Mineralocorticoid Receptor Antagonist Use and Hard Renal Outcomes in Real-World Patients With Chronic Kidney Disease

Background: Real-world evidence about mineralocorticoid receptor antagonist (MRA) use has been limited in chronic kidney disease, particularly regarding its association with hard renal outcomes. Methods: In this retrospective cohort study, adult chronic kidney disease outpatients referred to the department of nephrology at an academic hospital between January 2005 and December 2018 were analyzed. The main inclusion criteria were estimated glomerular filtration rate ≥10 and <60 mL/min per 1.73 m 2 and follow-up ≥90 days. The exposure of interest was MRA use, defined as the administration of spironolactone, eplerenone, or potassium canrenoate. The primary outcome was renal replacement therapy initiation, defined as the initiation of chronic hemodialysis, peritoneal dialysis, or kidney transplantation. A marginal structural model using inverse probability of weighting was applied to account for potential time-varying confounders. Results: Among a total of 3195 patients, the median age and estimated glomerular filtration rate at baseline were 66 years and 38.4 mL/min per 1.73 m 2 , respectively. During follow-up (median, 5.9 years), 770 patients received MRAs, 211 died, and 478 started renal replacement therapy. In an inverse probability of weighting-weighted pooled logistic regression model, MRA use was significantly associated with a 28%-lower rate of renal replacement therapy initiation (hazard ratio, 0.72 [95% CI, 0.53–0.98]). The association between MRA use and renal replacement therapy initiation was dose-dependent ( P for trend <0.01) and consistent across patient subgroups. The incidence of hyperkalemia (>5.5 mEq/L) was somewhat higher in MRA users but not significant (hazard ratio, 1.14 [95% CI, 0.88–1.48]). Conclusions: MRA users showed a better renal prognosis across various chronic kidney disease subgroups in a real-world chronic kidney disease population.

Platelet Decreases following Continuous Renal Replacement Therapy Initiation as a Novel Risk Factor for Renal Nonrecovery

<b><i>Background:</i></b> Continuous renal replacement therapy (CRRT) is a form of dialysis used in critically ill patients, and has recently been associated with renal nonrecovery. Decreases in platelets following CRRT initiation are common and are associated with mortality, but associations with renal recovery are unclear. Our objective was to determine if platelet nadir or the degree of platelet decrease following CRRT initiation was associated with renal nonrecovery. <b><i>Methods:</i></b> This is a secondary analysis of the Randomized Evaluation of Normal versus Augmented Level (RENAL) trial. Primary predictors were platelet nadir discretized by median value and percent platelet decrease following CRRT initiation, with cut points evaluated by decile from 30 to 60%. The 2 primary outcomes were time to RRT-independence and RRT-free days. Secondary outcomes were 28-day mortality, 90-day mortality, intensive care unit (ICU)-free, and hospital-free days. <b><i>Results:</i></b> Time to RRT independence censored for death was achieved less frequently in patients with low platelet nadir (hazard ratio [HR] 0.77, confidence interval [CI] 0.66–0.91) and in those with &#x3e;50% platelet decrease (HR 0.84, CI 0.72–0.97). RRT-free days were lower in both low platelet nadir (odds ratio [OR] 0.94, CI 0.90–0.97) and &#x3e;50% platelet decrease (OR 0.91, CI 0.88–0.95). These groups also had higher rates of 28- and 90-day mortality and fewer ICU-free and hospital-free days. Thrombocytopenia at CRRT initiation was also associated with renal nonrecovery, although the clinical effect was small. <b><i>Conclusions:</i></b> Platelet nadir &#x3c;100 × 10³/µL and platelet decrease by &#x3e;50% following CRRT initiation were both associated with lower rates of renal recovery. Further research is needed to evaluate mechanisms-linking platelet changes and renal nonrecovery in CRRT.

Presepsin and prognostic nutritional index are predictors of septic acute kidney injury, renal replacement therapy initiation in sepsis patients, and prognosis in septic acute kidney injury patients: a pilot study

Background Sepsis is the most common cause of acute kidney injury (AKI) among critically ill patients. This study aimed to determine whether presepsin is a predictor of septic acute kidney injury, renal replacement therapy initiation (RRTi) in sepsis patients, and prognosis in septic AKI patients. Methods Presepsin values were measured immediately after ICU admission (baseline) and on Days 2, 3, and 5 after ICU admission. Glasgow Prognostic Score (GPS), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio, Prognostic Index, and Prognostic Nutritional Index (PNI) were measured at baseline, and total scores (“inflammation-presepsin scores [iPS]”) were calculated for category classification. Presepsin values, inflammation-based prognostic scores, and iPS were compared between patients with and without septic AKI or RRTi and between survivors and non-survivors. Results Receiver operating characteristic curve analyses identified the following variables as predictors of septic AKI and RRTi in sepsis patients: presepsin on Day 1 (AUC: 0.73) and Day 2 (AUC: 0.71) for septic AKI, and presepsin on Day 1 (AUC: 0.71), Day 2 (AUC: 0.9), and Day 5 (AUC: 0.96), Δpresepsin (Day 2 – Day 1) (AUC: 0.84), Δpresepsin (Day 5 – Day 1) (AUC: 0.93), and PNI (AUC: 0.72) for RRTi. Multivariate logistic regression analyses identified presepsin on Day 2 as a predictor of prognosis in septic AKI patients. Conclusions Presepsin and PNI were found to be predictors of septic AKI, RRTi in sepsis patients, and prognosis in septic AKI patients.

MO839URGENCY OF RENAL REPLACEMENT THERAPY INITIATION AS A PREDICTOR FOR POOR PROGNOSIS IN PATIENTS WITH KIDNEY DISEASE

Background and Aims It is known that mortality from COVID-19 among patients with kidney disease is significantly higher than in general population. The worst prognosis is seen for patients receiving renal replacement therapy (RRT). At the same time, many patients undergo an urgency start of hemodialysis (HD) while suffering from COVID-19. The aim of the study was to determine the significance of the RRT urgency for the prognosis in patients with COVID-19. Method A retrospective analysis of case histories for 253 patients who received RRT at the infectious ward of St. Petersburg State Healthcare Institution City Hospital No. 15 from May to December 2020 was performed. All patients had a diagnosis of COVID-19, confirmed by PCR and/or clinical symptoms. Urgency RRT was performed in case of detection of indications, both in acute kidney injury (AKI), and in the diagnosis of end-stage chronic kidney disease (esCKD). Kaplan-Meier curves and multivariate Cox regression were used to perform cohort analyzes of survival and relative risk of death. For the calculations, the applied statistical software package SPSS 21.0, SPSS Ink (USA) was used. Results Of the 253 treated patients, 197 were patients with chronic outpatient HD, in 56 HD therapy was started urgently: 45 for AKI, 11 for esCKD. Totally 83 patients died. The overall mortality rate was 33%, while in outpatient HD group it was 18% and in the urgent HD start group - 84%. After adjusting for gender and age the fact of the urgency of starting RRT was an independent risk factor that increased the probability of death by 2.5 times (95% Cl 1.6÷3.9) compared to outpatients HD (Log Rank: P&lt;0.001, Fig. 1). The patients age over 60 was also a factor significantly worsening the prognosis (Log Rank: P &lt;0.001). Conclusion Among patients with COVID-19 and kidney disease the urgency of RRT initiating is a factor that significantly worsens the prognosis, especially among patients of the older age group.

Presepsin and Prognostic Nutritional Index are predictors of septic acute kidney injury, renal replacement therapy initiation in sepsis patients, and prognosis in septic acute kidney injury patients: a pilot study

Background Sepsis is the most common cause of acute kidney injury (AKI) among critically ill patients. This study aimed to determine whether presepsin is a predictor of septic acute kidney injury, renal replacement therapy initiation (RRTi) in sepsis patients, and prognosis in septic AKI patients. Methods Presepsin values were measured immediately after ICU admission (baseline) and on Days 2, 3, and 5 after ICU admission. Glasgow Prognostic Score (GPS), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio, Prognostic Index, and Prognostic Nutritional Index (PNI) were measured at baseline. Total scores were calculated (hereafter, “inflammation-presepsin scores [iPS]”) for category classification. Presepsin values, inflammation-based prognostic scores, and iPS were compared between patients with and without septic AKI or RRTi and between survivors and non-survivors. Results Receiver operating characteristic curve analyses identified the following variables as predictors of septic AKI and RRTi in sepsis patients: presepsin on Day 1 (AUC: 0.73) and Day 2 (AUC: 0.71) for septic AKI, and presepsin on Day 1 (AUC: 0.71), Day 2 (AUC: 0.9), and Day 5 (AUC: 0.96), Δpresepsin (Day 2 – Day 1) (AUC: 0.84), Δpresepsin (Day 5 – Day 1) (AUC: 0.93), and PNI (AUC: 0.72) for RRTi. Multivariate logistic regression analyses identified presepsin on Day 2 as a predictor of prognosis in septic AKI patients. Conclusions Presepsin and PNI were found to be predictors of septic AKI, RRTi in sepsis patients, and prognosis in septic AKI patients.

Spurious point-of-care lactate elevation in ethylene glycol intoxication: rediscovering a clinical pearl

A 76-year-old man was found unresponsive and brought to the emergency department. Initial workup showed profound lactic acidosis on a point-of-care arterial blood gas, without clinical signs of hypoperfusion. Investigations for types A and B lactic acidosis revealed no unifying diagnosis to explain both his altered mental status and profound lactic acidosis. A toxicology workup revealed an increased osmolar gap and an elevated ethylene glycol level. The lactic acidosis and his mental status completely normalised within 8 hours of renal replacement therapy initiation and fomepizole administration. Ethylene glycol metabolites have similar molecular structure with L-lactate. Some blood gas analysers are unable to differentiate them, resulting in an artefactual lactate elevation. Our case highlights the importance of recognising a falsely elevated lactate, which should raise clinical suspicion of ethylene glycol poisoning, as the treatment is time-sensitive to prevent complications and mortality.

IMPACT OF TIMING OF RENAL REPLACEMENT THERAPY INITIATION ON OUTCOME OF ACUTE KIDNEY INJURY IN SEPTIC PATIENTS

Objective: To identify whether the timing of initiation of continuous renal replacement therapy affects outcome in septic patients with acute kidney injury in term of 28 days mortality. Study Design: Cross sectional analytical study. Place and Duration of Study: This research was conducted at department of Anaesthesiology and critical careunit of the Aga Khan University Hospital, Karachi, from Oct 2018 to Jun 2019. Methodology: The study reviewed all adult patients aged >18 years who developed acute kidney injury afterseptic shock and required continuous renal replacement therapy in surgical intensive care unit. Considering thevalue of blood urea nitrogen, patients were classified into two groups. One was in early group that‟s was defined as blood urea nitrogen value of <100 mg/dl just before continuous renal replacement therapy initiation while the patients who have blood urea nitrogen value of ≥100 mg/dl just prior to continuous renal replacement therapy initiation were classified as late group. Kaplan-Meier survival analysis was performed and median survival was computed. Results: Forty patients were included for analysis. There were thirty patients (75%) in early group in whomcontinuous renal replacement therapy was started with mean blood urea nitrogen of 66 ± 20.2 mg/dL and 10(25%) patients were in late group with mean blood urea nitrogen of 137 ± 28.4 mg/dL. The overall survival ratesin both groups were 49.6%, and 10.4% at 10 and 25 days, respectively. Median survival time was not statisticallysignificant between early and late continuous renal replacement...........