Low caloric and protein intake is associated with mortality in patients with acute kidney injury.

BACKGROUND: Acute renal injury (AKI) interferes greatly with nutritional status, affecting the metabolism of all macronutrients and increased mortality rates in hospitalized patients. Our objective was to evaluate the association of nutritional parameters (albumin, cholesterol, caloric and protein intake and nitrogen balance (NB)) with mortality in patients with AKI. METHODS: This is a prospective observational study that evaluated 595 consecutive patients over the age of 18 years with AKI, requiring enteral or parenteral feeding. At the time of the patient's enrollment, demographic and laboratorial data, caloric and protein supply and NB were recorded on the first day of referral to the nephrologist. All patients were followed throughout the hospital stay and mortality rate was also recorded. RESULTS: The medium age of patients with AKI was 64 (54-75) years, 64.5% male, 62% admitted to intensive care unit (ICU), 52% on dialysis and the majority (48%) were at stage 3 by AKIN. Length of stay and hospital mortality were 18 (10-31) days and 46%, respectively. Superior age, AKI severity, lower body weight and body mass index (BMI), higher need for dialysis, ICU admission and shorter hospital stay were associated with higher mortality. At logistic regression, caloric (OR: 0.946; CI:95%: 0.901-0.994; p:0.029) and protein intake (OR: 0.947; CI:95%: 0.988-0.992; p = 0.028) and serum albumin (OR: 0.545; CI:95%: 0.401-0741; p < 0.001) were associated with hospital mortality. Cholesterol (OR: 0.995; CI:95%: 0.991-1.000; p = 0.052) was not associated with increased mortality in the adjusted analysis. Analysis of the receiver operating characteristic (ROC) curve showed that calorie intake < 12 kcal/kg (AUC: 0.745; CI:95%: 0.684-0.765; p < 0.001) and protein intake < 0.5 g/kg (AUC: 0.726; CI:95%: 0.686-0.767; p < 0.001) were predictors of hospital mortality, as well as a negative NB < -6.47 g N/day (AUC: 0.745; CI:95%: 0.704-0.786; p < 0.001). CONCLUSIONS: In conclusion, low caloric and protein intake, negative NB and low albumin value are conditions associated with higher hospital mortality in patients with AKI.

Handgrip strength and weight predict long-term mortality in acute kidney injury patients.

INTRODUCTION: Surviving acute kidney (AKI) patients have a higher late mortality compared with those admitted without AKI. The negative impact of malnutrition on the early outcome of AKI patients has recently been confirmed by various studies. However, its impact after hospital discharge has not been studied. The objective of the study was to determine the role of anthropometric measurements and handgrip strength as predictors of mortality 180 days after discharge. METHODOLOGY: Eighty-two survivors AKI patients who were older than 18 y old and followed by AKI team were prospectively evaluated. Patient's characteristics were recorded, anthropometric measurements were taken, handgrip strength (HGS) was measured, subjective global assessment and bioimpedance were applied and blood samples were collected during hospitalization at first and last nephrologist evaluation and in after hospital discharge at 1 month, 3 and 6 months. Multivariable logistic regression was used to adjust confounding and selection bias. RESULTS: Age was 62.3 ± 14.7 years, prevalence of hospitalization in medical wards of 71.6%, index of severity of AKI (ATN-ISS) was 28% and late mortality rates was 25.6%. Risk factors associated with late mortality were the number of comorbidities (HR = 1.79, 95% CI = 1.45-2.46, p = 0.04), cancer (HR = 1.89, 95 CI% = 1.48-3.16, p = 0.01), sepsis (HR = 1.47, 95% CI = 1.18-2.38, p = 0.03), no recovery of renal function at hospital discharge (HR = 1.46, 95% CI = 1.02-2.16, p = 0.03), malnutrition at first evaluation (HR = 1.58, 95% CI = 1.14-2.94, p = 001), the HGS value at the moment of last evaluation by nephrologist (HR = 1.81, 95% CI = 1.17-2.31, p = 0.04) and gain weigh < 1 kg between the moment at first evaluation by nephrologist and one month after hospital discharge (HR = 1.95, 95 CI% = 1.29-3.3, p = 0.02). CONCLUSION: HGS and gain weight were identified as predictors of late mortality. Simple and ease methods can be applied in AKI patients during and after hospitalization to diagnose nutritionally patients who are at higher risk for poor prognosis and, consequently intervention measures can be performed to improve survival in long-term.

A randomized clinical trial of high volume peritoneal dialysis versus extended daily hemodialysis for acute kidney injury patients.

BACKGROUND: Acute kidney injury (AKI) requiring dialysis in critically ill patients is associated with an in-hospital mortality rate of 50-80 %. Extended daily hemodialysis (EHD) and high volume peritoneal dialysis (HVPD) have emerged as alternative modalities. METHODS: A double-center, randomized, controlled trial was conducted comparing EHD versus HVPD for the treatment for AKI in the intensive care unit (ICU). Four hundred and seven patients were randomized and 143 patients were analyzed. Principal outcome measure was hospital mortality, and secondary end points were recovery of renal function and metabolic and fluid control. RESULTS: There was no difference between the two groups in relation to median ICU stay [11 (5.7-20) vs. 9 (5.7-19)], recovery of kidney function (26.9 vs. 29.6 %, p = 0.11), need for chronic dialysis (9.7 vs. 6.5 %, p = 0.23), and hospital mortality (63.4 vs. 63.9 %, p = 0.94). The groups were different in metabolic and fluid control. Blood urea nitrogen (BUN), creatinine, and bicarbonate levels were stabilized faster in EHD group than in HVPD group. Delivered Kt/V and ultrafiltration were higher in EHD group. Despite randomization, there were significant differences between the groups in some covariates, including age, pre-dialysis BUN, and creatinine levels, biased in favor of the EHD. Using logistic regression to adjust for the imbalances in group assignment, the odds of death associated with HVPD was 1.4 (95 % CI 0.7-2.4, p = 0.19). A detailed investigation of the randomization process failed to explain the marked differences in patient assignment. CONCLUSIONS: Despite faster metabolic control and higher dialysis dose and ultrafiltration with EHD, this study provides no evidence of a survival benefit of EHD compared with HVPD. The limitations of this study were that the results were not presented according to the intention to treat and it did not control other supportive management strategies as nutrition support and timing of dialysis initiation that might influence outcomes in AKI.

Long-term outcome of patients followed by nephrologists after an acute tubular necrosis episode.

Aims of our study were to describe the long-term survival in patients surviving an acute tubular necrosis (ATN) episode and determine factors associated with late mortality. We performed a prospective cohort study that evaluated the long-term outcome of 212 patients surviving an ATN episode. Mortality at the end of followup was 24.5%, and the probability of these patients being alive 5 years after discharge was 55%. During the followup, 4.7% of patients needed chronic dialysis. Univariate analysis showed that previous CKD (P = 0.0079), cardiovascular disease (P = 0.019), age greater than 60 years (P < 0.0001), and higher SCr baseline (P = 0.001), after 12 months (P = 0.0015) and 36 months (P = 0.004), were predictors of long-term mortality. In multivariate analysis, older age (HR = 6.4, CI 95% = 1.2-34.5, P = 0.02) and higher SCr after 12 months (HR = 2.1, 95% CI 95% = 1.14-4.1, P = 0.017) were identified as risk factors associated with late mortality. In conclusion, 55% of patients surviving an ATN episode were still alive, and less than 5% required chronic dialysis 60 months later; older age and increased Scr after 12 months were identified as risk factors associated with late death.

High volume peritoneal dialysis vs daily hemodialysis: a randomized, controlled trial in patients with acute kidney injury.

There is no consensus in the literature on the best renal replacement therapy (RRT) in acute kidney injury (AKI), with both hemodialysis (HD) and peritoneal dialysis (PD) being used as AKI therapy. However, there are concerns about the inadequacy of PD as well as about the intermittency of HD complicated by hemodynamic instability. Recently, continuous replacement renal therapy (CRRT) have become the most commonly used dialysis method for AKI around the world. A prospective randomized controlled trial was performed to compare the effect of high volume peritoneal dialysis (HVPD) with daily hemodialysis (DHD) on AKI patient survival. A total of 120 patients with acute tubular necrosis (ATN) were assigned to HVPD or DHD in a tertiary-care university hospital. The primary end points were hospital survival rate and renal function recovery, with metabolic control as the secondary end point. Sixty patients were treated with HVPD and 60 with DHD. The HVPD and DHD groups were similar for age (64.2+/-19.8 and 62.5+/-21.2 years), gender (male: 72 and 66%), sepsis (42 and 47%), hemodynamic instability (61 and 63%), severity of AKI (Acute Tubular Necrosis-Index Specific Score (ATN-ISS): 0.68+/-0.2 and 0.66+/-0.2), Acute Physiology, Age, and Chronic Health Evaluation Score (APACHE II) (26.9+/-8.9 and 24.1+/-8.2), pre-dialysis BUN (116.4+/-33.6 and 112.6+/-36.8 mg per 100 ml), and creatinine (5.8+/-1.9 and 5.9+/-1.4 mg per 100 ml). Weekly delivered Kt/V was 3.6+/-0.6 in HVPD and 4.7+/-0.6 in DHD (P<0.01). Metabolic control, mortality rate (58 and 53%), and renal function recovery (28 and 26%) were similar in both groups, whereas HVPD was associated with a significantly shorter time to the recovery of renal function. In conclusion, HVPD and DHD can be considered as alternative forms of RRT in AKI.

Is 44-hour better than 24-hour ambulatory blood pressure monitoring in hemodialysis?

The aim of this study is to evaluate if hemodialysis (HD) patients with similar blood pressure (BP) in the whole inter-HD period could have different target organ lesions and survival if the behavior of BP differs from the first to the second day of the inter-HD period. The present study compares 44-hour ambulatory BP monitoring (ABPM) patterns in 45 HD patients. Three BP patterns emerged: group A (n = 15) had similar BPs throughout (138 +/- 11/88 +/- 12 in the first 22 h vs. 140 +/- 11/87 +/- 12 mm Hg in the second 22-hour period); group B (n = 15) had a significant systolic BP rise from the first to the second period (132 +/- 15/80 +/- 12 vs. 147 +/- 12/86 +/- 13 mm Hg, p < 0.05); group C (n = 15) had significantly higher BPs (p < 0.05) than the other 2 groups throughout the whole inter-HD period, with no significant change between the 2 halves (172 +/- 14/108 +/- 12 vs. 173 +/- 18/109 +/- 14 mm Hg). Ventricular mass and survival during the 30-month follow-up period were statistically significantly better in group A, intermediate in group B and worse in group C. The data suggest that a 44-hour ABPM is more accurate than a 24-hour one in evaluating organ lesion and prognosis in HD patients.

Association between hypervolemia and ventricular hypertrophy in hemodialysis patients.

BACKGROUND: Left ventricular hypertrophy (LVH) is a well-known predictor of cardiovascular mortality in patients who have end-stage renal disease and are maintained on hemodialysis (HD), and LVH is not always correlated with the severity of hypertension in these patients. The purpose of this study was to investigate the role of other factors contributing to LVH. METHODS: A total of 50 patients with HD were classified in three groups according to whether their LV mass index (LVMI) was higher than (n = 15), equal to (n = 20), or lower than (n = 15) that predicted by a formula based on their ambulatory blood pressure monitoring (ABPM). RESULTS: Subjects with higher LVMI than predicted had significantly greater inter-HD weight gain (3.4 +/- 0.8 v 2.7 +/- 0.8 and 2.6 +/- 05 kg, respectively, in the other two groups, P < .05), and subjects with lower LVMI than predicted had a tendency toward a more pronounced nocturnal dipping pattern of BP (P = .07 v the other two groups), although daytime and night-time average BP levels did not differ between groups. All other clinical and laboratory parameters were similar among the three groups except higher cardiac output and various indices of LVH, which were more pronounced in the group with higher LVMI by ABPM. This group had also the lowest survival rate over the 2 to 3 years of follow-up, with five deaths versus two in each of the other two groups. CONCLUSIONS: The data suggest that correct management of inter-HD weight gain by nutritional counseling and shorter inter-HD intervals may prevent LVH and improve survival independently of BP control.

Estudo comparativo das complicaçöes terapêuticas no Lúpus Eritematoso Sistêmico e nas glomerulopatias idiopáticas / A comparative study of therapeutic complications in Systemic Lupus Erythematosus and in idiopathic glomerulopathy

A utilizaçäo terapêutica de doses elevadas de imunossupressores pode promover diversas complicaçöes, principalmente infecciosas. OBJETIVOS: Avaliar as complicaçöes secundárias ao uso de corticóide e ciclofosfamida em portadores de nefropatias. MÉTODOS: Foram estudados retrospectivamente 76 pacientes atendidos no Hospital das Clínicas da Faculdade de Medicina de Botucatu - UNESP, sendo divididos em três grupos: G1= Lúpus Eritematoso Sistêmico sem lesäo renal (n=15); G2= nefrite lúpica (n=33) e G3= síndrome nefrótica por glomerulopatia idiopática (n=28). RESULTADOS: Näo houve diferença em relaçäo ao tempo de acompanhamento (G1= 42,4 ± 51, G2= 52,3 ± 51, G3= 41,8 ± 47,8 meses), dose total de corticóide utilizada (G1= 20, G2= 28, G3= 16 gramas) e tempo de uso da droga (G1= 20, G2= 26, G3= 14,5 meses). Quanto ao uso de ciclofosfamida, näo houve diferença na percentagem de pacientes que a utilizaram (13 por cento no G1, 51 por cento no G2, 28 por cento no G3), porém pacientes do G1 receberam dose total menor que G2 (mediana de zero e um grama, respectivamente -- p<0.05). Aspecto cushingóide, manifestaçöes gástricas, distúrbios comportamentais, diabetes mellitus e alteraçöes oculares ocorreram nos três grupos, sem diferença estatística. Quanto às complicaçöes infecciosas, aquelas consideradas clinicamente mais graves, foram mais freqüentes no G2 (G1= 6 por cento, G2= 15 por cento, G3= 0 por cento - p<0.05), o mesmo ocorrendo em relaçäo aos óbitos (7 por cento no G1, 30 por cento no G2, 0 por cento no G3 -- p<0.05). CONCLUSÖES: Pacientes portadores de nefrite lúpica apresentaram maior freqüência de complicaçöes infecciosas decorrentes da imunossupressäo prolongada, o que pode representar um marcador de gravidade deste tipo de lesäo

[A comparative study of therapeutic complications in Systemic Lupus Erythematosus and in idiopathic glomerulopathy]. / Estudo comparativo das complicações terapêuticas no Lúpus Eritematoso Sistêmico e nas glomerulopatias idiopáticas.

PURPOSE: To evaluate the therapeutic complications due to the use of immunosupressors in patients with nephropathy. METHODS: 76 patients who had used steroids and cyclophosphamide were retrospectively studied. The cases were divided into three groups: G1= 15 patients with Systemic Lupus Erythematosus without renal lesion; G2= 33 patients with lupus nephritis and G3= 28 patients with nephrotic syndrome owing to idiopathic glomerulopathy. RESULTS: There were no differences related to time of follow up (G1= 42.4 +/- 51, G2= 52.3 +/- 51, G3= 41.8 +/- 47.8 months), total used dosage of steroids (G1= 20, G2= 28, G3= 16 grams) and time of drug use (G1= 20, G2= 26, G3= 14.5 months). About cyclophosphamide use, there was no difference in the percentage of patients who used it (13% in G1, 51% in G2, 28% in G3), but the patients from G1 received lower total dosage than those from G2 (p<0.05). Cushingoid appearance, epigastric distress, psychiatric disorders, diabetes mellitus and ocular alterations occurred in all the three groups, with no statistically significant differences. The infections complications, those considered more severe clinically, were more frequent in G2 (G1= 6%, G2= 15%, G3= 0% - p<0.05), the same occurring with the deaths (7% in G1, 30% in G2, 0% in G3 - p<0.05). CONCLUSION: In patients with lupus nephritis there were more infections complications owing to prolonged immunosuppresion what may indicate a severity marker of this type of lesion.

Renal artery clipping attenuates the progression of adriamycin nephropathy.

This study was designed to analyze the impact of diminished renal perfusion pressure due to renal clipping on the rat model of adriamycin nephropathy. Male Wistar rats, divided into four groups (n = 9 per group) were injected with saline as control (C), adriamycin 3 ml/kg (Ad), saline with the left renal artery clipped (Rv), and adriamycin plus clip (AdRv). After 24 weeks mean arterial pressure (MAP), inulin, and p-aminohippurate (PAH) clearances were performed to evaluate renal function. Morphologic analysis included histologic criteria of percentage of glomerulosclerosis and tubulointerstitial lesion index (TILI). The MAP (mm Hg) was similar between Rv (143+/-13) and AdRv (154+/-20), but higher (P < .05) than C (120 +/-8) and Ad (124+/-11). Inulin clearance (mL/min/ 100 g) in Ad (0.2+/-0.05) was smaller than in C (0.53+/-0.17) and Rv (0.4+/-0.01) (P < .05), and was at an intermediate level in AdRv (0.33+/-0.2). The level of PAH (mL/min/100 g) was normal at 1.76 in C, and diminished more in Ad (0.58) than in Rv (1.06) and AdRv (1.18) (P < .05). Both Ad and the AdRv nonclipped kidneys had the highest degree of glomerulosclerosis (33% and 25%) and TILI (7% and 8%), respectively, compared with C and Rv (both 0%), whereas the clipped kidneys displayed intermediate degrees (9% and 5%) (P < .05 v nonclipped). The data suggest that diminished perfusion pressure of the clipped kidney, by decreasing the intraglomerular pressure, protects the glomerulus from damage and attenuates the evolution of adriamycin nephropathy.

Acute renal failure in renal allograft recipients and patients with native kidneys.

In order to evaluate the role of underlying disease in the high mortality observed in acute renal failure (ARF) and risk factors related to the development of oliguric ARF in renal allograft recipients, two groups were selected: 34 patients with native kidneys, aged 16 and 57 years, and presenting ischemic ARF caused by cardiovascular collapse, with no signs of infection at the time of diagnosis; and 34 renal allograft recipients who developed ARF immediately after transplantation, without rejection. ARF was defined either as 30% increase of basal plasmatic creatinine in patients with native kidneys or nonnormalization of plasmatic creatinine at day 5 after transplantation in renal allograft recipients; oliguria as diuresis < or = 400 mL/24 h. There were no differences in age, male frequency, oliguria presence and duration, need for dialysis, and infection episodes for renal allograft recipients and patients with native kidneys. The development of sepsis (3% and 41%) and death rate (3% and 44%) were higher in patients with native kidneys (p < 0.01). The renal allograft recipients with both oliguric (n = 18) and nonoliguric (n = 16) ARF were evaluated and no difference was observed in the recipient's age, donor's age, cold ischemia time, time elapsed until plasmatic creatinine normalization, donor's plasmatic creatinine or urea, and mean arterial pressure. No differences were observed between the groups regarding frequency of infection episodes during ARF and frequency of death. In conclusion, renal allograft recipients presented a lower death rate and were less susceptible to sepsis. Cold ischemia time, age, and hemodynamic characteristics of the donor did not affect the development of oliguria.

[An open comparative study of captopril + hydrochlorothiazide versus chlorthalidone for the treatment of mild and moderate primary hypertension]. / Estudo aberto comparativo captopril + hidroclorotiazida versus clortalidona para tratamento da hipertensão primária leve e moderada.

PURPOSE: To compare the antihypertensive and metabolic effects of captopril combined with hydrochlorothiazide (C+HCTZ) versus chlorthalidone (CT) in mild and moderate primary hypertensive patients. METHODS: Fifty five patients, without treatment or treated with 15 days placebo were randomized for treatment with the combination of captopril 50mg and hydrochlorothiazide 25mg (n = 29) against chlorthalidone (n = 26). The clinical evaluation was done during placebo and monthly throughout three months, and the laboratory tests were done before and at the end of the study. RESULTS: The blood pressure were similar between groups during placebo period (C + HCTZ: 161 +/- 25/102 +/- 6-CT: 155 +/- 18/101 +/- 6 mmHg); the diastolic blood pressure decreases significantly at first month already in the group C + HCTZ (89 +/- 8 mmHg) compared to group CT (94 +/- 8 mmHg, p < 0.05). The percentile diastolic and mean blood pressure dropped, in average, 12% in C + HCTZ group and in CT varied between 7 (1st and 2nd month) to 11% (3rd month). Without statistical difference, the blood pressure normalization was obtained in 69% of the patients with the association captopril and diuretic and in 50% of the patients in the chlorthalidone group. It was observed a significant reduction of potassium in patients treated with chlorthalidone (4.2 +/- 0.7 to 3.7 +/- 0.4 mEq/L, p < 0.01) that was not observed with the captopril and the thiazide associated. The last treatment also significantly reduced the cholesterol levels (219 +/- 39 mg/dl to 202 +/- 39 mg/dl, p < 0.04). CONCLUSION: Our results indicate that captopril combined with low diuretic dose normalize the blood pressure in 69% mild to moderate primary hypertensive patients, and acts faster than chlorthalidone in this control. In addition has metabolic benefits reducing cholesterol levels with no alteration in potassium levels.