilation was associated with renal recovery (developed countries only). CONCLUSIONS: This study contrasts the clinical features and management of AKI and demonstrates worse outcomes in emerging than in developed countries. Differences in variations in care may explain these findings and should be considered in future trials.
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Lesión Renal Aguda/terapia , Disparidades en Atención de Salud , Unidades de Cuidados Intensivos , Diálisis Renal , APACHE , Lesión Renal Aguda/sangre , Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/mortalidad , Lesión Renal Aguda/fisiopatología , Adulto , Anciano , Biomarcadores/sangre , Brasil , China , Creatinina/sangre , Enfermedad Crítica , Países en Desarrollo , Europa (Continente) , Femenino , Humanos , India , Riñón/fisiopatología , Tiempo de Internación , Masculino , Persona de Mediana Edad , América del Norte , Estudios Prospectivos , Recuperación de la Función , Diálisis Renal/efectos adversos , Diálisis Renal/mortalidad , Características de la Residencia , Respiración Artificial , Factores de Riesgo , Factores de Tiempo , Tiempo de Tratamiento , Resultado del Tratamiento , Regulación hacia ArribaRESUMEN
BACKGROUND AND OBJECTIVES: The present study aimed to evaluate the prognostic impact of predialysis dysnatremia in patients with acute kidney injury requiring renal replacement therapy (RRT). DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: A secondary analysis of a prospective multicenter cohort study was performed. Serum sodium (Na) concentrations were categorized immediately before the first RRT as normonatremia (135≤Na ≤145mEq/L), hyponatremia (mild [130≤Na ≤134mEq/L] or severe [Na ≤129mEq/L]), and hypernatremia (mild [146≤Na ≤155mEq/L] or severe [Na ≥156mEq/L]). Multivariable logistic regression was used to estimate the impact of sodium levels categories on hospital mortality. RESULTS: Dysnatremia occurred in 47.3% of 772 included patients. Hypernatremia was more frequent than hyponatremia (33.7% vs 13.6%, P=.001). Intensive care unit (ICU) and hospital mortality rates were 64.6% and 69%, respectively. Hospital mortality was higher in severe hypernatremia (89.1% [95% confidence interval {CI}, 78.7%-95.8%] vs 64.6% [CI, 59.8%-69.2%], P<.001, in normonatremia). Older patients, clinical admission, number of comorbidities, length of ICU stay before the beginning of RRT, and the number of organ dysfunctions were associated with higher hospital mortality. In multivariate analysis, severe hypernatremia (odds ratio, 2.87; 95% CI, 1.2-6.9), poor chronic heath status, severity of illness, sepsis, and lactate were independently associated with outcome. CONCLUSION: Almost 50% of patients with acute kidney injury in need of RRT in the ICU had mild or severe dysnatremia before dialysis initiation. Hypernatremia was the main sodium disturbance and independently associated with poor outcome in the study population.
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Lesión Renal Aguda/sangre , Hipernatremia/sangre , Terapia de Reemplazo Renal/métodos , Sodio/sangre , Lesión Renal Aguda/complicaciones , Lesión Renal Aguda/mortalidad , Lesión Renal Aguda/terapia , Anciano , Comorbilidad , Femenino , Mortalidad Hospitalaria , Humanos , Hipernatremia/mortalidad , Hipernatremia/fisiopatología , Unidades de Cuidados Intensivos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Pronóstico , Estudios Prospectivos , Diálisis Renal , Índice de Severidad de la EnfermedadRESUMEN
OBJECTIVE: To evaluate the prognostic value of platelet counts in acute kidney injury patients requiring renal replacement therapy. METHODS: This prospective cohort study was performed in three tertiary-care hospitals. Platelet counts were obtained upon admission to the intensive care unit and during the first week of renal replacement therapy on days 1, 3, 5 and 7. The outcome of interest was the hospital mortality rate. With the aim of minimizing individual variation, we analyzed the relative platelet counts on days 3, 5, 7 and at the point of the largest variation during the first week of renal replacement therapy. Logistic regression analysis was used to test the prognostic value of the platelet counts. RESULTS: The study included 274 patients. The hospital mortality rate was 62%. The survivors had significantly higher platelet counts upon admission to the intensive care unit compared to the non-survivors [175.5×10(3)/mm(3) (108.5-259×10(3)/mm(3)) vs. 148×10(3)/mm(3) (80-141×10(3)/mm(3))] and during the first week of renal replacement therapy. The relative platelet count reductions were significantly associated with a higher hospital mortality rate compared with the platelet count increases (70% vs. 44% at the nadir, respectively). A relative platelet count reduction >60% was significantly associated with a worse outcome (mortality rate=82.6%). Relative platelet count variations and the percentage of reduction were independent risk factors of hospital mortality during the first week of renal replacement therapy. CONCLUSION: Platelet counts upon admission to the intensive care unit and at the beginning of renal replacement therapy as well as sequential platelet count evaluation have prognostic value in acute kidney injury patients requiring renal replacement therapy.
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Lesión Renal Aguda/terapia , Evaluación de Necesidades , Recuento de Plaquetas/métodos , Diálisis Renal , Lesión Renal Aguda/mortalidad , Anciano , Anciano de 80 o más Años , Métodos Epidemiológicos , Femenino , Mortalidad Hospitalaria , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Valores de Referencia , Centros de Atención Terciaria , Factores de TiempoRESUMEN
OBJECTIVE: To evaluate the prognostic value of platelet counts in acute kidney injury patients requiring renal replacement therapy. METHODS: This prospective cohort study was performed in three tertiary-care hospitals. Platelet counts were obtained upon admission to the intensive care unit and during the first week of renal replacement therapy on days 1, 3, 5 and 7. The outcome of interest was the hospital mortality rate. With the aim of minimizing individual variation, we analyzed the relative platelet counts on days 3, 5, 7 and at the point of the largest variation during the first week of renal replacement therapy. Logistic regression analysis was used to test the prognostic value of the platelet counts. RESULTS: The study included 274 patients. The hospital mortality rate was 62%. The survivors had significantly higher platelet counts upon admission to the intensive care unit compared to the non-survivors [175.5×103/mm3 (108.5-259×103/mm3) vs. 148×103/mm3 (80−141×103/mm3)] and during the first week of renal replacement therapy. The relative platelet count reductions were significantly associated with a higher hospital mortality rate compared with the platelet count increases (70% vs. 44% at the nadir, respectively). A relative platelet count reduction >60% was significantly associated with a worse outcome (mortality rate = 82.6%). Relative platelet count variations and the percentage of reduction were independent risk factors of hospital mortality during the first week of renal replacement therapy. CONCLUSION: Platelet counts upon admission to the intensive care unit and at the beginning of renal replacement therapy as well as sequential platelet count evaluation have prognostic value in acute kidney injury patients requiring renal replacement therapy. .
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Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Lesión Renal Aguda/terapia , Evaluación de Necesidades , Recuento de Plaquetas/métodos , Diálisis Renal , Lesión Renal Aguda/mortalidad , Métodos Epidemiológicos , Mortalidad Hospitalaria , Unidades de Cuidados Intensivos , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Valores de Referencia , Centros de Atención Terciaria , Factores de TiempoRESUMEN
BACKGROUND: Studies on cancer patients with acute kidney injury (AKI) are restricted to specialized intensive care units (ICUs). The aim of this study was to compare the characteristics and outcomes of cancer and non-cancer patients requiring renal replacement therapy (RRT) for AKI in general ICUs. METHODS: A prospective cohort study was conducted in 14 ICUs from three tertiary care hospitals. A total of 773 (non-cancer 85%; cancer 15%) consecutive patients were included over a 44-month period. Logistic regression was used to identify factors associated with hospital mortality. RESULTS: Continuous RRT was used in 79% patients. The main contributing factors for AKI were sepsis (72%) and ischaemia/shock (66%); AKI was multifactorial in 87% of cancer and in 71% non-cancer patients. Hospital mortality rates were higher in cancer (78%) than in non-cancer patients (68%) (P=0.042). However, in multivariate analyses, older age, medical admission, poor chronic health status, comorbidities, ICU days until the RRT start and number of associated organ dysfunctions were associated with hospital mortality. The diagnosis of cancer was not independently associated with mortality [odds ratio=1.54 (95% confidence interval, 0.88-2.62), P=0.115]. Mortality in cancer patients was mostly dependent on the number of associated organ dysfunctions. Of note, 85% cancer patients recovered renal function at hospital discharge. CONCLUSIONS: In general ICUs, one in six patients requiring RRT has cancer. Despite a relatively higher mortality, the presence of cancer was not independently associated with mortality in the present cohort.
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Lesión Renal Aguda/terapia , Neoplasias/complicaciones , Terapia de Reemplazo Renal , Lesión Renal Aguda/complicaciones , Lesión Renal Aguda/mortalidad , Anciano , Anciano de 80 o más Años , Cuidados Críticos , Enfermedad Crítica , Femenino , Mortalidad Hospitalaria , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del TratamientoRESUMEN
Patients can experience acute kidney injury and require renal replacement therapy at any time during their admission to intensive care units. Prognostic scores have been used to characterize and stratify patients by the severity of acute disease, but scores based on findings during the day of admission may not be reliable surrogate markers of the severity of acute illness in this population. The aim of this study was to evaluate the performance of SAPS 3 and MPM(0)-III scores, determined at the start of renal replacement therapy, in 244 patients admitted to 11 units of three hospitals in Rio de Janeiro, Brazil. Continuous renal replacement therapy was used as first indication in 84% of these patients. Discrimination by area under the receiver operating characteristic curve was significantly better for SAPS 3 than for MPM(0)-III, as was the calibration measured by the Hosmer-Lemeshow goodness-of-fit test. Mortality prediction and calibration approached those eventually found when a customized equation of SAPS 3 for Central and South America was used. After adjusting for other relevant covariates in multivariate analyses, both higher prognostic scores and length of stay in the unit prior to the start of renal replacement therapy were the main predictive factors for hospital mortality. Our study shows that a customized SAPS 3 model was accurate in predicting mortality and seems a promising algorithm to characterize and stratify patients in clinical studies.
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Lesión Renal Aguda/diagnóstico , Terapia de Reemplazo Renal/estadística & datos numéricos , Índice de Severidad de la Enfermedad , Lesión Renal Aguda/mortalidad , Lesión Renal Aguda/terapia , Anciano , Anciano de 80 o más Años , Algoritmos , Brasil , Enfermedad Crítica , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Curva ROC , Tasa de SupervivenciaRESUMEN
BACKGROUND: This study aimed to evaluate and compare the characteristics and outcomes of patients with end-stage renal disease (ESRD) with those of matched controls of patients with acute kidney injury (AKI) requiring renal replacement therapy. METHODS: A case-control study was performed at the intensive care units (ICU) of three tertiary-care hospitals between December 2004 and September 2007. Patients were admitted with life-threatening complications and were matched for age and for severity of illness and organ dysfunctions. Conditional logistic regression was used to identify factors associated with hospital mortality. RESULTS: A total of 54 patients with ESRD and 54 patients with AKI were eligible for the study and were well matched. In general, clinical characteristics were similar. Nonetheless, comorbidities were more frequent in patients with ESRD, and patients with AKI more frequently required mechanical ventilation. ICU (43% versus 20%, P = 0.023) and hospital (50% versus 24%, P = 0.010) mortality rates were higher in patients with AKI. In addition, patients with AKI experienced longer ICU and hospitals stays. The SAPS II score had a regular ability in discriminating survivors and non-survivors, and tended to underestimate mortality in patients with AKI and overestimate in patients with ESRD. When all patients were evaluated, older age [OR = 1.05 (95% CI, 1.01-1.09)], poor chronic health status [OR = 3.90(1.19-12.82)] and number of associated organ failures [OR = 4.44(1.97-10.00)] were the main independent predictors of mortality. After adjusting for those covariates, ESRD was still associated with a lower probability of death [OR = 0.17 (0.06-0.050)]. CONCLUSIONS: ESRD patients with life-threatening complications had significantly better outcome than AKI patients.
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Lesión Renal Aguda/terapia , Fallo Renal Crónico/terapia , Terapia de Reemplazo Renal , Lesión Renal Aguda/mortalidad , Anciano , Anciano de 80 o más Años , Brasil/epidemiología , Estudios de Casos y Controles , Cuidados Críticos , Enfermedad Crítica , Femenino , Humanos , Fallo Renal Crónico/mortalidad , Masculino , Persona de Mediana Edad , Pronóstico , Diálisis Renal , Resultado del TratamientoRESUMEN
INTRODUCTION: Acute kidney injury usually develops in critically ill patients in the context of multiple organ dysfunctions. OBJECTIVE: To evaluate the effect of changes in associated organ dysfunctions over the first three days of renal replacement therapy on the outcomes of patients with acute kidney injury. METHODS: Over a 19-month period, we evaluated 260 patients admitted to the intensive care units of three tertiary-care hospitals who required renal replacement therapy for > 48 h. Organ dysfunctions were evaluated by SOFA score (excluding renal points) on the first (D1) and third (D3) days of renal replacement therapy. Absolute (A-SOFA) and relative (Delta-SOFA) changes in SOFA scores were also calculated. RESULTS: Hospital mortality rate was 75%. Organ dysfunctions worsened (A-SOFA>0) in 53%, remained unchanged (A-SOFA=0) in 17% and improved (A-SOFA<0) in 30% of patients; and mortality was lower in the last group (80% vs. 84% vs. 61%, p=0.003). SOFA on D1 (p<0.001), SOFA on D3 (p<0.001), A-SOFA (p=0.019) and Delta-SOFA (p=0.016) were higher in non-survivors. However, neither A-SOFA nor Delta-SOFA discriminated survivors from non-survivors on an individual basis. Adjusting for other covariates (including SOFA on D1), A-SOFA and Delta-SOFA were associated with increased mortality, and patients in whom SOFA scores worsened or remained unchanged had poorer outcomes. CONCLUSIONS: In addition to baseline values, early changes in SOFA score after the start of renal replacement therapy were associated with hospital mortality. However, no prognostic score should be used as the only parameter to predict individual outcomes.
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Enfermedad Crítica/mortalidad , Insuficiencia Multiorgánica/mortalidad , Terapia de Reemplazo Renal/mortalidad , Lesión Renal Aguda/mortalidad , Lesión Renal Aguda/terapia , Anciano , Brasil/epidemiología , Femenino , Escala de Coma de Glasgow , Mortalidad Hospitalaria , Humanos , Unidades de Cuidados Intensivos , Masculino , Estudios Prospectivos , Diálisis Renal , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
JUSTIFICATIVA E OBJETIVOS: Não existe consenso sobre qual modelo prognóstico deva ser utilizado em pacientes com disfunção renal aguda (DRA). O objetivo deste estudo foi avaliar o desempenho de seis escores de prognóstico em pacientes que necessitaram de suporte renal. MÉTODO: Coorte prospectiva de pacientes internados nas unidades de terapia intensiva (UTI) de três hospitais terciários que necessitaram de suporte renal por DRA durante 32 meses. Foram excluídos os pacientes crônicos em programa de diálise ou com < 24h de internação na UTI. Os dados das primeiras 24h de UTI foram utilizados no cálculo do SAPS II e do APACHE II, e os dados das primeiras 24h de suporte renal foram utilizados no cálculo dos escores LOD, ODIN, Liaño e Mehta. A discriminação foi avaliada através da área sobre a curva ROC (AUROC) e a calibração através do teste do goodness-of-fit de Hosmer-Lemeshow. A letalidade hospitalar foi o desfecho de interesse. RESULTADOS: Quatrocentos e sesseta e sete pacientes foram incluídos e a letalidade hospitalar foi 75 por cento. Os valores dos escores SAPS II, APACHE II e LOD foram 48,5 ± 11,2, 27,4 ± 6,3, 7 (5-8) pontos, respectivamente. A calibração foi adequada para todos os escores, com exceção do Mehta (p = 0,001). Entretanto, a discriminação foi ruim para todos os modelos, com AUROC variando entre 0,60 para o ODIN e 0,72 para o SAPS II e Mehta. Com exceção do Mehta, todos os modelos subestimaram a letalidade. CONCLUSÕES: Todos os seis modelos estudados foram inadequados na predição prognóstica de pacientes graves com DRA e necessidade de suporte renal.
BACKGROUND AND OBJECTIVES: There is no consensus about prognostic scores for use in patients with acute kidney injury (AKI). The aim of this study was to evaluate the performance of six prognostic scores in predicting hospital mortality in patients with AKI and need for renal replacement therapy (RRT). METHODS: Prospective cohort of patients admitted to the intensive care units (ICU) of three tertiary care hospitals that required RRT for AKI over a 32-month period. Patients with end-stage renal disease and those with ICU stay < 24h were excluded. Data from the first 24h of ICU admission were used to calculate SAPS II and APACHE II scores, and data from the first 24h of RRT were used in the calculation of LOD, ODIN, Liaño and Mehta scores. Discrimination was evaluated using the area under ROC curve (AUROC) and calibration using the Hosmer-Lemeshow goodness-of-fit test. The hospital mortality was the end-point of interest. RESULTS: 467 patients were evaluated. Hospital mortality rate was 75 percent. Mean SAPS II and APACHE II scores were 48.5 ±11.2 and 27.4 ± 6.3 points, and median LOD score was 7 (5-8) points. Except for Mehta score (p = 0.001), calibration was appropriate in all models. However, discrimination was uniformly unsatisfactory; AUROC ranged from 0.60 for ODIN to 0.72 for SAPS II and Mehta scores. In addition, except for Mehta, all models tended to underestimate hospital mortality. CONCLUSIONS: Organ dysfunction, general and renal-specific severity-of-illness scores were inaccurate in predicting outcome in ICU patients in need for RRT.
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Humanos , Masculino , Femenino , Lesión Renal Aguda , Diálisis Renal/métodos , Unidades de Cuidados Intensivos , PronósticoRESUMEN
BACKGROUND AND OBJECTIVES: There is no consensus about prognostic scores for use in patients with acute kidney injury (AKI). The aim of this study was to evaluate the performance of six prognostic scores in predicting hospital mortality in patients with AKI and need for renal replacement therapy (RRT). METHODS: Prospective cohort of patients admitted to the intensive care units (ICU) of three tertiary care hospitals that required RRT for AKI over a 32-month period. Patients with end-stage renal disease and those with ICU stay < 24h were excluded. Data from the first 24h of ICU admission were used to calculate SAPS II and APACHE II scores, and data from the first 24h of RRT were used in the calculation of LOD, ODIN, Liaño and Mehta scores. Discrimination was evaluated using the area under ROC curve (AUROC) and calibration using the Hosmer-Lemeshow goodness-of-fit test. The hospital mortality was the end-point of interest. RESULTS: 467 patients were evaluated. Hospital mortality rate was 75%. Mean SAPS II and APACHE II scores were 48.5 ±11.2 and 27.4 ± 6.3 points, and median LOD score was 7 (5-8) points. Except for Mehta score (p = 0.001), calibration was appropriate in all models. However, discrimination was uniformly unsatisfactory; AUROC ranged from 0.60 for ODIN to 0.72 for SAPS II and Mehta scores. In addition, except for Mehta, all models tended to underestimate hospital mortality. CONCLUSIONS: Organ dysfunction, general and renal-specific severity-of-illness scores were inaccurate in predicting outcome in ICU patients in need for RRT.
RESUMEN
INTRODUCTION: Acute kidney injury usually develops in critically ill patients in the context of multiple organ dysfunctions. OBJECTIVE: To evaluate the effect of changes in associated organ dysfunctions over the first three days of renal replacement therapy on the outcomes of patients with acute kidney injury. METHODS: Over a 19-month period, we evaluated 260 patients admitted to the intensive care units of three tertiary-care hospitals who required renal replacement therapy for > 48 h. Organ dysfunctions were evaluated by SOFA score (excluding renal points) on the first (D1) and third (D3) days of renal replacement therapy. Absolute (A-SOFA) and relative (D-SOFA) changes in SOFA scores were also calculated. RESULTS: Hospital mortality rate was 75 percent. Organ dysfunctions worsened (A-SOFA>0) in 53 percent, remained unchanged (A-SOFA=0) in 17 percent and improved (A-SOFA<0) in 30 percent of patients; and mortality was lower in the last group (80 percent vs. 84 percent vs. 61 percent, p=0.003). SOFA on D1 (p<0.001), SOFA on D3 (p<0.001), A-SOFA (p=0.019) and D-SOFA (p=0.016) were higher in non-survivors. However, neither A-SOFA nor D-SOFA discriminated survivors from non-survivors on an individual basis. Adjusting for other covariates (including SOFA on D1), A-SOFA and D-SOFA were associated with increased mortality, and patients in whom SOFA scores worsened or remained unchanged had poorer outcomes. CONCLUSIONS: In addition to baseline values, early changes in SOFA score after the start of renal replacement therapy were associated with hospital mortality. However, no prognostic score should be used as the only parameter to predict individual outcomes.
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Anciano , Femenino , Humanos , Masculino , Enfermedad Crítica/mortalidad , Insuficiencia Multiorgánica/mortalidad , Terapia de Reemplazo Renal/mortalidad , Lesión Renal Aguda , Brasil/epidemiología , Escala de Coma de Glasgow , Mortalidad Hospitalaria , Unidades de Cuidados Intensivos , Estudios Prospectivos , Diálisis Renal , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVES: To evaluate the association of RIFLE classification with the outcomes of critically ill patients with acute kidney injury (AKI) who require renal replacement therapy (RRT). DESIGN AND SETTING: Prospective cohort study in the medical-surgical ICUs at three tertiary hospitals. PATIENTS: 214 patients over 1 year (mean age 71.4+/-15.8 years). Continuous RRT was used in 179 (84%); patients were classified as risk (25%), injury (27%), or failure (48%). Overall mortality was 76%. MEASUREMENTS AND RESULTS: There were no significant differences according to RIFLE classification (risk 72%, injury 79%, failure 76%). Variables selected in multivariate analysis were: older age (OR 1.03, 95% CI 1.01-1.06), presence of comorbidity (3.15, 1.10-9.02), poor chronic health status (6.51, 1.95-21.71), number of associated organ dysfunctions (patients with one or two organ dysfunctions 5.93, 2.03-17.33; patients with three or more organ dysfunctions 26.76, 6.28-114.11), and start of RRT after the first day of ICU (2.46, 1.09-5.53). RIFLE classification was forced into the model and was not selected. However, a subgroup analysis of 150 patients who received mechanical ventilation and vasopressors found failure to be associated with increased mortality (3.58, 1.08-11.80). CONCLUSIONS: Older age, number of organ dysfunctions, presence of comorbidities, and reduced functional capacity were the main prognostic factors. Patients who required RRT after the first day of ICU had a worse outcome. The RIFLE classification did not discriminate the prognosis in patients with AKI in need for RRT.
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Lesión Renal Aguda/clasificación , APACHE , Lesión Renal Aguda/terapia , Anciano , Comorbilidad , Creatinina/sangre , Femenino , Mortalidad Hospitalaria , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Terapia de Reemplazo Renal/métodosRESUMEN
Introduction: One important limitation of CRRT is the need of anticoagulation. The aim of this study was to compare the effect of three strategies to avoidcircuit coagulation in CRRT. Methods: Three strategies were analyzed: saline flushes, systemic anticoagulation with enoxaparin and regionalanticoagulation with citrate. Results: A total of 263 membranes used in 72 patients were evaluated. There were 61 (23%) membranes in the citrate group,23 (9%) in the enoxaparin group and 179 (68%) in the saline group. Median lifetime of membranes in the citrate group [48 (27-78) hours] was significantly higher than both of those in the enoxaparin [33 (23-48) hours, p=0.016] and in the saline group [30 (21-61) hours, p=0.008]. There were no difference between lifetimes of membranes in the enoxaparin and saline groups (p=0.604). With the exception of two patients presenting with mild metabolic alkalosis, there were no complication related to the use of citrate. Conclusions: Regional citrate anticoagulation was associated with an increased circuit lifetime incomparison with enoxaparin and saline flushes. With appropriate metabolic monitoring, this method is safe and may become a standard strategy ofanticoagulation in CRRT, even in patients with lower risks of hemorrhagic complications.
Introdução/Objetivos: A necessidade de anticoagulação do circuito extra-corpóreo é uma limitação importante à utilização de procedimentos contínuosde suporte renal (PCSR). O objetivo do presente estudo foi comparar o efeito de três estratégias de prevenção de coagulação em PCSR. Métodos: Trêsestratégias foram analisadas: lavagem com solução salina 0.9%, anticoagulação sistêmica com enoxaparina e anticoagulação regional com citrato. Resultados: Um total de 263 membranas utilizadas em 72 pacientes foi avaliado: 61 membranas (23%) no grupo citrato, 23 (9%) no grupo enoxaparina e 179 (68%) no grupo salina. A meia vida das membranas no grupo citrato [48 (27-78) horas] foi significantemente maior que a do grupo enoxaparina [33(23-48) hours, p=0.016] e salina 0,9% [30 (21-61) hours, p=0.008]. Não observamos diferença significante entre as meias-vidas das membranas no grupoenoxaparina e salina 0.9% (p=0.604). Com a exceção de dois pacientes que apresentaram discreta alcalose metabólica, não observamos complicações relacionadas ao uso do citrato. Conclusões: A anticoagulação regional com citrato esteve associada a uma maior meia vida do circuito extra-corpóreo quando comparada à anticoagulação com enoxaparina e ao uso de lavagem com solução salina 0.9%. Esse método de anticoagulação em PCSR é seguro e pode se tornar a opção de escolha, mesmo em pacientes com baixo risco de complicações hemorrágicas.
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Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano de 80 o más Años , Diálisis Renal , Heparina/análisis , Lesión Renal Aguda/complicaciones , Lesión Renal Aguda/metabolismo , Lesión Renal Aguda/patologíaRESUMEN
It has previously been shown that the mixture of bicarbonate and calcium in the solutions used for continuous renal replacement therapy led to crystallization and significant changes in calcium concentration and pH. The aim of this study was to investigate the impact of bicarbonate/calcium and lactate/calcium solutions for Continuous Renal Replacement Therapies (CRRT) on the viability and function of polymorphonuclear cells (PMN). We tested four customized bicarbonate buffered solutions: single bag (bicarbonate and calcium mixed 24 h before testing), double bag (mixed immediately before testing), filtered single bag and double bag solutions, and a commercial lactate buffered solution. Blood from 6 volunteers was incubated with the solutions for 30 min followed by PMN isolation. After overnight incubation, viability, phagocytosis, and peroxide production by PMN were determined by flow cytometry. There was no difference between the test solutions with respect to PMN viability and function. Therefore, the presence of microcrystals and the consequent changes in electrolyte concentrations do not seem to impair PMN function.