Kinetic estimated glomerular filtration rate as a predictor of successful continuous renal replacement therapy discontinuation

Yoshida, Teruhiko; Matsuura, Ryo; Komaru, Yohei; Miyamoto, Yoshihisa; Yoshimoto, Kohei; Hamasaki, Yoshifumi; Noiri, Eisei; Morimura, Naoto; Nangaku, Masaomi; Doi, Kent

doi:10.1111/nep.13396

Cited by 23 publications

(45 citation statements)

References 22 publications

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“…The optimal threshold values ranged from 1.85 to 2.98 mg/L, respectively. The predictive accuracy of serum creatinine was assessed in two studies at RRT initiation [17,18], and in four studies at the time of discontinuation [19,20], with threshold levels ranging from 224 to 300 μmol/L (Table 2). Due to variation in the timing of measurement and threshold values, the pooled analysis was not feasible.…”

Section: Studies Retrieved and Parameters Identified In A Systematic mentioning

confidence: 99%

“…2). Estimation of an optimal threshold to discriminate "successful" RRT discrimination was not feasible due to variation across studies, with thresholds ranging from 191 mL/24 h [37] to 1720 mL/24 h [17]. Overall certainty of evidence regarding this parameter was graded as very low (Fig.…”

Section: Urine Output Prior To Discontinuation Of Rrt To Predict Succmentioning

confidence: 99%

“…Diuretic use was associated with successful RRT discontinuation in three studies [21,37,42], although test characteristics were not reported. The effect of a diuretic challenge on the predictive accuracy of urine output was assessed in four studies [17,21,27,37] (Table 6). In two small studies [17,27], there was a suggestion of improved predictive accuracy in patients who had received diuretics.…”

Section: Effect Of Diuretic Use On Urine Output Test Characteristics mentioning

confidence: 99%

“…The effect of a diuretic challenge on the predictive accuracy of urine output was assessed in four studies [17,21,27,37] (Table 6). In two small studies [17,27], there was a suggestion of improved predictive accuracy in patients who had received diuretics. However, a larger study [21] found that urine output was a less reliable predictor of successful discontinuation when diuretics were given and another study did not compare the accuracy of urine output with or without diuretics [37].…”

Section: Effect Of Diuretic Use On Urine Output Test Characteristics mentioning

confidence: 99%

“…Numerous parameters have been evaluated to help identify patients for whom RRT may be safely discontinued, including traditional biochemical markers of kidney function (creatinine, urea, and estimates of glomerular filtration rate (GFR) [17][18][19][20][21][22][23][24][25][26]), clinical findings such as urine output [21-23, 26, 27], and newer kidney biomarkers including neutrophil gelatinase-associated lipocalin (NGAL) [19,28,29] and serum cystatin C [28][29][30][31]. Despite many criteria being evaluated in the existing literature, the available evidence has yet to be rigorously synthesized.…”

Section: Introductionmentioning

confidence: 99%

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Determining the optimal time for liberation from renal replacement therapy in critically ill patients: a systematic review and meta-analysis (DOnE RRT)

et al. 2020

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Introduction: Renal replacement therapy (RRT) is associated with high mortality and costs; however, no clinical guidelines currently provide specific recommendations for clinicians on when and how to stop RRT in recovering patients. Our objective was to systematically review the current evidence for clinical and biochemical parameters that can be used to predict successful discontinuation of RRT. Methods: A systematic review and meta-analysis were performed with a peer-reviewed search strategy combining the themes of renal replacement therapy (IHD, CRRT, SLED), predictors of successful discontinuation or weaning (defined as an extended period of time free from further RRT), and patient outcomes. Major databases were searched and citations were screened using predefined criteria. Studied parameters were reported and, where possible, data was analyzed in the pooled analysis. Results: Our search yielded 23 studies describing 16 variables for predicting the successful discontinuation of RRT. All studies were observational in nature. None were externally validated. Fourteen studies described conventional biochemical criteria used as surrogates of glomerular filtration rate (serum urea, serum creatinine, creatinine clearance, urine urea excretion, urine creatinine excretion). Thirteen studies described physiologic parameters such as urine output before and after cessation of RRT, and 13 studies reported on newer kidney biomarkers, such as serum cystatin C and serum neutrophil gelatinase-associated lipocalin (NGAL). Six studies reported sensitivity and specificity characteristics of multivariate models. Urine output prior to discontinuation of RRT was the most-studied variable, with nine studies reporting. Pooled analysis found a sensitivity of 66.2% (95% CI, 53.6-76.9%) and specificity of 73.6% (95% CI, 67.5-79.0%) for urine output to predict successful RRT discontinuation. Due to heterogeneity in the thresholds of urine output used across the studies, an optimal threshold value could not be determined. Conclusions: Numerous variables have been described to predict successful discontinuation of RRT; however, available studies are limited by study design, variable heterogeneity, and lack of prospective validation. Urine output prior to discontinuation of RRT was the most commonly described and robust predictor. Further research should focus on the determination and validation of urine output thresholds, and the evaluation of additional clinical and biochemical parameters in multivariate models to enhance predictive accuracy.

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Section: Studies Retrieved and Parameters Identified In A Systematic mentioning

confidence: 99%

Section: Urine Output Prior To Discontinuation Of Rrt To Predict Succmentioning

confidence: 99%

Section: Effect Of Diuretic Use On Urine Output Test Characteristics mentioning

confidence: 99%

Section: Effect Of Diuretic Use On Urine Output Test Characteristics mentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Determining the optimal time for liberation from renal replacement therapy in critically ill patients: a systematic review and meta-analysis (DOnE RRT)

et al. 2020

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Major Adverse Kidney Events in Pediatric Continuous Kidney Replacement Therapy

Fuhrman,

Stenson,

Alhamoud

et al. 2024

JAMA Netw Open

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ImportanceContinuous kidney replacement therapy (CKRT) is increasingly used in youths with critical illness, but little is known about longer-term outcomes, such as persistent kidney dysfunction, continued need for dialysis, or death.ObjectiveTo characterize the incidence and risk factors, including liberation patterns, associated with major adverse kidney events 90 days after CKRT initiation (MAKE-90) in children, adolescents, and young adults.Design, Setting, and ParticipantsThis international, multicenter cohort study was conducted among patients aged 0 to 25 years from The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) registry treated with CKRT for acute kidney injury or fluid overload from 2015 to 2021. Exclusion criteria were dialysis dependence, concurrent extracorporeal membrane oxygenation use, or receipt of CKRT for a different indication. Data were analyzed from May 2 to December 14, 2023.ExposurePatient clinical characteristics and CKRT parameters were assessed. CKRT liberation was classified as successful, reinstituted, or not attempted. Successful liberation was defined as the first attempt at CKRT liberation resulting in 72 hours or more without return to dialysis within 28 days of CKRT initiation.Main Outcomes and MeasuresMAKE-90, including death or persistent kidney dysfunction (dialysis dependence or ≥25% decline in estimated glomerular filtration rate from baseline), were assessed.ResultsAmong 969 patients treated with CKRT (529 males [54.6%]; median [IQR] age, 8.8 [1.7-15.0] years), 630 patients (65.0%) developed MAKE-90. On multivariable analysis, cardiac comorbidity (adjusted odds ratio [aOR], 1.60; 95% CI, 1.08-2.37), longer duration of intensive care unit admission before CKRT initiation (aOR for 6 days vs 1 day, 1.07; 95% CI, 1.02-1.13), and liberation pattern were associated with MAKE-90. In this analysis, patients who successfully liberated from CKRT within 28 days had lower odds of MAKE-90 compared with patients in whom liberation was attempted and failed (aOR, 0.32; 95% CI, 0.22-0.48) and patients without a liberation attempt (aOR, 0.02; 95% CI, 0.01-0.04).Conclusions and RelevanceIn this study, MAKE-90 occurred in almost two-thirds of the population and patient-level risk factors associated with MAKE-90 included cardiac comorbidity, time to CKRT initiation, and liberation patterns. These findings highlight the high incidence of adverse outcomes in this population and suggest that future prospective studies are needed to better understand liberation patterns and practices.

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The need for disruptive innovation in acute kidney injury

Doi

2020

Clin Exp Nephrol

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Acute kidney injury (AKI) is a threatening medical condition associated with poor outcomes at different settings. The development of standardized diagnostic criteria and new biomarkers addressed significant clinical impacts of AKI and the need for an early AKI detection, respectively. There have been some breakthroughs in understanding the pathogenesis of AKI through basic research; however, treatments against AKI aside from renal replacement therapy (RRT) have not shown adequate successful results. Biomarkers that could identify good responders to certain treatment are expected to facilitate translation of basic research findings. Most patients with severe AKI treated with RRT died due to multiple-organ failure, not renal dysfunction. Hence, it is essential to identify other organ dysfunctions induced by AKI as organ crosstalk. Also, a multidisciplinary approach of critical care nephrology is needed to evaluate a complex organ crosstalk in AKI. For disruptive innovation for AKI, we further explore these new aspects of AKI, which previously were considered outside the scope of nephrology.

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Kinetic estimated glomerular filtration rate as a predictor of successful continuous renal replacement therapy discontinuation

Abstract: This study evaluated kinetic eGFR as a predictive parameter for CRRT discontinuation. Kinetic eGFR combined with urine volume was a better predictor for CRRT discontinuation. Evaluation of kinetic eGFR utility in other clinical settings will be necessary.

Cited by 23 publications

References 22 publications

Determining the optimal time for liberation from renal replacement therapy in critically ill patients: a systematic review and meta-analysis (DOnE RRT)

Determining the optimal time for liberation from renal replacement therapy in critically ill patients: a systematic review and meta-analysis (DOnE RRT)

Major Adverse Kidney Events in Pediatric Continuous Kidney Replacement Therapy

The need for disruptive innovation in acute kidney injury

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