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      Renal replacement therapy is independently associated with a lower risk of death in patients with severe acute kidney injury treated with targeted temperature management after out-of-hospital cardiac arrest

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          Abstract

          Background

          The effect of renal replacement therapy (RRT) on the outcomes of severe acute kidney injury (AKI) after out-of-hospital cardiac arrest (OHCA) is uncertain. This study aimed to evaluate the association of RRT with 6-month mortality in patients with severe AKI treated with targeted temperature management (TTM) after OHCA.

          Methods

          This was a retrospective analysis of a prospectively collected multicentre observational cohort study that included adult OHCA patients treated with TTM across 22 hospitals in South Korea between October 2015 and December 2018. AKI was diagnosed using the Kidney Disease: Improving Global Outcomes criteria. The primary outcome was 6-month mortality and the secondary outcome was cerebral performance category (CPC) at 6 months. Multivariate Cox regression analysis was performed to define the role of RRT in stage 3 AKI.

          Results

          Among 10,426 patients with OHCA, 1373 were treated with TTM. After excluding those who died within 48 h of return of spontaneous circulation (ROSC) and those with pre-arrest chronic kidney disease, our study cohort comprised 1063 patients. AKI developed in 590 (55.5%) patients and 223 (21.0%) had stage 3 AKI. Among them, 115 (51.6%) were treated with RRT. The most common treatment modality among RRT patients was continuous renal replacement therapy (111 [96.5%]), followed by intermittent haemodialysis (4 [3.5%]). The distributions of CPC (1–5) at 6 months for the non-RRT vs. the RRT group were 3/108 (2.8%) vs. 12/115 (10.4%) for CPC 1, 0/108 (0.0%) vs. 1/115 (0.9%) for CPC 2, 1/108 (0.9%) vs. 3/115 (2.6%) for CPC 3, 6/108 (5.6%) vs. 6/115 (5.2%) for CPC 4, and 98/108 (90.7%) vs. 93/115 (80.9%) for CPC 5, respectively ( P = 0.01). The RRT group had significantly lower 6-month mortality than the non-RRT group (93/115 [81%] vs. 98/108 [91%], P = 0.04). Multivariate Cox regression analyses showed that RRT was independently associated with a lower risk of death in patients with stage 3 AKI (hazard ratio, 0.569 [95% confidence interval, 0.377–0.857, P = 0.01]).

          Conclusion

          Dialysis interventions were independently associated with a lower risk of death in patients with stage 3 AKI treated with TTM after OHCA.

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          Most cited references18

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          Obesity, Acute Kidney Injury, and Mortality in Critical Illness.

          Although obesity is associated with risk for chronic kidney disease and improved survival, less is known about the associations of obesity with risk of acute kidney injury and post acute kidney injury mortality.
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            Renal replacement therapy is an independent risk factor for mortality in critically ill patients with acute kidney injury

            Introduction Outcome studies in patients with acute kidney injury (AKI) have focused on differences between modalities of renal replacement therapy (RRT). The outcome of conservative treatment, however, has never been compared with RRT. Methods Nine Belgian intensive care units (ICUs) included all adult patients consecutively admitted with serum creatinine >2 mg/dl. Included treatment options were conservative treatment and intermittent or continuous RRT. Disease severity was determined using the Stuivenberg Hospital Acute Renal Failure (SHARF) score. Outcome parameters studied were mortality, hospital length of stay and renal recovery at hospital discharge. Results Out of 1,303 included patients, 650 required RRT (58% intermittent, 42% continuous RRT). Overall results showed a higher mortality (43% versus 58%) as well as a longer ICU and hospital stay in RRT patients compared to conservative treatment. Using the SHARF score for adjustment of disease severity, an increased risk of death for RRT compared to conservative treatment of RR = 1.75 (95% CI: 1.4 to 2.3) was found. Additional correction for other severity parameters (Acute Physiology And Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA)), age, type of AKI and clinical conditions confirmed the higher mortality in the RRT group. Conclusions The SHARF study showed that the higher mortality expected in AKI patients receiving RRT versus conservative treatment can not only be explained by a higher disease severity in the RRT group, even after multiple corrections. A more critical approach to the need for RRT in AKI patients seems to be warranted.
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              Timing of initiation and discontinuation of renal replacement therapy in AKI: unanswered key questions.

              Patients with acute kidney injury (AKI) often require initiation of renal replacement therapy (RRT). Currently, there is wide variation worldwide on the indications for and timing of initiation and discontinuation of RRT for AKI. Various parameters for metabolic, solute, and fluid control are generally used to guide the initiation and discontinuation of therapy; however, there are currently no standards in this field. Members of the recently established Acute Kidney Injury Network, representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI, participated in a 3-d conference in Vancouver in September 2006 to evaluate the available literature on this topic and draft consensus recommendations for research studies in this area. Key questions included the following: what are the indications for RRT, when should acute RRT support be initiated, and when should RRT be stopped? This report summarizes the available evidence and describes in detail the key questions, and some of the methods of answering them that will need to be addressed with the goal of standardizing the care of patients with AKI and improving outcomes.
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                Author and article information

                Contributors
                unii@ewha.ac.kr
                emdhlee@cau.ac.kr
                jehyeokoh@cau.ac.kr
                beautydoc21@naver.com
                emzzang@cu.ac.kr
                emvic98@catholic.ac.kr
                emsky@catholic.ac.kr
                Journal
                Crit Care
                Critical Care
                BioMed Central (London )
                1364-8535
                1466-609X
                23 March 2020
                23 March 2020
                2020
                : 24
                : 115
                Affiliations
                [1 ]GRID grid.411076.5, Department of Emergency Medicine, , Ewha Womans University Medical Center and Ewha Womans University Mokdong Hospital, ; 1071, Anyangcheon-ro, Yangcheon-gu, Seoul, 07985 Republic of Korea
                [2 ]GRID grid.254224.7, ISNI 0000 0001 0789 9563, Department of Emergency Medicine, , Chung-Ang University College of Medicine, ; 84, Heukseok-ro, Dongjak-gu, Seoul, 06974 Republic of Korea
                [3 ]GRID grid.410899.d, ISNI 0000 0004 0533 4755, Department of Emergency Medicine, , Wonkwang University College of Medicine, Sanbon Hospital, ; 321, Snabon-ro, Gunpo-si, Gyeonggi-do, 15865 Republic of Korea
                [4 ]Department of Emergency Medicine, Daegu Catholic University School of Medicine, 33, Duryugongwon-ro 17-gil, Nam-gu, Daegu, 42472 Republic of Korea
                [5 ]GRID grid.411947.e, ISNI 0000 0004 0470 4224, Department of Emergency Medicine, , Eunpyeong St. Mary’s Hospital, The Catholic University of Korea College of Medicine, ; 1021, Tongil-ro, Eunpyeong-gu, Seoul, 03312 Republic of Korea
                [6 ]GRID grid.411947.e, ISNI 0000 0004 0470 4224, Department of Emergency Medicine, , Seoul St. Mary’s Hospital, The Catholic University of Korea College of Medicine, ; 222, Banpo-daero, Seocho-gu, Seoul, 06591 Republic of Korea
                Author information
                https://orcid.org/0000-0002-5211-3838
                Article
                2822
                10.1186/s13054-020-2822-x
                7092437
                32204725
                cb174dc2-e40b-4558-88eb-bcaff5fecbcf
                © The Author(s). 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 11 December 2019
                : 6 March 2020
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100003725, National Research Foundation of Korea;
                Award ID: NRF-2018R1C1B5082969
                Award Recipient :
                Categories
                Research
                Custom metadata
                © The Author(s) 2020

                Emergency medicine & Trauma
                renal replacement therapy,acute kidney injury,out-of-hospital cardiac arrest,targeted temperature management,therapeutic hypothermia

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