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Acta Medica Colombiana

Print version ISSN 0120-2448

Acta Med Colomb vol.47 no.2 Bogotá Apr./June 2022  Epub Jan 04, 2023

https://doi.org/10.36104/amc.2022.2229 

Original works

Clinical outcomes in patients who need acute renal replacement therapy in the intensive care unit

JUAN CAMILO SALAZAR-RAMÍREZa  * 

MARÍA CRISTINA FLORIÁN-PÉREZb 

CÉSAR AUGUSTO RESTREPO-VALENCIAc 

ALAN DAVID MONTOYA-QUINTEROd 

LUIS ALBERTO MENESES-RIASCOSd 

VÍCTOR FABIO SUÁREZ-CHILMAe 

a Internista y Geriatra Universidad de Caldas; Manizales (Colombia).

b Internista e Intensivista Unidad de Cuidado Intensivo Hospital Uni versitario Santa Sofía de Caldas. Directora General de Posgrado de Medicina Crítica y Cuidado Intensivo Universidad de Manizales. Profesor Titular de Postgrado Medicina Interna y Geriatría Universidad de Caldas; Manizales (Colombia).

c Médico Internista y Nefrólogo SES Hospital de Caldas. Profesor Titular de Postgrado de Medicina Interna y Geriatría Universidad de Caldas; Manizales (Colombia).

d Médicos Generales Unidad de Cuidado Intensivo, Hospital Departamental Universitario Santa Sofía de Caldas; Manizales (Colombia).

e Magister en Ingeniería Industrial, Especialista en Educación con Nuevas Tecno logías, Universidad Nacional de Colombia-Sede Manizales. Manizales (Colombia).


Abstract

Objective:

to establish the renal outcomes of patients needing dialysis due to acute kidney injury who were admitted to the intensive care unit at Hospital Departamental Universitario Santa Sofía de Caldas from 2006 to 2018, and determine the factors associated with these outcomes.

Methods:

a retrospective cohort study carried out at Hospital Departamental Universitario Santa Sofía de Caldas on 122 patients over the age of 18 who required dialysis in the intensive care unit due to acute kidney injury, from 2006 to 2018. The major adverse kidney events (MAKE) composite outcome was evaluated, composed of partial recovery of kidney function, dialysis dependence and death, with 90-day and one-year follow up.

Results:

there is a relationship between diabetes, the APACHE II score, metabolic acidosis, anuria and the dialysis start time and MAKE at 90 days and one year. In the logistic regression, patients who developed MAKE at 90 days had a greater probability of having had anuria (OR=6.71; 95%CI: 1,497-30,076), acidosis (OR=4,349; 95%CI: 1,616-11.7) and a late treatment start (OR=3,013; 95%CI: 1,241-7,316). The one-year MAKE showed similar results, with the addition of the continu ous therapy modality (OR=2,841; 95%CI: 1,193-6,763).

Conclusions:

diabetes, a high APACHE II, anuria, metabolic acidosis and late dialysis treat ment are more frequent in patients who develop MAKE. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2229).

Keywords: dialysis; major kidney outcomes (MAKE); renal recovery

Resumen

Objetivo:

determinar los desenlaces renales de los pacientes con requerimiento de diálisis por lesión renal aguda, que ingresaron a la unidad de cuidado intensivo del Hospital Departamental Universitario Santa Sofía de Caldas desde el año 2006 a 2018 y determinar los factores asociados a estos desenlaces.

Métodos:

estudio retrospectivo de cohortes llevado a cabo en el Hospital Departamental Universitario Santa Sofía de Caldas en 122 pacientes mayores de 18 años, que requirieron diálisis por lesión renal aguda en la unidad de cuidado intensivo entre los años 2006 y 2018. Se evaluó el desenlace compuesto del MAKE (Major Adverse Kidney Events) conformado por recuperación parcial de la función renal, dependencia de la diálisis y muerte con seguimiento a los 90 días y un año.

Resultados:

existe asociación entre diabetes, puntaje APACHE II, acidosis metabólica, anuria y tiempo de inicio de la diálisis con el MAKE a 90 días y al año. En la regresión logística aquellos pacientes que desarrollaron MAKE a los 90 días tenían mayor probabilidad de haber presentado anuria (OR=6.71; IC95%: 1497-30 076), acidosis (OR=4349; IC95%: 1616-11.7) e inicio tardío de la terapia (OR=3013; IC95%: 1241-7316). En el MAKE a un año hubo resultados similares, adicionando modalidad de terapia continua (OR=2841; IC95%: 1193-6763).

Conclusiones:

diabetes, APACHE II alto, anuria, acidosis metabólica y terapia dialítica tardía son más frecuentes en pacientes que desarrollan MAKE. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2229).

Palabras clave: diálisis; desenlaces renales mayores (MAKE); recuperación renal

Introduction

Intensive care units (ICUs) have changed the overall focus of various diseases, increasing the treatment pos sibilities and decreasing the associated mortality and comorbidity. One of the diseases with the greatest change over the last few years has been acute kidney injury (AKI) with the need for renal replacement therapy (RRT). It is estimated that up to 21.6% of patients admitted to the hospital have AKI, with 10% of these cases requiring RRT 1. Wald et al. reported an increased incidence of acute kidney injury with the need for RRT comparing the five-year periods of 1996-2000 and 2006-2010, at 0.8% and 3.0%, respectively, with the 90-day need for chronic RRT at 25% in ICU patients 2.

Anywhere from 13-78% of AKI cases in the ICU have medical causes, and surgical conditions account for 16 to 30% of the cases 3, with 5.6% of all of these requiring RRT. The 28, 90 and 365-day mortality in this context is 51, 60 and 64%, respectively 4, with wide variances between studies 5. Furthermore, kidney function and the need for chronic dialysis have been the focus of ongoing research. Wald et al. reported that, in 21,234 patients, 90-day RRT dependence was 27.2% 2.

Many factors are associated with the clinical outcomes and a predisposition to needing dialysis in the ICU. The most frequently reported factors are high blood pressure, diabetes, heart failure, chronic kidney disease 6,7, and the chronic use of medications such as acetylsalicylic acid (ASA), angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), diuretics, non-steroidal anti-inflammatory drugs (NSAIDs), and proton pump inhibitors (PPIs) 8,9. The type of RRT and timing of its initiation are also included, with a substantial dispar ity in the results of different studies in this regard 10.

Moreover, there are different definitions of kidney recovery, specifically in this type of patient, based on dif ferent creatinine or glomerular filtration rate (GFR) cut-off points 11. Pannu et al. showed that a greater than 25% deterioration in kidney function from the baseline GFR is the point at which the risk of other outcomes such as death and the need for chronic RRT increases 12, this being the starting point for evaluating the composite outcome of major adverse kidney events (MAKE) in patients with AKI13. The objective of the current study was to determine the clinical outcomes of patients needing acute dialysis using MAKE assessment in 90-day and one-year follow-up.

Materials and methods

Study design

A single-center, longitudinal, analytical study with a retrospective cohort was carried out at a tertiary care hos pital (Hospital Departamental Universitario Santa Sofía de Caldas) in the city of Manizales, Caldas, Colombia, including all patients requiring renal replacement therapy exclusively due to AKI, according to the Clinical Practice Guidelines for Acute Kidney Injury (KDIGO) criteria14, with 90-day and one-year follow up. This study was approved by the ethics committee of the health sciences department at Universidad de Caldas, and the ethics com mittee of Hospital Departamental Universitario Santa Sofía de Caldas.

The clinical charts of all patients who were admitted to the hospital's ICU and required RRT between 2006 and 2018 were reviewed. The clinical charts were selected using the institution's Hosvital® software, which allows selection by institutional units and, within the units, a key word search using terms like «dialysis,» «hemodialyis,» «renal replacement therapy,» and «hemodiafiltration,» to select patients who received RRT. The primary outcome was the occurrence of the MAKE compound outcome composed of death, partial kidney function recovery (un derstood as a creatinine level more than 25% higher than the baseline creatinine, with no RRT requirement) and the need for dialysis at 90 days and one year>s follow up. The secondary outcomes included the MAKE components analyzed separately during the same follow up periods.

Patients

The inclusion criteria were: patients over the age of 18 who were admitted to the ICU from 2006 to 2018, AKI with the need for RRT, and a creatinine report recorded in the institution's computerized clinical chart within the last year. For patients without a record of the last creatinine, the first creatinine taken on admission was used, as long as the RRT was not begun less than 48 hours after draw ing this lab. Exclusion criteria: need for RRT in the year prior to hospitalization, kidney transplants, prior GFR <30 mL/min/m2 BS by MDRD, and no reported creatinine at 90 days or one year.

Variables

Sociodemographic and anthropometric variables, as well as medical history, prior use of medications associ ated with AKI (ACE inhibitors, ARBs, ASA, diuretics, PPIs, and NSAIDs), the etiology of the AKI and need for RRT (hypovolemic shock, cardiogenic shock, septic shock, obstructive uropathy, cardiovascular surgery or other etiologies), type of therapy (continuous/intermittent therapy), and timing of treatment initiation (early initia tion understood to be RRT in a patient with KDIGO 3 AKI without emergency dialysis criteria: hypercalcemia greater than 6.5 mEq/L with abnormal electrocardiographic find ings, diuretic-resistant fluid overload/anasarca or pulmo nary edema, metabolic acidosis, uremic encephalopathy, persistent anuria and uremia; or late initiation understood as KDIGO 3 AKI with any of the previously mentioned criteria for emergency dialysis) were analyzed. The severity of the patient's clinical condition was also considered using the APACHE II score, delirium and days of hospital stay. For renal function, baseline creatinine and GFR estimated by the MDRD formula were used. In addition, a creatinine sample was taken and the GFR was estimated at 90 days and one year, recorded in the institution's medical chart and verifying the presence or absence of chronic RRT or a record of death in the mentioned periods.

Statistical analysis

The analysis of the collected data was performed using SPSS version 21 statistical software. Categorical variables were described using absolute and relative frequencies. The Kolmogorov-Smirnov test was used to determine the normal or asymmetric distribution of quantitative variables. Measures of central tendency and dispersion were used, such as mean and standard deviation (SD) for variables with a normal distribution, and median and interquartile range (IQR) for variables with asymmetric distribution. Chi-square was used to evaluate the association between qualitative variables, and then a comparison of means of the dichotomous quantitative variables was conducted using the Mann Whitney U test for asymmetric variables and Student's t-test for those with a normal distribution. P values <0.05 were considered to be significant. Survival was assessed by the Kaplan-Meier method, using log rank to detect significant differences between the groups of interest evaluated. A logistic regression model was run, calculating the OR to evaluate predictors of MAKE (at 90 days and one year) and individual mortality.

Results

Patient selection and general characteristics

A total of 252 clinical charts of patients who received RRT from 2006 to 2018 were found. Eighty-six patients were excluded due to having begun RRT prior to being admitted to the ICU, 39 due to being admitted to the institution needing emergency dialysis without a prior creatinine report, and five due to not having GFR follow up at one year. A total of 122 patients were included in the study. Table 1 summarizes the patients' characteristics.

Table 1 General patient characteristics. 

Variable n=122
Sex
Male 81 (66.3)
Female 41 (33.6)
Age, median (IQR) 60 (42-71)
Weight, median (IQR) 60 (55-70)
Baseline creatinine, mean in mg/dL (SD) 1.1 (0.4)
Baseline GFR, median mL/min/m2 (IQR) 75.7 (51-101.8)
History of diabetes, n (%) 19 (15.5)
History of heart failure, n (%) 23 (18.8)
History of HTN, n (%) 52 (42.6)
Prior use of ASA, n (%) 23 (18.8)
Prior use of ACE inhibitors/ARBs, n (%) 38 (31.1)
Prior use of diuretics, n (%) 28 (22.9)
Prior use of NSAIDs, n (%) 7 (5.7)
Prior use of PPIs, n (%) 16(13.1)
Delirium, n (%) 47 (38.5)
APACHE II score on admission, median (IQR) 22 (17-27)
Days of hospital stay, median (IQR) 28.5 (10-54)
Etiology
Septic shock n (%) 79 (64.7)
Carcinogenic shock n (%) 34 (27.8)
Obstructive uropathy n (%) 3 (2.4)
Cardiovascular surgery n (%) 15 (12.2)
Hypovolemic shock n (%) 10 (8.1)
Other etiology 12 (9.8)
Therapy modality
Continuous therapy, n (%) 85 (69.6)
Intermittent therapy, n (%) 38 (31.1)
Timing of RRT
Early initiation, n (%) 34 (27.8)
Late initiation, n (%) 88 (72.1)
Criteria for initiating late therapy
Anuria n (%) 34 (27.8)
Metabolic acidosis n (%) 57 (46.7)
Oliguria n (%) 9 (7.3)
Hypercalcemia n (%) 13 (10.6)
Uremia n (%) 14 (11.4)
Fluid overload n (%) 26 (21.3)
Uremic encephalopathy n (%) 1 (0.8)
HTN: Hypertension, ACE inhibitors: Angiotensin converting enzyme inhibitors, ARBs: angiotensin II receptor blockers, NSAIDs: non-steroidal anti-inflammatory drugs, PPIs: proton pump inhibitors, GFR: glomerular filtration rate. RRT: renal replacement therapy. APACHE II: Acute Physiology And Chronic Health Evaluation IQR: interquartile range, SD: standard deviation.

Primary outcome

An evaluation of MAKE at 90 days showed that it was associated with a history of diabetes, a higher APACHE II score, anuria, acidosis, and the timing of RRT initiation (a greater percentage of patients in the late initiation group developed MAKE). In the one-year analysis, the therapy modality was added to the mentioned variables (a greater percentage of patients in the continuous therapy group), as shown in Table 2. No associations were found with the kidney stage on admission or other variables.

Table 2 MAKE compound outcome at 90 days and one year and associated variables. 

Variable MAKE 90 DAYS MAKE 1 YEAR
Absent, n=28 Present, n=94 P value Absent, n=29 Present, n=93 P value
Hisory of diabetes, n (%) 3.6 19.1 0.046* 0 20.4 0.008*
APACHE, median (IQR) 19.5 (15-23) 23 (17-28) 0.036* 19 (15-23) 23 (17-28) 0.036*
Days of hospital stay, median (IQR) 63 (49-80.5) 19.5 (9-39) 0.000* 62 (48-81) 19 (9-36) 0.000*
Baseline creatinine, mean (SD) 1.0 (0.4) 1.1 (0.4) 0.468 1.0 (0.4) 1.1 (0.4) 0.734
Baseline eGFR, median (IQR) 86.9 (64 101.8) 74 (48.7 101.4) 0.178 86.6 (62.8 98.5) 74.6 (48.8 102.5) 0.322
Type of therapy
Continuous therapy, n (%) 18.8 81.2 0.1 17.6 82.4 0.016*
Intermittent therapy, n (%) 31.6 68.4 0.127 36.8 63.2 0.23*
Timing of initiation
Early initiation, n (%) 38.2 61.8 0.013* 38.2 61.8 0.020*
Late initiation n (%) 17 83 0.013* 18.2 81.8 0.020*
Criteria for initiation
Anuria, n (%) 7.1 34 0.005* 6.9 34.4 0.004*
Acidosis, n (%) 21.4 54.3 0.002* 24.1 53.8 0.005*
APACHE II: Acute Physiology And Chronic Health Evaluation. HTN: Hypertension. MAKE: major adverse kidney events. eGFR: estimated glomerular filtration rate. IQR: interquartile range, SD: standard deviation.

Secondary outcomes

At the 90-day follow up, an association was found between dialysis dependence and a history of high blood pressure, obstructive uropathy, NSAIDs, metabolic acidosis, hypercalcemia, anuria and uremic encephalopathy, with a persistent association at one year with NSAIDs, metabolic acidosis, anuria and uremic encephalopathy (Table 3). At 12 months, an analysis of renal outcomes according to the chronic kidney disease stage on admission showed that 65.6% of the patients were in stage 2 or better, 18.9% in 3a and 15.6% in 3b. Altogether, 64.2% of the cases fully recovered kidney function, 45.2% of whom were in stage 2 on admission. An association was found between the kidney stage on admission and the renal outcomes after 12 months (p=0.000), mainly showing a greater dependence on dialysis for patients with GFR in stage.

Table 3 Renal results of surviving patients at 90 days and one year. 

Variable 90-day survivors One-year survivors
Full recovery (n=21) Partial recovery (n=7) Dialysis (n=4) P value Full recover (n=21) Partial recover (n=7) Dialysis (n=3) P value
History of HTN, n (%) 38.1 14.3 100 0.049* 33.3 42.9 100 0.188
Use of NSAIDs, n (%) 0 0 50 0.001* 0 0 66.7 0.000*
Obstructive uropathy, n (%) 0 0 25 0.027* 0 14.3 0 0.194
Baseline eGFR, median, (IQR) 75.6 (38.6 12.8) 128.3 (87 174.5) 53.7(31.6 -98.5) 0.001* 85.3 (55.9 93.3) 98.5 (86.2 134.8) 40.4 (31.6 44.2) 0.010*
Type of therapy
Continuous therapy, n (%) 81.3 18.8 0 0.069 80 20 0 0.170
Intermittent therapy, n (%) 50 25 25 0.069 56.30 25 18.8 0.170
Timing of RRT initiation
Early initiation, n (%) 69.2 30.8 0 0.168 62.9 30.8 0 0.242
Late initiation, n (%) 63.2 15.8 21.1 0.168 66.7 16.7 16.7 0.242
Criterion for initiation
Anuria, n (%) 9.5 0 0 0.015* 9.5 0 0 0.020*
Acidosis, n (%) 28.6 0 100 0.002* 23.8 28.6 100 0.022*
Hypercalcemia, n (%) 4.8 28.6 50 0.019* 9.5 14.3 33.3 0.615
Uremic encephalopathy, n (%) 0 0 25 0.000* 0 0 33.3 0.000*
NSAIDs: non-steroidal anti-inflammatory drugs. APACHEII: Acute Physiology And Chronic Health Evaluation. ARBs: angtiotensin II receptor blockers. HTN: Hypertension, ACE inhibi tors: Angiotensin converting enzyme inhibitors. eGFR: estimated glomerular filtration rate. IQR: interquartile range, SD: standard deviation.

Inpatient mortality was 73.7% (90 patients). Thirty-two patients had survived at 90 days, and 31 at 12 months. An as sociation was found between one-year mortality and a higher APACHE II score, diabetes, and the type and timing of RRT initiation, with a greater percentage of deaths in continuous and late-initiating therapy, and in the presence of anuria. A Kaplan-Meier analysis was performed comparing mortality according to timing of initiation and type of therapy, with statistically significant differences found (Figures 1 and 2).

Figure 1 Graph of 12-month survival using the Kaplan-Meier method by treatment modality (p=0.000 by log rank). 

Figure 2 Graph of 12-month survival using the Kaplan-Meier method by timing of treatment (p=0.027 by log rank). 

A logistic regression analysis was performed with the variables associated with MAKE outcomes at 90 days and one year, and mortality at one year, finding that patients who developed MAKE at 90 days were more likely to have initiated therapy late, and to have had anuria and metabolic acidosis. There were similar results in the one-year follow up of MAKE and the mortality analysis, where continuous therapy was added (Table 4). The severity of the clinical condition on admission was evaluated according to the APACHE II score between therapy modalities and the timing of initiation variables, with no differences found for either comparison (p=0.836 between intermittent vs. continuous RRT, and p=0.808 between early vs. late RRT).

Table 4 Multivariate analysis using logistic regression. 

Variable OR 95% CI
90-day MAKE
Early initiation 0.332 0.137-0.806*
Late initiation 3.013 1.241-7.316*
Anuria 6.71 1.497-30.076*
Metabolic acidosis 4.349 1.616-11.7*
Diabetes 6.39 0.814-50.222
One-year MAKE
Early initiation 0.359 0.149-0.864*
Late initiation 2.786 1.157-6.706*
Continuous therapy 2.841 1.193-6.763*
Intermittent therapy 0.373 0.157-0.884*
Anuria 7.082 1.582-31.697*
Metabolic acidosis 3.654 1.423-9.385*
Death at one year
Early initiation 0.415 0.175-0.986*
Late initiation 2.407 1.015-5.713*
Continuous therapy 3.556 1.509-8.375*
Intermittent therapy 0.299 0.127-0.701*
Anuria 7.86 1.76-35.10*
MAKE: major adverse kidney events

Discussion

This study found a relationship between the compound outcome of MAKE and diabetes, APACHE II, timing of RRT initiation and anuria at 90 days and one year, when the modality of RRT was added, with similar results on the logistic regression. In addition, arterial hypertension, NSAIDs, obstructive uropathy, anuria, metabolic acidosis, hypercalcemia and uremic encephalopathy were associated with chronic RRT therapy at 90 days, with an association with NSAIDs, anuria, metabolic acidosis and uremic en cephalopathy persisting at one year.

The results evidence the complexity and worse prognosis of patients who require RRT due to AKI in the ICU. Inpatient mortality was 73.77% at 90 days and 74.5% at one year. Compared with other studies reporting mortality between 41 and 65%, ours had greater inpatient mortality. However, we had a lower mortality between the follow up periods 15-19, also associated with the severity of the clinical condition. Other authors described an association with a positive fluid balance, metabolic acidosis, late initiation of therapy and continuous therapy, similar to the findings of this study, although they did not maintain these findings in the multivariate analysis 15. There are likely to be differences in mortality, mainly related to sociodemographic variables, given the origin of the patients admitted to our institution, compared with international studies.

One of the important points in this study is the evalu ation of the MAKE compound outcome, which in recent years has been proposed as the best way to characterize the results in patients with AKI. Few studies have evaluated this outcome in the ICU. De Corte et al. 15 analyzed MAKE in 1,292 patients, 86 and 87.5% of whom developed this outcome at 90 days and one year of follow up, respectively, these being higher results than those of our study (77.04% for MAKE at 90 days and 76.22% for MAKE at one year). The most significant associations included kidney stage 3 on ICU admission, oligo/anuria, and the severity of the clinical condition on admission 15, similar to our study. M. Meersch et al. followed the patients who participated in the ELAIN study, with MAKE analysis at the 12 month follow up, finding that 64.9% of the patients who received early therapy developed MAKE at one year compared with 89.1% of the patients who began therapy late 20. Although there is some concordance with our findings, the differences in the definition of the timing of therapy should be noted. The STARRT-AKI study evaluated the results of early vs. late implementation of RRT, with secondary analysis of the MAKE components at 90 days, finding no differences 21. As can be seen, a large proportion of the compound outcome is due to inpatient mortality, as found in the studies men tioned as well as our own. It is clear that MAKE evaluation provides important information regarding these patients' outcomes; however, looking at its individual components also supplies other relevant data, as done in our study.

Within the renal outcomes, 65.62% had full recovery of renal function, 21.87% had partial recovery and 12.5% were dialysis-dependent at 90 days, with similar results after one year. Compared with similar studies, there was a lower per centage of RRT requirement compared with the FINNAKI study 22 (18.9%) and a greater percentage compared with the RENAL 23 and IVOIRE 24 studies (5.6% and 1.4%, respectively). At one-year follow up, there was a similar need for RRT in the studies by Meersch et al. 20 and Conroy et al. 19, coinciding in the association of this outcome with oligo/anuria and worse kidney function on admission 15. An association was found between worse kidney function on admission (kidney stage 3b) and the need for chronic dialysis, just as in studies by other authors 15,25-27.

The bivariate analysis showed an association between the type of therapy and timing of initiation, and MAKE and mortality. Regarding the continuous therapy outcomes, these could be explained by the implementation of this therapy in patients with greater hemodynamic instability, reflecting a worse clinical condition at a given time. Most randomized studies have not shown any differences when evaluating the therapy modality, mentioning the great equality between the various study arms compared with ours 28,29. Further more, an association has not been found between dialysis dependence and the modality of treatment, a situation which some authors have presented in their papers, noting that the vast majority of these are observational studies 30-32. In Schneider et al.'s systematic review 33, this hetero geneity is mainly found in observational studies, in which differences are found in clinical outcomes, as opposed to randomized studies.

Regarding the timing of initiation, we found worse results in MAKE and mortality in the group with late initiation, with no effect found on kidney outcomes. These findings differ partially from the randomized studies of recent years. We share findings with the ELAIN study 34 with, however, a clear difference in the definition of early initiation, which makes comparison difficult. On the other hand, in other randomized studies with 28 and 90-day follow up and a similar initiation criterion to ours, there is no similarity in the findings, which could be partially explained by the dif ference in the number of patients in the treatment initiation groups compared with these papers 21,35-37. While there are differences in the findings with regard to mortality, there is consistency in the kidney outcomes, corroborated by vari ous meta-analyses 38-40.

The strengths include: a broad analysis of the condi tions associated with clinical outcomes not included in other publications, as well as 90-day and one-year follow up. The MAKE evaluation is a more comprehensive way of analyzing the effects of treatment in this type of patient. The limitations include retrospective data collection, a sample from a single institution, the different number of patients according to the type and timing of RRT, the low number of patients in follow up, and not including other sociodemographic and nutritional variables which could be determining factors in mortality.

In conclusion, the APACHE II score, high blood pressure, NSAIDs, obstructive uropathy, metabolic acidosis, anuria, hypercalcemia and uremic encephalopathy were associated with the need for RRT at 90 days. Mortality was greater in patients with late-starting or continuous RRT. Anuria, a higher APACHE II score, and continuous or late-starting RRT are more frequent in patients who develop MAKE.

References

1. Levey Andrew S, James Matthew T. Acute Kidney Injury. Ann Intern Med. 2017 Nov 7;167(9):ITC66. doi: 10.7326/AITC201711070 [ Links ]

2. Wald Ron, McArthur Eric, Adhikari Neill KJ, Bagshaw Sean M, Burns Karen EA, Garg Amit X, et al. Changing Incidence and Outcomes Following Dialysis-Requiring Acute Kidney Injury Among Critically Ill Adults: A Population-Based Cohort Study. Am J Kidney Dis. 2015 Jun;65(6):870-7. Available from: doi:10.1053/j.ajkd.2014.10.017 [ Links ]

3. Case J, Khan S, Khalid R, Khan A. Epidemiology of acute kidney injury in the intensive care unit. Crit Care Res Pr. 2013;2013:479730. Available from: doi:10.1155/2013/479730 [ Links ]

4. Bagshaw Sean M, Laupland Kevin B, Doig Christopher J, Mortis Garth, Fick Gordon H, Mucenski Melissa, et al. Prognosis for long-term survival and renal recovery in critically ill patients with severe acute renal failure: a population-based study. Crit Care. 2005;9(6):R700-9. Available from: doi:10.1186/cc3879 [ Links ]

5. Ponce Daniela, Zorzenon Caroline de Pietro Franco, Santos Nara Yamane dos, Teixeira Ubirajara Aparecido, Balbi André Luís. Injúria renal aguda em unidade de terapia intensiva: estudo prospectivo sobre a incidência, fatores de risco e mortalidade. Rev Bras Ter Intensiva. 2011 Sep;23(3):321-6. Available from: doi:10.1590/S0103-507X2011000300010 [ Links ]

6. Cartin-Ceba Rodrigo, Kashiouris Markos, Plataki Maria, Kor Daryl J, Gajic Ognjen, Casey Edward T. Risk Factors for Development of Acute Kid ney Injury in Critically Ill Patients: A Systematic Review and Meta-Analysis of Observational Studies. Crit Care Res Pract. 2012;2012:1-15. Available from: doi:10.1155/2012/691013 [ Links ]

7. Czempik Piotr, Ciesla Daniel, Knapik Piotr, Krzych Lukasz J. Risk factors of acute kidney injury requiring renal replacement therapy based on regional registiy data. Anestezjol Intens Ter. 2016 Jul 19;48(3): 185-90. Available from: doi:10.5603/AIT.a2016.0033 [ Links ]

8. Perazella Mark A. Drug use and nephrotoxicity in the intensive care unit. Kidney Int. 2012;81(12): 1172-8. Available from: doi:10.1038/ki.2010.475 [ Links ]

9. Yang Yi, George Kaisha C, Shang Wei Feng, Zeng Rui, Ge Shu Wang, Xu Gang. Proton-pump inhibitors use, and risk of acute kidney injury: A meta-analysis of observational studies. Drug Des Devel Ther. 2017;11:1335-51. doi: 10.2147/DDDT.S130568 [ Links ]

10. Bagshaw Sean M, Darmon Michael, Ostermann Marlies, Finkelstein Fredric O, Wald Ron, Tolwani Ashita J, et al. Current state of the art for renal replace ment therapy in critically ill patients with acute kidney injury. Intensive Care Med. 2017;43(6):841-54. doi: 10.1007/s00134-017-4762-8 [ Links ]

11. Fortrie Gijs, Geus Hilde RH De, Betjes Michiel GH. The aftermath of acute kidney injury: a narrative review of long-term mortality and renal function. Crit Care. 2019;23(24): 1-11. [ Links ]

12. Pannu Neesh, James Matthew, Hemmelgarn Brenda, Klarenbach Scott. Association between AKI, Recovery of Renal Function, and Long-Term Outcomes after Hospital Discharge. Clin J Am Soc Nephrol. 2013 Feb;8(2): 194-202. Avail able from: doi:10.2215/CJN.06480612 [ Links ]

13. Kellum John A. How Can We Define Recovery after Acute Kidney Injuiy? Considerations from Epidemiology and Clinical Trial Design. Nephron Clin Pract. 2014 Sep 24;127(1-4):81-8. Available from: doi:10.1159/000363681 [ Links ]

14. Kellum John a, Lameire Norbert, Aspelin Peter, Barsoum Rashad S, Burdmann Emmanuel A, Goldstein Stuart L, et al. Summary of Recommendation Statements. Kidney IntSuppl. 2012 Mar;2(1):8-12. Available from: doi:10.1038/kisup.2012.7 [ Links ]

15. De Corte Wouter, Dhondt Annemieke, Vanholder Raymond, De Waele Jan, Decruyenaere Johan, Sergoyne Veerle, et al. Long-term outcome in ICU patients with acute kidney injury treated with renal replacement therapy: A prospective cohort study. Crit Care. 2016;20(1). Available from: doi:10.1186/s13054-016-1409-z [ Links ]

16. Uchino Shigehiko, Kellum John A, Bellomo Rinaldo, Morimatsu Hiroshi, Morgera Stanislao, Schetz Miet, et al. [Acute renal failure in critically ill pa tients]. JAMA. 2005;294(7):813-8. Available from: doi:10.4045/tidsskr.10.34549 [ Links ]

17. Schif Helmut, Lang Susanne M, Fischer Rainald. Long-term outcomes of survivors of ICU acute kidney injury requiring renal replacement therapy: a 10 year prospective cohort study. Clin Kidney J. 2012;5:297-302. Available from: doi:10.1093/ckj/sfs070 [ Links ]

18. Gallagher Martin, Cass Alan, Bellomo Rinaldo, Finfer Simon, Gattas David, Lee Joanne, et al. Long-Term Survival and Dialysis Dependency Following Acute Kidney Injury in Intensive Care: Extended Follow-up of a Randomized Controlled Trial. PLoS Med. 2014;11(2). doi: 10.1371/journal.pmed.1001601 [ Links ]

19. Conroy Michael, Flynn John O, Marsh Brian. Mortality and long-term dialysis requirement among elderly continuous renal replacement therapy patients in a tertiary referral intensive care unit. J Intensive Care Soc. 2019;20(2):138-43. doi: 10.1177/1751143718784868 [ Links ]

20. Meersch Melanie, Küllmar Mira, Schmidt Christoph, Gerss Joachim, Weinhage Toni, Margraf Andreas, et al. Long-Term Clinical Outcomes after Early Initiation of RRT in Critically Ill Patients with AKI. 2018; doi: 10.1681/ ASN.2017060694 [ Links ]

21. Bin Du, M.D., Ph.D., Martin P. Gallagher, M.D., Ph.D., Stéphane Gaudry, M.D., Ph.D., Eric A. Hoste, M.D., Ph.D., François Lamontagne, M.D., Michael Joannidis, M.D., Giovanni Landoni, M.D., Kathleen D. Liu, M.D., Ph.D., Daniel F. McAuley, M.D., Shay P. McG MD. Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury. N Engl J Med. 2020;383:240-51. doi: 10.1056/NEJMoa2000741 [ Links ]

22. Nisula Sara, Kaukonen Kirsi-Maija, Vaara Suvi T, Korhonen Anna-Maija, Poukkanen Meri, Karlsson Sari, et al. Incidence, risk factors and 90-day mortality of patients with acute kidney injury in Finnish intensive care units: the FINNAKI study. Intensive Care Med. 2013;39(3):420-8. Available from: doi:10.1007/s00134-012-2796-5 [ Links ]

23. Rinaldo Bellomo, M.D., Alan Cass, M.D., Ph.D., Louise Cole, M.D., Ph.D., Simon Finfer, M.D., Martin Gallagher, M.D., Serigne Lo, Ph.D., Colin McArthur, M.D., Shay McGuinness, M.D., John Myburgh, M.D., Ph.D., Robyn Norton, M.D., Ph.D., M.P.H., Carlos Sch Ph D. Intensity of Con tinuous Renal-Replacement Therapy in Critically Ill Patients. N Engl J Med. 2009;362(1):1597-605. doi: 10.1056/NEJMoa1215817 [ Links ]

24. Joannes-boyau Olivier, Bagshaw Sean M, Dewitte Antoine, Spapen Herbert D, Ouattara Alexandre. High-volume versus standard-volume haemofiltration for septic shock patients with acute kidney injury (IVOIRE study): a multicentre randomized controlled trial. Intensive Care Med. 2013;1535-46. doi: 10.1007/s00134-013-2967-z [ Links ]

25. Ponte Belén, Felipe Carmen, Muriel Alfonso, Tenorio Maria Teresa, Liaño Fernando. Long-term functional evolution after an acute kidney injury: A 10-year study. Nephrol Dial Transplant. 2008;23(12):3859-66. doi: 10.1093/ndt/gfn398 [ Links ]

26. Rimes-Stigare Claire, Frumento Paolo, Bottai Matteo, Mårtensson Johan, Martling Claes Roland, Bell Max. Long-term mortality and risk factors for development of end-stage renal disease in critically ill patients with and without chronic kidney disease. Crit Care. 2015;19(1). Available from: doi:10.1186/s13054-015-1101-8 [ Links ]

27. Sawhney Simon, Mitchell Mhairi, Marks Angharad, Fluck Nick, Black Corrinda. Long-term prognosis after acute kidney injury (AKI): What is the role of baseline kidney function and recovery? A systematic review. BMJ Open. 2015;5(1). doi: 10.1136/bmjopen-2014-006497 [ Links ]

28. Vinsonneau Christophe, Camus Christophe, Combes Alain, Alyette Marie, Beauregard Costa De, Klouche Kada, et al. Continuous venovenous haemodiafi ltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet. 2006;368:379-85. [ Links ]

29. Schefold Joerg C, Haehling Stephan V., Pschowski Rene, Bender Thorsten O, Berkmann Cathrin, Briegel Sophie, et al. The effect of continuous versus intermittent renal replacement therapy on the outcome of critically ill patients with acute renal failure (CONVINT): A prospective randomized controlled trial. Crit Care. 2014;18(1):1-11. doi: 10.1186/cc13188 [ Links ]

30. Wald Ron, Shariff Salimah Z, Adhikari Neill KJ, Bagshaw Sean M, Burns Karen EA, Friedrich Jan O, et al. The association between renal replacement therapy modality and long-term outcomes among critically ill adults with acute kidney injury: A retrospective cohort study. Crit Care Med. 2014;42(4):868-77. doi: 10.1097/CCM.0000000000000042 [ Links ]

31. Truche Anne Sophie, Darmon Michael, Bailly Sébastien, Clec'h Christophe, Dupuis Claire, Misset Benoit, et al. Continuous renal replacement therapy versus intermittent hemodialysis in intensive care patients: impact on mortality and renal recovery. Intensive Care Med. 2016;42(9):1408-17. doi: 10.1007/s00134-016-4404-6 [ Links ]

32. Liang Kelly V., Sileanu Florentina E, Clermont Gilles, Murugan Raghavan, Pike Francis, Palevsky Paul M, et al. Modality of RRT and recovery of kidney function after AKI in patients surviving to hospital discharge. Clin J Am Soc Nephrol. 2016;11(1):30-8. doi: 10.2215/CJN.01290215 [ Links ]

33. Schneider Antoine G, Bellomo Rinaldo, Bagshaw Sean M, Glassford Neil J, Lo Serigne, Jun Min, et al. Choice of renal replacement therapy modality and dialysis dependence after acute kidney injury: A systematic review and meta-analysis. Intensive Care Med. 2013;39(6):987-97. doi: 10.1007/s00134-013-2864-5 [ Links ]

34. Zarbock Alexander, Kellum John A, Schmidt Christoph, Van Aken Hugo, Wempe Carola, Pavenstädt Hermann, et al. Effect of early vs delayed initia tion of renal replacement therapy on mortality in critically ill patients with acute kidney injury: The elain randomized clinical trial. JAMA - J Am Med Assoc. 2016;315(20):2190-9. doi: 10.1001/jama.2016.5828 [ Links ]

35. Wald Ron, Adhikari Neill KJ, Smith Orla M, Weir Matthew A, Pope Karen, Cohen Ashley, et al. Comparison of standard and accelerated initiation of renal replacement therapy in acute kidney injury. Kidney Int. 2015;88(4):897-904. Available from: doi:10.1038/ki.2015.184 [ Links ]

36. Gaudry Stéphane, Hajage David, Schortgen Fréderique, Martin-Lefevre Laurent, Pons Bertrand, Boulet Eric, et al. Initiation Strategies for Renal-Re placement Therapy in the Intensive Care Unit. N Engl J Med. 2016;375(2): 122-33. Available from: doi:10.1007/BF01123134 [ Links ]

37. Lumlertgul Nuttha, Peerapornratana Sadudee, Trakarnvanich Thananda, Pongsittisak Wanjak, Surasit Kajbundit, Chuasuwan Anan, et al. Early versus standard initiation of renal replacement therapy in furosemide stress test non-re sponsive acute kidney injury patients (the FST trial). Crit Care. 2018;101(22):1-9. [ Links ]

38. Wei-ting L, Chih-cheng L, Shen-peng C, Jian-jhong W. Effects of early dialysis on the outcomes of critically ill patients with acute kidney injury: a systematic review and meta-analysis of randomized controlled trials. Sci Rep. 2019;(9):1-8. doi: 10.1038/s41598-019-54777-9 [ Links ]

39. Gaudry Stéphane, Hajage David, Benichou Nicolas, Chaïbi Khalil, Barbar Saber, Zarbock Alexander, et al. Delayed versus early initiation of renal replace ment therapy for severe acute kidney injury: a systematic review and individual patient data meta-analysis of randomised clinical trials. Lancet. 2020;395:1506-15. doi: 10.1016/S0140-6736(20)30531-6 [ Links ]

40. Aii Fayad, Dg Buamscha, Ciapponi A. Timing of renal replacement therapy initiation for acute kidney injury (Review). Cochrane Database Syst Rev Timing. 2018;(12). doi: 10.1002/14651858.CD010612.pub2. www.cochranelibrary.comLinks ]

Received: June 10, 2021; Accepted: January 27, 2022

*Correspondencia: Dr. Juan Camilo Salazar-Ramírez. Manizales (Colombia). E-Mail: greatsalaz@hotmail.com

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