Inpatient Kidney Function Recovery among Septic Shock Patients Who Initiated Kidney Replacement Therapy in the Hospital

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Abstract

Background: Sepsis and septic shock are life-threatening causes of acute kidney injury (AKI) frequently seen and managed in intensive care units (ICUs). Sepsis-associated AKI (SA-AKI) independently contributes to the mortality of sepsis. Understanding the potential factors involved in kidney function recovery may further aid in the prevention and management of SA-AKI. This study aimed to describe the clinical characteristics of septic shock patients who required kidney replacement therapy and factors associated with kidney function recovery. Methods: We conducted a retrospective cohort study of adult septic shock patients who received in-hospital kidney replacement therapy at medical intensive care unit (MICU) at the Mayo Clinic, Rochester, from January 1, 2006, to May 31, 2018. Kidney function recovery was defined as liberation from kidney replacement therapy before hospital discharge. Associations between clinical features and kidney recovery were analyzed using multivariable Fine and Gray regression accounting for death as a competing event. Results: Our retrospective cohort consisted of 229 patients with a median (interquartile range [IQR]) age of 64 (52–74) years: 55% were men, 89% were Caucasians, 39% had diabetes mellitus (DM), 16% had heart failure, APACHE (Acute Physiology and Chronic Health Evaluation) III score was 105 (84–123), and SOFA (Sequential [Sepsis-related] Organ Failure Assessment) score was 12 (9–14). The patients received 1,567 (524–4,108) mL of intravenous fluids in the first 3 h, 92% required vasopressor support, and 83% required mechanical ventilation. The median MICU and hospital stays were 7 (4–13) and 19 (10–31) days, respectively. Median (IQR) kidney replacement therapy duration was 7 (3.5–17.1) days. Among 158 ICU survivors, 73 (46%) patients were weaned from RRT in ICU and 85 (54%) were transitioned to intermittent RRT. A higher volume of fluid resuscitation in the first 3 h (hazard ratio [HR] = 1.07 per 1 L, CI: 1.01–1.14, p = 0.04) and a history of DM (HR = 1.70, CI: 1.14–2.54, p = 0.009) were associated with kidney function recovery. Conclusion: Among septic shock patients who initiated kidney replacement therapy in the MICU, 41% recovered kidney function before discharge. A higher initial fluid resuscitation volume was associated with recovery, and interestingly, patients with DM had a higher chance of recovery.

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Most cited references 40

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Estimation of failure probabilities in the presence of competing risks: new representations of old estimators.

T Gooley, W Leisenring, J. Crowley … (1999)

A topic that has received attention in both the statistical and medical literature is the estimation of the probability of failure for endpoints that are subject to competing risks. Despite this, it is not uncommon to see the complement of the Kaplan-Meier estimate used in this setting and interpreted as the probability of failure. If one desires an estimate that can be interpreted in this way, however, the cumulative incidence estimate is the appropriate tool to use in such situations. We believe the more commonly seen representations of the Kaplan-Meier estimate and the cumulative incidence estimate do not lend themselves to easy explanation and understanding of this interpretation. We present, therefore, a representation of each estimate in a manner not ordinarily seen, each representation utilizing the concept of censored observations being 'redistributed to the right.' We feel these allow a more intuitive understanding of each estimate and therefore an appreciation of why the Kaplan-Meier method is inappropriate for estimation purposes in the presence of competing risks, while the cumulative incidence estimate is appropriate.

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Acute kidney injury in sepsis.

Rinaldo Bellomo, John A. Kellum, Claudio Ronco … (2017)

Acute kidney injury (AKI) and sepsis carry consensus definitions. The simultaneous presence of both identifies septic AKI. Septic AKI is the most common AKI syndrome in ICU and accounts for approximately half of all such AKI. Its pathophysiology remains poorly understood, but animal models and lack of histological changes suggest that, at least initially, septic AKI may be a functional phenomenon with combined microvascular shunting and tubular cell stress. The diagnosis remains based on clinical assessment and measurement of urinary output and serum creatinine. However, multiple biomarkers and especially cell cycle arrest biomarkers are gaining acceptance. Prevention of septic AKI remains based on the treatment of sepsis and on early resuscitation. Such resuscitation relies on the judicious use of both fluids and vasoactive drugs. In particular, there is strong evidence that starch-containing fluids are nephrotoxic and decrease renal function and suggestive evidence that chloride-rich fluid may also adversely affect renal function. Vasoactive drugs have variable effects on renal function in septic AKI. At this time, norepinephrine is the dominant agent, but vasopressin may also have a role. Despite supportive therapies, renal function may be temporarily or completely lost. In such patients, renal replacement therapy (RRT) becomes necessary. The optimal intensity of this therapy has been established, while the timing of when to commence RRT is now a focus of investigation. If sepsis resolves, the majority of patients recover renal function. Yet, even a single episode of septic AKI is associated with increased subsequent risk of chronic kidney disease.

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Septic acute kidney injury in critically ill patients: clinical characteristics and outcomes.

Sean Bagshaw, Shigehiko Uchino, Rinaldo Bellomo … (2007)

Sepsis is the most common cause of acute kidney injury (AKI) in critical illness, but there is limited information on septic AKI. A prospective, observational study of critically ill patients with septic and nonseptic AKI was performed from September 2000 to December 2001 at 54 hospitals in 23 countries. A total of 1753 patients were enrolled. Sepsis was considered the cause in 833 (47.5%); the predominant sources of sepsis were chest and abdominal (54.3%). Septic AKI was associated with greater aberrations in hemodynamics and laboratory parameters, greater severity of illness, and higher need for mechanical ventilation and vasoactive therapy. There was no difference in enrollment kidney function or in the proportion who received renal replacement therapy (RRT; 72 versus 71%; P = 0.83). Oliguria was more common in septic AKI (67 versus 57%; P < 0.001). Septic AKI had a higher in-hospital case-fatality rate compared with nonseptic AKI (70.2 versus 51.8%; P < 0.001). After adjustment for covariates, septic AKI remained associated with higher odds for death (1.48; 95% confidence interval 1.17 to 1.89; P = 0.001). Median (IQR) duration of hospital stay for survivors (37 [19 to 59] versus 21 [12 to 42] d; P < 0.0001) was longer for septic AKI. There was a trend to lower serum creatinine (106 [73 to 158] versus 121 [88 to 184] mumol/L; P = 0.01) and RRT dependence (9 versus 14%; P = 0.052) at hospital discharge for septic AKI. Patients with septic AKI were sicker and had a higher burden of illness and greater abnormalities in acute physiology. Patients with septic AKI had an increased risk for death and longer duration of hospitalization yet showed trends toward greater renal recovery and independence from RRT.

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Journal

Journal ID (publisher-id): NEF

Journal ID (nlm-ta): Nephron

Journal ID (doi): 10.1159/issn.1660-8151

Title: Nephron

Publisher: S. Karger AG

ISSN (Print): 1660-8151

ISSN (Electronic): 2235-3186

Publication date Subscription-year: 2020

Publication date (Print): August 2020

Publication date (Electronic): 23 June 2020

Volume: 144

Issue: 8

Pages: 363-371

Affiliations

[_a] _aDepartment of Medicine, Mayo Clinic, Rochester, Minnesota, USA

[_b] _bDivision of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA

[_c] _cDepartment of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China

[_d] _dDivision of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA

[_e] _eDivision of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA

Author notes

*Kianoush B. Kashani, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 (USA), Kashani.Kianoush@mayo.edu

Author information

Joy C.Y. Chen https://orcid.org/0000-0003-0960-0718

Kianoush B. Kashani https://orcid.org/0000-0003-2184-3683

Article

Publisher ID: 507999 Other ID: Nephron 2020;144:363–371

DOI: 10.1159/000507999

PubMed ID: 32575100

SO-VID: e7c53dbb-955f-449a-b5e9-8bc61914574b

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Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

History

Date received : 20 June 2019

Date accepted : 19 April 2020

Page count

Figures: 1, Tables: 4, Pages: 9

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Inpatient Kidney Function Recovery among Septic Shock Patients Who Initiated Kidney Replacement Therapy in the Hospital

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Abstract

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Karger: Nephrology

Most cited references 40

Estimation of failure probabilities in the presence of competing risks: new representations of old estimators.

Acute kidney injury in sepsis.

Septic acute kidney injury in critically ill patients: clinical characteristics and outcomes.

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