Hemodynamic instability related to renal replacement therapy (HIRRT) may increase the risk of death and limit renal recovery. Studies in end-stage renal disease populations on maintenance hemodialysis suggest that some renal replacement therapy (RRT)-related interventions (e.g., cool dialysate) may reduce the occurrence of HIRRT, but less is known about interventions to prevent HIRRT in critically ill patients receiving RRT for acute kidney injury (AKI). We sought to evaluate the effectiveness of RRT-related interventions for reducing HIRRT in such patients across RRT modalities. A systematic review of publications was undertaken using MEDLINE, MEDLINE in Process, EMBASE, and Cochrane's Central Registry for Randomized Controlled Trials (RCTs). Studies that assessed any intervention's effect on HIRRT (the primary outcome) in critically ill patients with AKI were included. HIRRT was variably defined according to each study's definition. Two reviewers independently screened abstracts, identified articles for inclusion, extracted data, and evaluated study quality using validated assessment tools. Five RCTs and four observational studies were included (n = 9; 623 patients in total). Studies were small, and the quality was mostly low. Interventions included dialysate sodium modeling (n = 3), ultrafiltration profiling (n = 2), blood volume (n = 2) and temperature control (n = 3), duration of RRT (n = 1), and slow blood flow rate at initiation (n = 1). Some studies applied more than one strategy simultaneously (n = 5). Interventions shown to reduce HIRRT from three studies (two RCTs and one observational study) included higher dialysate sodium concentration, lower dialysate temperature, variable ultrafiltration rates, or a combination of strategies. Interventions not found to have an effect included blood volume and temperature control, extended duration of intermittent RRT, and slower blood flow rates during continuous RRT initiation. How HIRRT was defined and its frequency of occurrence varied widely across studies, including those involving the same RRT modality. Pooled analysis was not possible due to study heterogeneity. Small clinical studies suggest that higher dialysate sodium, lower temperature, individualized ultrafiltration rates, or a combination of these strategies may reduce the risk of HIRRT. Overall, for all RRT modalities, there is a paucity of high-quality data regarding interventions to reduce the occurrence of HIRRT in critically ill patients.
PURPOSE: The objective of this study was to determine practical diet and exercise strategies for energy balance and metabolic efficiency leading to weight loss in overweight/obese 25 to 54 year old females. METHODS: The sample included 29 overweight/obese 25 to 54 year old sedentary women (median: 42 years, 77.6 kg, 165.cm, 38.11 %BF) stratified and permuted block randomized by age and % body fat (% BF). All participants were prescribed a plant-based diet (set menu plan) with a 200 kcal deficit determined by indirect calorimetry below resting energy expenditure (REE). Following the first 2 weeks, participant’s REE was re-measured to analyze diet effect on energy balance. Participants were then randomized into three different exercise intensities and effort was set by VO2max test determined from the respiratory quotient (RQ = CO2/O2) and controlled via corresponding heart rate response. Participants exercise consisted of either low continuous walking (LCW n=9), moderate interval walking (MIW n=8) or high interval walking (HIW n=12) with heart rates corresponding to RQ .75 (83% Fat utilization), RQ .85 (50/50 Fat/Carb utilization), or RQ .95 (83% Carb utilization) respectively. Participants in the LCW group were limited to walking in their prescribed exercise intensity group. Interval training (short exercise bouts mixed with short periods of rest) was used for the MIW and HIW groups. RESULTS: Repeated-measures ANOVA analysis was used to assess outcome variables between the groups. There were no significant group differences in age, height, weight, % BF, REE, RQ, VO2max or fitness level. Resting REE demonstrated a significant change (R = -0.539, p = 0.031) in all groups due to the first 2 weeks of the plant based diet alone. Additionally, significant change was noted in all participants for % BF change (F 1,29 = 28.041, p = 0.000, eta2 0.651), but no significant differences were noted between the three exercise groups. CONCLUSION: Plant based diet of 200 calorie deficit together with LCW, MIW or HIW exercise are equally effective for increased REE and % BF loss. However further investigation is warranted to look at additional parameters of metabolic efficiency, physical activity motivation and injury complications of the high intensity exercise group in the overweight / obese population. Funded by Grant # ARC 122751
Abstract BACKGROUND Primary sclerosing cholangitis (PSC) is a cholestatic immune-mediated liver disease that can be associated with inflammatory bowel disease (IBD) in up to 80% of patients. Those with concurrent PSC-IBD exhibit a distinct disease phenotype with increased risk of complications such as malignancy and pouchitis; however, the risk of infections is not yet clearly defined in this population. AIMS The aims of this systematic review and meta-analysis are (1) to determine the incidence of infections in patients with PSC-IBD and (2) to identify risk factors for infections in this population. METHODS MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception to March 24, 2022 for primary studies that reported incidence or risk factors for infection in adult and pediatric patients with PSC and IBD. Case reports and case series with less than five patients were excluded, as were any studies where infection rates in PSC-IBD patients could not be separated from those with PSC or IBD alone. The primary outcome of this study was incidence of all-cause infections including bacterial, viral, or fungal infections, and sepsis. The secondary outcomes included incidence of site-specific infections and mortality due to infection. A random-effects model was used to calculate pooled odds ratios (OR) with 95% confidence intervals (CI) comparing incidence of all-cause infections in PSC-IBD to those with PSC alone or IBD alone. RESULTS Seventy-one studies were included. The pooled incidence of all-cause infections in patients with PSC-IBD was 21.8% (95% CI 0.17-0.26, I2=95.9%), 31.1% (95% CI 0.16-0.46, I2=93.4%) in those with PSC alone, and 4.4% (95% CI -0.01-0.10, I2=99.2%) in those with IBD alone. Patients with PSC-IBD had an over three-fold increased odds of all-cause infection compared to those with isolated IBD (OR 3.67, 95% CI 2.07-6.50). Patients with PSC-IBD were more likely to develop sepsis (OR 3.35, 95% CI 2.29-4.90) and have infections resulting in mortality (OR 11.25, 95% CI 2.03-62.37) compared to those with IBD. The most common infections in the PSC-IBD group were sepsis followed by clostridioides difficile infection. There was no significant difference in the odds of infection between patients with PSC-IBD and those with PSC alone (OR 1.21, 95% CI 0.68-2.18). However, on sub-group analysis, patients with PSC-IBD undergoing liver transplantation (LT) were more likely to develop infection post-LT compared to those with PSC alone (OR 4.86, 95% CI, 2.32-10.17), with cytomegalovirus (CMV) being the most commonly reported infection. CONCLUSION Compared to those with IBD, patients with PSC-IBD appear to be at a higher risk of infection and resultant complications such as sepsis and death. Future studies are needed to elucidate specific risk factors such as immunosuppressive therapy and disease activity.
Periodontal diseases are prevalent among the general population and are associated with several systemic conditions, such as chronic kidney disease and type 2 diabetes mellitus. Chronic liver disease and cirrhosis have also been linked with periodontal disease, an association with complex underlying mechanisms, and with potential prognostic implications. Multiple factors can explain this relevant association, including nutritional factors, alcohol consumption, disruption of the oral-gut-liver axis and associated dysbiosis. Additionally, patients with liver disease have been observed to exhibit poorer oral hygiene practices compared with the general population, potentially predisposing them to the development of periodontal disease. Therefore, it is recommended that all patients with liver disease undergo screening and subsequent treatment for periodontal disease. Treatment of periodontal disease in patients with cirrhosis may help reduce liver-derived inflammatory damage, with recent research indicating a potential benefit in terms of reduced mortality. However, further studies on periodontal disease treatment in patients with liver disease are still warranted to determine optimal management strategies. This narrative review describes current concepts on the association between periodontal disease and chronic liver disease.
Background: Safety lapses in hospitalized patients with acute kidney injury (AKI) may lead to hemodialysis (HD) being required before renal recovery might have otherwise occurred. We sought to identify safety lapses that, if prevented, could reduce the need for unnecessary HD after AKI; Methods: We conducted a retrospective observational study that included consecutive patients treated with HD for AKI at a large, tertiary academic center between 1 September 2015 and 31 August 2016. Exposures of interest were pre-specified iatrogenic processes that could contribute to the need for HD after AKI, such as nephrotoxic medication or potassium supplement administration. Other outcomes included time from AKI diagnosis to initial management steps, including Nephrology referral; Results: After screening 344 charts, 80 patients were included for full chart review, and 264 were excluded because they required HD within 72 h of admission, were deemed to have progression to end-stage kidney disease (ESKD), or required other renal replacement therapy (RRT) modalities in critical care settings such as continuous renal replacement therapy (CRRT) or sustained low efficiency dialysis (SLED). Multiple safety lapses were identified. Sixteen patients (20%) received an angiotensin converting enzyme inhibitor or angiotensin receptor blocker after AKI onset. Of 35 patients with an eventual diagnosis of pre-renal AKI due to hypovolemia, only 29 (83%) received a fluid bolus within 24 h. For 28 patients with hyperkalemia as an indication for starting HD, six (21%) had received a medication associated with hyperkalemia and 13 (46%) did not have a low potassium diet ordered. Nephrology consultation occurred after a median (IQR) time after AKI onset of 3.0 (1.0⁻5.7) days; Conclusions: Although the majority of patients had multiple indications for the initiation of HD for AKI, we identified many safety lapses related to the diagnosis and management of patients with AKI. We cannot conclude that HD initiation was avoidable, but, improving safety lapses may delay the need for HD initiation, thereby allowing more time for renal recovery. Thus, development of automated processes not only to identify AKI at an early stage but also to guide appropriate AKI management may improve renal recovery rates.
Dr. Jeff Warren, MD, FRCPC, is an associate professor at the University of Ottawa within the Department of Surgery, Division of Urology. He has been a staff Urologist since 2009 and obtained his fellowship in multi-organ transplants, including kidneys and pancreases, from the University of Western Ontario. He received his MD from the University of Ottawa in 2002 and also completed his residency at the University of Ottawa in 2007. He is currently the head of surgical foundations for all surgical residency programs at the University of Ottawa. His clinical interests are in kidney transplantation surgery, minimally invasive surgery, and medical education.
Dr. Tom Skinner, MD, FRCPC, is a transplant fellow at the University of Ottawa within the Department of Surgery, Division of Urology. He received his MD from Dalhousie University in 2012 and completed his Urology residency at Queen’s University in 2017. He has a BSc. from the University of British Columbia and a MSc. from McGill University. His clinical interests are in minimally invasive surgery, renal transplantation, surgical education, and healthcare economics. During this interview, Dr. Skinner and Dr. Warren discuss the current state of transplant surgery, the biggest challenges to transplanting patients, and the future of the specialty. They also discuss robotic surgery and the Spanish model for organ donation.
1Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada 2Division of Gastroenterology, Department of Internal Medicine, Hepatology, and Nutrition, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA 3Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile Abbreviations: AIH, Autoimmune hepatitis; CBR, complete biochemical remission; 6TGN, 6-thiopurine nucleotides. Correspondence Juan Pablo Arab, Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Stravitz-Sanyal Institute of Liver Disease and Metabolic Health, Virginia Commonwealth University School of Medicine. 1201 E. Broad St. P.O. Box 980341, Richmond, VA 23284, USA. Email: [email protected]
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