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Background: Acute kidney injury (AKI) occurs frequently in the neurocritical intensive care unit and is associated with greater morbidity and mortality. AKI and its treatment, including acute kidney replacement therapy, can expose patients to a secondary greater brain injury. This study aimed to explore the role of peritoneal dialysis (PD) in neurocritical AKI patients in relation to metabolic and fluid control, complications related to PD and outcome., Methods: Neurocritical AKI patients were treated by PD (prescribed Kt/V = 0.40/session) using a flexible catheter and a cycler and lactate as a buffer., Results: A total of 58 patients were included. The mean age was 61.8 ± 13.2 years, 65.5% were in the intensive care unit, 68.5% needed intravenous inotropic agents, 72.4% were on mechanical ventilation, APACHE II was 16 ± 6.67 and the main neurological diagnoses were stroke (25.9%) and intracerebral haemorrhage (31%). Ischaemic acute tubular necrosis (iATN) was the most common cause of AKI (51.7%), followed by nephrotoxic ATN AKI (25.8%). The main dialysis indications were uraemia and hypervolemia. Blood urea and creatinine levels stabilised after four sessions at around 48 ± 11 mg/dL and 2.9 ± 0.4 mg/dL, respectively. Negative fluid balance and ultrafiltration increased progressively and stabilised around 2.1 ± 0.4 L /day. Weekly delivered Kt/V was 2.6 ± 0.31. The median number of high-volume PD sessions was 6 (4-10). Peritonitis and mechanical complications were not frequent (8.6% and 10.3%, respectively). Mortality rate was 58.6%. Logistic regression identified as factors associated with death in neurocritical AKI patients: age (odds ratio (OR) = 1.14, 95% confidence interval (CI) = 1.09-2.16, p = 0.001), nephrotoxic AKI (OR = 0.78, 95% CI = 0.69- 0.95, p = 0.03), mechanical ventilation (OR = 1.54, 95% CI = 1.17-2.46, p = 0.01), intracerebral haemorrhage as main neurological diagnoses (OR = 1.15, 95% CI = 1.09-2.11, p = 0.03) and negative fluid balance after two PD sessions (OR = 0.94, 95% CI = 0.74-0.97, p = 0.009)., Conclusion: Our study suggests that careful prescription may contribute to providing adequate treatment for most neurocritical AKI patients without contraindications for PD use, allowing adequate metabolic and fluid control, with no increase in the number of infectious, mechanical and metabolic complications. Mechanical ventilation, positive fluid balance and intracerebral haemorrhage were factors associated with mortality, while patients with nephrotoxic AKI had lower odds of mortality compared to those with septic and ischaemic AKI. Further studies are needed to investigate better the role of PD in neurocritical patients with AKI., Competing Interests: Declaration of conflicting interestsThe authors declared the following potential conflicts of interest with respect to the research, authorship and/or publication of this article: The authors report no conflicts of interest. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article. The authors alone are responsible for the content and writing of this article. The lead authors (DP and ALB) confirm that the manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as originally planned (and, if relevant, registered) have been explained.

Background: Magalhães et al. demonstrated that the incidence of acute kidney injury was high in hospitalized patients with COVID-19 and that the second wave was associated with greater severity; however, the mortality rates were similar between the two periods. This may reflect both the effectiveness of vaccines and the constant learning that frontline professionals gained throughout the pandemic to provide greater support to their patients., Background: ◼ Renal involvement was frequent in patients with COVID-19 and related to worse outcomes., Background: ◼ Diuretic use, mechanical ventilation, proteinuria, hematuria, age, and creatine phosphokinase and D-dimer levels were risk factors for acute kidney injury., Background: ◼ Acute kidney injury, mechanical ventilation, elevated SOFA Score, and elevated ATN-ISS were associated with mortality., Background: ◼ The second wave was associated with greater severity; however, the mortality rates were similar between the two periods., Background: ◼ This may reflect the effectiveness of vaccines and the constant learning that frontline professionals gained throughout the pandemic., Objective: This study aimed to evaluate the incidence of acute kidney injury in hospitalized Brazilian patients with COVID-19 and identify the risk factors associated with its development and prognosis during the two waves of the disease., Methods: We performed a prospective cohort study of hospitalized patients with COVID-19 at a public university hospital in São Paulo from March 2020 to May 2021., Results: Of 887 patients hospitalized with COVID-19, 54.6% were admitted to the intensive care unit. The incidence of acute kidney injury was 48.1%, and the overall mortality rate was 38.9%. Acute kidney replacement therapy was indicated for 58.8% of the patients. The factors associated with acute kidney injury were diuretic use (odds ratio [OR] 2.2, 95%CI= 1.2-4.1, p=0.01), mechanical ventilation (OR= 12.9, 95%CI= 4.3-38.2, p<0.0001), hematuria(OR= 2.02, 95%CI= 1.1-3.5, p<0.0001), chronic kidney disease (OR= 2.6, 95%CI= 1.2-5.5, p=0.009), age (OR= 1.03, 95%CI= 1.01-1.07, p=0.02), and elevated creatine phosphokinase (OR= 1.02, 95%CI= 1.01-1.07, p=0.02) and D-dimer levels (OR= 1.01, 95%CI= 1.01-1.09, p<0.0001). Mortality was higher among those with acute kidney injury (OR= 1.12, 95%CI= 1.02-2.05, p=0.01), elevated Sequential Organ Failure Assessment Scores (OR= 1.35, 95%CI= 1.1-1.6, p=0.007), elevated Acute Tubular Necrosis-Injury Severity Score (ATN-ISS; (OR= 96.4, 95%CI= 4.8-203.1, p<0.0001), and who received mechanical ventilation (OR= 12.9, 95%CI= 4.3-38.2, p<0.0001). During the second wave, the number of cases requiring mechanical ventilation (OR= 1.57, 95%CI= 1.01-2.3, p=0.026), with proteinuria (OR= 1.44, 95%CI= 1.01-2.1, p=0.04), and with higher ATN-ISS Scores (OR= 40.9, 95%CI= 1.7-48.1, p=0.04) was higher than that during the first wave., Conclusion: Acute kidney injury was frequent in hospitalized patients with COVID-19, and the second wave was associated with greater severity. However, mortality rates were similar between the two periods, which may reflect both the effectiveness of vaccines and the constant learning that frontline professionals gained throughout the pandemic to provide greater support to their patients., Registry of Clinical Trials: RBR-62y3h7.

Introduction: Recovery of kidney function to liberate patients from acute kidney replacement therapy (AKRT) is recognized as a vital patient-centered outcome. The lack of specific guidelines providing specific recommendations on therapy interruption is an important obstacle. We aimed to determine the prevalence of successful discontinuation of AKRT and its predictive factors after the elaboration of clinical protocol with these recommendations., Methodology: A prospective cohort study was performed with 156 patients at a public Brazilian university hospital between July 2020 and July 2021., Results: Success and hospital discharge were achieved for most patients (84.6% and 89%, respectively). Multivariable logistic regression analysis showed that C-reactive protein (CRP), urine output, and creatinine clearance at the time of interruption were variables associated with discontinuation success (OR: 0.943, CI: 0.905-0.983, p = 0.006; OR: 1.078, CI: 1.008-1.173, p = 0.009 and OR: 1.091, CI: 1.012-1.213, p = 0.004; respectively). The areas under the curve for CRP, urine output, and creatinine clearance at the time of interruption were 0.78, 0.62, and 0.82, respectively. Both CRP and creatinine clearance were good predictors of successful liberation of AKRT. The optimal cutoff value of them had sensitivity and specificity of 0.88 and 0.87, 0.91 and 0.90, respectively. The use of noradrenalin at the time of interruption (OR: 0.143, CI: 0.047-0.441, p = 0.001) and successful discontinuation (OR: 3.745, CI: 1.047-13.393, p = 0.042) were identified as variables associated with hospital discharge., Conclusion: Our results show the factors related to success in discontinuing AKRT are the CRP, creatinine clearances, and urinary output at the time of AKRT interruption and it was associated with lower mortality., (© 2023 S. Karger AG, Basel.)

Acute kidney injury (AKI) is a heterogeneous syndrome with multiple etiologies. It occurs frequently in the neurocritical intensive care unit and is associated with greater morbidity and mortality. In this scenario, AKI alters the kidney-brain axis, exposing patients who receive habitual dialytic management to greater injury. Various therapies have been designed to mitigate this risk. Priority has been placed by KDIGO guidelines on the use of continuous over intermittent acute kidney replacement therapies (AKRT). On this background, continuous therapies have a pathophysiological rationale in patients with acute brain injury. A low-efficiency therapy such as PD and CRRT could achieve optimal clearance control and potentially reduce the risk of secondary brain injury. Therefore, this work will review the evidence on peritoneal dialysis as a continuous AKRT in neurocritical patients, describing its benefits and risks so it may be considered as an option when deciding among available therapeutic options., (© 2023 Wiley Periodicals LLC.)

Introduction: Acute kidney injury (AKI) is one of the main complications of COVID-19 caused by SARS-CoV-2. This study aimed to evaluate the incidence of AKI in Brazilian hospitalized patients diagnosed with COVID-19 and identify the risk factors associated with its onset and those associated with its prognosis., Methods: A prospective cohort study of hospitalized patients diagnosed with COVID-19 at a public and tertiary university hospital in São Paulo from March to December 2020., Results: There were 347 patients hospitalized with COVID-19, 52.4% were admitted to the intensive care unit (ICU) and 47.6% were admitted to the wards. The overall incidence of AKI was 46.4%, more frequent in the ICU (68.1% vs 22.4, p < 0.01) and the overall mortality was 36.1%. Acute kidney replacement therapy was indicated in 46.6% of patients with AKI. In the general population, the factors associated with AKI were older age (OR 1.03, CI 1-1.05, p < 0.05), mechanical ventilation (OR 1.23, CI 1.06-1.83, p < 0.05), presence of proteinuria (OR 1.46, CI 1.22-1.93, p < 0.05), and use of vasoactive drugs (OR 1.26, CI 1.07-1.92, p < 0.05). Mortality was higher in the elderly (OR 1.08, CI 1.04-1.11, p < 0.05), in those with AKI (OR 1.12, CI 1.02-2.05, p < 0.05), particularly KDIGO stage 3 AKI (OR 1.10, CI 1.22-2.05, p < 0.05) and in need of mechanical ventilation (OR 1.13, CI 1.03-1.60, p < 0.05)., Conclusion: AKI was frequent in hospitalized patients with COVID-19 and the factors associated with its development were older age, mechanical ventilation, use of vasoactive drugs, and presence of proteinuria, being a risk factor for death., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

Peritoneal dialysis (PD) as an AKI treatment in adults was widely accepted in critical care settings well into the 1980s. The advent of extracorporeal continuous KRT led to widespread decline in the use of PD for AKI across high-income countries. The lack of familiarity and comfort with the use of PD in critical care settings has also led to lack of use even among those receiving maintenance PD. Many critical care units reflexively convert patients receiving maintenance PD to alternative dialysis therapies at admission. Renewed interest in the use of PD for AKI therapy has emerged due to its increasing use in low- and middle-income countries. In high-income countries, the coronavirus disease 2019 (COVID-19) pandemic, saw PD for AKI used early on, where many critical care units were in crisis and relied on PD use when resources for other AKI therapy modalities were limited. In this review, we highlight advantages and disadvantages of PD in critical care settings and indications and contraindications for its use. We provide an overview of literature to support both PD treatment during AKI and its continuation as a maintenance therapy during critical illness. For AKI therapy, we further discuss establishment of PD access, PD prescription management, and complication monitoring and treatment. Finally, we discuss expansion in the use of PD for AKI therapy extending beyond its role during times of resource constraints., (Copyright © 2023 by the American Society of Nephrology.)

Unassigned: In the 1970s, acute peritoneal dialysis (PD) was widely accepted for the treatment of acute kidney injury (AKI), but this practice has declined in favor of extracorporeal therapies, mainly in developed world. The lack of familiarity with the use of PD in critically ill patients has also led to a lack of use even among those receiving maintenance PD. Renewed interest in the use of PD for AKI therapy has emerged due to its increasing use in low- and middle-income countries due to its lower cost and minimal infrastructural requirements. In high-income countries, the coronavirus disease 2019 pandemic saw PD for AKI used early on, where many critical care units were in crisis and relied on PD use when resources for other AKI therapy modalities were limited. In this review, we highlight the advantages and disadvantages of PD in AKI patients and indications and contraindications for its use. We also provide an overview of advances to support PD treatment during AKI, discussing PD access, PD prescription, complications related to PD, and its use in particular clinical conditions. (Rev Invest Clin. 2023;75(6):327-36)., (Copyright: © 2023 Permanyer.)

Background: Treatment for severe acute kidney injury (AKI) typically involves the use of acute kidney replacement therapy (AKRT) to prevent or reverse complications., Methodology: We aimed to determine the prevalence of successful discontinuation of AKRT and its predictive factors. A retrospective cohort study was performed with 316 patients hospitalized at a public Brazilian university hospital between January 2011 and June 2020., Results: Success and hospital discharge were achieved for most patients (85% and 74%, respectively). Multivariable logistic regression analysis showed that C-reactive protein (CRP), urine output, and need mechanical ventilation at the time of interruption were variable associated with discontinuation success (OR 0.969, CI 0.918-0.998, p = 0.031; OR 1.008, CI 1.001-1.012, p = 0.041 and OR 0.919, CI 0.901-0.991, p = 0.030; respectively), while the absence of comorbidities such as chronic kidney disease (OR 0.234, CI 0.08-0.683, p = 0.008), cardiovascular disease (OR 0.353, CI 0.134-0.929, p = 0.035) and hypertension (OR 0.278, CI 0.003-0.882, p = 0.009), as well as pH values at the time of AKRT indication (OR 1.273, CI 1.003-1.882, p = 0.041), mechanical ventilation at the time of interruption (OR 0.19, CI 0.19-0.954, p = 0.038) and successful discontinuation (OR 8.657, CI 3.135-23.906, p < 0.001) were identified as variables associated with hospital discharge., Conclusion: These results show that clinical conditions such as comorbidities, urine output, and mechanical ventilation, and laboratory variables such as pH and CRP are factors associated with hospital discharge and AKRT discontinuation success, requiring larger studies for confirmation., (© 2022 International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Background: Acute kidney injury (AKI) is frequently associated with COVID-19, and the need for kidney replacement therapy (KRT) is considered an indicator of disease severity. This study aimed to develop a prognostic score for predicting the need for KRT in hospitalised COVID-19 patients, and to assess the incidence of AKI and KRT requirement., Methods: This study is part of a multicentre cohort, the Brazilian COVID-19 Registry. A total of 5212 adult COVID-19 patients were included between March/2020 and September/2020. Variable selection was performed using generalised additive models (GAM), and least absolute shrinkage and selection operator (LASSO) regression was used for score derivation. Accuracy was assessed using the area under the receiver operating characteristic curve (AUC-ROC)., Results: The median age of the model-derivation cohort was 59 (IQR 47-70) years, 54.5% were men, 34.3% required ICU admission, 20.9% evolved with AKI, 9.3% required KRT, and 15.1% died during hospitalisation. The temporal validation cohort had similar age, sex, ICU admission, AKI, required KRT distribution and in-hospital mortality. The geographic validation cohort had similar age and sex; however, this cohort had higher rates of ICU admission, AKI, need for KRT and in-hospital mortality. Four predictors of the need for KRT were identified using GAM: need for mechanical ventilation, male sex, higher creatinine at hospital presentation and diabetes. The MMCD score had excellent discrimination in derivation (AUROC 0.929, 95% CI 0.918-0.939) and validation (temporal AUROC 0.927, 95% CI 0.911-0.941; geographic AUROC 0.819, 95% CI 0.792-0.845) cohorts and good overall performance (Brier score: 0.057, 0.056 and 0.122, respectively). The score is implemented in a freely available online risk calculator ( https://www.mmcdscore.com/ )., Conclusions: The use of the MMCD score to predict the need for KRT may assist healthcare workers in identifying hospitalised COVID-19 patients who may require more intensive monitoring, and can be useful for resource allocation., (© 2022. The Author(s).)

The Department of Acute Kidney Injury (IRA) of the Brazilian Society of Nephrology prepared this document for the purpose of standardizing AKI terminology and dialysis modalities in the Portuguese language for Brazil. Several terms with similar meanings have been used in AKI and its dialysis modalities, causing confusion and disparities among patients, nephrologists, health institutions, private care companies, insurance companies and government entities. These disparities can impact medical care, hospital organization and care, as well as the funding and reimbursement of AKI-related procedures. Thus, consensual nomenclature and definitions were developed, including the definitions of AKI, acute kidney disease (AKD) and chronic kidney disease (CKD). Additionally, we addressed all dialysis modalities and extracorporeal procedures related to AKI, currently approved and available in the country. The Brazilian Society of Nephrology hopes that this Consensus can standardize the terminology and provide technical support to all involved in AKI care in Brazil.

Acute kidney injury (AKI) is frequently associated with COVID-19 and it is considered an indicator of disease severity. This study aimed to develop a prognostic score for predicting in-hospital mortality in COVID-19 patients with AKI (AKI-COV score). This was a cross-sectional multicentre prospective cohort study in the Latin America AKI COVID-19 Registry. A total of 870 COVID-19 patients with AKI defined according to the KDIGO were included between 1 May 2020 and 31 December 2020. We evaluated four categories of predictor variables that were available at the time of the diagnosis of AKI: (1) demographic data; (2) comorbidities and conditions at admission; (3) laboratory exams within 24 h; and (4) characteristics and causes of AKI. We used a machine learning approach to fit models in the training set using tenfold cross-validation and validated the accuracy using the area under the receiver operating characteristic curve (AUC-ROC). The coefficients of the best model (Elastic Net) were used to build the predictive AKI-COV score. The AKI-COV score had an AUC-ROC of 0.823 (95% CI 0.761-0.885) in the validation cohort. The use of the AKI-COV score may assist healthcare workers in identifying hospitalized COVID-19 patients with AKI that may require more intensive monitoring and can be used for resource allocation., (© 2021. The Author(s).)

Summary Statements: (1) Peritoneal dialysis (PD) should be considered a suitable modality for treatment of acute kidney injury (AKI) in all settings (1B) ., Guideline 2: Access and Fluid Delivery for Acute Pd in Adults: (2.1) Flexible peritoneal catheters should be used where resources and expertise exist (1B) (optimal) .(2.2) Rigid catheters and improvised catheters using nasogastric tubes and other cavity drainage catheters may be used in resource-poor environments where they may still be life-saving (1C) (minimum standard) .(2.3) We recommend catheters should be tunnelled to reduce peritonitis and peri-catheter leak (practice point) .(2.4) We recommend that the method of catheter implantation should be based on patient factors and locally available skills (1C) .(2.5) PD catheter implantation by appropriately trained nephrologists in patients without contraindications is safe and functional results equate to those inserted surgically (1B) .(2.6) Nephrologists should receive training and be permitted to insert PD catheters to ensure timely dialysis in the emergency setting (practice point). (2.7) We recommend, when available, percutaneous catheter insertion by a nephrologist should include assessment with ultrasonography (2C) .(2.8) Insertion of PD catheter should take place under complete aseptic conditions using sterile technique (practice point) .(2.9) We recommend the use of prophylactic antibiotics prior to PD catheter implantation (1B) .(2.10) A closed delivery system with a Y connection should be used (1A) (optimal) . In resource poor areas, spiking of bags and makeshift connections may be necessary and can be considered (minimum standard) .(2.11) The use of automated or manual PD exchanges are acceptable and this will be dependent on local availability and practices (practice point) ., Guideline 3: Peritoneal Dialysis Solutions for Acute Pd: (3.1) In patients who are critically ill, especially those with significant liver dysfunction and marked elevation of lactate levels, bicarbonate containing solutions should be used ( 1B) (optimal) . Where these solutions are not available, the use of lactate containing solutions is an alternative (practice point) (minimum standard) .(3.2) Commercially prepared solutions should be used (optimal) . However, where resources do not permit this, then locally prepared fluids may be life-saving and with careful observation of sterile preparation procedure, peritonitis rates are not increased (1C) (minimum standard) .(3.3) Once potassium levels in the serum fall below 4 mmol/L, potassium should be added to dialysate (using strict sterile technique to prevent infection) or alternatively oral or intravenous potassium should be given to maintain potassium levels at 4 mmol/L or above (1C) .(3.4) Potassium levels should be measured daily (optimal) . Where these facilities do not exist, we recommend that after 24 h of successful dialysis, one consider adding potassium chloride to achieve a concentration of 4 mmol/L in the dialysate (minimum standard) (practice point)., Guideline 4: Prescribing and Achieving Adequate Clearance in Acute Pd: (4.1) Targeting a weekly K t / V urea of 3.5 provides outcomes comparable to that of daily HD in critically ill patients; targeting higher doses does not improve outcomes (1B) . This dose may not be necessary for most patients with AKI and targeting a weekly K t / V of 2.2 has been shown to be equivalent to higher doses (1B) . Tidal automated PD (APD) using 25 L with 70% tidal volume per 24 h shows equivalent survival to continuous venovenous haemodiafiltration with an effluent dose of 23 mL/kg/h (1C) .(4.2) Cycle times should be dictated by the clinical circumstances. Short cycle times (1-2 h) are likely to more rapidly correct uraemia, hyperkalaemia, fluid overload and/or metabolic acidosis; however, they may be increased to 4-6 hourly once the above are controlled to reduce costs and facilitate clearance of larger sized solutes (2C) .(4.3) The concentration of dextrose should be increased and cycle time reduced to 2 hourly when fluid overload is evident. Once the patient is euvolemic, the dextrose concentration and cycle time should be adjusted to ensure a neutral fluid balance (1C) .(4.4) Where resources permit, creatinine, urea, potassium and bicarbonate levels should be measured daily; 24 h K t / V urea and creatinine clearance measurement is recommended to assess adequacy when clinically indicated (practice point) .(4.5) Interruption of dialysis should be considered once the patient is passing >1 L of urine/24 h and there is a spontaneous reduction in creatinine (practice point) ., The use of peritoneal dialysis (PD) to treat patients with acute kidney injury (AKI) has become more popular among clinicians following evidence of similar outcomes when compared with other extracorporeal therapies. Although it has been extensively used in low-resource environments for many years, there is now a renewed interest in the use of PD to manage patients with AKI (including patients in intensive care units) in higher income countries. Here we present the update of the International Society for Peritoneal Dialysis guidelines for PD in AKI. These guidelines extensively review the available literature and present updated recommendations regarding peritoneal access, dialysis solutions and prescription of dialysis with revised targets of solute clearance.

Background: The aim of this study is to evaluate the peptidylarginine deiminase 4 (PAD 4) concentration and PADI4 polymorphisms as predictors of acute kidney injury (AKI) development, the need for renal replacement therapy (RRT), and mortality in patients with septic shock., Methods: We included all individuals aged ≥ 18 years, with a diagnosis of septic shock at ICU admission. Blood samples were taken within the first 24 hours of the patient's admission to determine serum PAD4 concentration and its PADI4 polymorphism (rs11203367) and (rs874881). Patients were monitored during their ICU stay and the development of SAKI was evaluated. Among the patients in whom SAKI developed, mortality and the need for RRT were also evaluated., Results: There were 99 patients, 51.5% of whom developed SAKI and of these, 21.5% needed RRT and 80% died in the ICU. There was no difference between PAD4 concentration (p = 0.116) and its polymorphisms rs11203367 (p = 0.910) and rs874881 (p = 0.769) in patients in whom SAKI did or did not develop. However, PAD4 had a positive correlation with plasma urea concentration (r = 0.269 and p = 0.007) and creatinine (r = 0.284 and p = 0.004). The PAD4 concentration and PADI4 polymorphisms were also not associated with RRT and with mortality in patients with SAKI., Conclusion: PAD4 concentration and its polymorphisms were not associated with SAKI development, the need for RRT, or mortality in patients with septic shock. However, PAD4 concentrations were associated with creatinine and urea levels in these patients.

Purpose: While considerable information is available on acute kidney injury (AKI) in North America and Europe, large comprehensive epidemiologic studies on AKI from Latin America and Asia are still lacking. The present study aimed to evaluate the epidemiology and outcomes of AKI in patients evaluated by nephrologists in a Brazilian teaching hospital., Methods: We performed a large retrospective observational study that looked into the epidemiology of AKI and its effect on patient outcomes across time periods. For comparison purposes, patients were divided into two groups according to the year of follow up: 2011-2014 and 2015-2018., Results: We enrolled 7976 AKI patients and, after excluding patients with chronic kidney disease stages 4 and 5, kidney transplant recipients and those with incomplete data, 5428 AKI patients were included (68%). The maximum AKI stage was 3 (50.6%), and there was a mortality rate of 34.3% (1865 patients). Dialysis treatment was indicated in 928 patients (17.1%). Patient survival improved along the study periods, and patients treated in 2015-2018 had a relative risk death reduction of 0.89 (95% CI 0.81-0.98, p = 0.02). The independent risk factors for mortality were sepsis, > 65 years of age, admission to the intensive care unit, AKI-KDIGO 3, recurrent AKI, no metabolic and fluid demand to capacity imbalance (as a dialysis indication), and the period of treatment., Conclusion: We observed an improvement in AKI patient survival over the years, even after correction for several confounders and using a competing risk approach. Identification of risk factors for mortality can help in decision-making for timely intervention, leading to better clinical outcomes.

Studies on vancomycin pharmacokinetics in acute kidney injury (AKI) patients on high-volume peritoneal dialysis (HVPD) are lacking. We studied the pharmacokinetics of intravenous (IV) vancomycin in AKI patients treated by HVPD who received a prescribed single IV dose of vancomycin (15 - 20 mg/kg total body weight) to determine the extent of vancomycin removal and to establish vancomycin dosing guidelines for the empirical treatment of AKI patients receiving HVPD. The application of 18 mg/kg vancomycin every 48 - 72 hours in AKI patients undergoing HVPD was required to maintain therapeutic concentrations., (Copyright © 2019 International Society for Peritoneal Dialysis.)

Introduction: Hemodialysis (HD) is one treatment for acute kidney injury (AKI) patients. Studies have shown that this dialysis modality may lead to changes in pulmonary function with an impact on prognosis. The aim of our study was to evaluate changes in respiratory mechanics and oxygenation of AKI patients admitted to an intensive care unit who were undergoing intermittent mechanical ventilation (IMV) and daily HD., Methods: This prospective cohort study evaluated 94 AKI patients and 234 HD sessions. Pulmonary static compliance (Pcs), resistance (Rsr), and arterial partial pressure of oxygen and the fraction of inspired oxygen (PaO 2 /FiO 2 ) ratio were assessed during the initial three-day period of daily HD therapy., Findings: Psc increased progressively during HD sessions, from 39.4 ± 21.4 mL/cm H 2 O prior to the initial dialysis to 55.5 ± 25.2 at the end of the last dialysis during the study period (P = 0.04). Similarly, Rsr and PaO 2 /FiO 2 ratio also improved, from 11.1 ± 6.3 cm H 2 O/L/s prior to the initial dialysis to 8.8 ± 4.2 at the end of the last dialysis (P =0.0027) and from 228 ± 85 prior to the initial dialysis to 312.1 ± 111.5, P < 0.001, to the end of the last dialysis, respectively., Conclusion: This study showed that AKI patients undergoing IMV and daily HD improve their respiratory mechanics and oxygenation., (© 2018 International Society for Hemodialysis.)

Background: Peritoneal dialysis (PD) and hemodialysis (HD) are options for the treatment of acute kidney injury (AKI) patients. The aim of this study was to compare the effects of PD and daily HD on respiratory mechanics of AKI patients undergoing invasive mechanical ventilation (IMV)., Methods: A prospective cohort study evaluated 154 patients, 37 on continuous PD and 94 on HD. Respiratory mechanics parameters such as pulmonary static compliance (Psc) and resistance of the respiratory system (Rsr) and oxygenation index (OI) were assessed for 3 days. Patients were evaluated at moments 1, 2 and 3 (pre- and post-dialysis)., Results: The initial clinical parameters were similar in the two groups, except the age that was higher in continuous PD group (70.8 ± 11.6 vs. 60 ± 15.8; p < 0.0001). In both groups, Psc increased significantly, with no difference between the two groups-pre-dialysis (continuous PD 40 ± 17.4, 42.8 ± 17.2, 48 ± 19; HD 39.1 ± 21.3, 39. 5 ± 18.9, 45.2 ± 21) and post-dialysis (continuous PD 42.8 ± 7.2, 48 ± 19, 57.1 ± 18.3; HD 42 ± 19, 45 ± 18.5, 56 ± 24.8). Rsr remained stable among patients on continuous PD (pre-dialysis 10.4 ± 5.1, 13.3 ± 7.7, 13.5 ± 10.3, post-dialysis 13.3 ± 7.7, 13.5 ± 10.3, 11.1 ± 5.9) and decreased among HD patients (pre-dialysis 10.4 ± 5.1, 10.4 ± 5.1, 10.4 ± 5, 1, post-dialysis 10.5 ± 6.8, 10 ± 4.9, 8.9 ± 4.2). There was difference in Rsr between the two groups at the post-dialysis moments 1 and 2 (p = 0.03). OI increased in both groups (continuous PD 260.7 ± 119, 252.7 ± 87.1, 287.3 ± 88.4; HD 228 ± 85, 257 ± 84, 312.1 ± 111.5, p > 0.05), although there was no difference between them., Conclusion: AKI patients undergoing IMV and HD or PD had improvement in the mechanical ventilation and oxygenation, with no difference between the two groups.

Purpose of Review: Although historically peritoneal dialysis was widely used in nephrology, it has been underutilized in recent years. In this review, we present several key opportunities and strategies for revitalization of urgent start peritoneal dialysis use, and discuss the recent literature on clinical experience with peritoneal dialysis use in the acute and unplanned setting., Recent Findings: Interest in using urgent start peritoneal dialysis to manage acute kidney injury (AKI) and unplanned chronic kidney disease (CKD) stage 5 patients has been increasing. To overcome some of the classic limitations of peritoneal dialysis use in AKI, such as a high chance of infectious and mechanical complications, and no control of urea, the use of cycles, flexible catheters, and a high volume of dialysis fluid has been proposed. This knowledge can be used in the case of an unplanned start on chronic peritoneal dialysis, and may be a tool to increase the peritoneal dialysis penetration rate among incident patients starting chronic dialysis therapy., Summary: Peritoneal dialysis should be offered in an unbiased way to all patients starting unplanned dialysis, and without contraindications to peritoneal dialysis. It may be a feasible, well tolerated, and complementary alternative to hemodialysis, not only in the chronic setting, but also in the acute.

Acute kidney injury (AKI) is a frequent and serious condition with high mortality. The presence of hypermetabolism may be a factor related to poorer prognosis. This study evaluated the resting energy expenditure (REE) of intensive care unit (ICU) patients with severe AKI using indirect calorimetry (IC) and identified factors associated with metabolism categories. Patients were evaluated through measurement of REE and estimation of basal energy expenditure (BEE) using the Harris⁻Benedict equation. Metabolism categories were as follows: hypermetabolism (REE/BEE > 1.3) and hypometabolism (REE/BEE < 0.9). The metabolism categories were compared using ANOVA and the chi-square test. Variables were analyzed by multiple logistic regression tests. Also, survivors and non-survivors were compared using Student&rsquo;s t -tests along with Cox regression tests. Kaplan⁻Meier survival curves were also performed. We evaluated 124 patients with a mean age of 61.08 &plusmn; 16.6 years. Sixty-four patients were hypermetabolic (62%) and 18 were hypometabolic (14%). Vasoactive drug (VAD) dose and younger age were independently associated with hypermetabolism. The survival analysis was not associated with metabolism categorization. In conclusion, patients with severe AKI are mostly hypermetabolic and hypermetabolic patients of a lower age receiving treatment with higher VAD doses. The only factors associated with death were protein intake and VAD dose.

Background: Acute renal injury (AKI) interferes greatly with nutritional status, affecting the metabolism of all macronutrients and increased mortality rates in hospitalized patients. Our objective was to evaluate the association of nutritional parameters (albumin, cholesterol, caloric and protein intake and nitrogen balance (NB)) with mortality in patients with AKI., Methods: This is a prospective observational study that evaluated 595 consecutive patients over the age of 18 years with AKI, requiring enteral or parenteral feeding. At the time of the patient's enrollment, demographic and laboratorial data, caloric and protein supply and NB were recorded on the first day of referral to the nephrologist. All patients were followed throughout the hospital stay and mortality rate was also recorded., Results: The medium age of patients with AKI was 64 (54-75) years, 64.5% male, 62% admitted to intensive care unit (ICU), 52% on dialysis and the majority (48%) were at stage 3 by AKIN. Length of stay and hospital mortality were 18 (10-31) days and 46%, respectively. Superior age, AKI severity, lower body weight and body mass index (BMI), higher need for dialysis, ICU admission and shorter hospital stay were associated with higher mortality. At logistic regression, caloric (OR: 0.946; CI:95%: 0.901-0.994; p:0.029) and protein intake (OR: 0.947; CI:95%: 0.988-0.992; p = 0.028) and serum albumin (OR: 0.545; CI:95%: 0.401-0741; p < 0.001) were associated with hospital mortality. Cholesterol (OR: 0.995; CI:95%: 0.991-1.000; p = 0.052) was not associated with increased mortality in the adjusted analysis. Analysis of the receiver operating characteristic (ROC) curve showed that calorie intake < 12 kcal/kg (AUC: 0.745; CI:95%: 0.684-0.765; p < 0.001) and protein intake < 0.5 g/kg (AUC: 0.726; CI:95%: 0.686-0.767; p < 0.001) were predictors of hospital mortality, as well as a negative NB < -6.47 g N/day (AUC: 0.745; CI:95%: 0.704-0.786; p < 0.001)., Conclusions: In conclusion, low caloric and protein intake, negative NB and low albumin value are conditions associated with higher hospital mortality in patients with AKI., (Copyright © 2018 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.)

The objective of the present study was to evaluate protein carbonyl concentration as a predictor of AKI development in patients with septic shock and of renal replacement therapy (RRT) and mortality in patients with SAKI. This was a prospective observational study of 175 consecutive patients over the age of 18 years with septic shock upon Intensive Care Unit (ICU) admission. After exclusion of 46 patients (27 due to AKI at ICU admission), a total of 129 patients were enrolled in the study. Demographic information and blood samples were taken within the first 24 h of the patient's admission to determine serum protein carbonyl concentrations. Among the patients who developed SAKI, the development of AKI was evaluated, along with mortality and need for RRT. The mean age of the patients was 63.3 ± 15.7 years, 47% were male and 51.2% developed SAKI during ICU stay. In addition, protein carbonyl concentration was shown to be associated with SAKI. Among 66 patients with SAKI, 77% died during the ICU stay. Protein carbonyl concentration was not associated with RRT in patients with SAKI. However, the ROC curve analysis revealed that higher levels of protein carbonyl were associated with mortality in these patients. In logistic regression models, protein carbonyl level was associated with SAKI development (OR: 1.416; 95% CI: 1.247-1.609; P <0.001) and mortality when adjusted by age, gender, and APACHE II score (OR: 1.357; 95% CI: 1.147-1.605; P <0.001). In conclusion, protein carbonyl concentration is predictive of AKI development and mortality in patients with SAKI, with excellent reliability., (© 2018 The Author(s).)

Background: Currently, the execution of indirect calorimetry, which is considered the gold standard for measuring energy expenditure, is not indicate during dialysis, and it may interfere on nutritional therapy of these patients. This study aimed to evaluate the resting energy expenditure (REE) in patients with severe acute kidney injury treated by different modalities of dialysis and to identify whether dialysis influences on REE., Methods: This was a prospective cohort study that evaluated patients admitted in intensive care units with diagnosis of acute kidney injury AKIN-3, mechanically ventilated, and submitted to conventional hemodialysis (CHD), extended hemodialysis (EHD) or high volume peritoneal dialysis (HVPD). Indirect calorimetry was performed at pre dialysis time and during the dialysis procedure. Parameters that could change REE were also evaluated., Results: One-hundred patients undergoing 290 dialysis sessions were evaluated, with mean age 60.3 ± 17 years, 69% were male and 74% have died. There was no significant difference between REE of predialysis time and during dialysis time (2156 ± 659 kcal vs. 2100 ± 634 kcal, respectively, p = 0.15). No difference was observed in the REE before and during dialysis of different modalities. There were no differences between parameters pre and during dialysis of each modality. There was only a difference in norepinephrine dose, which was higher in pre dialysis time in HVPD and EHD modalities, compared with CHD modality. Moreover, during dialysis time, EHD modality had significantly higher VAD compared to other dialysis modalities., Conclusion: The three evaluated modalities did not change REE. Indirect calorimetry can be performed during dialysis procedures and there was no difference between ventilation parameters, sedatives use, body temperature and VAD in both moments., (Copyright © 2016 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Sepsis is the most common cause of death in critically ill patients and it may be associated with multiorgan failure, including acute kidney injury (AKI). This situation can require acute renal support and increase mortality. Therefore, it is essential to administrate antimicrobials in dosis to achieve adequate serum levels, preventing overdosis and drug toxicity or underdosing and risk for resistance to antibiotics and higher mortality. To date, there aren't validated guidelines on antibiotic dosis adjustment in septic patients with AKI and the recommendations are extrapolated from studies conducted in non-critical patients with chronic kidney disease in end stage receiving chronic renal replacement therapy. This study aimed to review and discuss the complexity of that issue, considering the several factors related to the drugs removal: critically ill patient characteristics, antimicrobial properties and dialysis method.

Introduction: It is needed for nutrition prescription correct estimate of resting energy expenditure (REE), which is a challenge given the possible daily variation in critically ill patients with acute kidney injury (AKI)., Objective: To evaluate the daily variability of REE measured by indirect calorimetry (IC) in patients with AKI and dialysis indication and identify clinical variables associated with REE., Methods: The REE was measured on the time of dialysis indication and the subsequent four days. We also evaluated parameters that can influence the REE. The daily differences were analyzed by generalized linear model for repeated measures. We also used Spearman correlation and multiple linear regression., Results: There were 301 IC measurements in 114 patients, mean age of 60.65 ± 16.9 years and 68.4% were male. The average REE was 2081 ± 645 kcal, rising on day 5 (2270 ± 556 kcal) compared to the days 2 and 3 (2022 ± 754; 2022 ± 660 kcal, respectively, p = 0,04). When normalized to weight, there was no significant difference in REE (kcal/kg/day) during follow-up. REE was positively correlated with total leukocyte count, C-reactive protein, minute volume (MV), fraction of inspired oxygen (FiO2) urea nitrogen appearance (UNA), weight and height and inversely with age. After multiple regression, MV, FiO2, weight and age are correlated independently with REE., Conclusion: Patients with AKI have REE stable. The REE was associated independently with FiO2, MV, body weight and age. Thus, ventilatory parameters should be evaluated each day for the necessary dietary changes may be made.

Introduction: Surviving acute kidney (AKI) patients have a higher late mortality compared with those admitted without AKI. The negative impact of malnutrition on the early outcome of AKI patients has recently been confirmed by various studies. However, its impact after hospital discharge has not been studied. The objective of the study was to determine the role of anthropometric measurements and handgrip strength as predictors of mortality 180 days after discharge., Methodology: Eighty-two survivors AKI patients who were older than 18 y old and followed by AKI team were prospectively evaluated. Patient's characteristics were recorded, anthropometric measurements were taken, handgrip strength (HGS) was measured, subjective global assessment and bioimpedance were applied and blood samples were collected during hospitalization at first and last nephrologist evaluation and in after hospital discharge at 1 month, 3 and 6 months. Multivariable logistic regression was used to adjust confounding and selection bias., Results: Age was 62.3 ± 14.7 years, prevalence of hospitalization in medical wards of 71.6%, index of severity of AKI (ATN-ISS) was 28% and late mortality rates was 25.6%. Risk factors associated with late mortality were the number of comorbidities (HR = 1.79, 95% CI = 1.45-2.46, p = 0.04), cancer (HR = 1.89, 95 CI% = 1.48-3.16, p = 0.01), sepsis (HR = 1.47, 95% CI = 1.18-2.38, p = 0.03), no recovery of renal function at hospital discharge (HR = 1.46, 95% CI = 1.02-2.16, p = 0.03), malnutrition at first evaluation (HR = 1.58, 95% CI = 1.14-2.94, p = 001), the HGS value at the moment of last evaluation by nephrologist (HR = 1.81, 95% CI = 1.17-2.31, p = 0.04) and gain weigh < 1 kg between the moment at first evaluation by nephrologist and one month after hospital discharge (HR = 1.95, 95 CI% = 1.29-3.3, p = 0.02)., Conclusion: HGS and gain weight were identified as predictors of late mortality. Simple and ease methods can be applied in AKI patients during and after hospitalization to diagnose nutritionally patients who are at higher risk for poor prognosis and, consequently intervention measures can be performed to improve survival in long-term., (Copyright © 2016 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.)

Hypercatabolism has been described as the main nutritional change in acute kidney injury. Catabolism may be defined as the excessive release of amino acids from skeletal muscle. Conditions such as fasting, inadequate nutritional support, renal replacement therapy, metabolic acidosis, and secretion of catabolic hormones are the main factors that affect protein catabolism. Given the imprecision of the methods conventionally used to assess and monitor the nutritional status of hospitalized patients, the parameters of protein catabolism, such as nitrogen balance, urea nitrogen appearance, and protein catabolic rate appear to be the main measures in this population. Considering the high prevalence of malnutrition in this population and important limitations in this clinical condition, such as the inflammatory state and altered fluid, catabolism parameters are accurate and reliable methods that could contribute to minimize adverse prognosis in this population., (Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Peritoneal dialysis (PD) may be a feasible and safe alternative to haemodialysis not only in the chronic but also in the acute setting. It was previously widely accepted as a modality for acute kidney injury (AKI) treatment, but its practice declined in favor of other types of extracorporeal therapies., Summary: The interest in PD to manage AKI patients has been increased and PD is now frequently used in developing countries because of its lower cost and minimal infrastructural requirements. Studies from these countries have shown that, with careful thought and planning, critically ill patients can be successfully treated using PD. Some of the classic limitations of PD use in AKI, such as infectious and mechanical complications and poor metabolic control, have been decreased with the use of cyclers, flexible catheters, and a high volume of dialysate. The recent publication of the International Society of Peritoneal Dialysis guidelines for PD in AKI has tried to address these issues and provide an evidence-based standard by which to initiate therapy. Key Message: In this review, advances in technical aspects and the advantages and limitations of PD were discussed; it clearly showed that PD is a simple, safe, and efficient way to correct metabolic, electrolyte, acid - base, and volume disturbances generated by AKI and it can be used as a renal replacement therapy modality to treat AKI, both in and out of the intensive care unit setting., (© 2017 S. Karger AG, Basel.)

Peritoneal dialysis (PD) may be a feasible, safe, and complementary alternative to hemodialysis not only in the chronic setting, but also in the acute setting. It previously was widely accepted for acute kidney injury (AKI) treatment, but its practice decreased in favor of other types of extracorporeal therapies. The interest in PD to manage AKI patients has been reignited and PD now frequently is used in developing countries because of its lower cost and minimal infrastructural requirements. Studies from these countries have shown that, with careful thought and planning, critically ill patients can be treated successfully using PD. Some of the classic limitations of PD use in AKI, such as a high chance of infectious and mechanical complications and poor metabolic control, have been overcome with the use of cyclers, flexible catheters, and a high volume of dialysis fluid. However, in developing countries the infrastructure for quality research often is lacking and the result has been limited evidence on standardized treatment regimens such as indications, dosing, and technical failure and mortality. The recent publication of the International Society for Peritoneal Dialysis guidelines for PD in AKI have tried to address these issues and provide an evidence-based standard by which to initiate therapy. In this article, advances in technical aspects and the advantages and limitations of PD are discussed, and recent literature on clinical experience with PD for the treatment of AKI patients is reviewed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Aim: This study aimed to evaluate the long-term outcome of patients after a severe episode of acute kidney injury (AKI) on survival and progression to chronic kidney disease (CKD) and to identify risk factors associated with these outcomes., Methods: We performed a prospective study that evaluated the long-term outcome of 509 AKI stage 3 patients who were followed by nephrologists in a Brazilian University Hospital from 2004 to 2013., Results: Age was 60.2 years (47.5-71) and the follow-up time was 25 months (12-44). The late mortality was 38.1% and age (HR 2.89, 95% CI=1.88 to 4.46, P < 0.0001), diabetes (HR 1.46, 95% CI=1 0.02 to 2.16, P < 0.047), liver disease (HR 2.95, 95% CI=1.19 to 7.3, P = 0.02) and creatinine (Cr) at the time of hospital discharge (HR 1.21, 95% CI=1.04 to 1.41, P = 0.01) were associated with poor long-term survival. At the moment of hospital discharge, 52.1% of patients had complete recovery of renal function, 39.7% had partial recovery and 8.3% had not recovered renal function. After 36 months, 43.5% of patients progressed to CKD, and 5.3% needed for chronic dialysis. Factors associated with progression to CKD were age (HR 1.02, 95% CI=1.008 to 1.035, P = 0.009), CKD (HR 1.05 95% CI=1.007 to 1.09, P = 0.04), diabetes (HR 1.12, CI 1.008-1.035, P = 0.009) and number of AKI episodes (HR 1.65, 95% CI=1.19 to 2.2, P = 0.0023)., Conclusion: This study showed that AKI patients have high mortality after hospital discharge and age, diabetes, liver disease, and Cr value at the time of discharge were factors associated with long-term mortality. The risk factors for this progression to CKD were age, the presence of diabetes and the number of AKI episodes., (© 2015 Asian Pacific Society of Nephrology.)

Background: There are multiple equations for predicting resting energy expenditure (REE), but how accurate they are in severe acute kidney injury (AKI) patients is not clear. Our aim was to determine if predictive equations for estimated REE accurately reflect the requirements of AKI patients., Methods: We included in this prospective and observational study AKI patients AKIN-3 assessed by indirect calorimetry (IC). Bland-Altman, intraclass correlation coefficient and precision (percentagem of predicted values within 10% of measured values) were performed to compare REE by equations with REE measured by IC., Results: IC was applied in 125 AKI patients. The mean age was 62.5 ± 16.6 and 65.6% were male. Mean REE measured was 2,029.11 ± 760.4 kcal/day. There were low precision, and poor agreement between measured and predicted REE by the Harris-Benedict (HB), Mifflin, Ireton-Jones, Penn state, American College of Chest Physicians, and Faisy equations. HB without using injury factor was the least precise (18% of precision). Modified Penn state equation had the best precision, although the precision rate was only 41%. For all equations, the limits of agreement range were large leading to the potential under or overfeeding of individual patients., Conclusion: None of these equations accurately estimated measured REE in severe AKI patients and most of them underestimated energy needs., (© 2016 S. Karger AG, Basel.)

Purpose: Acute kidney injury (AKI) is a common source of morbidity in sepsis. We sought to determine risk factors for AKI, by acute kidney injury network (AKIN) criteria, in septic patients admitted in emergency clinical room (ER)., Materials and Methods: Prospective cohort study of 200 patients admitted to the ER of a University Hospital, followed for development of AKI over 5 days., Results: AKI developed in 144/200 (72 %) patients. In multivariable regression analysis, independent risk factors for AKI included age over 65 years (OR 1.28; 95 % CI 1.12-1.89; p = 0.04), mean blood pressure (MBP) lower than 65 mmHg at moment of admission (OR 1.89; 95 % CI 1.43-2.64, p = 0.003) and diabetes mellitus (OR 1.66; 95 % CI 1.30-3.20; p = 0.012). Mortality rate was 51.4 % in AKI patients compared with 26.8 % for those without AKI (p = 0.002). Septic shock (OR = 1.83, 95 % CI 1.23-2.74, p = 0.007), AKIN 3 (OR = 1.64; 95 % CI 1.19-1.89, p = 0.02), APACHE 2 > 20 (OR 1.92, 95 % CI 1.34-2.02, p = 0.009) and need for dialysis (OR = 1.26, 95 % CI 1.13-1.75, p = 0.03) were identified as independent risk factors for death in multivariable regression analysis., Conclusions: AKI severity in septic patients admitted in ER is associated with mortality. Diabetes, age over 65 years, and low MBP are independent risk factors for AKI and deserve further study to prevent AKI and, consequently, decreasing mortality.

During the 1970s and 1980s, peritoneal dialysis (PD) was widely accepted as the standard treatment for acute kidney injury (AKI). However, advances in the techniques of extracorporeal blood purification gradually reduced its use, making PD an underused modality in this context. Although PD for AKI is an underutilized modality worldwide, it is frequently used in developing countries because of its lower cost and minimal infrastructure requirements. Recent studies have shown that PD administered continuously through a flexible catheter and cycler is an effective treatment in AKI because it ensures adequate fluid status and metabolic control. However, the use of PD in AKI has several limitations, such as the need for an intact peritoneal cavity and, in emergency situations such as severe fluid overload and severe hyperkalemia, an efficacy that is lower than that with extracorporeal blood purification techniques. Metabolic, infectious, and mechanical disorders related to PD are also limitations.Among the metabolic complications of PD are hyperglycemia, hypernatremia, protein loss into the dialysate, and hypercatabolism. Hyperglycemia is caused by the use of dialysate containing high concentrations of glucose. Hypernatremia is a result of short dialysate dwell times during the rapid exchanges of high-volume PD. Protein loss into the dialysate can reach 48 g daily, worsening the nutrition status of patients already depleted by AKI. Severe hypercatabolism caused by PD remains controversial and occurs because PD methods cannot provide an adequate dialysis dose for AKI patients.Few studies have assessed the metabolic implications of PD in AKI patients. Evaluation of these implications is relatively simple, imposes no additional costs, and can provide information about the severity of the disease. Evaluation could also guide the selection of therapeutic, dialytic, and nutrition measures, preventing metabolic complications. The present manuscript describes the metabolic implications of PD and reviews the literature on how to prevent metabolic complications., (Copyright © 2015 International Society for Peritoneal Dialysis.)

Peritoneal dialysis (PD) should be considered a suitable method of renal replacement therapy in acute kidney injury (AKI) patients. This study is the largest cohort providing patient characteristics, clinical practice, patterns and their relationship to outcomes in a developing country. Its objective was to describe the main determinants of patient and technique survival, including trends over time of PD treatment in AKI patients. This was a Brazilian prospective cohort study in which all adult AKI patients on PD were studied from January/2004 to January/2014. For comparison purposes, patients were divided into 2 groups according to the year of treatment: 2004-2008 and 2009-2014. Patient survival and technique failure (TF) were analyzed using the competing risk model of Fine and Gray. A total of 301 patients were included, 51 were transferred to hemodialysis (16.9%) during the study period. The main cause of TF was mechanical complication (47%) followed by peritonitis (41.2%). There was change in TF during the study period: compared to 2004-2008, patients treated at 2009-2014 had relative risk (RR) reduction of 0.86 (95% CI 0.77-0.96) and three independent risk factors were identified: period of treatment at 2009 and 2014, sepsis and age> 65 years. There were 180 deaths (59.8%) during the study. Death was the leading cause of dropout (77.9% of all cases) mainly by sepsis (58.3%), followed cardiovascular disease (36.1%). The overall patient survival was 41% at 30 days. Patient survival improved along study periods: compared to 2004-2008, patients treated at 2009-2014 had a RR reduction of 0.87 (95% CI 0.79-0.98). The independent risk factors for mortality were sepsis, age >70 years, ATN-ISS > 0.65 and positive fluid balance. As conclusion, we observed an improvement in patient survival and TF along the years even after correction for several confounders and using a competing risk approach.

Prolonged intermittent renal replacement therapy (PIRRT) has emerged as an alternative to continuous renal replacement therapy in the management of acute kidney injury (AKI) patients. This trial aimed to compare the dialysis complications occurring during different durations of PIRRT sessions in critically ill AKI patients. We included patients older than 18 years with AKI associated with sepsis admitted to the intensive care unit and using noradrenaline doses ranging from 0.3 to 0.7 µg/kg/min. Patients were divided into two groups randomly: in G1, 6-h sessions were performed, and in G2, 10-h sessions were performed. Seventy-five patients were treated with 195 PIRRT sessions for 18 consecutive months. The prevalence of hypotension, filter clotting, hypokalemia, and hypophosphatemia was 82.6, 25.3, 20, and 10.6%, respectively. G1 was composed of 38 patients treated with 100 sessions, whereas G2 consisted of 37 patients treated with 95 sessions. G1 and G2 were similar in male predominance (65.7 vs. 75.6%, P = 0.34), age (63.6 ± 14 vs. 59.9 ± 15.5 years, P = 0.28) and Sequential Organ Failure Assessment score (SOFA; 13.1 ± 2.4 vs. 14.2 ± 3.0, P = 0.2). There was no significant difference between the two groups in hypotension (81.5 vs. 83.7%, P = 0.8), filter clotting (23.6 vs. 27%, P = 0.73), hypokalemia (13.1 vs. 8.1%, P = 0.71), and hypophosphatemia (18.4 vs. 21.6%, P = 0.72). However, the group treated with sessions of 10 h were refractory to clinical measures for hypotension, and dialysis sessions were interrupted more often (9.5 vs. 30.1%, P = 0.03). Metabolic control and fluid balance were similar between G1 and G2 (blood urea nitrogen [BUN]: 81 ± 30 vs. 73 ± 33 mg/dL, P = 1.0; delivered Kt/V: 1.09 ± 0.24 vs. 1.26 ± 0.26, P = 0.09; actual ultrafiltration: 1731 ± 818 vs. 2332 ± 947 mL, P = 0.13) and fluid balance (-731 ± 125 vs. -652 ± 141 mL, respectively) . In conclusion, intradialysis hypotension was common in AKI patients treated with PIRRT. There was no difference in the prevalence of dialysis complications in patients undergoing different durations of PIRRT., (Copyright © 2015 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Background: Few studies have investigated the predictive properties of urinary (u) NGAL as an AKI marker in septic population., Objectives: This study evaluated the efficacy of uNGAL as predictor of AKI and death in septic patients admitted to the clinical emergency room (ER)., Methodology: We prospectively studied patients with sepsis admitted to the ER. Urine was analyzed for NGAL within the first 24 hours after admission (classified as NGAL1), between 24 and 48 h (NGAL2), and at moment of AKI diagnosis (NGAL3)., Results: Among 168 septic patients admitted to ER, 72% developed AKI. The uNGAL and its relationship with creatinine (Cr) were high in septic patients but statistically higher in those with sepsis and AKI. The uNGAL1 and uNGAL2, as well as uNGAL1/uCr1 and uNGAL2/uCr2, were good predictors for AKI (AUC-ROC 0.73, 0.70, 0.77, and 0.84, resp.). The uNGAL1 and uNGAL1/uCr1 were poor predictors for death (AUC-ROC 0.66 and 0.68, resp.), whereas uNGAL2 and uNGAL2/uCr2 were better predictors (AUC-ROC 0.70 and 0.81, resp.)., Conclusion: The uNGAL is highly sensitive but nonspecific predictor of AKI and death in septic patients admitted into ER.

This review will focus on long-term outcomes after acute kidney injury (AKI). Surviving AKI patients have a higher late mortality compared with those admitted without AKI. Recent studies have claimed that long-term mortality in patients after AKI varied from 15% to 74% and older age, presence of previous co-morbidities, and the incomplete recovery of renal function have been identified as risk factors for reduced survival. AKI is also associated with progression to chronic kidney (CKD) disease and the decline of renal function at hospital discharge and the number and severity of AKI episodes have been associated with progression to CKD. IN the most studies, recovery of renal function is defined as non-dependence on renal replacement therapy which is probably too simplistic and it is expected in 60-70% of survivors by 90 days. Further studies are needed to explore the long-term prognosis of AKI patients.

Objective: The objective of this study was to perform a nutritional assessment of acute kidney injury patients and to identify the relationship between nutritional markers and outcomes., Method: This was a prospective and observational study. Patients who were hospitalized at the Hospital of Botucatu School of Medicine were evaluated between January 2009 and December 2011. We evaluated a total of 133 patients with a clinical diagnosis of acute kidney injury and a clinical presentation suggestive of acute tubular necrosis. We explored the associations between clinical, laboratory and nutritional markers and in-hospital mortality. Multivariable logistic regression was used to adjust for confounding and selection bias., Results: Non-survivor patients were older (67 ± 14 vs. 59 ± 16 years) and exhibited a higher prevalence of sepsis (57.1 vs. 21.4%) and higher Acute Tubular Necrosis-Individual Severity Scores (0.60 ± 0.22 vs. 0.41 ± 0.21) than did survivor patients. Based on the multivariable analysis, laboratorial parameters such as blood urea nitrogen and C-reactive protein were associated with a higher risk of death (OR: 1.013, p=0.0052; OR: 1.050, p=0.01, respectively), and nutritional parameters such as low calorie intake, higher levels of edema, lower resistance based on bioelectrical impedance analysis and a more negative nitrogen balance were significantly associated with a higher risk of death (OR: 0.950, p=0.01; OR: 1.138, p=0.03; OR: 0.995, p=0.03; OR: 0.934, p=0.04, respectively)., Conclusions: In acute kidney injury patients, a nutritional assessment seems to identify nutritional markers that are associated with outcome. In this study, a low caloric intake, higher C-reactive protein levels, the presence of edema, a lower resistance measured during a bioelectrical impedance analysis and a lower nitrogen balance were significantly associated with risk of death in acute kidney injury patients.

Objectives: The purpose of this study was to determine if intra-abdominal pressure (IAP) could predict acute renal injury (AKI) in the postoperative period of abdominal surgeries, and which would be its cutoff value., Patients and Methods: A prospective observational study was conducted in the period from January 2010 to March 2011 in the Intensive Care Units (ICUs) of the University Hospital of Botucatu Medical School, UNESP. Consecutive patients undergoing abdominal surgery were included in the study. Initial evaluation, at admission in ICU, was performed in order to obtain demographic, clinical surgical and therapeutic data. Evaluation of IAP was obtained by the intravesical method, four times per day, and renal function was evaluated during the patient's stay in the ICU until discharge, death or occurrence of AKI., Results: A total of 60 patients were evaluated, 16 patients developed intra-abdominal hypertension (IAH), 45 developed an abnormal IAP (>7 mmHg) and 26 developed AKI. The first IAP at the time of admission to the ICU was able to predict the occurrence of AKI (area under the receiver-operating characteristic curve was 0.669; p=0.029) with the best cutoff point (by Youden index method) ≥ 7.68 mmHg, sensitivity of 87%, specificity of 46% at this point. The serial assessment of this parameter did not added prognostic value to initial evaluation., Conclusion: IAH was frequent in patients undergoing abdominal surgeries during ICU stay, and it predicted the occurrence of AKI. Serial assessments of IAP did not provided better discriminatory power than initial evaluation.

Acute kidney injury (AKI) is a well-documented complication of massive attack by Africanised bees and can be observed 48-72 h after the accident. We report a case of Africanised bees attack followed by severe and lethal AKI. A 56-year-old man was admitted to emergency department after a massive attack of Africanised bees (>1000 bee stings). He was unconscious, presenting with hypotension and tachycardia. Mechanical ventilation, volume expansion and care for anaphylaxis were instituted. The patient was transferred to the intensive care unit (ICU) and after 48 h he developed rhabdomyolysis, oliguria, increased creatinine levels, hyperkalaemia and refractory acidosis. A diagnosis of AKI secondary to rhabdomyolysis and shock was made. The patient was treated with a prolonged course of haemodialysis. However, he progressed to refractory shock and died 5 days after admission.

This trial aimed to compare the dialysis complications occurring during different durations of extended daily dialysis (EDD) sessions in critically ill AKI patients. We included patients older than 18 years with AKI associated with sepsis admitted to the intensive care unit and using noradrenaline dose ranging from 0.3 to 0.7 μg/kg/min. Patients were divided into two groups randomly: in G1, 6 h sessions were performed and, in G2, 10 h sessions were performed. Seventy-five patients were treated with 195 EDD sessions for 18 consecutive months. The prevalence of hypotension, filter clotting, hypokalaemia, and hypophosphataemia was 82.6, 25.3, 20, and 10.6%, respectively. G1 and G2 were similar in male predominance and SOFA. There was no significant difference between the two groups in hypotension, filter clotting, hypokalaemia, and hypophosphataemia. However, the group treated with sessions of 10 hours showed higher refractory to clinical measures for hypotension and dialysis sessions were interrupted more often. Metabolic control and fluid balance were similar between G1 and G2. In conclusion, intradialysis hypotension was common in AKI patients treated with EDD. There was no difference in the prevalence of dialysis complications in patients undergoing different durations of EDD.

Unlabelled: Intermittent hemodialysis (IHD) and continuous renal replacement therapies (CRRT) are used as Acute Kidney Injury (AKI) therapy and have certain advantages and disadvantages. Extended daily dialysis (EDD) has emerged as an alternative to CRRT in the management of hemodynamically unstable AKI patients, mainly in developed countries., Objectives: We hypothesized that EDD is a safe option for AKI treatment and aimed to describe metabolic and fluid control of AKI patients undergoing EDD and identify complications and risk factors associated with death., Study Selection: This is an observational and retrospective study describing introduction of EDD at our institution. A total of 231 hemodynamically unstable AKI patients (noradrenalin dose between 0.3 and 1.0 ucg/kg/min) were assigned to 1367 EDD session. EDD consisted of 6-8 h of HD 6 days a week, with blood flow of 200 ml/min, dialysate flows of 300 ml/min., Data Synthesis: Mean age was 60.6±15.8 years, 97.4% of patients were in the intensive care unit, and sepsis was the main etiology of AKI (76.2). BUN and creatinine levels stabilized after four sessions at around 38 and 2.4 mg/dl, respectively. Fluid balance decreased progressively and stabilized around zero after five sessions. Weekly delivered Kt/V was 5.94±0.7. Hypotension and filter clotting occurred in 47.5 and 12.4% of treatment session, respectively. Regarding AKI outcome, 22.5% of patients presented renal function recovery, 5.6% of patients remained on dialysis after 30 days, and 71.9% of patients died. Age and focus abdominal sepsis were identified as risk factors for death. Urine output and negative fluid balance were identified as protective factors., Conclusions: EDD is effective for AKI patients, allowing adequate metabolic and fluid control. Age, focus abdominal sepsis, and lower urine output as well as positive fluid balance after two EDD sessions were associated significantly with death.

Background: Peritoneal dialysis (PD) is a treatment for selected acute kidney injury patients (AKI), but little is known about its metabolic implications. The aim of the present study was to evaluate the metabolic implications of glucose absorption, sodium removal, protein loss into the dialysate, and catabolism in AKI patients undergoing high-volume PD and to identify risk factors associated with those metabolic effects., Methods: A prospective cohort study over 18 consecutive months evaluated 208 sessions of high-volume PD performed in 31 AKI patients. One session of high-volume PD lasted 24 hours. Repeated-measures analysis was performed, and correlations were calculated using the Spearman test for continuous variables and generalized linear models for categorical variables., Results: Glucose absorption remained at approximately 35.3% ± 10.5% per session. Protein loss measured 4.2 ± 6.1 g daily, with higher values initially, which declined significantly after 2 sessions. Nitrogen balance (NB) was initially negative, but stabilized at approximately zero after 3 sessions. Glucose uptake was positively correlated with the Acute Tubular Necrosis Individual Severity Score [ATNISS (r = 0.21, p = 0.0036)], C-reactive protein (r = 0.26, p = 0.0167), protein loss (r = 0.36, p < 0.0001), and sodium removal (r = 0.24, p = 0.002). Protein loss was positively correlated with sodium removal (r = 0.22, p = 0.0085) and gastrointestinal disease (p = 0.0004). Sodium removal was positively correlated with serum sodium (r = 0.21, p = 0.0064), ATNISS (r = 0.15, p = 0.0411), urea nitrogen appearance [UNA (r = 0.24, p = 0.0019)], and fluid overload as an indication for dialysis (p < 0.0001). Urea nitrogen appearance was positively correlated with the indication for dialysis (electrolyte disturbances: p = 0.0287) and negatively correlated with nephrotoxic AKI (p < 0.0001). Nitrogen balance was negatively correlated with UNA (r = -0.389, p < 0.0001) and ischemic AKI (p = 0.0047)., Conclusions: High-volume PD did not increase hypercatabolism in AKI patients, and protein loss and glucose uptake remained constant during treatment. Those parameters were influenced by the clinical condition of the patients, including the cause of AKI, inflammation, and comorbidities-factors that should be known before the prescription of dialysis and nutrition, thus avoiding metabolic complications such as hyperglycemia, hypernatremia, and worsening catabolism.

Unlabelled: Association between severe hypothyroidism and acute kidney injury (AKI) is rare. A 40-year-old woman presented with 15 days history of generalised muscle pain, weakness, weight gain and oedema., Medical History: hypertension and hypothyroidism., Physical Examination: dry skin, peripheral/periorbital oedema, slow thought and speaking, thyroid increased. Laboratory examinations: high levels of creatine kinase , creatinine, uric acid and lactate dehydrogenase. Free T4 was very low (<0.3 ng/dL) and thyroid-stimulating hormone was high (21.7 µIU/mL). Urinalysis showed haem pigment without haematuria. We performed the diagnosis of AKI secondary to hypothyroidism-induced rhabdomyolysis. Intravenous fluids were started, urinary alkalisation and increased l-thyroxine dose replacement. On the day after admission, forced diuresis with furosemide was introduced leading to a progressive improvement of symptoms. Although hypothyroidism and AKI is unusual, it should be suspected in patients presenting decrease of renal function and high creatine kinase in the absence of other causes of rhabdomyolysis.

Background: Acute kidney injury (AKI) requiring dialysis in critically ill patients is associated with an in-hospital mortality rate of 50-80 %. Extended daily hemodialysis (EHD) and high volume peritoneal dialysis (HVPD) have emerged as alternative modalities., Methods: A double-center, randomized, controlled trial was conducted comparing EHD versus HVPD for the treatment for AKI in the intensive care unit (ICU). Four hundred and seven patients were randomized and 143 patients were analyzed. Principal outcome measure was hospital mortality, and secondary end points were recovery of renal function and metabolic and fluid control., Results: There was no difference between the two groups in relation to median ICU stay [11 (5.7-20) vs. 9 (5.7-19)], recovery of kidney function (26.9 vs. 29.6 %, p = 0.11), need for chronic dialysis (9.7 vs. 6.5 %, p = 0.23), and hospital mortality (63.4 vs. 63.9 %, p = 0.94). The groups were different in metabolic and fluid control. Blood urea nitrogen (BUN), creatinine, and bicarbonate levels were stabilized faster in EHD group than in HVPD group. Delivered Kt/V and ultrafiltration were higher in EHD group. Despite randomization, there were significant differences between the groups in some covariates, including age, pre-dialysis BUN, and creatinine levels, biased in favor of the EHD. Using logistic regression to adjust for the imbalances in group assignment, the odds of death associated with HVPD was 1.4 (95 % CI 0.7-2.4, p = 0.19). A detailed investigation of the randomization process failed to explain the marked differences in patient assignment., Conclusions: Despite faster metabolic control and higher dialysis dose and ultrafiltration with EHD, this study provides no evidence of a survival benefit of EHD compared with HVPD. The limitations of this study were that the results were not presented according to the intention to treat and it did not control other supportive management strategies as nutrition support and timing of dialysis initiation that might influence outcomes in AKI.