Hydroxyethyl Starch for Fluid Management in Patients Undergoing Major Abdominal Surgery: A Systematic Review With Meta-analysis and Trial Sequential Analysis
Joris PensierLucas DeffontisAmélie RolleYassir AarabMathieu CapdevilaClément MonetJulie CarrEmmanuel FutierNicolas MolinariSamir JaberAudrey De Jong
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BACKGROUND: In critically ill patients, warnings about a risk of death and acute kidney injury (AKI) with hydroxyethyl starch (HES) solutions have been raised. However, HES solutions may yet have a role to play in major abdominal surgery. This meta-analysis and trial sequential analysis (TSA) aimed to investigate the effect of HES intravascular volume replacement on the risk of AKI, intraoperative blood transfusion, and postoperative intra-abdominal complications compared to crystalloid intravascular volume replacement. METHODS: In this meta-analysis and TSA, we searched for randomized controlled trials (RCTs) comparing intraoperative HES intravascular volume replacement to crystalloid intravascular volume replacement in adult patients undergoing major abdominal surgery. Primary outcome was 30-day AKI, defined as a binary outcome according to Kidney Disease Improving Global Outcomes (KDIGO) criteria, combining stages 1, 2, and 3 into an AKI category versus no AKI category (stage 0). Secondary outcomes included rates of intraoperative blood transfusion and postoperative intra-abdominal complications. We used random effects models to calculate summary estimates. We used relative risk (RR) as summary measure for dichotomous outcomes, with corresponding 95% confidence intervals (CIs) for the primary outcome ( P value <.05 was considered statistically significant) and 99% CI after Bonferroni correction for the secondary outcomes ( P value <.01 was considered statistically significant). RESULTS: Seven RCTs including 2398 patients were included. HES intravascular volume replacement was not associated with an increased risk of 30-day AKI (RR = 1.22, 95% CI, 0.94–1.59; P = .13), when compared to crystalloid intravascular volume replacement. According to TSA, this analysis was underpowered. HES intravascular volume replacement was associated with higher rates of blood transfusion (RR = 1.57 99% CI, 1.10–2.25; P = .001), and similar rates of postoperative intra-abdominal complications (RR = 0.76 99% CI, 0.57–1.02; P = .02). CONCLUSIONS: In this meta-analysis to focus on HES intravascular volume replacement in major abdominal surgery, HES intravascular volume replacement was not associated with a higher risk of 30-day AKI when compared to crystalloid intravascular volume replacement. However, CI and TSA do not exclude harmful effects of HES intravascular volume replacement on the renal function.Keywords:
Intravascular volume status
Renal replacement therapy
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Sepsis is the leading cause of acute kidney injury (AKI) in the intensive care unit. As the most common treatment of septic AKI, it is believed that continuous renal replacement therapy (CRRT) can not only maintain the water balance and excrete the metabolic products but also regulate the inflammation and promote kidney recovery. CRRT can remove the inflammatory cytokines to regulate the metabolic adaption in kidney and restore the kidney recovery to protect the kidney in septic AKI. Second, CRRT can provide extra energy supply in septic AKI to improve the kidney energy balance in septic AKI. Third, the anticoagulant used in CRRT also regulates the inflammation in septic AKI. CRRT is not only a treatment to deal with the water balance and metabolic products, but also a method to regulate the inflammation in septic AKI. Video Journal Club ‘Cappuccino with Claudio Ronco’ at https://www.karger.com/Journal/ArticleNews/223997?sponsor=52.
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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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INTRODUCTION: Acute kidney injury (AKI) is defined as a sudden reduction in kidney function, which ranges from mild changes in kidney biomarkers to severe conditions that require renal replacement therapy (RRT). RRT is the most effective treatment for patients with severe AKI, and the most used RRT methods are: conventional hemodialysis (HD), continuous hemodialysis and peritoneal dialysis (PD). OBJECTIVES: This study aims to analyze the epidemiological profile and outcome of patients diagnosed with Acute Kidney Injury undergoing renal replacement therapy in the Intensive Care Unit. METHODS: For this, a descriptive, observational, cross-sectional study was carried out through the retrospective collection of data obtained through the electronic medical record system. RESULTS: Among the hospitalizations during the study period, 3.67% required RRT due to AKI, with sepsis as the main cause (48.57%). Most patients underwent RRT through HD. The mortality rate was 45.7%, showing higher mortality in those who developed AKI during hospitalization compared to those who were already admitted with AKI. CONCLUSION: It is possible to conclude that most patients undergoing RRT due to AKI are under 2 years of age and more than 50% have comorbidities. The presence of comorbidities and PIM2 are related to mortality.
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Despite substantial advances in dialytic techniques and machines, acute kidney injury (AKI) requiring renal replacement therapy (RRT) is associated with up to 60% in-hospital mortality. But, there is no full detail of definite RRT to overcome the significant morbidity and mortality of AKI. What is most important in the treatment for AKI is that RRT is not a cause-specific therapy but a life-supportive management. This review discusses the indications of, proper initiation of, and optimal prescription for RRT to improve the survival of the patients with AKI. (Korean J Med 2012;82:17-21) Keywords: Renal replacement therapy; Acute kidney injury ì¤ì¬ ë¨ì´: ëì¹ ìë²; ê¸ì± ì ìì
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Acute kidney injury (AKI) is increasingly common in critically ill patients and many patients with severe kidney injury require continuous renal replacement therapy (CRRT). However, little is known regarding the incidence rate and associated factors for developing chronic kidney disease after CRRT in AKI patients. This study aimed to investigate renal outcome and the factors associated with incomplete renal recovery in AKI patients who received CRRT.
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Nearly 60% of patients admitted to intensive care units have evidence of acute kidney injury (AKI). In the recent AKI EPI study, 13.5% of patients admitted to ICUs were treated with renal replacement therapy (RRT) and 23.5% of patients with AKI required RRT (1).
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Introduction The timing of renal replacement therapy (RRT) initiation in patients having acute kidney disease has been a controversial issue for many years. A recently published systematic review and meta-analysis on this topic failed to demonstrate measurable benefits of early RRT. Patients and methods We compared RRT initiation timing in critically ill patients and defined early or late RRT in reference to the timing after which stage 3 Acute Kidney Injury Network criteria were met. Patients beginning RRT within 24 h after reaching stage 3 acute kidney injury (AKI) were considered early starters, whereas those beginning RRT past 24 h after reaching stage 3 AKI were considered late starters. Acute Kidney Injury Network criteria were evaluated by both urine output and serum creatinine. Patients with acute-on-chronic kidney disease were excluded. A propensity score methodology was used to control variables. Results A total of 123 critically ill patients were subjected to RRT. Only 40 patients with pure stage 3 AKI were analyzed. Mortality was lower in the early RRT group than in the late RRT group (18.6 vs. 81.1%, P=0.000). Moreover, patients in the early RRT group had a lower duration of mechanical ventilation, RRT duration, vasopressor duration, and ICU discharge creatinine level. Conclusion Using a time-based approach could be a better means of assessing the association between RRT initiation and outcomes in patients with AKI. In patients with stage 3 AKI, RRT initiation within 24 h should be considered.
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Acute kidney injury (AKI) is a complex syndrome with a high incidence and considerable morbidity in critically ill patients. Renal replacement therapy (RRT) remains the mainstay of treatment for AKI. There are at present multiple disparities in uniform definition, diagnosis, and prevention of AKI and timing of initiation, mode, optimal dose, and discontinuation of RRT that need to be addressed. The Indian Society of Critical Care Medicine (ISCCM) AKI and RRT guidelines aim to address the clinical issues pertaining to AKI and practices to be followed for RRT, which will aid the clinicians in their day-to-day management of ICU patients with AKI.Mishra RC, Sodhi K, Prakash KC, Tyagi N, Chanchalani G, Annigeri RA, et al. ISCCM Guidelines on Acute Kidney Injury and Renal Replacement Therapy. Indian J Crit Care Med 2022;26(S2):S13-S42.
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