Early initiation of continuous renal replacement therapy improves survival of elderly patients with acute kidney injury: a multicenter prospective cohort study

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Abstract

Background

Continuous renal replacement therapy (CRRT) is essential in the management of critically ill patients with acute kidney injury (AKI). However, the optimal timing for initiating CRRT remains controversial, especially in elderly patients. Therefore, we investigated the outcomes of early CRRT initiation in elderly patients with AKI.

Methods

A total of 607 patients ≥65 years of age who started CRRT due to AKI between August 2009 and December 2013 were prospectively enrolled. They were divided into two groups based on the median 6-hour urine output immediately before CRRT initiation. Propensity score matching was used to compare the overall survival rate, CRRT duration, and hospitalization duration.

Results

The median age of both groups was 73.0 years, and 60 % of the patients were male. The most common cause of AKI was sepsis. In the early CRRT group, the mean arterial pressure was higher, but the prothrombin time and total bilirubin, aspartate aminotransferase, and alanine aminotransferase levels were lower. The overall cumulative survival rate was higher in the early CRRT group (log-rank P < 0.01). Late CRRT initiation was associated with a higher mortality rate than early initiation after adjusting for age, sex, the Charlson comorbidity index, systolic arterial pressure, prothrombin time, the total bilirubin, aspartate aminotransferase, and alanine aminotransferase levels, cumulative fluid balance and diuretic use (hazard ratio, 1.35; 95 % confidence interval 1.06, 1.71, P = 0.02). Following propensity score matching, patient survival was significantly better in the early CRRT group than in the late CRRT group ( P < 0.01). The total duration of hospitalization from the start of CRRT was shorter among the survivors when CRRT was started earlier (26.7 versus 39.1 days, P = 0.04).

Conclusion

A better prognosis can be expected if CRRT is applied early in the course of AKI in critically ill, elderly patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1437-8) contains supplementary material, which is available to authorized users.

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Most cited references 51

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Dual action of neutrophil gelatinase-associated lipocalin.

Kai M Schmidt-Ott, Kiyoshi Mori, Jau Yi Li … (2007)

Neutrophil gelatinase-associated lipocalin (NGAL) is expressed and secreted by immune cells, hepatocytes, and renal tubular cells in various pathologic states. NGAL exerts bacteriostatic effects, which are explained by its ability to capture and deplete siderophores, small iron-binding molecules that are synthesized by certain bacteria as a means of iron acquisition. Consistently, NGAL deficiency in genetically modified mice leads to an increased growth of bacteria. However, growing evidence suggests effects of the protein beyond fighting microorganisms. NGAL acts as a growth and differentiation factor in multiple cell types, including developing and mature renal epithelia, and some of this activity is enhanced in the presence of siderophore:iron complexes. This has led to the hypothesis that eukaryotes might synthesize siderophore-like molecules that bind NGAL. Accordingly, NGAL-mediated iron shuttling between the extracellular and intracellular spaces may explain some of the biologic activities of the protein. Interest in NGAL has been sparked by the observation that NGAL is massively upregulated after renal tubular injury and may participate in limiting kidney damage. This review summarizes the current knowledge about the dual effects of NGAL as a siderophore:iron-binding protein and as a growth factor and examines the role of these effects in renal injury.

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Classifying AKI by Urine Output versus Serum Creatinine Level.

John A. Kellum, Florentina E Sileanu, Raghavan Murugan … (2015)

Severity of AKI is determined by the magnitude of increase in serum creatinine level or decrease in urine output. However, patients manifesting both oliguria and azotemia and those in which these impairments are persistent are more likely to have worse disease. Thus, we investigated the relationship of AKI severity and duration across creatinine and urine output domains with the risk for RRT and likelihood of renal recovery and survival using a large, academic medical center database of critically ill patients. We analyzed electronic records from 32,045 patients treated between 2000 and 2008, of which 23,866 (74.5%) developed AKI. We classified patients by levels of serum creatinine and/or urine output according to Kidney Disease Improving Global Outcomes staging criteria for AKI. In-hospital mortality and RRT rates increased from 4.3% and 0%, respectively, for no AKI to 51.1% and 55.3%, respectively, when serum creatinine level and urine output both indicated stage 3 AKI. Both short- and long-term outcomes were worse when patients had any stage of AKI defined by both criteria. Duration of AKI was also a significant predictor of long-term outcomes irrespective of severity. We conclude that short- and long-term risk of death or RRT is greatest when patients meet both the serum creatinine level and urine output criteria for AKI and when these abnormalities persist.

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Community-based incidence of acute renal failure.

C-Y Hsu, C E McCulloch, D Fan … (2007)

There is limited information about the true incidence of acute renal failure (ARF). Most studies could not quantify disease frequency in the general population as they are hospital-based and confounded by variations in threshold and the rate of hospitalization. Earlier studies relied on diagnostic codes to identify non-dialysis requiring ARF. These underestimated disease incidence since the codes have low sensitivity. Here we quantified the incidence of non-dialysis and dialysis-requiring ARF among members of a large integrated health care delivery system - Kaiser Permanente of Northern California. Non-dialysis requiring ARF was identified using changes in inpatient serum creatinine values. Between 1996 and 2003, the incidence of non-dialysis requiring ARF increased from 322.7 to 522.4 whereas that of dialysis-requiring ARF increased from 19.5 to 29.5 per 100,000 person-years. ARF was more common in men and among the elderly, although those aged 80 years or more were less likely to receive acute dialysis treatment. We conclude that the use of serum creatinine measurements to identify cases of non-dialysis requiring ARF resulted in much higher estimates of disease incidence compared with previous studies. Both dialysis-requiring and non-dialysis requiring ARFs are becoming more common. Our data underscore the public health importance of ARF.

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Author and article information

Contributors

Jae Yoon Park: nephrojyp@gmail.com

Jung Nam An: lovingjn@gmail.com

Jong Hyun Jhee: JJHLOVE77@yuhs.ac

Dong Ki Kim: dkkim73@gmail.com

Hyung Jung Oh: OHJMD@yuhs.ac

Sejoong Kim: imsejoong@hanmail.net

Kwon Wook Joo: junephro@gmail.com

Yun Kyu Oh: yoonkyuoh@gmail.com

Chun-Soo Lim: cslimjy@snu.ac.kr

Shin-Wook Kang: kswkidney@yuhs.ac

Yon Su Kim: yonsukim@snu.ac.kr

Jung Tak Park: +82 2 2228 5347 , jtpark@yuhs.ac

Jung Pyo Lee: +82 2 870 3206 , nephrolee@gmail.com

Journal

Journal ID (nlm-ta): Crit Care

Title: Critical Care

Publisher: BioMed Central (London )

ISSN (Print): 1364-8535

ISSN (Electronic): 1466-609X

Publication date (Electronic): 16 August 2016

Publication date PMC-release: 16 August 2016

Publication date Collection: 2016

Volume: 20

Electronic Location Identifier: 260

Affiliations

[1 ]Department of Internal Medicine, Dongguk University Ilsan Hospital, 27 Dongguk-ro, Ilsandong-gu, Goyang-si, Gyeonggido 10326 Korea

[2 ]Department of Internal Medicine, Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744 Korea

[3 ]Department of Critical Care Medicine, Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 07061 Korea

[4 ]Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722 Korea

[5 ]Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Korea

[6 ]Department of Internal Medicine, Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 07061 Korea

Article

Publisher ID: 1437

DOI: 10.1186/s13054-016-1437-8

PMC ID: 4986348

PubMed ID: 27526933

SO-VID: d9afe5d5-19c4-42cf-926d-2778b8296aa5

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. 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.

History

Date received : 8 April 2016

Date accepted : 26 July 2016

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ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: elderly patients,survival,continuous renal replacement therapy,acute kidney injury,propensity score matching

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ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: elderly patients, survival, continuous renal replacement therapy, acute kidney injury, propensity score matching

Early initiation of continuous renal replacement therapy improves survival of elderly patients with acute kidney injury: a multicenter prospective cohort study

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Abstract

Background

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Results

Conclusion

Electronic supplementary material

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Karger: Nephrology

Most cited references 51

Dual action of neutrophil gelatinase-associated lipocalin.

Classifying AKI by Urine Output versus Serum Creatinine Level.

Community-based incidence of acute renal failure.

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