Peritoneal dialysis in acute kidney injury: trends in the outcome across time periods

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

METABOLIC IMPLICATIONS OF PERITONEAL DIALYSIS IN PATIENTS WITH ACUTE KIDNEY INJURY

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.Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq

Nutritional parameters are associated with mortality in acute kidney injury

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

Probability of technique failure according to time period.

<p>Probability of technique failure according to time period.</p

Dropout causes according to time period.

<p>Dropout causes according to time period.</p

Subdistribuition Hazard Ratio of Covariates for mortality.

<p>Subdistribuition Hazard Ratio of Covariates for mortality.</p

Acute kidney injury (AKI) patient outcome treated with high volume peritoneal dialysis.

<p>Acute kidney injury (AKI) patient outcome treated with high volume peritoneal dialysis.</p

Clinical data of acute kidney injury patient treated with high volume peritoneal dialysis according to time period of high volume peritoneal dialysis treatment.

<p>ICU: intensive care unit, i ATN: ischemic acute tubular necrosis, ATN-ISS: acute tubular necrosis individual severity score</p><p>* others: acidosis, more than one indication;</p><p>** others: liver diseases and post surgery;</p><p>*** others: nephrotoxic AKI, obstructive AKI and mixed AKI</p><p>Clinical data of acute kidney injury patient treated with high volume peritoneal dialysis according to time period of high volume peritoneal dialysis treatment.</p

Prescription and metabolic and fluid control of acute kidney injury patient treated with high volume peritoneal dialysis according to time period.

<p>Prescription and metabolic and fluid control of acute kidney injury patient treated with high volume peritoneal dialysis according to time period.</p

Subdistribuition Hazard Ratio of Covariates for technique failure.

<p>Subdistribuition Hazard Ratio of Covariates for technique failure.</p