Background Little information is available about the geo-economic variations in demographics, management, and outcomes of patients with acute respiratory distress syndrome (ARDS). We aimed to characterise the effect of these geo-economic variations in patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE). Methods LUNG SAFE was done during 4 consecutive weeks in winter, 2014, in a convenience sample of 459 intensivecare units in 50 countries across six continents. Inclusion criteria were admission to a participating intensive-care unit (including transfers) within the enrolment window and receipt of invasive or non-invasive ventilation. One of the trial's secondary aims was to characterise variations in the demographics, management, and outcome of patients with ARDS. We used the 2016 World Bank countries classification to define three major geo-economic groupings, namely European high-income countries (Europe-High), high-income countries in the rest of the world (rWORLD-High), and middle-income countries (Middle). We compared patient outcomes across these three groupings. LUNG SAFE is registered with ClinicalTrials.gov, number NCT02010073. Findings Of the 2813 patients enrolled in LUNG SAFE who fulfilled ARDS criteria on day 1 or 2, 1521 (54%) were recruited from Europe-High, 746 (27%) from rWORLD-High, and 546 (19%) from Middle countries. We noted significant geographical variations in demographics, risk factors for ARDS, and comorbid diseases. The proportion of patients with severe ARDS or with ratios of the partial pressure of arterial oxygen (PaO 2) to the fractional concentration of oxygen in inspired air (F I O 2) less than 150 was significantly lower in rWORLD-High countries than in the two other regions. Use of prone positioning and neuromuscular blockade was significantly more common in Europe-High countries than in the other two regions. Adjusted duration of invasive mechanical ventilation and length of stay in the intensive-care unit were significantly shorter in patients in rWORLD-High countries than in Europe-High or Middle countries. High gross national income per person was associated with increased survival in ARDS; hospital survival was significantly lower in Middle countries than in Europe-High or rWORLD-High countries. Interpretation Important geo-economic differences exist in the severity, clinician recognition, and management of ARDS, and in patients' outcomes. Income per person and outcomes in ARDS are independently associated.

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Continuous renal replacement therapy (CRRT) is frequently used to treat recipients with renal failure before or after liver transplantation (LT), though evidence supporting its use during surgery remains unclear. Therefore, we conducted a quantitative meta‐analysis to evaluate the effect of intraoperative continuous renal replacement therapy (IORRT) in recipients with pretransplant severe renal dysfunction. We searched PubMed, Embase, and the Cochrane database for trials focusing on LT recipients supported with or without IORRT. Outcomes assessed were mortality, preoperative characteristics, intraoperative data, and predefined postoperative outcomes. Seven trials with 1051 recipients were eligible. Preoperatively, the IORRT group recipients had higher Model for End‐Stage Liver Disease scores (weighted mean difference [WMD], 6.19; 95% confidence interval [CI], 2.51‐9.87), Charlson scores (WMD, 0.45; 95% CI, 0.09‐0.80), acute liver failure (odds ratio [OR], 1.82; 95% CI, 1.27‐2.61), serum creatinine (WMD, 71.33 μmol/L; 95% CI, 1.98‐140.69 μmol/L), total bilirubin level (WMD, 5.05 μmol/L; 95% CI, 1.75‐8.35 μmol/L), intensive care unit admission (OR, 3.53; 95% CI, 1.23‐10.13), vasoactive therapy (OR, 3.80; 95% CI, 2.64‐5.46), ventilator care (OR, 2.52; 95% CI, 1.18‐5.35), and renal replacement therapy (RRT) (OR, 29.37; 95% CI, 7.66‐112.54) compared with control patients. IORRT patients also required more intraoperative blood product transfusion and had more post‐LT RRT (OR, 25.67; 95% CI, 4.92‐133.85). However, there were no significant differences in short‐term mortality (OR, 2.12; 95% CI, 0.82‐5.44) between the groups. In addition, worse longterm mortality was seen in the IORRT group. In conclusion, IORRT is feasible and safe and may help sicker recipients tolerate the LT procedure to achieve short‐term clinical outcomes comparable with less ill patients without IORRT. More high‐quality evidence is needed to verify our conclusion in the future.

Background:Urine output (UO) is an essential criterion of the Kidney Disease Improving Global Outcomes (KDIGO) definition and classification system for acute kidney injury (AKI), of which the diagnostic value has not been extensively studied. We aimed to determine whether AKI based on KDIGO UO criteria (KDIGOUO) could improve the diagnostic and prognostic accuracy, compared with KDIGO serum creatinine criteria (KDIGOSCr).Methods:We conducted a secondary analysis of the database of a previous study conducted by China Critical Care Clinical Trial Group (CCCCTG), which was a 2-month prospective cohort study (July 1, 2009 to August 31, 2009) involving 3063 patients in 22 tertiary Intensive Care Units in Mainland of China. AKI was diagnosed and classified separately based on KDIGOUO and KDIGOSCr. Hospital mortality of patients with more severe AKI classification based on KDIGOUO was compared with other patients by univariate and multivariate regression analyses.Results:The prevalence of AKI increased from 52.4% based on KDIGOSCr to 55.4% based on KDIGOSCr combined with KDIGOUO. KDIGOUO also resulted in an upgrade of AKI classification in 7.3% of patients, representing those with more severe AKI classification based on KDIGOUO. Compared with non-AKI patients or those with maximum AKI classification by KDIGOSCr, those with maximum AKI classification by KDIGOUO had a significantly higher hospital mortality of 58.4% (odds ratio [OR]: 7.580, 95% confidence interval [CI]: 4.141–13.873, P < 0.001). In a multivariate logistic regression analysis, AKI based on KDIGOUO (OR: 2.891, 95% CI: 1.964–4.254, P < 0.001), but not based on KDIGOSCr (OR: 1.322, 95% CI: 0.902–1.939, P = 0.152), was an independent risk factor for hospital mortality.Conclusion:UO was a criterion with additional value beyond creatinine criterion for AKI diagnosis and classification, which can help identify a group of patients with high risk of death.