May 27, 2016

Perfect timing

The story

Two of the most viewed articles in medicine this week looked at the timing of renal replacement therapy (RRT) initiation in the ICU.  Their conclusions weren't quite opposite, but close.

The case for early

Zorbeck and colleagues made a splash with some flashy numbers for early RRT. Their single-center study of 223 patients in Germany found a 15% decrease in 90-day mortality for early initiation of RRT (when patients reached KDIGO stage 2 acute kidney injury) vs. late RRT (stage 3 AKI). The early group needed RRT for shorter time periods, had shorter hospital stays, and spent fewer hours on mechanical ventilation.   

The case for late

We told you last week about the multicenter, 620 patient AKIKI trial. Early (stage 3 AKI) vs. late RRT (strict RRT indication) did not produce a difference in mortality at 60 days, but the late group had fewer line infections and was often spared dialysis.

Side by side

The two trials have serious differences. Big picture stuff includes the method of RRT – Zarbock's study used continuous veno-venous hemofiltration (CVVH), while AKIKI mostly used intermittent hemodialysis – and the meaning of 'early initiation', since Zarbock's early group started RRT sooner than AKIKI's. Critics of the Zarbock study found the mortality difference a bit too good to be true, since the median delay in RRT initiation between the early and late groups was a mere 19 hours.

The takeaway

In the ICU, you call the renal fellow more than your significant other, and that's not about to change. But with a possible mortality benefit for early RRT, expect more research to help settle the subject.

Say it on rounds

When a good bowel prep teaches life lessons

What goes in must come out, so checking urine can tell you if your patients are eating salty foods. Chronic kidney disease patients in the highest quartile of urinary sodium excretion were 11% more likely to have a cardiovascular event than those in the lowest quartile. The difference was mostly driven by new heart failure, and hypertension did not seem to mediate adverse outcomes.

When you run to a tele arrest

Sometimes fake is better than real. Emicizumab, a humanized antibody that mimics cofactor function in factor VIII, markedly decreased bleeding episodes in 18 Japanese patients with severe Hemophilia A in an open-label study. A robot video narrarator can take you through the details.

When easier hours on your outpatient block come coupled with weekend night coverage

It's tough to have it all in residency. And with aspirin use after a lower GI bleed, you can't get the benefits of cardio protection without the risks of recurrent bleeding. A retrospective review of 290 patients found that resuming aspirin after an episode of bleeding was associated with a 12% increased risk of recurrent lower GI bleeding, but a 14% decreased risk of cardiovascular events.

Brush up

Extracorporeal membrane oxygenation (ECMO)

In severe respiratory or cardiac failure, an ECMO circuit can function as an artificial heart and lungs. Venous blood is withdrawn from a drainage cannula, then passed through an oxygenator where gas exchange occurs, and reinfused into the right atrium through a cannula in the internal jugular vein (venovenous). If circulatory support is needed in addition to respiratory support, blood can be returned into an artery (venoarterial).

What's the evidence

For ECMO in severe acute respiratory distress syndrome (ARDS)? 2009's CESAR trial showed a relative risk of death of 37% vs. 53% when patients were referred to an experienced center for consideration of ECMO vs. managed with standard (non-lung protective) ventilation. A trial comparing ECMO to ARDS standard management is underway.

What your GI friends are talking about

Intestinal fortitude? A study presented at DDW suggests fecal transplant may improve symptoms in refractory ulcerative colitis. But the practice takes commitment: patients self-administered 40 enemas over 8 weeks.

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