Management of the dialysis patient in general intensive care

Arulkumaran, N; Montero, Rosa; Singer, Mervyn

doi:10.1093/bja/aer461

Cited by 25 publications

(22 citation statements)

References 103 publications

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“…The maladies of our ICU maintenance dialysis patients with a high burden of coexisting diseases mirror the acute illnesses commonly encountered in non-renal ICU patients. We observed short-term and mid-term mortality rates well within published ranges (5,16).…”

Section: Dialysis Dosing In Maintenance Hd Patients 471supporting

confidence: 84%

Assessment of Dialysis Dose in Critically Ill Maintenance Dialysis Patients

2014

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Maintenance dialysis patients are admitted more frequently to the intensive care unit (ICU) and have higher ICU mortality than the general population. It is unclear if such dialysis patients receive adequate dialysis in the ICU setting. Using the Daugirdas formula for calculation of spKt/Vurea, single treatment delivered dialysis dose was assessed in 85 critically ill maintenance hemodialysis patients during their first ICU dialysis session. Weekly delivered spKt/Vurea was determined in the surviving 64 patients and compared with their corresponding delivered outpatient dialysis dosages. Outcome measures were ICU and in-hospital mortality and mortality at 6 and 12 months after discharge. Prescribed dose of the first ICU dialysis was a spKt/Vurea of 1.43 ± 0.11, the single treatment delivered dose was 1.02 ± 0.14. The weekly prescribed ICU Kt/Vurea was 4.25 ± 0.12 and delivered ICU Kt/Vurea was 3.48 ± 0.19. Patients with sepsis had the lowest mean spKt/Vurea values (0.87 ± 0.12). Serial measurements of delivered dialysis dose suggest that this gap is explained by variability of volume of urea distribution. ICU mortality was 25% and was related to APACHE II score, but not to delivered intermittent hemodialysis dose. Critically ill maintenance dialysis patients receive suboptimal dialysis doses. The impact of short-term underdialysis on survival of hospitalized maintenance dialysis patients remains unknown. Assessment of dialysis adequacy should be routinely performed in these patients and delivered dialysis should be tracked through the initial clinical course.

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Section: Dialysis Dosing In Maintenance Hd Patients 471supporting

confidence: 84%

Assessment of Dialysis Dose in Critically Ill Maintenance Dialysis Patients

2014

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“…Impaired renal function is a major risk factor for cardiovascular morbidity and mortality [14]. Several factors may contribute to the increased incidence of cardio-respiratory dysfunction in patients with ESRD, including left ventricular hypertrophy, rapid electrolyte shifts during dialysis, QT dispersion, sympathetic over-activity, and deposition of calcium-phosphate precipitants within arteries [14,15]. Acute pulmonary infections, perioperative volume overload, excessive inter-dialytic weight gain, and primary cardiac events may also contribute to respiratory failure in patients with ESRD.…”

Section: Discussionmentioning

confidence: 99%

“…The higher prevalence of hepatic failure in our patients may be explained by the higher incidence of liver cirrhosis in these patients compared with those without ESRD. The impairment of renal elimination of hypnotic and sedative agents given perioperatively in patients with ESRD [14] may explain the high occurrence of neurological failure in these patients. Interestingly, we found that hematologic failure occurred up to 4 times more frequently in patients with ESRD than in those without.…”

Section: Discussionmentioning

confidence: 99%

End-stage renal disease and outcome in a surgical intensive care unit

et al. 2013

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IntroductionEnd-stage renal disease (ESRD) is associated with an increased propensity for critical illness, but whether ESRD is independently associated with a greater risk of death after major surgical procedures is unclear.MethodsThis was a retrospective analysis of prospectively collected data from all adult (>18 years) patients admitted to a 50-bed surgical intensive care unit (ICU) between January 2004 and January 2009. ESRD was defined as the need for chronic peritoneal dialysis or hemodialysis for at least 6 weeks prior to ICU admission. We used multivariable logistic regression analysis and propensity-score matching to adjust for possible confounders.ResultsIn total, 12,938 adult patients were admitted during the study period; 199 patients had ESRD at ICU admission, giving a prevalence of 1.5%. Patients with ESRD were more likely to be male (72.9% versus 63.0%, P = 0.004) and had higher severity scores, a higher incidence of diabetes mellitus and cirrhosis, and a lower incidence of cancer at ICU admission than those without ESRD. Patients with ESRD were more likely to have any type of organ failure at ICU admission and during the ICU stay. Patients with ESRD had higher ICU and hospital mortality rates (23.1% and 31.2% versus 5.5% and 10.0%, respectively, P <0.001 pairwise) and longer ICU length of stay (2 (1 to 7) versus 1 (1 to 3) days, P <0.001). In multivariable logistic regression analysis, ESRD was independently associated with a greater risk of in-hospital death (odds ratio = 3.84, 95% confidence interval 2.68 to 5.5, P <0.001). In 199 pairs of patients, hematologic and hepatic failures were more prevalent, ICU and hospital mortality rates were higher (23.1% versus 15.1% and 31.2% versus 19.1%, P <0.05 pairwise), and ICU length of stay was longer (2 (1 to 7) versus 1 (1 to 7) days, P <0.001) in patients with ESRD.ConclusionsIn this large cohort of surgical ICU patients, presence of ESRD at ICU admission was associated with greater morbidity and mortality and independently associated with a greater risk of in-hospital death. Our data can be useful in preoperative risk stratification.

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“…The management of the ESRD patient on ICU is beyond the scope of this article and is detailed elsewhere in the literature. 37…”

Section: Causes Of Admissionmentioning

confidence: 99%

Patients with end-stage renal disease admitted to the intensive care unit: systematic review

Arulkumaran

Annear

Singer

2013

British Journal of Anaesthesia

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The number of patients with end-stage renal disease (ESRD) is increasing worldwide, with a growing demand on healthcare services. A systematic review of the literature was performed to determine the requirement for intensive care unit (ICU) services, reasons for admission, predictors of mortality, and short- and long-term outcomes of ESRD patients admitted to ICU. Sixteen studies were identified, comprising 6591 ICU admissions. Cardiovascular disease and sepsis accounted for the majority of admissions. Acute illness severity scores tend to overestimate mortality among ESRD patients. Critical illness associated with acute kidney injury (AKI) requiring renal replacement therapy (RRT) is associated with significantly higher hospital mortality compared with ESRD patients admitted to the ICU [odds ratio (OR) 3.9; 3.5-4.4; P<0.0001]. However, hospital mortality of ESRD patients is less favourable compared with matched patients with mild AKI (OR 1.5; 1.4-1.6; P<0.0001). Although the mortality rate remains high shortly after hospital discharge, the duration of increased mortality risk is unclear. Patients with ESRD frequently benefit from ICU admission, despite chronic co-morbidity. Further studies are required to modify and validate existing illness severity scores for ESRD patients admitted to the ICU, and to establish the duration of increased mortality risk after discharge from ICU.

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Management of the dialysis patient in general intensive care

Cited by 25 publications

References 103 publications

Assessment of Dialysis Dose in Critically Ill Maintenance Dialysis Patients

Assessment of Dialysis Dose in Critically Ill Maintenance Dialysis Patients

End-stage renal disease and outcome in a surgical intensive care unit

Patients with end-stage renal disease admitted to the intensive care unit: systematic review

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