Robert L. Lins

Intermittent versus continuous renal replacement therapy for acute kidney injury patients admitted to the intensive care unit: results of a randomized clinical trial

BACKGROUND There is uncertainty on the effect of different dialysis modalities for the treatment of patients with acute kidney injury (AKI), admitted to the intensive care unit (ICU). This controlled clinical trial performed in the framework of the multicentre SHARF 4 study (Stuivenberg Hospital Acute Renal Failure) aimed to investigate the outcome in patients with AKI, stratified according to severity of disease and randomized to different treatment options. METHODS This was a multicentre prospective randomized controlled trial with stratification according to severity of disease expressed by the SHARF score. ICU patients were eligible for inclusion when serum creatinine was >2 mg/dL, and RRT was initiated. The selected patients were randomized to intermittent (IRRT) or continuous renal replacement therapy (CRRT). RESULTS A total of 316 AKI patients were randomly assigned to IRRT (n = 144) or CRRT (n = 172). The mean age was 66 (range 18-96); 59% were male. Intention-to-treat analysis revealed a mortality of 62.5% in IRRT compared to 58.1% in CRRT (P = 0.430). No difference between IRRT and CRRT could be observed in the duration of ICU stay or hospital stay. In survivors, renal recovery at hospital discharge was comparable between both groups. Multivariate analysis, including the SHARF score, APACHE II and SOFA scores for correction of disease severity, showed no difference in mortality between both treatment modalities. This result was confirmed in pre-specified subgroup analysis (elderly, patients with sepsis, heart failure, ventilation) and after exclusion of possible confounders (early mortality, delayed ICU admission). CONCLUSIONS Modality of RRT, either CRRT or IRRT, had no impact on the outcome in ICU patients with AKI. Both modalities need to be considered as complementary in the treatment of AKI (Clinical Trial: SHARF 4, NCT00322933, http://ClinicalTrials.gov).

Renal replacement therapy is an independent risk factor for mortality in critically ill patients with acute kidney injury

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

Outcome of Acute Kidney Injury with Different Treatment Options: Long-Term Follow-up

BACKGROUND AND OBJECTIVES The multicenter Stuivenberg Hospital Acute Renal Failure 4 study investigated outcome in patients with acute kidney injury (AKI) stratified according to disease severity by the Stuivenberg Hospital Acute Renal Failure score. Patients in need of renal replacement therapy (RRT) received intermittent RRT or continuous RRT. This study investigated long-term mortality, renal function, comorbidity, and quality of life. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS All AKI hospital survivors were included. Mortality at 1 and 2 years of follow-up was traced for all patients. Between 1 and 2 years after hospital discharge, survivors were visited at home to determine morbidity (renal function), comorbidity (Charlson comorbidity index [CCI]), and quality of life (Medical Outcome Survey SF-36). RESULTS The baseline population consisted of 595 AKI patients. Mortality rates were 23.0 and 7.6%, respectively, during the first and second year after discharge. Total mortality increased from 50.7% at discharge to 65.7% 2 years after AKI and was not related to disease severity or treatment modality offered during hospitalization. Two hundred four survivors could be visited at home. Mean serum creatinine did not differ between discharge and follow-up. CCI was only related with age. SF-36 scores were negatively correlated with CCI, age, and body mass index, but not with disease severity, renal function, or dialysis modality. CONCLUSIONS Long-term outcome of AKI consists of a high additional mortality unrelated to treatment modality offered during hospitalization, varying evolution of renal recovery, and many comorbidities, but a mental health at the same level as the general population.

Erythropoietin Resistance due to Vitamin B12 Deficiency

We describe the first reported case of resistance to human recombinant erythropoietin (rhEPO) treatment caused by vitamin B12 deficiency in a chronic hemodialysis patient. Despite a normal

Treatment of severe Thallium intoxication

CASE REPORT We report a successfully treated case of severe thallium intoxication. In spite of very high serum thallium (5,240 micrograms/L), symptomatology was minor and recovery complete. Prussian Blue was administered, diuresis was enhanced by intravenous fluids and a prolonged hemodialysis was started early. High blood flows (300 mL/min) and intravenous potassium chloride supplements, to mobilize thallium from the tissues, resulted in good clearances (96 to 150 mL/min). In order to prevent the well known complications, we recommend aggressive treatment of severe thallium intoxication.

Abdominal aortic aneurysm and polycystic kidneys.

Rudolph G. Vanmaelé, MD, PhD, Division of Thoracic and Vascular Surgery, University Hospital Antwerp, Wilrijkstraat 10, B-2650 Edegem (Belgium) Dear Sir, The association of autosomal dominant polycystic kidney disease (ADPKD), also known as adult polycystic kidney disease, with various cardiovascular disorders is well known. The diagnosis of abdominal aortic aneurysm (AAA) associated with ADPKD has been reported in only a few cases. A personal case of successful aneurysmectomy is reported and incidence and treatment of AAA in the ADPKD patient population are discussed. A 48-year-old Caucasian male, with known ADPKD, arterial hypertension, and chronic renal failure since 1979, was admitted in March 1991. During the last year he complained of progressive abdominal pain, essentially in the left flank, irradiating to both legs. At physical examination, the abdomen was tender and distended by two very large polycystic kidneys palpable as far as the midline. Peripheral arterial pulses were normal. The systolic blood pressure was 170 mm Hg upon admission. Other physical findings were irrelevant. Serum creatinine was 3.7 mg/dl (320 μmol/l). Computed tomography of the abdomen showed voluminous polycystic kidneys, liver cysts, and a 5 cm wide fusiform infrarenal aortic aneurysm, however, without signs of leakage. There was no evidence of other cardiovascular abnormalities. The pain was attributed to the cystic kidneys, and the patient was transferred to the Department of Vascular Surgery for further investigation and elective aneurysmectomy. During the operation, the kidneys were carefully retracted laterally as far as possible, giving limited access to the aneurysm and the aortic bifurcation. After opening of the aneurysmal sac, an aortobifemoral bypass with a bifurcated Dacron prosthesis was performed. The postoperative course was uneventful. Pedal pulses were normal, and serum creatinine remained at the preoperative level during 10 months. After this period, the renal function started slowly deteriorating. At the present time, 30 months after surgery, serum creatinine is 6.3 mg/dl (546 μmol/l), but the patient is still not under dialysis treatment, and he remains in good general condition without vascular symptoms. ADPKD is frequently associated with lesions in the cardiovascular system. In a combined retrospective and prospective study, the incidence was estimated to be 18% by clinical

Acceptability of rilmenidine and long-term surveillance of plasma concentrations in hypertensive patients with renal insufficiency.

Acceptability and plasma concentrations of rilmenidine, a new antihypertensive agent mainly eliminated via the kidney, were evaluated in 17 hypertensive patients (supine diastolic blood pressure, 104 +/- 3 mmHg) with renal insufficiency (creatinine clearance, 35 +/- 4 ml.minute-1/1.73 m2; range, 12 to 58). Patients were treated for six months with rilmenidine at the dose of 1 mg in the morning or 1 mg twice daily as single-drug therapy in untreated patients, or in combination or as substitution in patients already treated. Plasma concentrations of rilmenidine were measured by gas chromatography combined with mass spectrometry at Days 0, 1, 5, 7, 9, and 11, and Months 1.5, 3, 4.5, and 6 before administration. Supine and erect blood pressure (sphygmomanometer) measurements and side effects were noted at the same times. Laboratory and electrocardiographic parameters were evaluated at Days 0 and 11, and Months 1.5 and 6. Blood pressure was effectively controlled during the trial in 12 patients (mean decrease in systolic/diastolic blood pressure of 12/8 mmHg). Five patients were removed from the trial after Month 1.5 because of a rise in blood pressure (three cases) or noncompliance (two cases). Side effects were moderate and transient (dry mouth, constipation, daytime drowsiness, mood disturbances, insomnia) never requiring treatment withdrawal. Surveillance of renal function revealed no significant mean variation. Rilmenidine plasma concentrations reached steady state the fifth day at the latest and were related to the degree of renal insufficiency. When renal function was stable (13 cases), plasma concentrations did not vary until the end of the trial. When renal function was progressive (four cases), plasma concentrations increased in parallel in two patients, without the onset of side effects, and remained stable in the other two patients. In conclusion, this study confirmed the good acceptability of rilmenidine in hypertensive patients with chronic renal insufficiency. It showed stable plasma concentrations of rilmenidine during a six-month treatment in hypertensive patients with renal insufficiency, reflecting the absence of accumulation of the drug.

RRT treatment for AKI: is more always better?

Acute kidney injury (AKI) is an increasingly common condition, occurring in up to 25% of critically ill patients admitted to the intensive care unit (ICU) [1]. It is associated with significant morbidity and up to 60% in-hospital mortality in its most severe form, necessitating renal replacement therapy (RRT) [2]. In the absence of effective pharmacological therapy, the treatment of patients with AKI is predominantly supportive, managing haemodynamic and volume status, correcting electrolyte and acid–base disturbances, providing adequate nutrition and adjusting drug doses. In patients with sustained, severe renal failure, RRT is indicated for the management of volume overload, hyperkalaemia, acidosis and symptoms of uraemia while awaiting the recovery of kidney function. Most clinicians are convinced that RRT is life saving and not starting RRT will lead to death in severely ill AKI patients, but data are lacking to support this opinion. Conservative treatment for AKI has only been considered as the treatment option for less severe patients. In recent years, several controlled studies [3–7] and metaanalysis [8–10 ]s howed similar benefit with continuous and intermittent dialysis modalities. Critics of the published studies, however, pointed to different shortcomings in these studies [11, 12]. However, hard data remain absent or conflictive regarding when to start dialytic therapy and what constitutes the appropriate dose [13]. In 2011, the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for AKI was developed, aiming to assist practitioners caring for adults and children at risk for or with AKI [14]. They recommend to initiate RRT emergently when life-threatening changes in fluid, electrolyte and acid–base balance exist. Continuous RRT (CRRT) and intermittent RRT (IRRT) are considered as complementary therapies, but they suggest using CRRT, rather than standard IRRT, for haemodynamically unstable patients. The dose of RRT to be delivered should be prescribed before starting each session of RRT. KDIGO recommend delivering a Kt/V of 3.9/week when using IRRT or extended RRT and an effluent volume of 20–25 mL/kg/h for CRRT. This will usually require a higher prescription of effluent volume. Numerous modalities of RRT can be used in the treatment of patients with AKI. These include various modalities of intermittent haemodialysis (IHD), of CRRT, ‘hybrid’ modalities such as sustained low-efficiency dialysis (SLED), that combine aspects of both conventional IHD and CRRT, and peritoneal dialysis. Although there are many arguments favouring the use of continuous therapies in critically ill patients with AKI [15], the predominance of current evidence does not support a benefit of CRRT compared with IRRT. Nonetheless, the use of CRRT versus IRRT remains a subject of ongoing controversy, in particular because studies of modality must

Hypoventilation during Hemodialysis

M.E. De Broe, MD, PhD, Department of Nephrology-Hypertension, University Hospital Antwerp, Wilrijkstr. 10, B-2520 Edegem (Belgium) Dear Sir, Methods In a recent article in this journal [1], Faro et al. studied the influence of C02 changes, due to Co2 extraction during acetate dialysis, on the central venous blood composition and their effect on the pulmonary ventilation. They postulated that the decrease in C02 in the venous line blood has influence on the central venous blood composition, and that this plays a role in the control of the pulmonary ventilation in these patients. In this communication we present our results on the influence of C02 loss through the dialyzer on the carbon dioxide tension measured in the pulmonary artery (mixed venous blood). Ten patients, mean age 54,7 years (24–72 years), 6 male and 4 female, undergoing 4-hour maintenance hemodialysis sessions three times weekly, were studied. Nine patients were studied during hemodynamic monitoring for evaluation of different cardiac problems. They were all critically ill at the time of the study and treated with oxygen through a nasal cannula. One male patient volunteered to participate in the study. All patients gave informed consent. The patients were dialyzed with acetate-containing dialysate and a single-needle, double-headed pump system. A Swan-Ganz thermodilution catheter (93A-131H-7F; Edwards Laboratory, Santa Anna, Calif., USA) was introduced percutane-ously through the internal jugular vein into the pulmonary artery, at least 15 min before the start of the first measurement. Blood samples were drawn from the pulmonary artery and from the arterial side of

De nieuwste richtlijnen (2007) voor de aanpak van hypertensie volgens de Europese verenigingen voor hypertensie en cardiologie

De laatste jaren werden door het Belgisch Hypertensie Comite de richtlijnen ondersteund die in 1999 uitgevaardigd werden door het Guidelines Subcommittee van de Wereldgezondheidsorganisatie (WGO) en de Internationale Vereniging voor Hypertensie (ISH) (1). Onlangs werden deze richtlijnen aangepast door de Europese Verenigingen voor Hypertensie en Cardiologie (2, 3), teneinde te beantwoorden aan de meer specifieke en homogene Europese situatie en om de richtlijnen aan te vullen met de meest recente wetenschappelijke informatie. Het is belangrijk te onderstrepen dat deze richtlijnen voortbouwen op de WGO-ISH-richtlijnen zodat de artsen er zich gemakkelijk in kunnen terugvinden. De kern van het document bestaat uit de classificatie van hypertensie, de evaluatie en de risicostratificatie van de patient en de daaraan gekoppelde richtlijnen voor aanpak en behandeling. Deze tekst is geen letterlijke vertaling van de richtlijnen, maar een zo getrouw mogelijke weergave van de belangrijkste aspecten.