Welder Zamoner

Introduction: Acute kidney injury (AKI) and chronic kidney disease (CKD) are widely correlated. However, the risk factors associated with outcomes of AKI in CKD patients have not been widely studied to date. Objectives: To identify factors associated with outcomes of death and need for kidney support therapy (KST) in patients with CKD who present with AKI during hospital stay. Methods: Retrospective cohort conducted from July 2018 to June 2022 that included patients with CKD and superimposed AKI. Sociodemographic data related to CKD, AKI, and the progression of patients to outcomes as death and KST were collected. The results were discussed with a significance level of p < 0.05. Results: A total of 327 patients were included. The patients had a mean age of 68.6 ± 11.4 years, the majority were men, and the most prevalent comorbidities were hypertension (81.7%) and cardiovascular disease (61.5%). The mean creatinine was 1.85 ± 0.74 mg/dL. The main etiology of CKD was undetermined (26.6%) and of AKI was septic (45.3%). Patients were hospitalized mainly for infectious or cardiovascular causes (22.3% each). Overall mortality was 29.1%, and the need for KST was 35.2%. In the intensive care unit (ICU), 73.2% required dialysis and 74.4% died, reaching 85.7% in those with KST. CKD staging was not associated with any of the primary outcomes. The risk factors for KST were obesity, ATN‐ISS score, and creatinine elevation greater than three times the baseline. The risk factors for death were ATN‐ISS score, undetermined CKD, septic AKI, ICU admission, and KST. Conclusions: Mortality and need for KST in CKD patients admitted to the ICU and who develop AKI are high. Variables related to AKI were more relevant than those related to CKD for clinical outcomes.

Peritoneal dialysis (PD) for AKI patients using a flexible catheter and cycler was started in 2004 in Botucatu, São Paulo, Brazil. This study aimed to describe the main determinants of patient and technique survival, including PD treatment trends in AKI patients over time. This was a large Brazilian retrospective cohort study in which adult AKI patients with PD were studied from January/2004 to January/2024. For comparison purposes, patients were divided into two groups according to the year of treatment: 2004–2014 and 2015–2024. We included 487 patients. The mean age was 64.02 ± 15.01 years and 327 (67.1%) patients were male. Most patients needed vasoactive drugs and mechanical ventilation (66.1% and 73.1%, respectively). The mean ATN-index specific score (ISS) was 0.61 ± 0.2, and the median APACHE-II score was 27 (20–31). Sepsis was the primary diagnosis (33.7%), followed by cardiovascular etiologies (29.2%). Uremia or azotemia was the main indication for dialysis (46.4%). The delivered urea Kt/V was 0.55 ± 0.18/session and 3.22 ± 0.6/week. Over the years, the prevalence of catabolism increased from 7.6 to 26.5% (p < 0.0001), and PD has been used more in patients with liver cirrhosis (from 5.3 to 14.1%, p < 0.0001) and with nephrotoxic AKI (from 0 to 5.9%, p < 0.0001), and less in septic patients (40.1 vs. 23.2%). The groups were similar in terms of APACHE2. The indication for dialysis due to azotemia/uremia decreased from 64.9% to 16.2% (p < 0.0001) and increased by metabolic and fluid demand to capacity imbalance (from 4 to 68.1%, p < 0.0001). The prescribed dialysis PD dose decreased from 0.56 ± 0.09 to 0.44 ± 0.08 (p < 0.001), and there was no difference in metabolic and volume control. There was an increase in kidney function recovery from 24.8 to 35.7% (p < 0.0001) and a reduction in mortality over 30 days from 59.9% to 49.2% (p 0.02) and in technical failure (TF) from 15.6% to 5.9% (p < 0.0001). The main cause of TF was mechanical complication followed by peritonitis. Cox regression identified the period 2004–2014 as a risk factor for death and technique failure (OR 2.4, 95%CI 1.16–4.93, p = 0.018, and OR 12.58, 95%CI 2.74–57.69, p = 0.001, respectively). In the second period, PD was indicated earlier and prescribed at a lower dose, with no difference in the patient’s metabolic and volume control. There was an improvement in patient survival and technique over the years, suggesting better indication and management of this therapy. This is the largest cohort in the world to provide patient characteristics, clinical practice, and its relationship with clinical outcomes.

Exposures, predominantly vancomycin, iodinated contrast, and aminoglycosides. While these DI-AKI cases demonstrated lower mortality compared to other AKI etiologies, the need for acute kidney replacement therapy (AKRT) was similar.These findings support growing interest in the development of bundle care strategies for DI-AKI that may mitigate the severity and long-term impact of these events. For example, as discussed by Colares et al., even Recent studies emphasize the need for standardized clinical and histopathologic criteria and suggest that early diagnosis and minimal fibrosis are associated with better outcomes (8,9). Noninvasive diagnostic tools are under investigation, including gallium-67 scintigraphy and the lymphocyte transformation test (LTT), which may help identify AIN and its causative agents, particularly in patients on immunotherapy (10,11). Biomarkers are also gaining traction. Moledina and colleagues (9) identified urinary cytokines, particularly TNF-α and IL-9, as promising diagnostic markers for AIN in a prospective study. These markers outperformed clinical suspicion and standard laboratory parameters in distinguishing AIN from acute tubular injury (ATI) and other AKI subtypes.The evidence presented across this issue reinforces the need for comprehensive epidemiological studies that address the heterogeneous phenotypes and outcomes of DI-AKI. There is increasing momentum behind the development of

The pharmacokinetics and pharmacodynamics (PK/PD) of vancomycin change during HD, increasing the risk of subtherapeutic concentrations. The aim of this study was to evaluate during and after the conventional and prolonged hemodialysis sessions to identify the possible risk of the patient remaining without adequate antimicrobial coverage during therapy. Randomized, non-blind clinical trial, including critically ill adults with septic AKI on conventional (4 h) and prolonged HD (6 and 10 h) and using vancomycin for at least 72 h. Sessions were analyzed and randomized into three groups (G): control (C), dose of 15 mg/kg after session), intervention (I) 2 h (dose of 7.5 mg/kg in the second hour and 7.5 mg/kg after) and IG continuous infusion (dose of 30 mg/kg in 24 h). Of the 316 patients recruited, 87 were randomized, and 174 HD sessions were monitored. For the analysis, 28 sessions belonged to the CG, 47 to the 2-hour IG, and 31 to the continuous IG. The groups were similar in age, weight, severity scores, use of nephrotoxins, sérum albumin, Kt/V, HD modality, ultrafiltration, and intradialytic intercurrences. The intervention groups showed a higher therapeutic concentration frequency than the control group (p < 0.002). The initial concentration was identified as a risk factor (OR 1.16, p = 0.001) for a non-therapeutic vancomycin concentration in the logistic regression. In contrast, the 2-hour IG was identified as a protective factor (OR 0.24, p = 0.04). Administration of vancomycin during dialysis proved to be a protective factor against concentrations outside the therapeutic target. Further studies are needed to suggest more appropriate doses of vancomycin for patients with AKI on dialysis therapy and to assess the impact of these results on clinical outcomes.

Introdução: A diálise peritoneal (DP) para pacientes com injúria renal aguda (IRA) usando cateter flexível e cicladora iniciou-se em 2004 em hospital do interior de SP. Objetivo: Comparar as principais alterações na epidemiologia, prescrição e desfechos clínicos ao longo do tempo. Métodos: Coorte retrospectiva de pacientes adultos com IRA e tratados por DP de jan/2004 a jan/2024. Para fins de comparação, os pacientes foram divididos em dois grupos de acordo com o período: 2004-2014 e 2015-2024. Resultados: Foram incluídos 487 pacientes, com idade 64,02±15,01 anos, 67,1% do sexo masculino, 66,1% em uso de droga vasoativa, 73,1% em ventilação mecânica, com APACHE2 27(20-31). O diagnóstico primário foi sepse (33,7%), seguido de etiologia cardiovascular (29,2%). A uremia/azotemia foi a principal indicação de diálise (46,4%) e o Kt/V prescrito foi 0,55±0,18/sessão. Ao longo dos anos, a prevalência de pacientes hipercatabólicos aumentou (7,6 vs 26,5%, p< 0,001) e a DP foi mais utilizada em doentes com cirrose hepática (5,3 vs 14,1%, p< 0,0001) e IRA nefrotóxica (0 vs 5,9%, p< 0,001) e menos nos pacientes sépticos (40,1 vs 23,2%). Os grupos foram semelhantes quanto ao APACHE2. A indicação de diálise por azotemia/uremia diminuiu (64,9 vs 16,2%, p< 0,0001) e aumentou por desequilíbrio entre demanda metabólica/fluidos e capacidade renal (4 vs 68,1%, p< 0,001). A dose de diálise prescrita diminuiu (0,56±0,09 vs 0,44±0,08, p< 0,001) e não houve diferença entre os grupos no controle metabólico/volêmico. Houve aumento da recuperação de função renal (24,8 vs 35,7%, p< 0,001) e redução, tanto da mortalidade (59,9 vs 49,2%, p= 0,02), quanto da falência da técnica-FT (15,6 vs 5,9%, p< 0,001). As principais causas de FT foram complicação mecânica e peritonite, e ambas diminuíram no segundo período (10,6 vs para 3,8%, p< 0,001 e 11,3 vs 0,5%, p< 0,001, respectivamente). Regressão de Cox identificou o período 2004-2014 como fator de risco para óbito e para falência de técnica (OR 2,4, IC95% 1,16-4,93, p=0,018, e OR 12,58, IC95% 2,74-57,69, p=0,001, respectivamente). Conclusão: No segundo período a DP foi indicada mais precocemente e prescrita em menor dose, não havendo diferença no controle metabólico e volêmico dos pacientes. Houve melhora na sobrevida dos pacientes e da técnica ao longo dos anos, o que sugere melhor indicação e condução desta terapia. Trata-se da maior coorte mundial que forneceu características dos pacientes, prática clínica e sua relação com os desfechos clínicos.

In Brief Magalhães et al. demonstrated that the incidence of acute kidney injury was high in hospitalized patients with COVID-19 and that the second wave was associated with greater severity; however, the mortality rates were similar between the two periods. This may reflect both the effectiveness of vaccines and the constant learning that frontline professionals gained throughout the pandemic to provide greater support to their patients. Highlights Renal involvement was frequent in patients with COVID-19 and related to worse

Introduction: COVID-19, caused by the SARS-CoV-2 virus, has been associated with oligosymptomatic cases or severe acute respiratory syndrome, with multiple organ failure and death. One of the most significant events for clinical outcomes is Acute Kidney Injury (AKI). It is known that AKI in COVID-19 is multifactorial, and the main mechanisms are cytokine storm, metabolic stress, use of nephrotoxic drugs, rhabdomyolysis, viral tropism to kidney tissues, and multiple organ failure. However, little is known about the impact of AKI clinical presentation and pathophysiological mechanisms on the outcome of patients affected by COVID-19. Objectives: To identify AKI clinical presentation and etiology, also known as phenotypes, and pathophysiological mechanisms, also known as subphenotypes, in patients affected by COVID-19 and associate them with death. This cohort and retrospective study evaluate the medical records of patients with SARS-CoV-2 infection admitted to a tertiary public hospital from 1 June 2020, to 31 July 2021, from admission to clinical outcome (hospital discharge or death). Clinical and laboratory data were analyzed during the hospitalization. Renal function was estimated by urine output and serum creatinine; therefore, the diagnosis and AKI classification were based on the 2012 KDIGO criteria. The occurrence of AKI was the inclusion criterion. According to clinical and laboratory presentations, we recognized two phenotypes of AKI (the direct and indirect impact of SARS-CoV-2 on the kidney) and several pathophysiological mechanisms. Subphenotypes of the direct impact of SARS-CoV-2 on kidneys were associated with Kidney Viral Tropism, Cytokine Storm, COVID-19-Related Multiple Organ Failure, and Mixed (more than one mechanism associated with COVID-19). Subphenotypes of indirect impact of SARS-CoV-2 on kidney phenotypes were Ischemic, Nephrotoxic due to rhabdomyolysis, and Septic. Univariate and multivariate analyses were performed to identify risk factors associated with death. Result: In total, 372 patients were included; 55.6% were male, 82.3% were Caucasians, and the mean age was 61.4 years. The majority of patients were admitted to the ICU (88.2%) and required mechanical ventilation (86.3%). AKI was predominantly KDIGO 3 (65.6%). When classifying our patients’ AKI in two kidney phenotypes based on their clinical presentation, the direct impact of the SARS-CoV-2 phenotype was predominant (71,5%) and associated with higher mortality (83.8 vs. 46.3%, p = 0.001). Among the AKI pathophysiological mechanisms, Mixed—synergism of viral mechanisms—was the most prevalent (23.4%), followed by Viral Tropism (19.9%), Multiple Organ Failure—MOF (18%), Septic (15.6%), Ischemic (12.9%), and Cytokine Storm (10.2%). Mortality was high (73.1%). Logistic regression identified APACHE II, ATN-ISS, and the direct impact of SARS-CoV-2 on the kidney as factors associated with death, while ischemic AKI was associated with lower mortality. Conclusions: We can conclude that APACHE II and ATN-ISS scoring are clinical predictions of hospital mortality in COVID patients with AKI, as well as AKI etiology involving the direct impact of SARS-CoV-2 on the kidney, while ischemic pathophysiological mechanisms of AKI are associated with lower mortality.

Introduction Acute kidney injury (AKI) is one of the main complications of COVID-19 caused by SARS-CoV-2. This study aimed to evaluate the incidence of AKI in Brazilian hospitalized patients diagnosed with COVID-19 and identify the risk factors associated with its onset and those associated with its prognosis. Methods A prospective cohort study of hospitalized patients diagnosed with COVID-19 at a public and tertiary university hospital in São Paulo from March to December 2020. Results There were 347 patients hospitalized with COVID-19, 52.4% were admitted to the intensive care unit (ICU) and 47.6% were admitted to the wards. The overall incidence of AKI was 46.4%, more frequent in the ICU (68.1% vs 22.4, p < 0.01) and the overall mortality was 36.1%. Acute kidney replacement therapy was indicated in 46.6% of patients with AKI. In the general population, the factors associated with AKI were older age (OR 1.03, CI 1–1.05, p < 0.05), mechanical ventilation (OR 1.23, CI 1.06–1.83, p < 0.05), presence of proteinuria (OR 1.46, CI 1.22–1.93, p < 0.05), and use of vasoactive drugs (OR 1.26, CI 1.07–1.92, p < 0.05). Mortality was higher in the elderly (OR 1.08, CI 1.04–1.11, p < 0.05), in those with AKI (OR 1.12, CI 1.02–2.05, p < 0.05), particularly KDIGO stage 3 AKI (OR 1.10, CI 1.22–2.05, p < 0.05) and in need of mechanical ventilation (OR 1.13, CI 1.03–1.60, p < 0.05). Conclusion AKI was frequent in hospitalized patients with COVID-19 and the factors associated with its development were older age, mechanical ventilation, use of vasoactive drugs, and presence of proteinuria, being a risk factor for death.

Background: In the absence of direct therapy for COVID-19, extracorporeal blood treatment (EBT) could represent an option for cytokine removal. Objective: This study aimed to describe and compare cytokine removal during intermittent haemodialysis (IHD) and continuous renal replacement therapy (CRRT) in COVID-19 patients with Acute Kidney Injury (AKI). Methods: It was a cohort study that studied patients with COVID-19-related AKI according to KDIGO criteria and admitted at Intensive Care Unit (ICU). Blood samples were collected at the start and end of both IHD using high flux (HF) membranes (10 patients) and continuous venovenous haemodiafiltration (CVVHDF:10 patients) in two sessions for measuring 13 different plasma interleukins and calculating the cytokine removal rate. Results: There was no difference between the two groups regarding mechanical ventilation, vasoactive drug, age or prognostic scores. Patients treated by CRRT presented higher levels of IL-2 and IL-8 than patients treated by IHD at dialysis start. Cytokine removal ranged from 9% to 78%. Patients treated by CRRT presented higher cytokine removal for IL-2, IL-6 IL-8, IP-10 and TNF. The removal rates of IL-4, IL-10, IL-17A, IFN, MCP-1 and TGF-B1 were similar in two groups. After one session of CVVHDF (24 h), IL-2 and IL-1β levels did not vary significantly, whereas IL-4, IL-6, IL-8, IL-10, IL-17A, TNF, IFN, IP-10, MCP-1, IL-12p70 and TGF-B1 decreased by 33.8– 76%, and this decrease was maintained over the next 24 h. In IHD groups, IL-2, IL-6, TNF, IP-10 and IL-1β levels did not decrease significantly whereas IL-4, IL-8, IL-10, IL-17A, IFN, MCP-1, IL-12p70 and TGF-B1 decreased by 21.8– 72%; however, cytokine levels returned to their initial values after 24 h. Conclusion: Cytokine removal is lower in IHD using HF membranes than in CVVHDF, and in IHD the removal is transient and selective, which can be associated with mortality during cytokines storm-related COVID-19.