Health economics of kidney replacement therapy in Singapore: Taking stock and looking ahead

The prevalence of end-stage kidney disease (ESKD) in Singapore remains high and continues to rise. We continue to face major challenges in containing the rising incidence of ESKD and providing sustainable kidney replacement therapy. Our cost projections provide an insight into the present and future, urging a call to action to augment existing initiatives to address the emergent issues.

Prognosis factors for death within 90 days of discharge in patients with acute kidney injury requiring continuous renal replacement therapy after surgery for Stanford type A acute aortic dissection / 中华外科杂志

Objective: To investigate the prognosis factors for death within 90 days after discharge in patients with acute kidney injury(AKI) treated requiring continuous renal replacement therapy(CRRT) undergoing surgery for acute Standford type A aortic dissection. Methods: The clinic data of 126 patients undergoing CRRT for postoperative AKI after acute type A aortic dissection surgery in the Center for Cardiac Intensive Care, Beijing Anzhen Hospital from July 2016 to February 2019 were analyzed retrospectively. There were 83 males and 43 females, aging (52.9±11.2) years(range: 25 to 70 years). The patients' demographic characteristics, disease-related information, perioperative data, laboratory indexes during CRRT, complications, and survival information within 90 days after discharge were recorded. Independent prognosis factors for death within 90 days of discharge were determined by Kaplan-Meier survival analysis, univariate and multifactorial Cox regression analysis. Results: Totally 57 of 126 patients(45.2%) died over the first 90 days after discharge. Kaplan-Meier survival analysis and univariate Cox regression analysis showed that there were significant differences between the non-survival and survival group including ≥65 years old, high lactate values 12 hours after CRRT, pulmonary infection, liver dysfunction, presence of permanent neurological complications, and postoperative ejection fraction(EF)<45%. Multifactorial Cox regression analysis revealed that ≥65 years old(HR=2.14, 95%CI: 1.09 to 4.21, P=0.03), high lactate values 12 hours after CRRT(HR=1.13, 95%CI: 1.06 to 1.20, P=0.01) and postoperative EF<45%(HR=2.21, 95%CI: 1.09 to 4.51, P=0.03) were independent prognosis factors for patients' death within 90 days after hospital discharge. Conclusions: ≥65 years old, high lactate values 12 hours after CRRT and postoperative EF<45% are independent prognosis factors for death within 90 days after discharge in patients undergoing CRRT for AKI after acute type A aortic dissection surgery. Proper identification and management of prognosis factors could be beneficial to improve patients' outcomes.

Anticoagulação em terapias contínuas de substituição renal / Anticoagulation in continuous renal replacement therapies (CRRT)

As terapias contínuas de substituição renal (TSRC) são comumente usadas na maioria de pacientes criticamente enfermos com indicação de diálise. O sucesso das TSRC depende de um protocolo de anticoagulação eficiente para manter permeável o circuito de diálise, minimizando complicações como sangramento por anticoagulação excessiva ou a necessidade da troca do sistema por coagulação do mesmo, por anticoagulação insuficiente. Vários fatores podem contribuir para a trombose do circuito de diálise, como a velocidade do fluxo de sangue através do circuito, o cateter de diálise, o tipo de membrana utilizada no filtro dialisador e, também, o tipo de terapia prescrita. A heparina não fracionada (HNF) é o anticoagulante mais utilizado para as diferentes técnicas de diálise e, mais recentemente, as heparinas de baixo peso molecular (HBPM) têm se mostrado seguras e efetivas para TRSC. Em pacientes criticamente enfermos que freqüentemente têm contra-indicação para anticoagulação sistêmica, existe a alternativa da anticoagulção regional com citrato trissódico, método eficiente e seguro, se aplicado com controle metabólico estrito. A anticoagulação regional com HNF/protamina tem seu uso limitado, atualmente, por apresentar muitas complicações decorrentes de efeitos adversos da protamina. Na impossibilidade do paciente ser anticoagulado, ou se a anticoagulação regional com citrato não for disponível, a lavagem freqüente do circuito de diálise com solução salina é a única alternativa aplicável. Novas drogas ainda não disponíveis no Brasil, como prostaglandinas, hirudina recombinante, argatroban e nafamostat podem ser utilizadas em pacientes com contra-indicação para heparinização.

Continuous renal replacement therapies (CRRT) are commonly used in the majority of critically ill patients who need dialysis. Treatment success depends on an efficient anticoagulation protocol devised to maintain the dialysis circuit unclotted, with minimal complications such as bleeding due to excessive anticoagulation. Several features can contribute to dialysis circuit thrombosis, such as the speed of pump blood flow, dialysis catheter, type of dialyzer membrane and also, the type of technique prescribed. Unfractioned heparin (UFH) is the anticoagulant most used in CRRT. Recently, low-molecular weight heparins (LMWH) have been shown to be safe and effective drugs for this purpose. In critically ill patients, who frequently have contraindications to systemic anticoagulation, regional anticoagulation with trisodium citrate is an increasingly accepted method due to its safety and efficiency if applied under strict metabolic control. Regional anticoagulation with UFH/protamin now has limited use because of side effects related to protamin. If the patient has contraindication to systemic anticoagulation or if regional anticoagulation with citrate is not available, continuous flushing of circuit dialysis with saline is the only applicable alternative. In patients with contraindication to heparinization, new drugs not yet available in Brazil, such as prostaglandins, recombinant hirudin, argatroban and nafamostat can be used.