Continuous peritoneal dialysis compared with daily hemodialysis in patients with acute kidney injury

Background: In some parts of the world, peritoneal dialysis is widely used for renal replacement therapy (RRT) in acute kidney injury (AKI), despite concerns about its inadequacy. It has been replaced in recent years by hemodialysis and, most recently, by continuous venovenous therapies. We performed a prospective study to determine the effect of continuous peritoneal dialysis (CPD), as compared with daily hemodialysis (dHD), on survival among patients with AKI.Methods: A total of 120 patients with acute tubular necrosis (ATN) were assigned to receive CPD or dHD in a tertiary-care university hospital. The primary endpoint was hospital survival rate; renal function recovery and metabolic, acid-base, and fluid controls were secondary endpoints.Results: of the 120 patients, 60 were treated with CPD (G1) and 60 with dHD (G2). The two groups were similar at the start of RRT with respect to age (64.2 +/- 19.8 years vs 62.5 +/- 21.2 years), sex (men: 72% vs 66%), sepsis (42% vs 47%), shock (61% vs 63%), severity of AKI [Acute Tubular Necrosis Individual Severity Score (ATNISS): 0.68 +/- 0.2 vs 0.66 +/- 0.22; Acute Physiology and Chronic Health Evaluation (APACHE) II: 26.9 +/- 8.9 vs 24.1 +/- 8.2], pre-dialysis blood urea nitrogen [BUN (116.4 +/- 33.6 mg/dL vs 112.6 +/- 36.8 mg/dL)], and creatinine (5.85 +/- 1.9 mg/dL vs 5.95 +/- 1.4 mg/dL). In G1, weekly delivered Kt/V was 3.59 +/- 0.61, and in G2, it was 4.76 +/- 0.65 (p < 0.01). The two groups were similar in metabolic and acid-base control (after 4 sessions, BUN < 55 mg/dL: 46 +/- 18.7 mg/dL vs 52 +/- 18.2 mg/dL; pH: 7.41 vs 7.38; bicarbonate: 22.8 +/- 8.9 mEq/L vs 22.2 +/- 7.1 mEq/L). Duration of therapy was longer in G2 (5.5 days vs 7.5 days; p = 0.02). Despite the delivery of different dialysis methods and doses, the survival rate did not differ between the groups (58% in G1 vs 52% in G2), and recovery of renal function was similar (28% vs 26%).Conclusion: High doses of CPD provided appropriate metabolic and pH control, with a rate of survival and recovery of renal function similar to that seen with dHD. Therefore, CPD can be considered an alternative to other forms of RRT in AKI.

High-Volume Peritoneal Dialysis in Acute Kidney Injury: Indications and Limitations

Background and objectives Peritoneal dialysis is still used for AKI in developing countries despite concerns about its limitations. The objective of this study was to explore the role of high-volume peritoneal dialysis in AM patients in relation to metabolic and fluid control, outcome, and risk factors associated with death.Design, setting, participants, & measurements A prospective study was performed on 204 AKI patients who were assigned to high-volume peritoneal dialysis (prescribed Kt/V=0.60/session) by flexible catheter and cycler; 150 patients (80.2%) were included in the final analysis.Results Mean age was 63.8 +/- 15.8 years, 70% of patients were in the intensive care unit, and sepsis was the main etiology of AKI (54.7%). BUN and creatinine levels stabilized after four sessions at around 50 and 4 mg/dl, respectively. Fluid removal and nitrogen balance increased progressively and stabilized around 1200 ml and -1 g/d after four sessions, respectively. Weekly delivered Kt/V was 3.5 +/- 0.68. Regarding AKI outcome, 23% of patients presented renal function recovery, 6.6% of patients remained on dialysis after 30 days, and 57.3% of patients died. Age and sepsis were identified as risk factors for death. In urine output, increase of 1 g in nitrogen balance and increase of 500 ml in ultrafiltration after three sessions were identified as protective factors.Conclusions High-volume peritoneal dialysis is effective for a selected AKI patient group, allowing adequate metabolic and fluid control. Age, sepsis, and urine output as well as nitrogen balance and ultrafiltration after three high-volume peritoneal dialysis sessions were associated significantly with death. Clin J Am Soc Nephrol 7: 887-894, 2012. doi: 10.2215/CJN.11131111

Experimental model of bladder instability in rabbits

OBJECTIVE: Propose a new experimental model of bladder instability in rabbits after partial bladder obstruction. MATERIALS and METHODS: Thirty North Folk male rabbits, weighting 1,700 to 2,820 g (mean: 2,162 g) were studied. The animals were distributed in 2 experimental groups, formed by 15 rabbits each: Group 1 - clinical control. In this group there was no surgical intervention; Group 2 - bladder outlet obstruction. In this group, after anesthetizing the animal, urethral cannulation with Foley catheter 10F was performed and then an adjustable plastic bracelet was passed around the bladder neck. It was then adjusted in order to not constrict the urethra. The following parameters were studied in M1 - pre-operative period; M2 - 4 weeks post-operatively moments: 1)- urine culture; 2)- cystometric study; 3)- serum creatinine and BUN. RESULTS: Bladder weight was 2.5 times larger in the group with obstruction than in the control group. Cystometric evaluation showed a significant increase in maximal vesical volume in the final moment at Group G2. However, there was no statistically significant difference among the groups studied. There was no statistically significant difference between maximal detrusor pressure and vesical compliance in the different moments or in the studied groups. There was an absence of uninhibited detrusor contractions in all the animals in group 1, and involuntary contractions were detected in 93% of group 2 animals. There was no significant variation in BUN and serum creatinine either among the groups or in the same group. CONCLUSIONS: We observed in the group with obstruction a bladder weight 2.5 higher than normal bladders. We detected involuntary contractions in 93% of the animals in group 2, establishing this experimental model as appropriate to secondary bladder instability and partial bladder outlet obstruction.

Acompanhamento laboratorial da função renal de cães sadios tratados experimentalmente com doses terapêuticas de anfotericina B

O presente trabalho objetivou avaliar a função renal de dez cães adultos saudáveis submetidos à administração de doses terapêuticas do antifúngico anfotericina B, cuja utilização tem sido limitada pelo seu elevado potencial nefrotóxico, e avaliar o método laboratorial mais sensível e precoce de diagnóstico de lesão renal. Foram realizadas, diariamente, urinálise, excreção fracionada de sódio e potássio, dosagem sérica de creatinina e uréia e atividade urinária de gama-glutamiltransferase (GGT). Concluiu-se que a anfotericina B provoca lesões nos túbulos proximal e distal, induzindo acidose tubular renal do tipo I e Diabetes insipidus nefrogênico em cães. Avaliação da função renal, preferencialmente por dosagens de creatinina, uréia e potássio séricos, é recomendada antes de cada aplicação do fármaco. A densidade urinária foi o parâmetro mais precocemente alterado pela lesão renal. A GGT urinária não foi eficaz para o diagnóstico precoce de lesão induzida por anfotericina B.

High volume peritoneal dialysis for acute renal failure

Background. Peritoneal dialysis (PD) is still widely used for acute renal failure (ARF) in developing countries despite concerns about its inadequacy. Continuous PD has been evaluated in ARF by analyzing the resolution of metabolic abnormality and normalization of plasma pH, bicarbonate, and potassium.Methodology: A prospective study was performed on 30 ARF patients who were assigned to high-dose continuous PD (Kt/V = 0.65 per session) via a flexible catheter (Tenckhoff) and automated PD with a cycler. Fluid removal, pH and metabolic control, protein Loss, and patient outcome were evaluated.Results: Patients received 236 continuous PD sessions; 76% were admitted to ICUs. APACHE II score was 32.2 +/- 8.65. BUN concentrations stabilized after 3 sessions, creatinine after 4, and bicarbonate and pH after 2. Fluid removal was 2.1 +/- 0.62 L/day. Creatinine and urea clearances were 15.8 +/- 4.16 and 17.3 +/- 5.01 mL/minute respectively. Normalized creatinine clearance and urea Kt/V values were 110.6 +/- 22.5 L/week/1.73 m(2) body surface area and 3.8 +/- 0.6 respectively. Solute reduction index was 41% +/- 6.5% per session. Serum albumin values remained stable in spite of considerable protein tosses (median 21.7 g/day, interquartile range 9.1 - 29.8 g/day). Regarding ARF outcome, 23% of patients presented renal function recovery, 13% remained on dialysis after 30 days of follow-up, and 57% died.Conclusion: High-dose continuous PD by flexible catheter and cycler was an effective treatment for ARF. It provided high solute removal, allowing appropriate metabolic and pH control, and adequate dialysis dose and fluid removal. Continuous PD can therefore be considered an alternative to other forms of renal replacement therapy in ARF.

Renal Evaluation of Aotus azarai infulatus by Ultrasonography and Serum Chemistry Profile

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Avaliacao da necessidade da dosagem rotineira de hematocrito, hemoglobina, ureia e creatinina sericos durante a avaliacao pre-anestesica

Background and Objectives - There are many questions and opinions about the value of routine preoperative tests as an integral part of the preanesthetic evaluation. Current trends suggest that such tests should be based on detailed clinical and physical evaluation. Since such tests are still routinely performed and questions about their real value still persist, the aim of this study was to assess the value of routine hematocrit (Ht), hemoglobin concentration (Hb), blood urea nitrogen (BUN) and serum creatinine results in patients undergoing elective surgery, to establish when they are needed and aiming at answering such questions. Methods - 1065 patients aged 12 years and above, physical status ASA I, II and III, scheduled for elective surgery were studied. Patients were divided into 7 different age groups with randomized distribution of gender. Ht, Hb, BUN and serum creatinine results, routinely asked by our surgical departments, were observed and analyzed. Variance Analysis was used for each variable, and the Bonferroni Multiple Comparison Test was used to compare group to group. Differences were considered significant when p < 0.05 (5%). Results - For all patients, 4025 laboratory tests were obtained. The number of tests was the same for each group. There were no differences in Ht and Hb values which remained within normal ranges. Considering BUN and serum creatinine, there was a difference between younger and older patients, but the results were normal in all groups. Conclusions - We concluded that mean Ht, Hb, BUN and serum creatinine values in all age groups were all acceptable for surgical patients in general. However, they are barely useful if performed regardless of clinical evaluation. Thus, such preoperative routine tests should be abandoned and the good clinical practice with common sense should prevail in indicating them.

A randomized clinical trial of high volume peritoneal dialysis versus extended daily hemodialysis for acute kidney injury patients

Background: Acute kidney injury (AKI) requiring dialysis in critically ill patients is associated with an in-hospital mortality rate of 50-80 %. Extended daily hemodialysis (EHD) and high volume peritoneal dialysis (HVPD) have emerged as alternative modalities. Methods: A double-center, randomized, controlled trial was conducted comparing EHD versus HVPD for the treatment for AKI in the intensive care unit (ICU). Four hundred and seven patients were randomized and 143 patients were analyzed. Principal outcome measure was hospital mortality, and secondary end points were recovery of renal function and metabolic and fluid control. Results: There was no difference between the two groups in relation to median ICU stay [11 (5.7-20) vs. 9 (5.7-19)], recovery of kidney function (26.9 vs. 29.6 %, p = 0.11), need for chronic dialysis (9.7 vs. 6.5 %, p = 0.23), and hospital mortality (63.4 vs. 63.9 %, p = 0.94). The groups were different in metabolic and fluid control. Blood urea nitrogen (BUN), creatinine, and bicarbonate levels were stabilized faster in EHD group than in HVPD group. Delivered Kt/V and ultrafiltration were higher in EHD group. Despite randomization, there were significant differences between the groups in some covariates, including age, pre-dialysis BUN, and creatinine levels, biased in favor of the EHD. Using logistic regression to adjust for the imbalances in group assignment, the odds of death associated with HVPD was 1.4 (95 % CI 0.7-2.4, p = 0.19). A detailed investigation of the randomization process failed to explain the marked differences in patient assignment. Conclusions: Despite faster metabolic control and higher dialysis dose and ultrafiltration with EHD, this study provides no evidence of a survival benefit of EHD compared with HVPD. The limitations of this study were that the results were not presented according to the intention to treat and it did not control other supportive management strategies as nutrition support and timing of dialysis initiation that might influence outcomes in AKI. © 2012 Springer Science+Business Media Dordrecht.

Efeitos da Cetamina S(+) em dose subanestésica sobre a função e a histologia renal, em modelo de isquemia e reperfusão em ratos

Pós-graduação em Anestesiologia - FMB

Efeito do jejum e da realimentação sobre as funções metabólicas da tartaruga Kinosternon scorpioides (LINNAEUS, 1776) criada em cativeiro

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Extended Daily Dialysis in Acute Kidney Injury Patients: Metabolic and Fluid Control and Risk Factors for Death

Intermittent hemodialysis (IHD) and continuous renal replacement therapies (CRRT) are used as Acute Kidney Injury (AKI) therapy and have certain advantages and disadvantages. Extended daily dialysis (EDD) has emerged as an alternative to CRRT in the management of hemodynamically unstable AKI patients, mainly in developed countries.Objectives: We hypothesized that EDD is a safe option for AKI treatment and aimed to describe metabolic and fluid control of AKI patients undergoing EDD and identify complications and risk factors associated with death.Study Selection: This is an observational and retrospective study describing introduction of EDD at our institution. A total of 231 hemodynamically unstable AKI patients (noradrenalin dose between 0.3 and 1.0 ucg/kg/min) were assigned to 1367 EDD session. EDD consisted of 6-8 h of HD 6 days a week, with blood flow of 200 ml/min, dialysate flows of 300 ml/min.Data Synthesis: Mean age was 60.6 +/- 15.8 years, 97.4% of patients were in the intensive care unit, and sepsis was the main etiology of AKI (76.2). BUN and creatinine levels stabilized after four sessions at around 38 and 2.4 mg/dl, respectively. Fluid balance decreased progressively and stabilized around zero after five sessions. Weekly delivered Kt/V was 5.94 +/- 0.7. Hypotension and filter clotting occurred in 47.5 and 12.4% of treatment session, respectively. Regarding AKI outcome, 22.5% of patients presented renal function recovery, 5.6% of patients remained on dialysis after 30 days, and 71.9% of patients died. Age and focus abdominal sepsis were identified as risk factors for death. Urine output and negative fluid balance were identified as protective factors.Conclusions: EDD is effective for AKI patients, allowing adequate metabolic and fluid control. Age, focus abdominal sepsis, and lower urine output as well as positive fluid balance after two EDD sessions were associated significantly with death.

Dialysis complications in acute kidney injury patients treated with prolonged intermittent renal replacement therapy sessions lasting 10 versus 6 hours: results of a randomized clinical trial

Prolonged intermittent renal replacement therapy (PIRRT) has emerged as an alternative to continuous renal replacement therapy in the management of acute kidney injury (AKI) patients. This trial aimed to compare the dialysis complications occurring during different durations of PIRRT sessions in critically ill AKI patients. We included patients older than 18 years with AKI associated with sepsis admitted to the intensive care unit and using noradrenaline doses ranging from 0.3 to 0.7 mu g/kg/min. Patients were divided into two groups randomly: in G1, 6-h sessions were performed, and in G2, 10-h sessions were performed. Seventy-five patients were treated with 195 PIRRT sessions for 18 consecutive months. The prevalence of hypotension, filter clotting, hypokalemia, and hypophosphatemia was 82.6, 25.3, 20, and 10.6%, respectively. G1 was composed of 38 patients treated with 100 sessions, whereas G2 consisted of 37 patients treated with 95 sessions. G1 and G2 were similar in male predominance (65.7 vs. 75.6%, P=0.34), age (63.6 +/- 14 vs. 59.9 +/- 15.5 years, P=0.28) and Sequential Organ Failure Assessment score (SOFA; 13.1 +/- 2.4 vs. 14.2 +/- 3.0, P=0.2). There was no significant difference between the two groups in hypotension (81.5 vs. 83.7%, P=0.8), filter clotting (23.6 vs. 27%, P=0.73), hypokalemia (13.1 vs. 8.1%, P=0.71), and hypophosphatemia (18.4 vs. 21.6%, P=0.72). However, the group treated with sessions of 10h were refractory to clinical measures for hypotension, and dialysis sessions were interrupted more often (9.5 vs. 30.1%, P=0.03). Metabolic control and fluid balance were similar between G1 and G2 (blood urea nitrogen [BUN]: 81 +/- 30 vs. 73 +/- 33mg/dL, P=1.0; delivered Kt/V: 1.09 +/- 0.24 vs. 1.26 +/- 0.26, P=0.09; actual ultrafiltration: 1731 +/- 818 vs. 2332 +/- 947mL, P=0.13) and fluid balance (-731 +/- 125 vs. -652 +/- 141mL, respectively) . In conclusion, intradialysis hypotension was common in AKI patients treated with PIRRT. There was no difference in the prevalence of dialysis complications in patients undergoing different durations of PIRRT.

Ischemic postconditioning and subanesthetic S(+)-Ketamine infusion: effects on renal function and histology in rats

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Effects of an isostretching training protocol to increase the musculoarticular flexibility and other physiological aspetcs on the quality of life

Purpose: To apply the technique of Isostretching in a group of people over age 50 years and compare the flexibility of the posterior muscular chain before and after treatment, observing whether there was improvement in quality of life after the end of the sessions. Method: Eleven healthy and sedentary people from 51 to 74 years old participated in the study, which was conducted in Brazil. To evaluate the flexibility we applied the SF-36 questionnaire and test flexion of the spine before and after the study. Eight domains were accessed with the scores ranging form zero to one hundred. Results And Discussion:The technique was effective to gain flexibility of the posterior muscle group, which results in better quality of life for the participants. The results show that the domains related to physical health obtained the highest scores (“functional capacity”, “limitation in physical aspects” and “pain”). These aspects are strongly emphasised in a physical therapy treatment.

Acid-base and biochemical stabilization and quality of recovery in male cats with urethral obstruction and anesthetized with propofol or a combination of ketamine and diazepam

This study compared acid-base and biochemical changes and quality of recovery in male cats with experimentally induced urethral obstruction and anesthetized with either propofol or a combination of ketamine and diazepam for urethral catheterization. Ten male cats with urethral obstruction were enrolled for urethral catheterization and anesthetized with either ketamine-diazepam (KD) or propofol (P). Lactated Ringer's solution was administered by intravenous (IV) beginning 15 min before and continuing for 48 h after relief of urethral obstruction. Quality of recovery and time to standing were evaluated. The urethral catheter was maintained to measure urinary output. Hematocrit (Hct), total plasma protein (TPP), albumin, total protein (TP), blood urea nitrogen (BUN), creatinine, pH, bicarbonate (HCO3-), chloride, base excess, anion gap, sodium, potassium, and partial pressure of carbon dioxide in mixed venous blood (pvCO(2)) were measured before urethral obstruction, at start of fluid therapy (0 h), and at subsequent intervals. The quality of recovery and time to standing were respectively 4 and 75 min in the KD group and 5 and 16 min in the P group. The blood urea nitrogen values were increased at 0, 2, and 8 h in both groups. Serum creatinine increased at 0 and 2 h in cats administered KD and at 0, 2, and 8 h in cats receiving P, although the values were above the reference range in both groups until 8 h. Acidosis occurred for up to 2 h in both groups. Acid-base and biochemical stabilization were similar in cats anesthetized with propofol or with ketamine-diazepam. Cats that received propofol recovered much faster, but the ketamine-diazepam combination was shown to be more advantageous when treating uncooperative cats as it can be administered by intramuscular (IM) injection.