Inpatient Kidney Function Recovery among Septic Shock Patients Who Initiated Kidney Replacement Therapy in the Hospital.

BACKGROUND: Sepsis and septic shock are life-threatening causes of acute kidney injury (AKI) frequently seen and managed in intensive care units (ICUs). Sepsis-associated AKI (SA-AKI) independently contributes to the mortality of sepsis. Understanding the potential factors involved in kidney function recovery may further aid in the prevention and management of SA-AKI. This study aimed to describe the clinical characteristics of septic shock patients who required kidney replacement therapy and factors associated with kidney function recovery. METHODS: We conducted a retrospective cohort study of adult septic shock patients who received in-hospital kidney replacement therapy at medical intensive care unit (MICU) at the Mayo Clinic, Rochester, from January 1, 2006, to May 31, 2018. Kidney function recovery was defined as liberation from kidney replacement therapy before hospital discharge. Associations between clinical features and kidney recovery were analyzed using multivariable Fine and Gray regression accounting for death as a competing event. RESULTS: Our retrospective cohort consisted of 229 patients with a median (interquartile range [IQR]) age of 64 (52-74) years: 55% were men, 89% were Caucasians, 39% had diabetes mellitus (DM), 16% had heart failure, APACHE (Acute Physiology and Chronic Health Evaluation) III score was 105 (84-123), and SOFA (Sequential [Sepsis-related] Organ Failure Assessment) score was 12 (9-14). The patients received 1,567 (524-4,108) mL of intravenous fluids in the first 3 h, 92% required vasopressor support, and 83% required mechanical ventilation. The median MICU and hospital stays were 7 (4-13) and 19 (10-31) days, respectively. Median (IQR) kidney replacement therapy duration was 7 (3.5-17.1) days. Among 158 ICU survivors, 73 (46%) patients were weaned from RRT in ICU and 85 (54%) were transitioned to intermittent RRT. A higher volume of fluid resuscitation in the first 3 h (hazard ratio [HR] = 1.07 per 1 L, CI: 1.01-1.14, p = 0.04) and a history of DM (HR = 1.70, CI: 1.14-2.54, p = 0.009) were associated with kidney function recovery. CONCLUSION: Among septic shock patients who initiated kidney replacement therapy in the MICU, 41% recovered kidney function before discharge. A higher initial fluid resuscitation volume was associated with recovery, and interestingly, patients with DM had a higher chance of recovery.

Effect of initial infusion rates of fluid resuscitation on outcomes in patients with septic shock: a historical cohort study.

BACKGROUND: Fluid resuscitation has become the cornerstone of early septic shock management, but the optimal fluid rate is still not well studied. The goal of this investigation is to examine the relationship between fluid resuscitation rate and septic shock resolution. METHOD: We retrospectively studied adult (≥ 18 years) patients with septic shock, defined based on sepsis III definition, from January 1, 2006, through May 31, 2018, in the medical intensive care unit (MICU) of Mayo Clinic Rochester. The fluid resuscitation time was defined as the time required to infuse the initial fluid bolus of 30 ml/kg, based on the recommendations of the 2016 surviving sepsis campaign. The cohort was divided into four groups based on the average fluid rate (group 1 ≥ 0.5, group 2 0.25-0.49, group 3 0.17-0.24, and group 4 < 0.17 ml/kg/min). The primary outcome was the time to shock reversal. Multivariable regression analyses were conducted to account for potential confounders. RESULT: A total of 1052 patients met eligibility criteria and were included in the analysis. The time-to-shock reversal was significantly different among the groups (P < .001). Patients in group 1 who received fluid resuscitation at a faster rate had a shorter time to shock reversal (HR = 0.78; 95% CI 0.66-0.91; P = .01) when compared with group 4 with a median (IQR) time-to-shock reversal of 1.7 (1.5, 2.0) vs. 2.8 (2.6, 3.3) days, respectively. Using 0.25 ml/kg/min as cutoff, the higher fluid infusion rate was associated with a shorter time to shock reversal (HR = 1.22; 95% CI 1.06-1.41; P = .004) and with decreased odds of 28-day mortality (HR = 0.71; 95% CI 0.60-0.85; P < .001). CONCLUSION: In septic shock patients, initial fluid resuscitation rate of 0.25-0.50 ml/kg/min (i.e., completion of the initial 30 ml/kg IV fluid resuscitation within the first 2 h), may be associated with early shock reversal and lower 28-day mortality compared with slower rates of infusion.

Hyperammonemic encephalopathy in a patient with fibrolamellar hepatocellular carcinoma: case report and literature review.

Fibrolamellar hepatocellular carcinoma (fHCC) is a rare primary liver cancer that affects young adults with no prior liver disease. fHCC-associated hyperammonemic encephalopathy (HAE) is an uncommon and life-threatening complication. Hyperammonemia has been reported in both typical and fHCC as a result of intrahepatic shunting, side effect from immunotherapy or chemotherapy, or as a paraneoplastic phenomenon. We present a case of a 32-year-old woman with recurrent metastatic fHCC who developed HAE in the setting of steroid administration. Her hyperammonemia was exacerbated by steroid-induced protein catabolism. She was treated with ammonia scavenging medications, a low protein diet, and was placed on chronic ammonia scavenger therapy while undergoing chemotherapy. In this case report, we discuss the proposed mechanisms of HAE, and we review the literature regarding clinical presentation and treatment.