|Year : 2014 | Volume
| Issue : 1 | Page : 24-28
Investigate the initiation time of continuous blood purification in the multiple organ dysfunction syndrome patients complicated with acute kidney injury
Xiaohua Sheng, Niansong Wang, Guihua Jian, Yan Yan, Yongping Cui, Gang Yu
Department of Nephrology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233, China
|Date of Web Publication||25-Jul-2014|
Department of Nephrology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233
Source of Support: None, Conflict of Interest: None
Objective: The objective was to discuss the initiation time of continuous blood purification (CBP) in the multiple organ dysfunction syndrome (MODS) patients complicated with acute kidney injury (AKI). Materials and Methods: We retrospectively analyzed 84 MODS patients combined AKI treated with CBP in intensive care unit during January 2006 to December 2009. The Acute Physiology and Chronic Health Evaluation II scores, Sequential Organ Failure Assessment scores, and other medical records were reviewed. Different indications for CBP (1 - azotemia, 2 - fluid overload, 3 - hyperklemia, 4 - oliguria, and 5 - metabolic acidosis) were recorded. Patients were characterized as "early" or "late" starters, based upon whether the blood urea nitrogen was less than or greater than 25 mmol/L, prior to CBP initiation. Compare the medical records and the mortality of the two groups. Results: The overall mortality in hospital rate was 60.7%. The most indications for CBP initiation were azotemia (95.2%) and oliguria (78.6%). The mortality of the early was 32%, the late was 72.9% (P = 0.000). Conclusion: Earlier initiation of CBP may improve the prognosis of the MODS patients with AKI.
Keywords: Acute kidney injury, continuous blood purification, multiple organ dysfunction syndrome
|How to cite this article:|
Sheng X, Wang N, Jian G, Yan Y, Cui Y, Yu G. Investigate the initiation time of continuous blood purification in the multiple organ dysfunction syndrome patients complicated with acute kidney injury. J Integr Nephrol Androl 2014;1:24-8
|How to cite this URL:|
Sheng X, Wang N, Jian G, Yan Y, Cui Y, Yu G. Investigate the initiation time of continuous blood purification in the multiple organ dysfunction syndrome patients complicated with acute kidney injury. J Integr Nephrol Androl [serial online] 2014 [cited 2019 May 21];1:24-8. Available from: http://www.journal-ina.com/text.asp?2014/1/1/24/137550
| Introduction|| |
The prognosis of the multiple organ dysfunction syndromes (MODS) is not optimistic for a long time, which is one of the main causes of the death of critically ill patients. The total fatality rate of MODS in domestic is about 39-53.5%, ,, while in abroad is 40-80%. , The fatality rate greatly increases when it is combined with renal impairment. The continuous blood purification (CBP) has been widely used in curing patients with MODS, , especially those who also have an acute kidney injury (AKI), and its effect is uncertain. Now, the issues of it are mainly focusing on the time, mode, and dose of the treatment. In this study, we retrospectively analyzed those MODS patients with AKI who were treated with CBP for 3 years in our hospital, and further discussed the indication and initiation time of CBP treatment.
| Materials and methods|| |
Those MODS patients with AKI in intensive care unit (ICU) and electronic intensive care unit (EICU) of our hospital during January 2006 to December 2009 and the inclusion criteria include:
- Met the diagnostic criteria of MODS, with least two failing organs,
- Met the diagnostic criteria of AKI,
- Older than 18.
The exclusion criteria include:
- Blood creatinine baseline value >264 μmol/L,
- Maintenance hemodialysis or peritoneal dialysis patients,
- Widespread metastasis of malignant tumor,
- Those patients who merely accept terminal care,
- Moribund condition (<24 h).
Indication of continuous blood purification treatment
After the consultant with nephrology department and Blood Purification Center, those patients who met at least one of the following indications can be treated by CBP:
- Azotemia: Blood urea nitrogen (BUN) >28.56 mmol/L or serum creatinine >176 μmol/L, accompanied by significant symptoms of uremia (uremic encephalopathy, nausea and vomit, etc.);
- Fluid overload: Failed to respond to hydragogue, central venous pressure >12 mm Hg, or significant pulmonary edema, PaO 2 /FiO 2 <300 mm Hg;
- Oliguresis: Failed to respond to hydragogue, urine output <200 mL/8 h;
- Hyperkalemia: Those hyperkalemia that failed to respond to medicine (blood K + >5.5 mmol/L);
- Metabolic acidosis: Carbon dioxide combining a power <15 mmol/L.
All patients in ICU accepted standardized treatments such as fluid resuscitation, vasoactive drugs, anti-infection, breath support, nutritional support, monitoring vital signs, etc. The CBP treatment utilized AQUARIUS bedside hemofiltration apparatus with the filter was HF1200; temporary vascular access was established by single-needle double-current catheter through femoral vein or internal jugular vein; the treatment model was continuous veno-venous hemofiltration (CVVH), with the blood flow volume was 150-250 mL/min, displacement liquid flow volume was 4000 mL/h, and the treatment duration was at least 6 h and at most 160 h. Low molecular weight heparins were used as the anticoagulants, while those patients who had grave bleeding tendency were dialyzed without heparin, and the pipelines were periodically rinsed by physiological saline. The patients were divided into two groups by 25 mmol/L BUN at the beginning of CVVH; those whose BUN ≤25 mmol/L was classified into an early intervention group, while those whose BUN >25 mmol/L was classified into a late intervention group.
The general information of recorded patients, included sex, age, primary disease, the parameters at the beginning of CBP treatment involved blood biochemistry parameters, AKI stages, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Sequential Organ Failure Assessment score, number of failed organs, with or without mechanical ventilation, with or without sepsis and application of vasopressor agent, whether the outcome of treatment was alive or dead.
All data were analyzed by SPSS Inc, Statistical Program for Social Sciences, enumeration data were indicated by the number of cases, measurement data were signified by means ± SD (x- ± s), t-test or variance analysis was utilized to compare the groups, P < 0.05 meant statistically significant.
| Results|| |
There were 84 MODS patients with AKI in ICU and EICU of our hospital treated with CVVH between January 2006 and December 2009, among whom 59 were male and 25 were female, with the oldest was 87 years and the youngest 23 years, the average age was 57 ± 19.59 years. The causes of MODS involved 27 cases (32.1%) of varies serious wound and postsurgery, mainly by traffic accidents, stab, crush, and postsurgery; 18 cases (21.4%) of posttumor operation, mainly by gastrointestinal and breast cancer; 13 cases (15.5%) of postgeneral surgery, mainly by hepatobiliary and gastrointestinal operation; 8 cases (9.5%) of serious infection, mainly by pulmonary and gastrointestinal infection; 7 cases (8.3%) of serious and acute pancreatitis; 6 cases (7.1%) of postcardio-thoracic surgery, mainly by valve surgery; 4 cases (4.8%) of postgynecological and obstetrical surgery, among which 3 were postpartum hemorrhage transferred from other hospitals; 1 case (1.2%) of postsurgery of cerebral hemorrhage [Table 1].
|Table 1: The general information of 84 patients at the beginning of CVVH|
Click here to view
Indication of continuous veno-venous hemofiltration treatment
Azotemia was the most frequent indication at the beginning of CVVH, which existed in 80 patients and made up to 95.2% of the total indications; the second was 66 cases (78.6%) of oliguresis; the third was 53 cases (63.1%) of fluid overload; the fourth was 30 cases (35.7%) of acidosis; and the last one was 24 cases (28.6%) of hyperkalemia [Figure 1]. Eleven patients (13.1%) simultaneously had five kinds of causes mentioned above; 15 patients (17.9%) had 4; 31 patients (36.9%) had 3, 18 patients (21.4%) had 2, 9 patients (10.7%) had single cause.
|Figure 1: Different indications at the beginning of continuous veno-venous hemofiltration|
Click here to view
Thirty-three patients (39.3%) survived and 51 patients (60.7%) died in this group. There were 25 patients in an early intervention group, among which 8 died and 17 survived with the fatality rate was 32.0%; 59 patients in a late intervention group, among which 43 died and 16 survived with the fatality rate was 72.9%. The difference between the groups was significant (P = 0.000). The difference between the general information of the two groups was statistically significant in age (P = 0.020), numbers of failed organs, AKI stages (P < 0.05) and significantly different in urine output (P = 0.01); while no statistically difference existed in sex (P = 0.774) and APACHEII score before treatment (P = 0.151) [Table 2].
|Table 2: The comparison of the clinical information and fatality between those patients in early and late intervention group (based on BUN)|
Click here to view
| Discussion|| |
It is not unanimous in the indication and timing of the CBP treatment of AKI patients in ICU among various districts. ,, Some mild AKI patients can self-heal without CBP treatment. While some side-effect might appear during CBP treatment such as further deterioration of renal function caused by low blood pressure, hemorrhage, catheter-related infections, , so those patients might have accepted excess treatment and simultaneously have taken unnecessary risks mentioned above. For those complex AKI patients in ICU, especially those who are accompanied by MODS; however, the best time of treatment might have been missed if CBP treatment is accepted after the failure of conservative medical management.
Many researches have estimated when the CBP treatment should start, however, the definitions of early and late initiation in those researches were different. ,, Some researchers selected the timing of CBP treatment according to BUN level. Gettings et al.  retrospectively analyzed the start time of CBP on the outcome in 100 cases of posttraumatic ARF patients; they defined those patients with BUN <60 mg/dL (<21.4 mmol/L) at the beginning of CBP as "early starter," and those with BUN >60 mg/dL (>21.4 mmol/L) as "late starter," and the result suggested that the surviving rate in the hospital of "early starter" group was significantly higher than "late starter" group (39% vs. 28%, P < 0.05). Ronco et al.  divided 425 patients into several experimental groups of different doses, and the average BUN levels at the beginning of CVVH were significantly lower than those in dead patients no matter, which group was considered. We divided the patients into two groups based on 25 mmol/L (70 mg/dL) BUN during CBP treatment, there were total 59 patients in BUN >25 mmol/L group, 43 died and 16 survived, and the fatality rate was 72.9%; while 25 patients in BUN ≤25 mmol/L group, 8 died and 17 survived, the fatality rate was 32.0%, the difference between the groups was significant (P = 0.000), which suggested that the initiation of CBP treatment at the time when BUN was low contributed to improve prognosis.
At which level the BUN reaches is suitable for CBP treatment time needs to be further investigated. As the BUN level is significantly affected by diet and plasma protein concentration, the BUN standard, which is unmentioned in AKI stage diagnostic criteria will likely be ignored by non-specialists and thus delay the treatment. In recent years, RIFLE standards tend to be used in evaluating the time of CBP treatment in the research of intensive AKI, the retrospectively analyze of Bell et al.  found that the 30 day fatality rate of patients at AKI (F) stage was much higher than those at (R) stage and (I) stage. However, mere RIFLE stage is far from enough in MODS patients varies illness conditions must be considerably evaluated such as those in cardiovascular, respiratory, digestive, and coagulation systems. Ronco et al.  believed that oliguria is an important indication, but the issues of capacity and the effect of diuretic must be considered; the conventional BUN and creatine seem a little "slow" in the judgment of AKI. The rise of BUN and creatine was used as the indication of CBP treatment in most patients in our research, but diuretic had also been used in oliguric patients in ICU, so the judgment on partially complicated AKI patients in the research was not enough.
Continuous blood purification has showed its strong capability in rescuing critically ill patients due to its distinctive advantage. Although many research have showed that CBP treated early could improve the prognosis of critically ill patients, there is no available large randomized control trial, which can direct clinicians in determine when is the early stage, which clinical symptoms or biochemical indications can determine early CBP treatment, while some recent researches on some biomarkers of AKI ,, might be helpful. This strong weapon should also be coordinated with the clinical experience of clinicians, multidisciplinary in rescuing critically ill patients, and the CBP treatment schedule should be made in time against the illness condition of the patients.
| Acknowledgment|| |
The research is supported by grant 81270824 from the Project of National Nature Science Foundation of China, Shanghai Science and Technology Project (11DZ1921904; 11410708500). The funders had no role in study design, data collection and analysis, decision to publish and preparation of the manuscript.
| References|| |
|1.||Qiu H, Zhou S, Yang Y, Hang Y, Zheng R. Multiple organ dysfunction syndrome: Predictors of mortality and clinical therapeutic strategies. Chin J Emerg Med 2001;10:13-6. |
|2.||Du B, Chen D, Liu D. Prediction of prognosis of patients with multiple organ dysfunction syndrome by sepsis-related organ failure assessment. Zhonghua Yi Xue Za Zhi 2001;81:78-81. |
|3.||Wang C, Zhang S, Yin C, Yin H, Wang H ,Wang B. Epidemiological investigation on multiple organ dysfunction syndrome occurred in Beijing in recent years. Chin J Trauma 2004;20:730-3. |
|4.||Tran DD, Groeneveld AB, van der Meulen J, Nauta JJ, Strack van Schijndel RJ, Thijs LG. Age, chronic disease, sepsis, organ system failure, and mortality in a medical intensive care unit. Crit Care Med 1990;18:474-9. |
|5.||Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001;29:1303-10. |
|6.||Pupelis G, Plaudis H, Grigane A, Zeiza K, Purmalis G. Continuous veno-venous haemofiltration in the treatment of severe acute pancreatitis: 6-year experience. HPB (Oxford) 2007;9:295-301. |
|7.||Ma SY, Liu CY. Continuous renal replacement therapy on patients of multiple organs dysfunction syndrome with acute renal failure. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue 2003;15:97-9. |
|8.||Overberger P, Pesacreta M, Palevsky PM, VA/NIH Acute Renal Failure Trial Network. Management of renal replacement therapy in acute kidney injury: A survey of practitioner prescribing practices. Clin J Am Soc Nephrol 2007;2:623-30. |
|9.||Ricci Z, Ronco C, D′Amico G, De Felice R, Rossi S, Bolgan I, et al. Practice patterns in the management of acute renal failure in the critically ill patient: An international survey. Nephrol Dial Transplant 2006;21:690-6. |
|10.||Bagshaw SM, Bellomo R. Early diagnosis of acute kidney injury. Curr Opin Crit Care 2007;13:638-44. |
|11.||Santiago MJ, López-Herce J, Urbano J, Solana MJ, del Castillo J, Ballestero Y, et al. Complications of continuous renal replacement therapy in critically ill children: A prospective observational evaluation study. Crit Care 2009;13:R184. |
|12.||Oudemans-van Straaten HM. Primum non nocere, safety of continuous renal replacement therapy. Curr Opin Crit Care 2007;13:635-7. |
|13.||Seabra VF, Balk EM, Liangos O, Sosa MA, Cendoroglo M, Jaber BL. Timing of renal replacement therapy initiation in acute renal failure: A meta-analysis. Am J Kidney Dis 2008;52:272-84. |
|14.||Liu KD, Himmelfarb J, Paganini E, Ikizler TA, Soroko SH, Mehta RL, et al. Timing of initiation of dialysis in critically ill patients with acute kidney injury. Clin J Am Soc Nephrol 2006;1:915-9. |
|15.||Bagshaw SM, Uchino S, Bellomo R, Morimatsu H, Morgera S, Schetz M, et al. Timing of renal replacement therapy and clinical outcomes in critically ill patients with severe acute kidney injury. J Crit Care 2009;24:129-40. |
|16.||Gettings LG, Reynolds HN, Scalea T. Outcome in post-traumatic acute renal failure when continuous renal replacement therapy is applied early vs. late. Intensive Care Med 1999;25:805-13. |
|17.||Ronco C, Bellomo R, Homel P, Brendolan A, Dan M, Piccinni P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: A prospective randomised trial. Lancet 2000;356:26-30. |
|18.||Bell M, Liljestam E, Granath F, Fryckstedt J, Ekbom A, Martling CR. Optimal follow-up time after continuous renal replacement therapy in actual renal failure patients stratified with the RIFLE criteria. Nephrol Dial Transplant 2005;20:354-60. |
|19.||Ronco C, Grammaticopoulos S, Rosner M, De Cal M, Soni S, Lentini P, et al. Oliguria, creatinine and other biomarkers of acute kidney injury. Contrib Nephrol 2010;164:118-27. |
|20.||Mishra J, Dent C, Tarabishi R, Mitsnefes MM, Ma Q, Kelly C, et al. Neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker for acute renal injury after cardiac surgery. Lancet 2005;365:1231-8. |
|21.||Herget-Rosenthal S, Marggraf G, Hüsing J, Göring F, Pietruck F, Janssen O, et al. Early detection of acute renal failure by serum cystatin C. Kidney Int 2004;66:1115-22. |
[Table 1], [Table 2]