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Potassium abnormalities are frequent in intensive care but their incidence in the emergency department is unknown.We describe the spectrum of potassium abnormalities in our tertiary-level pediatric emergency department.Retrospective case-control study of all the patients admitted to a single-center tertiary emergency department over a 2.5-year period. We compared patients with hypokalemia (3.0mEq/L) and patients with hyperkalemia (6.0mEq/L) against a normal randomized population recruited on a 3:1 ratio with potassium levels between 3.5 and 5mEq/L.Between January 1, 2013 and August 31, 2016 we admitted 108,209 patients to our emergency department. A total of 9342 blood samples were tested and the following potassium measurements were found: 60 cases of hypokalemia (2.8±0.2mEq/L) and 55 cases of hyperkalemia (6.4±0.6mEq/L). In total, 200 patients with normokalemia were recruited (4.1±0.3mEq/L). The main causes of the disorders were non-specific: lower respiratory tract infection (23%) and fracture (15%) for hypokalemia, lower respiratory tract (21.8%) and ear-nose-throat infections (20.0%) for hyperkalemia. Patients with hyperkalemia had an elevated creatinine level (0.72±1.6 vs. 0.40±0.16mg/dL, P0.0001) with lower bicarbonate (19.4±3.8 vs. 21.8±2.8mmol/L, P=0.0001) and higher phosphorus levels (1.95±0.6 vs. 1.42±0.27mg/dL, P=0.0001). Patients with hypokalemia had an elevated creatinine level (0.66±0.71 vs. 0.40±0.16mg/dL, P0.0001) and a lower phosphorus level (1.12±0.31 vs. 1.42±0.27mg/dL, P=0.0001). We did not observe significant differences in pH, PCODyskalemia is rare in emergency department patients: 0.64% for hypokalemia and 0.58% for hyperkalemia. This condition could be explained by a degree of renal failure due to transient volume disturbance. The main mechanism is dehydration due to digestive losses, polypnea in young patients, and poor intake. In the case of hypokalemia, poor intake and digestive losses could be the main explanation. These disorders resolve easily with feeding or perfusion and do not impair development.Dyskalemia is rare in emergency department patients and is easily resolved with feeding or perfusion. A plausible etiological mechanism is a transient volume disturbance. Dyskalemia is not predictive of poor development in the emergency pediatric population.

Purpose There is wide variation in the practice of acute renal replacement therapy (RRT). Quality of care is suboptimal, and substantial knowledge-to-care gaps need to be addressed. The quality of care for patients receiving acute RRT has been recognized as a clinical and research priority. Quality indicators (QIs) can be implemented to measure the quality of care received by patients and further be used as targets for continuous quality improvement initiatives focused on the prescription, delivery, and monitoring of acute RRT care. Methods The 22nd ADQI meeting was held in San Diego, USA, from October 28th to 30th 2018. Prior to the meeting, a literature review was conducted, and 3 teleconferences were held to develop research questions and consensus statements. These were presented at the meeting and refined before being approved by all ADQI delegates. Results Four research questions and fifteen consensus statements were generated. These focused on monitoring the quality of acute RRT along with the Donabedian quality measure domains of structure, process, and outcome. Recommendations for clinical practice and a research agenda for each question were also proposed. Conclusion Currently, there remains few validated QIs for acute RRT. These need further evaluation, need benchmarks established, and ultimately require implementation into clinical practice.

Rationale & Objective Underlying kidney disease is an emerging risk factor for more severe COVID-19 illness. We examined the clinical courses of critically ill COVID-19 patients with and without pre-existing kidney disease and investigated the association between degree of underlying kidney disease and in-hospital outcomes. Study Design Retrospective cohort study Settings & Participants 4,264 critically ill COVID-19 patients (143 dialysis patients, 521 chronic kidney disease [CKD] patients, and 3,600 patients without CKD) admitted to ICUs at 68 hospitals in the United States. Predictor(s) Presence (versus absence) of pre-existing kidney disease Outcome(s) In-hospital mortality (primary); respiratory failure, shock, ventricular arrhythmia/ cardiac arrest, thromboembolic event, major bleed, and acute liver injury (secondary) Analytical Approach We used standardized differences to compare patient characteristics (values >0.10 indicate a meaningful difference between groups) and multivariable adjusted Fine and Gray survival models to examine outcome associations. Results Dialysis patients had a shorter time from symptom onset to ICU admission compared to other groups (median [quartile 1-quartile 3] days: 4 [2-9] for dialysis patients; 7 [3-10] for CKD patients; 7 [4-10] for patients without pre-existing kidney disease). More dialysis patients (25%) reported altered mental status than those with CKD (20%, standardized difference = 0.12) and no kidney disease (12%, standardized difference = 0.36). Half of dialysis and CKD patients died within 28-days of ICU admission versus 35% of patients without pre-existing kidney disease. Compared to patients without pre-existing kidney disease, dialysis patients had a higher risk of 28-day in-hospital death (adjusted HR 1.41; 95% CI 1.09, 1.81), while patients with CKD had an intermediate risk (adjusted HR 1.25; 95% CI 1.08, 1.44). Limitations Potential residual confounding Conclusions Findings highlight the high mortality of individuals with underlying kidney disease and severe COVID-19, underscoring the importance of identifying safe and effective COVID-19 therapies for this vulnerable population., Individuals with underlying kidney disease may be particularly vulnerable to severe COVID-19 illness, marked by multi-system organ failure, thrombosis, and a heightened inflammatory response. Among 4,264 critically ill adults with COVID-19 admitted to 68 intensive care units across the U.S., we found that both chronic kidney disease and dialysis patients had a ∼50% 28-day in-hospital mortality rate. Patients with underlying kidney disease had higher in-hospital mortality than patients without kidney disease, with patients on maintenance dialysis having the highest risk. As evidenced by differences in symptoms and clinical trajectories, patients with pre-existing kidney disease may have unique susceptibility to COVID-19-related complications which warrants additional study and special consideration in the pursuit and development of targeted therapies.

The substantial burden of acute kidney injury and end-stage kidney disease among patients with critical illness highlights the importance and need for a specialized nephrologist in the intensive care unit. The last decade has seen a growing interest in a career focused on critical care nephrology. However, the scope of practice and job satisfaction of those who completed dual training in nephrology and critical care are largely unknown. This article discusses the current practice landscape of critical care nephrology and describes the educational tracks available to pursue this pathway and considerations to enhance the future of this field.

In response to the recently released 2012 KDIGO (Kidney Disease: Improving Global Outcomes) clinical practice guideline for acute kidney injury (AKI), the National Kidney Foundation organized a group of US experts in adult and pediatric AKI and critical care nephrology to review the recommendations and comment on their relevancy in the context of current US clinical practice and concerns. The first portion of the KDIGO guideline attempts to harmonize earlier consensus definitions and staging criteria for AKI. While the expert panel thought that the KDIGO definition and staging criteria are appropriate for defining the epidemiology of AKI and in the design of clinical trials, the panel concluded that there is insufficient evidence to support their widespread application to clinical care in the United States. The panel generally concurred with the remainder of the KDIGO guidelines that are focused on the prevention and pharmacologic and dialytic management of AKI, although noting the dearth of clinical trial evidence to provide strong evidence-based recommendations and the continued absence of effective therapies beyond hemodynamic optimization and avoidance of nephrotoxins for the prevention and treatment of AKI.

Normal acid-base homeostasis is severely challenged in the intensive care setting. In this review, we address acid-base disturbances, with a special focus on the use of continuous (rather than intermittent) extracorporeal technologies in critical ill patients with acute kidney injury. We consider hypercapnic acidosis and lactic acidosis as examples in which continuous modalities may have different roles and indications than the traditional intermittent approaches to renal replacement therapy. Hypercapnic acidosis develops as a consequence of alveolar hypoventilation. In this condition, correction of pH above 7.2 is not currently recommended, and may even abrogate the beneficial effects of hypercapnic acidosis on overall outcomes. Extracorporeal technologies support lung protection while maintaining overall patient homeostasis. Similarly, in lactic acidosis, current evidence does not support bicarbonate infusions to correct acidosis. The management of lactic acidosis should correct the underlying causative disturbances. Most often, lactic acidosis is a biomarker denoting unfavorable outcomes, rather than an intrinsic pathogenetic mechanism. Extracorporeal procedures may assist in the removal of pathogenic drugs or toxins, as well as partially correcting acidemia. Whether or not these approaches will permit normalization of systemic pH, and the impact of these approaches on patient outcomes, needs to be addressed with prospective controlled trials.

Purpose Acute kidney injury in the pediatric intensive care unit (PICU) is associated with significant morbidity, with continued mortality greater than 50%. Previous studies have described an association between percentage of fluid overload (%FO) less than 20% and improved survival. We reviewed our continuous renal replacement therapy (CRRT) experience to evaluate for factors associated with mortality as well as secondary outcomes. Materials and Methods This is a retrospective chart review of pediatric CRRT intensive care unit patients from January 2000 to September 2005. Results Seventy-six admissions required CRRT during the study period. Overall survival was 55.3%. Median patient age was 5.8 years (range, 0-18.9). Median %FO at the time of CRRT initiation was 7.3% in survivors vs 22.3% in nonsurvivors ( P = .0001). Presence of sepsis was significantly associated with mortality ( P = .0001). All nonsurvivors had multiple organ dysfunction syndrome (MODS); only 69% of survivors had MODS ( P = .0003). For survivors, there was a significant relationship between %FO and time to renal recovery ( P = .0038). Greater %FO was also associated with significantly prolonged days of mechanical ventilation ( P = .0180), PICU stay ( P = .0425), and duration of hospitalization ( P = .0123). Conclusions For patients with acute kidney injury who require CRRT, the presence of sepsis, MODS, and FO greater than 20% at the time of CRRT initiation are significantly associated with higher mortality. In addition, we report that duration of mechanical ventilation, PICU stay, hospitalization, and time to renal recovery were all significantly prolonged for survivors who had FO greater than 20%.

21-YEAR-OLD man with no previous medical history presented to the emergency department 3 days after eing bitten in the left flank by a brown recluse spider. He eported fevers, chills, shortness of breath, hemoptysis, and ecreased urine output. He was febrile, hypotensive, and equired intubation for respiratory distress. Physical examiation was significant for an indurated and erythematous esion on his left flank. His weight was 73 kg. Before ntubation, arterial blood gas analysis showed a pH of 7.40, CO2 of 30 mm Hg, and PO2 of 58 mm Hg on 21% fraction of nspired oxygen. Sodium level was 130 mEq/L (mmol/L); otassium, 6.5 mEq/L (mmol/L); chloride, 101 mEq/L (mmol/ ); bicarbonate, 18 mEq/L (mmol/L); blood urea nitrogen, 6 mg/dL (16.4 mmol/L); creatinine, 3.4 mg/dL (301 mol/ ); glucose, 107 mg/dL (5.9 mmol/L); and lactic acid, 55 g/dL (6.1 mmol/L). Hematocrit was 22%, white blood cell ount was 20,000/ L, and platelet count was 107,000/ L. isseminated intravascular coagulation profile was remarkble for D-dimers of 1:32, fibrinogen of 114 mg/dL (3.4 mol/L), and international normalized ratio of 2.7. Urine nalysis was significant for 4 protein, 4 blood, coarse ranular casts, and no cells. Urine myoglobin was positive. he nephrology department was consulted, and a diagnosis f anuric acute tubular necrosis was made. The patient initially was started on intermittent hemodialyis (IHD) therapy for metabolic control and volume overload n the setting of anuric renal failure. However, after the first ialysis treatment, he developed hemodynamic instability nd was placed on continuous venovenous hemodiafiltration herapy using the Prisma machine with an M60 set with an N69 dialyzer (Gambro, Lakewood, CO) (effective surface rea, 0.6 m) and a blood flow rate of 120 mL/min. He was tarted empirically on a dialysate rate of 1,000 mL/h, prediutional replacement fluid rate of 300 mL/h, and fluid reoval rate of 200 mL/h, giving him a total effluent flow rate f 1,500 mL/h. Urea clearance was approximately 21 mL/ in/kg. He remained on this therapy for 3 months because f oligoanuria. During this period, his course was compliated by intra-abdominal compartment syndrome, enterocuaneous fistula, digital necrosis, pneumonia caused by seudomonas species, and other nosocomial infections. Depite this prolonged complicated hospital course and lengthy ialysis therapy, he recovered renal function, was extubated, nd eventually was transferred to a rehabilitation facility ith a creatinine level of 1.1 mg/dL (97 mol/L).

Acute renal failure in critically ill patients is a growing clinical problem. Options for renal replacement therapy in these patients use convective and diffusive clearance and may be intermittent, as in classic hemodialysis, or continuous. New ways of delivering dialysis in the intensive care unit, such as sustained low-efficiency dialysis, are also under development. It may be that renal replacement therapy needs to be tailored to the needs of each individual patient. Current and future research studies should provide the answers to many of these questions.

Predictors of adequacy of arteriovenous fistulas in hemodialysis patients.BackgroundDialysis access procedures and complications represent a major cause of morbidity, hospitalization, and cost for chronic dialysis patients. To improve the outcomes of hemodialysis access procedures, recent clinical guidelines have encouraged attempts to place an arteriovenous (A-V) fistula, rather than an A-V graft, whenever possible in hemodialysis patients. There is little information, however, about the success rate of following such an aggressive strategy in the prevalent dialysis population.MethodsWe evaluated the adequacy of all A-V fistulas placed in University of Alabama at Birmingham dialysis patients during a two-year period. A fistula was considered adequate if it supported a blood flow of ≥350 ml/min on at least six dialysis sessions in one month. Fistula adequacy was correlated with clinical and demographic factors.ResultsThe adequacy could be determined for 101 fistulas; only 47 fistulas (46.5%) developed sufficiently to be used for dialysis. The adequacy rate was lower in older (age ≥ 65) versus younger (age < 65) patients (30.0 vs. 53.5%, P = 0.03). It was also marginally lower in diabetics versus nondiabetics (35.0 vs. 54.1%, P = 0.061) and in overweight (BMI ≥ 27 kg/m2) versus nonoverweight patients (34.5 vs. 55.2%, P = 0.07). The adequacy rate was not affected by patient race, smoking status, surgeon, serum albumin, or serum parathyroid hormone. The adequacy rate was substantially lower for forearm versus upper arm fistulas (34.0 vs. 58.9%, P = 0.012). The adequacy of forearm fistulas was particularly poor in women (7%), patients age 65 or older (12%), and diabetics (21%). In contrast, upper arm fistulas were adequate in 56% of women, 54% of older patients, and 48% of diabetics.ConclusionsAn aggressive approach to the placement of fistulas in dialysis patients results in a less than 50% early adequacy rate, which is considerably lower than that reported in the past. Moreover, the success rate of fistulas is even lower for certain patient subsets. To achieve an optimal outcome with A-V fistulas, we recommend that they be constructed preferentially in the upper arm in female, diabetic, and older hemodialysis patients.