"Acute kidney injury in critically ill patients with COVID-19: The AKICOV multicenter study in Catalonia".

This study describes the incidence, evolution and prognosis of acute kidney injury (AKI) in critical COVID-19 during the first pandemic wave. We performed a prospective, observational, multicenter study of confirmed COVID-19 patients admitted to 19 intensive care units (ICUs) in Catalonia (Spain). Data regarding demographics, comorbidities, drug and medical treatment, physiological and laboratory results, AKI development, need for renal replacement therapy (RRT) and clinical outcomes were collected. Descriptive statistics and logistic regression analysis for AKI development and mortality were used. A total of 1,642 patients were enrolled (mean age 63 (15.95) years, 67.5% male). Mechanical ventilation (MV) was required for 80.8% and 64.4% of these patients, who were in prone position, while 67.7% received vasopressors. AKI at ICU admission was 28.4% and increased to 40.1% during ICU stay. A total of 172 (10.9%) patients required RRT, which represents 27.8% of the patients who developed AKI. AKI was more frequent in severe acute respiratory distress syndrome (ARDS) ARDS patients (68% vs 53.6%, p<0.001) and in MV patients (91.9% vs 77.7%, p<0.001), who required the prone position more frequently (74.8 vs 61%, p<0.001) and developed more infections. ICU and hospital mortality were increased in AKI patients (48.2% vs 17.7% and 51.1% vs 19%, p <0.001) respectively). AKI was an independent factor associated with mortality (IC 1.587-3.190). Mortality was higher in AKI patients who required RRT (55.8% vs 48.2%, p <0.04). Conclusions There is a high incidence of AKI in critically ill patients with COVID-19 disease and it is associated with higher mortality, increased organ failure, nosocomial infections and prolonged ICU stay.

Augmented renal clearance. An unnoticed relevant event.

Augmented renal clearance (ARC) is a phenomenon that can lead to a therapeutic failure of those drugs of renal clearance. The purpose of the study was to ascertain the prevalence of ARC in the critically ill patient, to study the glomerular filtration rate (GFR) throughout the follow-up and analyze the concordance between the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) estimation formula and measured GFR. Observational, prospective, multicenter study. ARC was defined as a creatinine clearance greater than 130 ml/min/1.73 m2. Eighteen hospitals were recruited. GFR measurements carried out twice weekly during a 2-month follow-up period. A total of 561 patients were included. ARC was found to have a non-negligible prevalence of 30%. More even, up to 10.7% already had ARC at intensive care unit (ICU) admission. No specific pattern of GFR was found during the follow-up. Patients in the ARC group were younger 56.5 (53.5-58.5) versus 66 (63.5-68.5) years than in the non-ARC group, p < 0.001. ICU mortality was lower in the ARC group, 6.9% versus 14.5%, p = 0.003. There was no concordance between the estimation of GFR by the CKD-EPI formula and GFR calculated from the 4-h urine. ARC is found in up to 30% of ICU patients, so renal removal drugs could be under dosed by up to 30%. And ARC is already detected on admission in 10%. It is a dynamic phenomenon without an established pattern that usually occurs in younger patients that can last for several weeks. And the CKD-EPI formula does not work to estimate the real creatinine clearance of these patients.

Control glucémico en el enfermo crítico: comparación de dos protocolos de insulinización intravenosa / The optimal blood glucose target in critically ill patient: comparison of two intensive insulin therapy protocols

Fundamento y objetivo: Estudios recientes en enfermos críticos tratados con intensive insulin therapy (ITT, «insulina intensiva intravenosa») han observado una mayor incidencia de hipoglucemia grave, mientras que la insulinoterapia intermitente subcutánea con sliding scales (conventional insulin therapy [CIT, «tratamiento convencional de insulina»]) se asocia a hiperglucemia. El objetivo del presente estudio es evaluar si el rango de control glucémico en IIT puede afectar a los valores de glucemia y a su variabilidad y compararlo con CIT. Pacientes y método: Estudio prospectivo comparativo de cohortes en una unidad de cuidados intensivos, con 2 períodos de estudio: Período 1, IIT con intervalo glucémico objetivo de 110-140 mg/dl, y Período 2, con reintervalo glucémico objetivo de 140-180 mg/dl. En ambos períodos la glucemia objetivo para CIT fue de 110-180 mg/dl. Se evaluó la hipoglucemia grave (< 50 mg/dl), moderada (51-79 mg/dl), hiperglucemia (> 216 mg/dl) y la variabilidad de los valores de glucemia. Resultados: Se estudiaron 221 pacientes con 12.825 determinaciones de glucemia. El 26 y 17% de los pacientes requirieron control glucémico mediante IIT en los períodos 1 y 2, respectivamente. La hipoglucemia se relacionó con una ingesta nutricional discontinua, un objetivo glucémico de 110-140 mg/dl y un índice de masa corporal (IMC) bajo (p = 0,002), mientras que la hiperglucemia se relacionó exclusivamente con el antecedente de diabetes mellitus (odds ratio 2,6, intervalo de confianza del 95% 1,6-4,5). La variabilidad de la glucemia se relacionó con una ingesta nutricional discontinua, IMC bajo, insulinización CIT, ser diabético, edad avanzada y APACHE II elevado (p < 0,001). Conclusiones: El uso de IIT es útil para disminuir la variabilidad de la glucemia. Aunque sería más seguro el intervalo 140-180 mg/dl, al presentar mayor variabilidad e hiperglucemia es más idóneo el de 110-140 mg/dl (AU)

Background and objective: Recent studies in critically ill patients receiving insulin intravenous therapy (IIT) have shown an increased incidence of severe hypoglycemia, while intermittent subcutaneous insulin «sliding scales» (conventional insulin therapy [CIT]) is associated with hyperglycemia. The objective of this study is to assess whether glycemic control range IIT can affect glucose levels and their variability and to compare it with CIT. Patients and method: Prospective comparative cohort study in intensive care unit, with 2 study periods: Period 1, IIT with glycemic target range 110-140 mg/dL, and Period 2, IIT of 140-180 mg/dL. In both periods CIT glycemic target was 110-180 mg/dL. We assessed severe hypoglycemia (< 50 mg/dL), moderate hypoglycemia (51-79 mg/dL), hyperglycemia (> 216 mg/L) and the variability of blood glucose. Results: We studied 221 patients with 12.825 blood glucose determinations. Twenty-six and 17% of patients required IIT for glycemic control in Period 1 and 2, respectively. Hypoglycemia was associated with a discontinuous nutritional intake, glycemic target 110-140 mg/dL and low body mass index (BMI) (P = .002). Hyperglycemia was exclusively associated with a history of diabetes mellitus (OR 2.6 [95% CI 1.6 to 4.5]). Glycemic variability was associated with a discontinuous nutritional intake, low BMI, CIT insulinization, diabetes mellitus, elderly and high APACHE II (P < .001). Conclusions: The use of IIT is useful to reduce the variability of blood glucose. Although the 140-180 mg/dL range would be more secure as to presenting greater variability and hyperglycemia, the 110-140 mg/dL range is most suitable (AU)

[The optimal blood glucose target in critically ill patient: comparison of two intensive insulin therapy protocols]. / Control glucémico en el enfermo crítico: comparación de dos protocolos de insulinización intravenosa.

BACKGROUND AND OBJECTIVE: Recent studies in critically ill patients receiving insulin intravenous therapy (IIT) have shown an increased incidence of severe hypoglycemia, while intermittent subcutaneous insulin «sliding scales¼ (conventional insulin therapy [CIT]) is associated with hyperglycemia. The objective of this study is to assess whether glycemic control range IIT can affect glucose levels and their variability and to compare it with CIT. PATIENTS AND METHOD: Prospective comparative cohort study in intensive care unit, with 2 study periods: Period 1, IIT with glycemic target range 110-140 mg/dL, and Period 2, IIT of 140-180 mg/dL. In both periods CIT glycemic target was 110-180 mg/dL. We assessed severe hypoglycemia (< 50 mg/dL), moderate hypoglycemia (51-79 mg/dL), hyperglycemia (> 216 mg/L) and the variability of blood glucose. RESULTS: We studied 221 patients with 12.825 blood glucose determinations. Twenty-six and 17% of patients required IIT for glycemic control in Period 1 and 2, respectively. Hypoglycemia was associated with a discontinuous nutritional intake, glycemic target 110-140 mg/dL and low body mass index (BMI) (P = .002). Hyperglycemia was exclusively associated with a history of diabetes mellitus (OR 2.6 [95% CI 1.6 to 4.5]). Glycemic variability was associated with a discontinuous nutritional intake, low BMI, CIT insulinization, diabetes mellitus, elderly and high APACHE II (P < .001). CONCLUSIONS: The use of IIT is useful to reduce the variability of blood glucose. Although the 140-180 mg/dL range would be more secure as to presenting greater variability and hyperglycemia, the 110-140 mg/dL range is most suitable.