Background and objectives AKI is associated with short-and long-term mortality. However, the exact contribution of AKI complications to the burden of mortality and whether RRT has any beneficial effect on reducing mortality rates in critically ill AKI patients are unknown.Design, setting, participants, & measurements This was a retrospective analysis using data from the Multiparameter Intelligent Monitoring in Intensive Care II project. A total of 18,410 adult patients were enrolled from four intensive care units from a university hospital from 2001 to 2008.Results Overall, 10,245 patients developed AKI. After adjustments, the odds ratios (ORs) for hospital mortality were 1.73 (95% confidence interval [95% CI], 1.52 to 1.98) for AKI stage 1, 1.88 (95% CI, 1.57 to 2.25) for stage 2, and 2.89 (95% CI, 2.41 to 3.46) for stage 3. Totals of 33%, 59%, and 70% of the excess mortality rates associated with AKI stages 1, 2, and 3, respectively, were attenuated by the inclusion of each AKI-related complication in the model. The main burden of excess hospital mortality associated with AKI was attenuated by metabolic acidosis and cumulative fluid balance. Long-term mortality was not attenuated by any of the associated complications. Next, we used two different approaches to explore the associations between RRT, AKI complications, and hospital mortality: multivariate analysis and propensity score matching. In both approaches, the sensitivity analysis for RRT was associated with a better hospital survival in only the following AKI-related subgroups: hyperkalemia (OR, 0.55; 95% CI, 0.35 to 0.85), metabolic acidosis (OR, 0.70; 95% CI, 0.53 to 0.92), cumulative fluid balance .5% of body weight (OR, 0.60; 95% CI, 0.40 to 0.88), and azotemia (OR, 0.57; 95% CI, 0.40 to 0.81).Conclusions A majority of the excess risk of mortality associated with AKI was attenuated by its fluid volume and metabolic complications, particularly in severe AKI. In addition, this study demonstrated that RRT is associated with a better outcome in patients with AKI-related complications.

IntroductionPrevious studies using Acute Kidney Injury Network (AKIN)/RIFLE criteria to classify early initiation of renal replacement therapy (RRT) have defined it as the therapy started in less severe AKIN/RIFLE stages. Generally, these studies failed in demonstrating measurable benefits.MethodsWe compared RRT initiation in critically ill patients and defined early or late RRT in reference to timing after stage 3 AKIN was met: patients beginning RRT within 24 hours after acute kidney injury (AKI) stage 3 were considered early starters. AKIN criteria were evaluated by both urine output (UO) and serum creatinine (sCr) and patients with acute-on-chronic kidney disease were excluded. A propensity score methodology was used to control variables.ResultsA total of 358 critically ill patients were submitted to RRT. Only 150 patients with pure AKI at stage 3 were analyzed. Mortality was lower in the early RRT group (51.5 vs. 77.9%, P = 0.001). After achieving balance between the groups using a propensity score, there was a significant 30.5 (95% confidence interval [CI] 14.4 to 45.2%, P = 0.002) relative decrease of mortality in the early RRT group. Moreover, patients on the early RRT group had lower duration of mechanical ventilation, time on RRT and a trend to lower intensive care unit (ICU) length of stay.ConclusionsFor the first time, AKIN was used with UO criterion to evaluate early and late RRT. Using a time-based approach could be a better parameter to access the association between RRT initiation and outcomes in patients with AKI.

SummaryThe impact of the use of loop diuretics to prevent cumulative fluid balance in non‐oliguric patients is uncertain. This is a retrospective study to estimate the association of time‐averaging loop diuretic exposure in a large population of non‐cardiac, critically ill patients with a positive fluid balance (> 5% of body weight). The exposure was loop diuretic and the main outcomes were 28‐day mortality, severe acute kidney injury and successful mechanical ventilation weaning. Time‐fixed and daily time‐varying variables were evaluated with a marginal structural Cox model, adjusting bias for time‐varying exposure and the presence of time‐dependent confounders. A total of 14,896 patients were included. Patients receiving loop diuretics had better survival (unadjusted hazard ratio 0.56, 95%CI 0.39–0.81 and baseline variables adjusted hazard ratio 0.53, 95%CI 0.45–0.62); after full adjusting, loop diuretics had no association with 28‐day mortality (full adjusted hazard ratio 1.07, 95%CI 0.74–1.54) or with reducing severe acute kidney injury occurrence during intensive care unit stay – hazard ratio 1.05 (95%CI 0.78–1.42). However, we identified an association with prolonged mechanical ventilation (hazard ratio 1.59, 95%CI 1.35–1.89). The main results were consistent in the sub‐group analysis for sepsis, oliguria and the study period (2002–2007 vs. 2008–2012). Also, equivalent doses of up to 80 mg per day of furosemide had no significant association with mortality. After adjusting for time‐varying variables, the time average of loop diuretic exposure in non‐cardiac, critically ill patients has no association with overall mortality or severe acute kidney injury; however, prolonged mechanical ventilation is a concern.

Although patients who received Polymyxin B plus vancomycin had more favorable clinical profile and higher previous GFR, they presented a higher AKI incidence than those patients who received Polymyxin B alone. Cumulative Polymyxin B dose > 10 million IU was independently associated to AKI.

Background and objectives Propofol has been shown to provide protection against renal ischemia/reperfusion injury experimentally, but clinical evidence is limited to patients undergoing cardiac surgery. There are no data about its association with oliguria and AKI in critically ill patients.Design, setting, participants, & measurements We obtained data from the Multiparameter Intelligent Monitoring in Intensive Care II database (2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008). Patient selection criteria included adult patients in their first intensive care unit (ICU) admission, need for mechanical ventilation, and treatment with propofol or midazolam. Propensity score analysis (1:1) was used and renal-related outcomes (AKI, oliguria, cumulative fluid balance, and need for RRT) were evaluated during the first 7 days of ICU stay.Results There were 1396 propofol/midazolam-matched patients. AKI in the first 7-day ICU time period was statistically lower in propofol-treated patients compared with midazolam-treated patients (55.0% versus 67.3%, P,0.001). Propofol was associated with lower AKI incidence using both urine output (45.0% versus 55.7%, P,0.001) and serum creatinine criteria (28.8% versus 37.2%, P=0.001). Patients receiving propofol had oliguria (,400 ml/d) less frequently (12.4% versus 19.6%, P=0.001) and had diuretics prescribed less often (8.5% versus 14.3%, P=0.001). In addition, during the first 7 days of ICU stay, patients receiving propofol less frequently achieved cumulative fluid balance .5% of body weight (50.1% versus 58.3%, P=0.01). The need for RRT in the first 7 days of ICU stay was also less frequent in propofol-treated patients (3.4% versus 5.9%, P=0.03). ICU mortality was lower in propofol-treated patients (14.6% versus 29.7%, P,0.001). ConclusionsIn this large, propensity-matched ICU population, patients treated with propofol had a lower risk of AKI, fluid-related complications, and need for RRT.

AKI classification proposed by a Cr kinetics model can be superior when diagnosing patients with previous CKD. However, KDIGO had a better performance in patients with no previous CKD.

BackgroundVisceral leishmaniasis (VL) is an important and potentially fatal neglected tropical disease. The aim of this study was to investigate hyponatremia and risk factors for death among VL patients.MethodsThis is a cross-sectional study with VL patients admitted to a tertiary hospital in Northeast Brazil, from 2002 to 2009. Patients were divided into two groups: non-survivors and survivors. Hyponatremia was defined as serum sodium < 135 mEq/L. A logistic regression model was done to investigate risk factors for death.ResultsA total of 285 VL patients were included, with mean age 37 ± 15 years, and 74% were males. Thirty-four patients died (11.9%). Non-survivors had a significantly higher prevalence of dyspnea (38.2 vs. 16.7%, p = 0.003), pulmonary crackles (11.8 vs. 4.0%, p = 0.049), dehydration (23.5 vs. 10.8%, p = 0.033), oliguria (8.8 vs. 0.8%, p = 0.001) and jaundice (47.1 vs. 14.3%, p < 0.001). They also presented higher prevalence of hyponatremia (41.9 vs. 24.1%, p = 0.035), thrombocytopenia (91.2 vs. 65.3%, p = 0.002) and severe hypoalbuminemia (78.3 vs. 35.3%, p < 0.001). In multivariate analysis, moderate/severe hyponatremia (OR = 2.278, 95% CI = 1.046–4.962), thrombocytopenia (OR = 5.482, 95% CI = 1.629–18.443), jaundice (OR = 5.133, 95% CI = 1.793–14.696) and severe hypoalbuminemia (OR = 6.479, 95% CI = 2.124–19.766) were predictors of death.ConclusionHigher prevalence of dehydration, oliguria, pulmonary symptoms and liver involvement was found in non-survivors VL patients. Hypoalbuminemia and hyponatremia were frequent and significantly associated with mortality.

The ATN prognostic model can be useful in a broad cohort of critically ill patients. Although it showed only moderate discrimination capacity when patients with elevated admission sCr were included, using a refitted model improved it, illustrating the need for continuous external validation and updating of prognostic models over time before their implementation in clinical practice.