Determinants of Major Adverse Kidney Events in Extracorporeal Membrane Oxygenation Survivors.

The majority of extracorporeal membrane oxygenation patients develop acute kidney injury, and 40-60% require renal replacement therapy. This study aimed to examine determinants of major adverse kidney events in extracorporeal membrane oxygenation survivors. DESIGN: Retrospective cohort study. SETTING: Barnes Jewish Hospital, St. Louis, MO. PATIENTS: Patients admitted at Barnes Jewish hospital between 2008 and 2017 and requiring extracorporeal membrane oxygenation. Patients 18 years old and older who survived to hospital discharge were considered for the study. INTERVENTIONS: None. MEASURES AND MAIN RESULTS: Patients who were admitted to a single center between 2008 and 2017, were on extracorporeal membrane oxygenation for more than 24 hours and survived hospital discharge were included. Major adverse kidney event was defined as either doubling serum creatinine, incident end-stage renal disease, or death. Acute kidney injury was defined as Kidney Disease: Improving Global Outcomes stages 2-3. Complete acute kidney injury recovery was defined as a return to 50% of baseline serum creatinine and partial recovery as an improvement in acute kidney injury stage without a return to 50% of baseline serum creatinine. Survival analysis plots and Cox regression models were fitted to examine the associations of acute kidney injury status, acute kidney injury recovery, and other factors with major adverse kidney event. Among 188 extracorporeal membrane oxygenation patients who survived until hospital discharge, 63% had acute kidney injury and 41% required renal replacement therapy. The mean follow-up time was 3.4 years. Kaplan-Meier survival curves showed that patients with no/partial recovery from acute kidney injury had a higher rate of major adverse kidney event compared with those with no acute kidney injury. Multivariate analysis showed that acute kidney injury (adjusted hazard ratio =1.79 [95% CI = 1.00-3.21]), no/partial recovery from acute kidney injury (adjusted hazard ratio = 2.94 [95% CI = 1.46-5.92]), and initiation of renal replacement therapy on the day or after extracorporeal membrane oxygenation (adjusted hazard ratio = 5.4 [95% CI = 1.14-25.6]) were significant determinants of major adverse kidney event after adjustment for potential confounders. CONCLUSIONS: Acute kidney injury, acute kidney injury recovery status, and timing of initiation of renal replacement therapy are determinants of major adverse kidney events in patients who received extracorporeal membrane oxygenation.

Plasma Biomarkers in Predicting Renal Recovery from Acute Kidney Injury in Critically Ill Patients.

BACKGROUND: Numerous studies have suggested a possible role for acute kidney injury (AKI) biomarkers in predicting renal recovery both before and after renal replacement therapy (RRT). However, definitions for recovery and whether to include patients dying but free of RRT may influence results. OBJECTIVES: To validate plasma neutrophil gelatinase-associated lipocalin (pNGAL) as a useful biomarker for predicting or improving the ability of clinical predictors alone to predict recovery following AKI, including in our model plasma B-type natriuretic peptide (pBNP) to account for cardiovascular events. METHODS: We analyzed 69 patients enrolled in the Acute Renal Failure Trial Network study. pNGAL and pBNP were measured on days 2, 7, and 14. We analyzed their predictive ability for subsequent recovery, defined as alive and independent from dialysis in 60 days. In sensitivity analyses, we explored changes in results with alternative definitions of recovery. RESULTS: Twenty-nine patients (42%) recovered from AKI. Neither pNGAL nor pBNP, alone or in combination, was accurate predictors of renal recovery-the best area under the receiver-operating characteristics curve (AUC) was for pNGAL using the largest relative change (AUC 0.59, 95% CI 0.45-0.74). The best clinical model achieved superior performance to biomarkers (AUC 0.69, 95% CI 0.56-0.81). The AUC was greatest (0.75, 95% CI 0.60-0.91) when pNGAL + pBNP on day 14 were added to the clinical model but this increase did not achieve statistical significance. However, integrated discrimination improvement analysis showed that the addition of pNGAL and pBNP on day 14 to the clinical model significantly improved the prediction of renal recovery (p = 0.008). CONCLUSIONS: pNGAL and pBNP can improve the accuracy of clinical parameters in predicting AKI recovery and a full model using biomarkers together with age achieved adequate discrimination.

Long-term survival in patients with septic acute kidney injury is strongly influenced by renal recovery.

BACKGROUND: Several studies have shown that long-term survival after acute kidney injury (AKI) is reduced even if there is clinical recovery. However, we recently reported that in septic shock patients those that recover from AKI have survival similar to patients without AKI. Here, we studied a cohort with less severe sepsis to examine the effects of AKI on longer-term survival as a function of recovery by discharge. METHODS: We analyzed patients with community-acquired pneumonia from the Genetic and Inflammatory Markers of Sepsis (GenIMS) cohort. We included patients who developed AKI (KDIGO stages 2-3) and defined renal recovery as alive at hospital discharge with return of SCr to within 150% of baseline without dialysis. Our primary outcome was survival up to 3 years analyzed using Gray's model. RESULTS: Of the 1742 patients who survived to hospital discharge, stage 2-3 AKI occurred in 262 (15%), of which 111 (42.4%) recovered. Compared to recovered patients, patients without recovery were older (75 ±14 vs 69 ±15 years, p<0.001) and were more likely to have at least stage 1 AKI on day 1 (83% vs 52%, p<0.001). Overall, 445 patients (25.5%) died during follow-up, 23.4% (347/1480) for no AKI, 28% (31/111) for AKI with recovery and 44.3% (67/151) for AKI without recovery. Patients who did not recover had worse survival compared to no AKI (HR range 1.05-2.46, p = 0.01), while recovering patients had similar survival compared to no AKI (HR 1.01, 95%CI 0.69-1.47, p = 0.96). Absence of AKI on day 1, no in-hospital renal replacement therapy (RRT), higher Apache III score and higher baseline SCr were associated with recovery after AKI. CONCLUSIONS: In patients with sepsis, recovery by hospital discharge is associated with long-term survival similar to patients without AKI.

Acceptance of Antidepressant Treatment by Patients on Hemodialysis and Their Renal Providers.

BACKGROUND AND OBJECTIVES: Depression is common in patients receiving chronic hemodialysis but seems to be ineffectively treated. We investigated the acceptance of antidepressant treatment by patients on chronic hemodialysis and their renal providers. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: As part of a clinical trial of symptom management in patients on chronic hemodialysis conducted from 2009 to 2011, we assessed depression monthly using the Patient Health Questionnaire 9. For depressed patients (Patient Health Questionnaire 9 score ≥10), trained nurses generated treatment recommendations and helped implement therapy if patients and providers accepted the recommendations. We assessed patients' acceptance of recommendations, reasons for refusal, and provider willingness to implement antidepressant therapy. We analyzed data at the level of the monthly assessment. RESULTS: Of 101 patients followed for ≤12 months, 39 met criteria for depression (Patient Health Questionnaire 9 score ≥10 on one or more assessments). These 39 patients had depression on 147 of 373 (39%) monthly assessments. At 103 of these 147 (70%) assessments, patients were receiving antidepressant therapy, and at 51 of 70 (70%) assessments, patients did not accept nurses' recommendations to intensify treatment. At 44 assessments, patients with depression were not receiving antidepressant therapy, and in 40 (91%) instances, they did not accept recommendations to start treatment. The primary reason that patients refused the recommendations was attribution of their depression to an acute event, chronic illness, or dialysis (57%). In 11 of 18 (61%) instances in which patients accepted the recommendation, renal providers were unwilling to provide treatment. CONCLUSIONS: Patients on chronic hemodialysis with depression are frequently not interested in modifying or initiating antidepressant treatment, commonly attributing their depression to a recent acute event, chronic illness, or dialysis. Renal providers are often unwilling to modify or initiate antidepressant therapy. Future efforts to improve depression management will need to address these patient- and provider-level obstacles to providing such care.