Critically ill allogenic HSCT patients in the intensive care unit: a systematic review and meta-analysis of prognostic factors of mortality
Colombe SaillardMichaël DarmonMagali BisbalAntoine SanniniLaurent Chow‐ChineMarion FaucherÉtienne LenglinéNorbert VeyDidier BlaiseÉlie AzoulayDjamel Mokart
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Outcome of patients undergoing allogenic hematopoietic stem cell transplantation (allo-HSCT) has improved. To investigate if this improvement can be transposed to the ICU setting, we conducted a systematic review and meta-analysis to assess short-term mortality of critically ill allo-HSCT patients admitted to the ICU and to identify prognostic factors of mortality. Public-domain electronic databases, including Medline via PubMed and the Cochrane Library were searched. All full-text articles written-English studies published from 2006 to 2016, including allo-HSCT adults transferred to the ICU were included. Eighteen studies were selected, including 2342 patients. Overall estimated ICU mortality was 51.7%. Prognostic factors associated with an increased ICU mortality were mechanical ventilation (OR = 12.2, 95% CI = 6.2–23.7), vasopressors (OR = 6.3, 95% CI = 3.6–11.1), renal replacement therapy (OR = 4.2, 95% CI = 2.8–6.2), ICU admission for acute respiratory failure (OR = 2.2, 95% CI = 1.1–4.4), acute kidney injury (OR = 2.2, 95% CI = 1.3–4), and acute graft-versus-host disease (OR = 1.6, 95% CI = 1.1–2.3). Factors associated with an increased ICU survival were a single-organ failure (OR = 0.2, 95% CI = 0.1–0.4), neurological failure (OR = 0.4, 95% CI = 0.2–0.8), and reduced-intensity conditioning regimens (OR = 0.7, 95% CI = 0.5–0.9). Septic shock, underlying malignancy, disease status, donor, and graft source did not impact prognosis. Outcome has improved, supporting the usefulness of ICU management. Organ failures at ICU admission, organ support requirement, and GVHD are the main prognostic factors.Keywords:
Renal replacement therapy
Septic shock is a common syndrome. In recent years, the incidence of septic shock increases year by year, and the mortality rate of septic shock is high. More and more medical workers and scho- lars begin to pay attention to septic shock's occurrence, development, diagnosis and treatment, expecting the standardized treatment to reduce the mortality. The current review is to update the management of sepsis and septic shock.
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急性腎障害（acute kidney injury：AKI）は人口の高齢化に伴い年々増加しており，予後も種々の努力にもかかわらず最近十数年でほとんど改善されていない．また，AKIに対する腎代替療法（renal replacement therapy：RRT）に関しても未だ開始基準，中止基準，方法についてコンセンサスは得られていないのが現状である．本稿ではAKIに対するRRT（特に持続的（continuous）なRRT（CRRT））を中心について最近の知見を含め概説する．
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The optimal timing for initiation of renal replacement therapy (RRT) in septic acute kidney injury (AKI) remains controversial. The aim of this study is to investigate the impact of early versus late initiation of continuous RRT (CRRT), as defined using the simplified RIFLE classification, on organ dysfunction among patients with septic shock and AKI.
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Nephrology
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The treatment of established acute kidney injury (AKI) is largely supportive in nature. Renal replacement therapy remains the cornerstone of management for the minority of patients who have severe AKI. Optimization of renal replacement therapy may modulate the high mortality associated with AKI. Recent trials indicated that continuous renal replacement therapy does not confer a survival advantage as compared to intermittent hemodialysis. Furthermore, there is no evidence to support a more intensive strategy of renal replacement therapy in the setting of AKI. There is comparatively limited data regarding the ideal timing of renal replacement therapy initiation and the preferred mode of solute clearance.
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Macrophage migration inhibitory factor (MIF) is known to amplify the immune response in septic animal models. Few clinical data support this pro-inflammatory role in septic patients. Renal replacement therapy (RRT) as adjuvants in the complex therapy of sepsis has been proposed as a possible approach to eliminate elevated circulating cytokines. Since recent data suggest that MIF can be effectively removed from the circulating blood pool in patients with chronic kidney disease, we here aimed to investigate whether RRT in septic shock can lower plasma levels of this pro-inflammatory cytokine in septic shock patients.An observational single-center study on an internist intensive care unit (ICU) was conducted. MIF plasma levels and mortality of n = 25 patients with septic shock were assessed with a previously validated method for reliable MIF values. The effect of continuous renal replacement therapy (CRRT) on daily MIF levels and mortality was assessed by comparing patients with and without need for CRRT due to acute kidney injury (AKI).MIF plasma levels in patients undergoing CRRT due to septic AKI were steadily decreased compared to those from patients without CRRT hinting at a MIF removal by hemodialysis. MIF release during ICU stay as assessed by MIFAUC was lower in patients undergoing CRRT, and Kaplan-Meier analysis revealed a distinctly lower mortality in patients undergoing CRRT. Analysis of daily MIF levels showed that patients who did not survive septic shock exhibited steadily higher MIF plasma levels and higher MIFAUC compared to those surviving sepsis. Low MIF levels were closely associated with improved survival.This is the first study investigating the effect of efficient MIF removal from the plasma pool of patients with septic shock. Reduction of high circulating MIF by CRRT therapy was accompanied by improved survival. Thus, targeted removal of MIF from the circulating blood pool might be a promising approach to reduce mortality in severe sepsis.
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Abstract Objective To review indications methods of renal replacement therapies ( RRT ) and practical considerations for the creation of a RRT program. Data Sources Current human and veterinary literature review with a focus on advanced renal physiology and clinical experience in RRT and acute/chronic kidney diseases. Data Synthesis Renal replacement therapies encompass intermittent hemodialysis, continuous renal replacement therapy as well as some “hybrid” techniques. Each method of RRT has practical and theoretical advantages but currently there is no evidence that one technique is superior to the other. Conclusions RRT is a valuable therapeutic tool for treatment of acute kidney injury and chronic kidney disease. The implementation of an RRT program needs to take into consideration multiple parameters beyond the choice of an RRT platform.
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A few pediatric studies were present which focused on renal replacement therapy used for critically ill children. This research aimed to determine the ratio of utilization of intermittent hemodialysis, continuous renal replacement therapy, and peritoneal dialysis, and to study the properties and outcomes of critically ill pediatric patients who underwent renal replacement therapy.Critically ill children admitted to the intensive care unit and received renal replacement therapy from February 2020 to May 2022 were included. The children were divided into three groups: hemodialysis, continuous renal replacement therapy, and peritoneal dialysis.A total of 37 patients (22 boys and 15 girls) who received renal replacement therapy met the criteria for this study. Continuous renal replacement therapy was used in 43%, hemodialysis in 38%, and peritoneal dialysis in 19%. In all, 28 (73%) children survived and 9 (27%) died in intensive care unit. The mean systolic blood pressure was significantly lower among children who received continuous renal replacement therapy (p<0.001). The need for inotropic medications and a higher PRISM III score were found to be the greatest indicators of mortality.The outcome of children receiving renal replacement therapy seems to be related to their needs for vasoactive drugs and the severity of the underlying disease in the continuous renal replacement therapy group relative to the other groups.
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