Outcome among patients with acute renal failure needing continuous renal replacement therapy: A single center study

Outcome of acute renal failure (ARF) and use of continuous renal replacement therapy (CRRT) have shown a consistently high mortality. (1) Evaluate the short-term patient survival. (2) Evaluate dialysis-free survival. (3) Evaluate risk factors associated with overall survival and the continued need for intermittent dialysis. We identified adults (≥18 years) needing CRRT, treated in the critical care units of Froedtert Medical and Lutheran Hospital from January 1, 2003 till December 31, 2005. Patients were divided into two major groups needing CRRT, end stage renal disease (ESRD) (chronic dialysis) and non-ESRD with ARF. Continuous renal replacement therapy was performed with an average of 2 L replacement fluid exchanges/h. Sigma stat software was used for analysis. Comparison was done for noncontinuous variables by chi-square and t test for categorical and continuous variables, respectively. A total of 110 (ESRD 24/non-ESRD 86) patients received CRRT during study period. Over all in-hospital mortality among non-ESRD patients was 63% vs. 46% for ESRD. Among non-ESRD patients who survived, 47% needed intermittent hemodialysis on intensive care unit discharge and 28% continued to need hemodialysis at last follow-up. Among non-ESRD patients alive at discharge, those who were dialysis dependent on last follow-up were older (64.5) than those who did not require dialysis on last follow-up (58.4) P=0.347. Non-ESRD patients who died were in the hospital for an average of 17.5 days compared with 29 days for those who were discharged from the hospital. Patients with ARF needing CRRT have high in-hospital mortality. A significant percentage of patients remained dialysis dependant on last follow-up.     

Effect of timing of dialysis on mortality in critically ill, septic patients with acute renal failure

Acute renal failure with concomitant sepsis in the intensive care unit is associated with significant mortality. The purpose of this study was to determine if the timing of initiation of renal replacement therapy (RRT) in septic patients had an effect on the 28-day mortality. Retrospective data on medical intensive care unit patients with sepsis and acute renal failure requiring RRT were included. Renal replacement therapy started with a blood urea nitrogen (BUN) of <100 mg/dL was defined as "early" initiation, and initiation with a BUN ≥100 mg/dL was defined as "late." Multivariate logistic regression analysis with the primary outcome of death at 14, 28, and 365 days following the initiation of RRT was performed. One hundred thirty patients were studied. The early dialysis (mean BUN 66 mg/dL) group had 85 patients; the late group (mean BUN 137 mg/dL) had 62 patients. The mean acute physiology and chronic health evaluation II score was 24.5 in both groups. The overall 14, 28, and 365-day survival rates were 58.1%, 41.9%, and 23.6%. Survival rates for the early group were 67%, 47.7%, and 30.7% at 14, 28, and 365 days. Survival rates for the late group were 46.7%, 31.7%, and 13.3% at 14, 28, and 365 days. Upon logistic regression analysis, initiating dialysis with a BUN >100 mg/dL predicted death at 14 days (odds ratio [OR] 3.6, 95% confidence interval [CI] 1.7–7.6, P=0.001), 28 days (OR 2.6, 95% CI 1.2–5.7, P=0.01), and 365 days (OR 3.5, 95% CI 1.2–10, P=0.02). Septic patients who started dialysis with a BUN <100 mg/dL had improved mortality rates up to 1 year after initiation of dialysis in this single-center, retrospective analysis.     

Predicting Acute Renal Failure after Cardiac Surgery: Validation and Re‐definition of a Risk‐Stratification Algorithm

Background:  Acute renal failure (ARF) after cardiac surgery is associated with significant morbidity and mortality, irrespective of the need for dialysis. Previous studies have attempted to identify predictors of ARF and develop risk stratification algorithms. This study aims to validate the algorithm in an independent cohort of patients that includes a significant proportion of female and black patients and compares two different definitions of renal outcome.
Methods:  A large single center cardiac surgery database was examined (n, 24,660; 1993–2000) which included 29.9% females and 3.7% black patients. Post‐operative ARF was defined as: a) ARF requiring dialysis, b) > 50% reduction in creatinine clearance relative to baseline or requiring dialysis. Clinical variables related to baseline renal function and cardiovascular disease were used in recursive partitioning analysis for both outcome definitions. Chi‐square goodness of fit analysis was performed to validate the algorithm.
Results:  The frequency of post‐operative ARF requiring dialysis ranged between 0.5 and 15.5% based on the risk categories with the area under the receiver operating characteristic (ROC) curve of 0.78. Using the more inclusive definition of ARF, the frequency was significantly higher ranging from 2.6 to 25%(P < 0.001) with an area under ROC curve of 0.65.
Conclusions:  The renal risk stratification algorithm is valid in predicting post‐operative ARF in an independent cohort of patients, well represented by differences in gender and race. Since the need for dialysis remains subjective, a more objective and inclusive definition of ARF may help in identifying a larger number of patients 'at‐risk'.     

Early,Frequent, and Efficient Hemodialysis: A New Trend or Déjà Vu From the 1970s?

After more than a quarter century of dialysis, two factors are still present in dialysis treatment of chronic renal failure patients: inadequacy of technology (the artificial kidney acts as an artificial glomerulus) and inadequate use of technology in terms of dialysis initiation and frequency. This paper presents the results of two less unphysiological dialysis programs, introduced in Bologna at the beginning of the 1960s, which proved their clinical value and are now becoming trendy, at the end of this century. Features of these programs are twofold: (1) daily dialysis, which aims at making treatment more biologically suited to the patient; its validity relies on lower intra- and interdialytic osmotic fluctuations; (2) early dialysis, which aims at making the patient more biologically suited to the treatment. After more than 25 years it is evident that this treatment has fulfilled its original expectations versus late dialysis. There is a 40% improvement in survival, a 35% decrease in morbidity, and a 24% improvement in the cost/benefit ratio. This report is based on a retrospective analysis of our overall experience and clinical results of chronic hemodialysis carried out in 224 patients on early dialysis and 1210 patients on late dialysis in Bologna from 1967 to 1997. Based on this experience, the following should be regarded as particularly important indications for early dialysis: adequate dialysis facilities; symptomatic patients despite renal creatinine clearances between 15 and 20 mL/min; patients unable to comply with dietary measures; children, to allow for adequate development; patients with diabetes mellitus; candidates for renal transplantation.     

Confounding factors for early death in incident end‐stage renal disease patients: Role of emergency dialysis start

Hemodialysis (HD) has been associated with higher 1‐year mortality than peritoneal dialysis (PD) after dialysis start. Confounding effects of late referral, emergency dialysis start, or start with central venous catheter on this association have never been studied concomitantly. Survival was studied among the 495 incident dialysed patients in our department from 1995 to 2006 and followed at least 1 year until December 31, 2007. Nested Cox models adjusted on patient characteristics explored factors associated with 1‐year and ≥1‐year mortality. Hemodialysis patients were 332 (67.1%), 104 (21.0%) were late referred (<6 months), 167 (33.7%) started dialysis in emergency, and 144 (29.1%) started with central venous catheter. When adjusted only on age, sex, and comorbidities, HD was associated with poor 1‐year outcome: adjusted hazard ratio (aHR) for death in HD vs. PD was 1.77, P=0.02. In fully adjusted model, among first dialysis feature variables, only emergency dialysis start was significantly associated with 1‐year mortality: aHR 1.53, P=0.02. Dialysis modality was not associated with 1‐year mortality rates in this fully adjusted model: aHR in HD vs. PD became 1.03, P=0.91. In ≥1‐year period, HD was associated with lower mortality than PD (aHR 0.61, P=0.004), whereas other first dialysis features were not associated with death. Other factors associated with death were age, type 2 diabetes, peripheral vascular disease, heart failure, and hepatic failure. Negative association between HD and 1‐year survival on dialysis was explained by confounders. Emergency dialysis start was strongly associated with early mortality on dialysis. Its prevention may improve patient survival.     

Early start on continuous hemodialysis therapy improves survival rate in patients with acute renal failure following coronary bypass surgery

Acute renal failure requiring dialysis therapy after cardiac surgery occurs in 1% to 5% of patients; however, the optimal timing for initiation of dialysis therapy still remains undetermined. To assess the validity of early start of dialysis therapy, we studied the comparative survival between 14 patients who started to receive dialysis therapy when urine volume decreased to less than 30 mL/hr and another group of 14 patients who waited to begin dialysis therapy until the level of urine volume was less than 20 mL/hr for 14 days following coronary bypass graft surgery. Twelve of 14 patients who received early intervention survived. In contrast, only 2 of 14 patients in the late‐dialysis group survived. There was a significant difference in survival between the two groups (p < 0.01). There were no significant differences between the two groups with respect to age, sex ratio, the APACHE (Acute Physiologic and Chronic Health Evaluation) II score, and the levels of serum creatinine at the start of dialysis therapy (2.9 ± 0.2 mg/dL vs. 3.1 ± 0.2 mg/dL), as well as the levels of serum creatinine at admission. We propose that the timing of the start for treatment of acute renal failure following cardiac surgery should be determined by the decrease of urine volume and not the levels of serum creatinine. Early start of dialysis therapy may help improve the survival of patients with acute renal failure following cardiac surgery.     

Choice Reaction Time and Adequacy of Dialysis: A New Application of an Old Method

Background:  Choice Reaction Time (CRT) is the time it takes for a subject to accurately respond to a flashing panel of lights. The CRT has been used to assess the quality of dialysis in hemodialysis patients and to assess the neurological impairments in patients with Parkinson's disease.
Methods:  Three groups of end‐stage renal disease (ESRD) patients on three different renal replacement therapies were tested using CRT: intermittent peritoneal dialysis (IPD, n = 11), thrice weekly hemodialysis (HD, n = 22), and well‐functioning kidney transplant (Tx, n = 6). A group of volunteers with normal renal function (NL, n = 12) was also tested.
Results:  The CRT was significantly longer in IPD patients (618 ± 89 ms) than observed in the other three groups (p < 0.0001). CRT in HD patients was 461 ± 50 ms, which was significantly longer than in Tx patients (396 ± 25 ms, p = 0.05). However, the CRT in the Tx patients was no different from the NL (382 ± 22, p = 0.32). There was a strong negative correlation between CRT and weekly creatinine clearance in the IPD group (r =− .96) and between the dialysis index and CRT in HD (r =− 0.79).
Conclusions:  CRT may be a useful tool in assessing the adequacy of dialysis.     

Early Start of Dialysis Therapy is Beneficial for Patients with Acute Renal Failure following Cardiac Surgery

Acute renal failure requiring dialysis therapy after cardiac surgery occurs in 1–5% of patients; however, the optimal timing for the initiation of dialysis therapy still remains undetermined. To assess the validity of early start of dialysis therapy, we studied the comparative survival between 14 patients who started to receive dialysis therapy with the timing of decrease of urine volume less than 30 mL/h and other 14 patients who waited to begin dialysis therapy until the level of urine volume of less than 20 mL/h during 14 days. Overall mortality of those patients was 50%. Twelve of 14 patients who received the early intervention survived. In contrast, only 2 of 14 patients in the other group survived. There was a significant difference of p < 0.01 between the two groups. Between the two groups, there were no significant differences in age, sex ratio, the score of APACHE (Acute Physiologic and Chronic Health Evaluation) II, and the levels of serum creatinine at the start of dialysis therapy (2.9 + 0.2 vs. 3.1 + 0.2 mg/dL) as well as in the levels of serum creatinine at admission. The start timing for the treatment of acute renal failure following cardiac surgery would be determined by the decrease of urine volume but not by the levels of serum creatinine. The early start of dialysis therapy might be preferable for the improvement of survival of the patients suffering from acute renal failure following cardiac surgery.     

Timely referral to the nephrologist: Essential to optimizing patient outcomes

Annual mortality on renal replacement therapy is about 10% in Western Europe and reaches 20% in the United States. The reasons responsible for this excess mortality include among others advanced age, high prevalence of diabetes and comorbid conditions, susceptibility to infections, and cancer. An additional cause that should be considered is late referral to overall renal care and for renal replacement therapy. It has been demonstrated recently that early referral may provide many advantages for the patient, such as prevention of organ damage secondary to uremia and even delay the onset of end‐stage renal disease. These benefits prompted numerous recommendations for timely referral, both for dialysis and for long‐term renal follow‐up. Despite available guidelines for nephrology referral the current practice is still suboptimal, resulting in delayed initiation of dialysis and clinical outcomes that are not ideal. There is an urgent need in the renal community to change the current practice of referral. Beyond the benefits for patients, society may also expect potential cost effectiveness from early renal care.     

Changing patterns of pericardial disease in patients with end-stage renal disease

Pericarditis can occur in patients with chronic renal failure before initiation of dialysis. It is also described in established dialysis patients. Traditionally, the cause of pericarditis in such settings has been attributed to uremia and/or inadequate dialysis and it is consequently thought that intensifying the dialysis process in such patients could improve outcome. We report here 7 cases of acute pericarditis in patients with end-stage renal disease on renal replacement therapy. Only 3 of the patients gave any history of chest pain, and a pericardial friction rub was only noted in 2. Despite a period of intensive dialysis, none of the patients improved and all required pericardial drainage as the definitive curative procedure. The clinical presentation of acute pericarditis in dialysis patients therefore may be atypical and pericardial drainage should be considered early, as intensive dialysis alone may not lead to resolution.     

Survival to discharge among patients treated with continuous renal replacement therapy

Continuous renal replacement therapy (CRRT) is widely used in critically ill patients with acute renal failure (ARF). The survival of patients who require CRRT and the factors predicting their outcomes are not well defined. We sought to identify clinical features to predict survival in patients treated with CRRT. We reviewed the charts of all patients who received CRRT at the Toronto General Hospital during the year 2002. Our cohort (n=85) represented 97% of patients treated with this modality in 3 critical care units. We identified demographic variables, underlying diagnoses, transplantation status, location (medical-surgical, coronary, or cardiovascular surgery intensive care units), CRRT duration, baseline estimated glomerular filtration rate (eGFR), and presence of oliguria (<400 mL/day) on the day of CRRT initiation. The principal outcome was survival to hospital discharge. Among those alive at discharge, we assessed whether there was an ongoing need for renal replacement therapy. Greater than one-third (38%, 32/85) of patients survived to hospital discharge. Three (9%) survivors remained dialysis-dependent at the time of discharge. Survivors were younger than nonsurvivors (mean age 56 vs. 60 years), were on CRRT for a shorter duration (7 vs. 13 days), and had a higher baseline eGFR (74 vs. 62 mL/min/m(2)). Patient survival varied among different critical care units (medical surgical 33%, coronary 38%, and cardiovascular surgery 45%). Multivariable logistic regression revealed that shorter duration of CRRT, nonoliguria, and baseline eGFR >60 mL/min/m(2) were independently associated with survival to hospital discharge (p<0.05). Critically ill patients with ARF who require CRRT continue to have high in-hospital mortality. A shorter period of CRRT dependence, nonoliguria and higher baseline renal function may predict a more favorable prognosis. The majority of CRRT patients who survive their critical illness are independent of dialysis at the time of hospital discharge.     

Optimal timing of initiation of chronic hemodialysis?

Despite the availability of clinical guidelines for the timing of dialysis initiation in both the United States and Canada, patients continue to start dialysis at very low levels of predicted glomerular filtration rate (GFR). A cross-sectional study was performed to determine the demographic and clinical characteristics of patients who started hemodialysis, their level of GFR, and mortality at 1 and 2 years following the initiation of dialysis. Retrospective data were collected on all eligible patients who commenced chronic hemodialysis in 1 tertiary care center in Canada from March 2001 to February 2005. Only those patients who had been followed by a nephrologist in the chronic kidney disease clinic before dialysis initiation were included (n=271). Seventeen percent of patients started hemodialysis late (GFR<5 mL/min/1.73 m(2)). Compared with the group of patients who started dialysis earlier, the late start group were significantly younger (p=0.008), had more females (p=0.013), more employed (p=0.051), less cardiac (p<0.001), and peripheral vascular disease (p=0.031), and were taking medication for hypertension (p=0.041). Serum albumin was lower in the late start group (p=0.023). At year 1, there was no difference in mortality rate while at year 2, the earlier the dialysis, the greater the mortality rate (p=0.022). After adjustment for demographic variables and comorbidities, only antihypertensive use had an independent but weak association with the 2 year mortality. Adjustment for all these variables eliminated the significant association noted for the 2 year mortality in the early versus late dialysis start. The survival benefit for late versus early dialysis start appears to be multifactorial and relates to a preponderance of clinical and demographic factors favoring a lengthened survival occurring in the late dialysis group. Our survival benefit findings suggest the premorbid health condition is a more important determinant of 2 year survival than the timing of dialysis initiation.     

Predictors of post‐hospitalization recovery of renal function among patients with acute kidney injury requiring dialysis

Introduction: Acute kidney injury (AKI) requiring dialysis complicates 1% of all hospital admissions, and up to 30% of survivors will still require dialysis at hospital discharge. There is a paucity of data to describe the postdischarge outcomes or to guide evidence‐based dialysis management of this vulnerable population. Methods: Single‐center, retrospective analysis of 100 consecutive patients with AKI who survived to hospital discharge and required outpatient dialysis. Data collection included baseline characteristics, hospitalization characteristics, and outpatient dialysis treatment variables. Primary outcome was dialysis independence 90 days after discharge. Findings: Overall, 43% of patients recovered adequate renal function to discontinue dialysis, with the majority recovering within 30 days post discharge. Worse baseline renal function was associated with lower likelihood of renal recovery. In the first week postdischarge, patients with subsequent nonrecovery of renal function had greater net fluid removal (5.3 vs. 4.1 L, P = 0.037), higher ultrafiltration rates (6.0 vs. 4.7 mL/kg/h, P = 0.041) and more frequent intradialytic hypotension (24.6% vs. 9.3% with 3 or more episodes, P = 0.049) compared to patients that later recovered. Discussion: A significant proportion of AKI survivors will recover renal function following discharge. Outpatient intradialytic factors may influence subsequent renal function recovery.     

Experience with continuous venovenous hemodiafiltration in four newborns: A case series and review of the literature

When conventional methods for treating complicated problems such as acute and chronic renal failure or metabolic diseases fail, the therapy of choice is peritoneal dialysis (PD) in neonatal period. However, in cases that involve technical difficulties, such as bulky lesions in the abdomen or complications from previous abdominal surgeries, it is not always possible to place a peritoneal catheter. In such situations, continuous venovenous hemodiafiltration (CVVHDF) can be effective. This case series presents our experience in 2013 with the administration of CVVHDF to four patients in our neonatal intensive care unit who could not undergo PD for various reasons.     

Phosphorus-enriched hemodialysis during pregnancy: Two case reports

Successful pregnancy leading to delivery of a viable infant is an uncommon occurrence either in women with established renal disease or in those with renal failure requiring chronic dialytic treatment. The frequency of conception in patients with renal failure has increased, however, and the outcome of such pregnancies has improved over the past 32 years. Current guidelines for dialysis in pregnant women include prolonged dialysis times, generally 20 or more hours per week. This extensive dialysis regimen often results in a decrease in the serum inorganic phosphorus levels, with possible detrimental effects to the health of the mother and the unborn child. In this article, we report the successful multidisciplinary management of two pregnant women with end-stage renal disease, both of whom developed hypophosphatemia after initiation of intensive hemodialysis. Sodium phosphate salts were added to the dialysate of each patient and this addition successfully corrected the decrease in serum inorganic phosphate concentration. One patient was able to carry the pregnancy for 28 weeks with delivery of a healthy 1260-g infant. The pregnancy of the second patient ended at 25 weeks of gestation with delivery of a nonviable infant.     

L carnitine in hemodialysis patients

Carnitine, 3-hydroxy-4-trimethylaminobutyrate, a small, water soluble molecule that is essential for mitochondrial fatty acid oxidation, is significantly reduced in hemodialysis patients. Uremia-induced carnitine deficiency, which is magnified by dialysis, is associated with symptoms or clinical problems such as anemia hyporesponsive to erythropoietin, cardiovascular diseases, and muscle weakness. This review examines studies dealing with the different clinical aspects of chronic renal failure patients in which carnitine deficiency may play a role and has also examined the studies, which have evaluated the effect of carnitine deficiency treatment. The reports reviewed in this study, including those more recent from our laboratory, have provided data suggesting that chronic renal failure and particularly hemodialysis patients can benefit from carnitine treatment in particular for renal anemia, insulin sensitivity, and protein catabolism. On the other hand, the heterogeneous clinical response to carnitine therapy in dialysis patients, reported by other studies, and the lack of large-scale randomized trials are the rationale for the reluctance regarding a widespread use of carnitine supplements in dialysis patients. Well-designed randomized clinical trials are therefore required to fully address the potentially important carnitine treatment in dialysis patients.     

Rationale for Daily Dialysis

The kidneys maintain the body's homeostasis by removing water and waste products continuously and efficiently. The ideal dialytic treatment should emulate the functions of the kidney. Of the dialysis treatments currently available for chronic renal failure, the only continuous ones are continuous ambulatory and continuous cyclic peritoneal dialysis; however, the efficiency of peritoneal dialysis is limited by the nature of the peritoneal membrane. Extracorporeal dialysis is markedly more efficient than peritoneal dialysis, but is performed intermittently (usually 3 times/week) with large fluctuations of body fluid volumes and concentrations of various solutes and electrolytes. These fluctuations cause intercompartmental disequilibrium during dialysis, induce intradialytic and interdialytic symptoms, and create difficulties in controlling blood pressure. Daily dialysis is both frequent and efficient and therefore seems to be superior to any other form of renal replacement therapy.     

Is Dialysis Always Justified? Ethics and Economics

Introduction:  Terminally ill patients requiring dialysis present complex ethical and medical dilemma to the nephrologists. With the rising health care costs and futility of care in such cases, the financial burden is a lingering concern.
Methods:  We describe a 77-year-old male with lymphoma and prostate cancer admitted for abdominal pain and weight loss. He was found to have metastatic pancreatic adenocarcinoma on laparotomy. His malignancy was deemed inoperable and was offered palliative care. Subsequent hospital course was complicated by sepsis with multiple organ failure resulting in acute renal failure requiring dialysis support. Being aware of his poor prognosis, patient initially declined interventions including dialysis. He was later convinced by his family and agreed to aggressive therapeutic intervention. Anticipating a complicated course, hemodialysis was initiated through cuffed tunneled catheter (CTC). Subsequently, he had multiple episodes of sepsis resulting in removal of CTC, necessitating insertion of 9 temporary dialysis catheters and 3 CTC over a 9-month period; further complicated by thrombosis of both femoral veins. Eventually, patient's condition progressively deteriorated and dialysis was withdrawn with family's consent 9 months following surgery. Patient was put on comfort care and died 2 days later. He spent a total of 7½ months in ICU, 1 month in skilled care facility, and 2 weeks on regular hospital floor. Total VAMC expenditure was $373,964, which in a private setting would be approximately $1.0 million.
Conclusion:  This case highlights the futility of aggressive management of renal failure in terminally ill elderly patients. Besides its inability to improve quality of life, it adds as a financial burden to the society.