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Impact of dialysis practice patterns on outcomes in acute kidney injury in Intensive Care Unit.

Annigeri RA, Nandeesh V, Karuniya R, Rajalakshmi S, Venkataraman R, Ramakrishnan N - Indian J Crit Care Med (2016)

Bottom Line: The overall mortality was high (68%) but was significantly reduced during period-2 compared to period-1 (59% vs. 79.7%, P = 0.006).Adaption of PIRRT resulted in 37% reduction of utilization of CRRT.The mortality rate was significantly reduced during the period of adaption of PIRRT, possibly due to early initiation of RRT in the latter period for indications such as anuria and metabolic acidosis.

View Article: PubMed Central - PubMed

Affiliation: Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India.

ABSTRACT

Aim: Recent advances in dialysis therapy have made an impact on the clinical practice of renal replacement therapy (RRT) in acute kidney injury (AKI) in Intensive Care Unit (ICU). We studied the impact of RRT practice changes on outcomes in AKI in ICU over a period of 8 years.

Subjects and methods: AKI patients requiring RRT in ICU referred to a nephrologist during two different periods (period-1: Between May 2004 and May 2007, n = 69; period-2: Between August 2008 and May 2011, n = 93) were studied. The major changes in the dialysis practice during the period-2, compared to period-1 were introduction of prolonged intermittent RRT (PIRRT), early dialysis for metabolic acidosis, early initiation of RRT for anuria and positive fluid balance and use of bicarbonate-based fluids for continuous RRT (CRRT) instead of lactate buffer. The primary study outcome was 28-day hospital mortality.

Results: The mean age was 53.8 ± 16.1 years and 72.6% were male. Introduction of PIRRT resulted in 37% reduction in utilization of CRRT during period-2 (from 85.5% to 53.7%). The overall mortality was high (68%) but was significantly reduced during period-2 compared to period-1 (59% vs. 79.7%, P = 0.006). Metabolic acidosis but not the mode of RRT, was the significant factor which influenced mortality.

Conclusions: Adaption of PIRRT resulted in 37% reduction of utilization of CRRT. The mortality rate was significantly reduced during the period of adaption of PIRRT, possibly due to early initiation of RRT in the latter period for indications such as anuria and metabolic acidosis.

No MeSH data available.


Related in: MedlinePlus

Indications for initiation of renal replacement therapy
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Figure 1: Indications for initiation of renal replacement therapy

Mentions: The mean age was 53.8 ± 16.1 years and 72.6% were male. Table 1 shows baseline demographic, clinical and laboratory parameters of study population. The tropical diseases such as malaria, leptospirosis and dengue infection were seen in 4 (7.6%) patients during study period-1 and in 5 (5.2%) patients during study period-2. The details of the indications for dialysis during two periods are shown in Figure 1. Anuria was more common at the time of initiation of RRT during period-1 compared to period-2, but was not statistically significant (43.5% vs. 29%, P = 0.069). Arterial pH of <7.25 was significantly more during period-1 compared to period-2 (53.6% vs. 31%, P = 0.007). The results of the study outcomes are shown in Table 2. The mortality was significantly reduced during period-2 compared to period-1 (79.7% vs. 59%, P = 0.006). Table 3 shows details of hemodynamic parameters between different modalities of RRT at the time of initiation of dialysis. The MAP (mmHg) at initiation of dialysis in CRRT was significantly lower than in PIRRT (74.9 ± 11.9 vs. 80.1 ± 12.1 mmHg, P = 0.024). The number of patients who required inotropes was significantly higher in CRRT compared to that of PIRRT (90% vs. 62%, P < 0.001). Figure 2 shows the mortality in different modalities of RRT during two periods. During period-2, there was no significant difference in the mortality between CRRT and PIRRT (72% vs. 55%, P = 0.32). The Kaplan-Meir survival curves for the two periods are shown in Figure 3. The log-rank test was significant for mortality between the two periods (P = 0.007). Table 4 shows results of univariate and multivariate logistic regression analysis to identify independent risk factors of hospital mortality. Several factors were significantly associated with mortality in univariate analysis, but the degree of metabolic acidosis was the only independent variable on multivariate analysis, which significantly influenced hospital mortality. In patients who survived, the mean BUN (mg/dL) was 42.5 ± 18.3 during period-1 and 45.7 ± 25.2 during period-2 (P = 0.53), 48 h after initiation of RRT. Similarly, the mean SCr (mg/dL) was 2.63 ± 1.1 during period-1 and 2.52 ± 1.4 during period-2 (P = 0.69), after 48 h of RRT initiation. Compared to pH of 7.35–7.45, the odds ratio of mortality in patients with pH of 7.25–7.35 was 1.47 (95% CI: 0.87–2.48, P = 0.14), in patients with pH 7.1–7.25 was 5.8 (95% CI: 1.87–18.2, P < 0.001), and in patients with pH < 7.1 was 5.9 (95% CI: 1.5–23.3, P = 0.003), respectively.


Impact of dialysis practice patterns on outcomes in acute kidney injury in Intensive Care Unit.

Annigeri RA, Nandeesh V, Karuniya R, Rajalakshmi S, Venkataraman R, Ramakrishnan N - Indian J Crit Care Med (2016)

Indications for initiation of renal replacement therapy
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4759988&req=5

Figure 1: Indications for initiation of renal replacement therapy
Mentions: The mean age was 53.8 ± 16.1 years and 72.6% were male. Table 1 shows baseline demographic, clinical and laboratory parameters of study population. The tropical diseases such as malaria, leptospirosis and dengue infection were seen in 4 (7.6%) patients during study period-1 and in 5 (5.2%) patients during study period-2. The details of the indications for dialysis during two periods are shown in Figure 1. Anuria was more common at the time of initiation of RRT during period-1 compared to period-2, but was not statistically significant (43.5% vs. 29%, P = 0.069). Arterial pH of <7.25 was significantly more during period-1 compared to period-2 (53.6% vs. 31%, P = 0.007). The results of the study outcomes are shown in Table 2. The mortality was significantly reduced during period-2 compared to period-1 (79.7% vs. 59%, P = 0.006). Table 3 shows details of hemodynamic parameters between different modalities of RRT at the time of initiation of dialysis. The MAP (mmHg) at initiation of dialysis in CRRT was significantly lower than in PIRRT (74.9 ± 11.9 vs. 80.1 ± 12.1 mmHg, P = 0.024). The number of patients who required inotropes was significantly higher in CRRT compared to that of PIRRT (90% vs. 62%, P < 0.001). Figure 2 shows the mortality in different modalities of RRT during two periods. During period-2, there was no significant difference in the mortality between CRRT and PIRRT (72% vs. 55%, P = 0.32). The Kaplan-Meir survival curves for the two periods are shown in Figure 3. The log-rank test was significant for mortality between the two periods (P = 0.007). Table 4 shows results of univariate and multivariate logistic regression analysis to identify independent risk factors of hospital mortality. Several factors were significantly associated with mortality in univariate analysis, but the degree of metabolic acidosis was the only independent variable on multivariate analysis, which significantly influenced hospital mortality. In patients who survived, the mean BUN (mg/dL) was 42.5 ± 18.3 during period-1 and 45.7 ± 25.2 during period-2 (P = 0.53), 48 h after initiation of RRT. Similarly, the mean SCr (mg/dL) was 2.63 ± 1.1 during period-1 and 2.52 ± 1.4 during period-2 (P = 0.69), after 48 h of RRT initiation. Compared to pH of 7.35–7.45, the odds ratio of mortality in patients with pH of 7.25–7.35 was 1.47 (95% CI: 0.87–2.48, P = 0.14), in patients with pH 7.1–7.25 was 5.8 (95% CI: 1.87–18.2, P < 0.001), and in patients with pH < 7.1 was 5.9 (95% CI: 1.5–23.3, P = 0.003), respectively.

Bottom Line: The overall mortality was high (68%) but was significantly reduced during period-2 compared to period-1 (59% vs. 79.7%, P = 0.006).Adaption of PIRRT resulted in 37% reduction of utilization of CRRT.The mortality rate was significantly reduced during the period of adaption of PIRRT, possibly due to early initiation of RRT in the latter period for indications such as anuria and metabolic acidosis.

View Article: PubMed Central - PubMed

Affiliation: Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India.

ABSTRACT

Aim: Recent advances in dialysis therapy have made an impact on the clinical practice of renal replacement therapy (RRT) in acute kidney injury (AKI) in Intensive Care Unit (ICU). We studied the impact of RRT practice changes on outcomes in AKI in ICU over a period of 8 years.

Subjects and methods: AKI patients requiring RRT in ICU referred to a nephrologist during two different periods (period-1: Between May 2004 and May 2007, n = 69; period-2: Between August 2008 and May 2011, n = 93) were studied. The major changes in the dialysis practice during the period-2, compared to period-1 were introduction of prolonged intermittent RRT (PIRRT), early dialysis for metabolic acidosis, early initiation of RRT for anuria and positive fluid balance and use of bicarbonate-based fluids for continuous RRT (CRRT) instead of lactate buffer. The primary study outcome was 28-day hospital mortality.

Results: The mean age was 53.8 ± 16.1 years and 72.6% were male. Introduction of PIRRT resulted in 37% reduction in utilization of CRRT during period-2 (from 85.5% to 53.7%). The overall mortality was high (68%) but was significantly reduced during period-2 compared to period-1 (59% vs. 79.7%, P = 0.006). Metabolic acidosis but not the mode of RRT, was the significant factor which influenced mortality.

Conclusions: Adaption of PIRRT resulted in 37% reduction of utilization of CRRT. The mortality rate was significantly reduced during the period of adaption of PIRRT, possibly due to early initiation of RRT in the latter period for indications such as anuria and metabolic acidosis.

No MeSH data available.


Related in: MedlinePlus