The document discusses implementing early vascular access planning for inpatients starting hemodialysis to improve outcomes during the first year of outpatient hemodialysis. It notes that over 85% of incident hemodialysis patients started dialysis as inpatients and over 90% initiated with a dialysis catheter. The highest mortality risk for hemodialysis patients is in the first 120 days and is largely due to use of dialysis catheters. Converting from catheters to arteriovenous fistulas or grafts can reduce mortality by 15-50%. The document proposes predicting which inpatients will require long-term dialysis to target for early vascular access planning, including fistula placement before discharge. This "Early V
How to manage delays in stroke treatment Jacek StaszewskiJacek Staszewski
This document discusses strategies to manage delays in stroke treatment. It notes that while thrombolysis and thrombectomy have improved outcomes, time is still critical factor. Various factors can contribute to delays including pre-hospital times, hospital workflows, and patient factors. Studies demonstrate improved outcomes with shorter onset-to-treatment and door-to-needle times. Initiatives like pre-notification, standardized protocols, telemedicine, and programs like Target: Stroke that focus on key strategies have been shown to reduce times and increase treatment rates. While challenges remain, an emphasis on collaboration, continuous quality improvement and learning from initiatives can help further reduce delays to improve patient outcomes.
The document discusses definitions, recognition, and interventions for sepsis. It begins by defining sepsis, severe sepsis, and septic shock according to the American College of Chest Physicians and Society of Critical Care Medicine. It then provides diagnostic criteria for systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock. The document discusses early goal-directed therapy (EGDT) as proven to reduce mortality in severe sepsis/septic shock. It outlines the Surviving Sepsis Care Bundles that are meant to be completed within 3 and 6 hours. The document discusses several studies related to sepsis management including lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy and the findings that cardiac filling pressures are
Advancingdialysis.org cardiac arrhythmia in thrice weekly hemodialysisAdvancingDialysis.org
This study used continuous cardiac monitoring to examine arrhythmias in hemodialysis patients over 6 months. It found that:
- Nearly all patients (97%) experienced arrhythmias, with clinically significant arrhythmias occurring in 2/3 of patients. Bradycardia was the most common arrhythmia.
- Arrhythmia rates were highest during the first dialysis session of the week and the long interdialytic gap between sessions. Bradycardic events peaked late in the long gap.
- Atrial fibrillation spiked during dialysis and gradually decreased after, climbing again in the last 36 hours of the long gap.
- Dialysis prescriptions like higher dialysate
Remote Ischaemic Conditioning: A Paper Review & Uses in Paramedic Practicebgander23
A 2 part presentation. Part 1 reviews a paper on the long-term clinical outcomes of STEMI patients undergoing remote ischaemic perconditioning prior to primary percutaneous coronary intervention. The 2nd part looks at how this technique can be used in Paramedic practice.
This document discusses using intrathoracic impedance measures from implantable cardiac devices to monitor changes in intravascular fluid volume during volume reduction therapy for heart failure patients. It found that two impedance vectors, between the right atrial ring to left ventricular ring and the left ventricular ring to right ventricular ring, were most closely associated with changes in plasma volume as measured by hematocrit levels. Monitoring these specific impedance vectors may help more accurately guide volume reduction therapy by tracking changes in the intravascular fluid compartment.
This study reviewed 7 previous studies to investigate whether a 90 minute door-to-balloon time (DTB) metric improves outcomes for STEMI patients undergoing percutaneous coronary intervention (PCI). The results of the studies were mixed, with some showing decreased mortality for shorter DTB times below 2 hours, while others found no significant change in mortality even as DTB times decreased. The authors concluded that while DTB is important and any treatment delay can increase mortality, it is not the sole determining factor and total ischemic time must also be considered. Efforts to improve outcomes should focus on decreasing time from symptom onset to hospital presentation as well as time to treatment.
This study analyzed 96 renal transplant patients to evaluate aortic stiffness and its relationship to renal function. The study found:
1) Aortic pulse wave velocity (APWV), a measure of aortic stiffness, was inversely correlated with estimated glomerular filtration rate (eGFR), a measure of renal function - the poorer the renal function, the higher the aortic stiffness.
2) APWV increased with more advanced stages of chronic kidney disease (CKD), based on eGFR levels.
3) APWV was positively correlated with blood pressure levels.
The study concludes that aortic stiffness, as measured by APWV, is related to renal graft dysfunction as reflected by decreased e
How to manage delays in stroke treatment Jacek StaszewskiJacek Staszewski
This document discusses strategies to manage delays in stroke treatment. It notes that while thrombolysis and thrombectomy have improved outcomes, time is still critical factor. Various factors can contribute to delays including pre-hospital times, hospital workflows, and patient factors. Studies demonstrate improved outcomes with shorter onset-to-treatment and door-to-needle times. Initiatives like pre-notification, standardized protocols, telemedicine, and programs like Target: Stroke that focus on key strategies have been shown to reduce times and increase treatment rates. While challenges remain, an emphasis on collaboration, continuous quality improvement and learning from initiatives can help further reduce delays to improve patient outcomes.
The document discusses definitions, recognition, and interventions for sepsis. It begins by defining sepsis, severe sepsis, and septic shock according to the American College of Chest Physicians and Society of Critical Care Medicine. It then provides diagnostic criteria for systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock. The document discusses early goal-directed therapy (EGDT) as proven to reduce mortality in severe sepsis/septic shock. It outlines the Surviving Sepsis Care Bundles that are meant to be completed within 3 and 6 hours. The document discusses several studies related to sepsis management including lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy and the findings that cardiac filling pressures are
Advancingdialysis.org cardiac arrhythmia in thrice weekly hemodialysisAdvancingDialysis.org
This study used continuous cardiac monitoring to examine arrhythmias in hemodialysis patients over 6 months. It found that:
- Nearly all patients (97%) experienced arrhythmias, with clinically significant arrhythmias occurring in 2/3 of patients. Bradycardia was the most common arrhythmia.
- Arrhythmia rates were highest during the first dialysis session of the week and the long interdialytic gap between sessions. Bradycardic events peaked late in the long gap.
- Atrial fibrillation spiked during dialysis and gradually decreased after, climbing again in the last 36 hours of the long gap.
- Dialysis prescriptions like higher dialysate
Remote Ischaemic Conditioning: A Paper Review & Uses in Paramedic Practicebgander23
A 2 part presentation. Part 1 reviews a paper on the long-term clinical outcomes of STEMI patients undergoing remote ischaemic perconditioning prior to primary percutaneous coronary intervention. The 2nd part looks at how this technique can be used in Paramedic practice.
This document discusses using intrathoracic impedance measures from implantable cardiac devices to monitor changes in intravascular fluid volume during volume reduction therapy for heart failure patients. It found that two impedance vectors, between the right atrial ring to left ventricular ring and the left ventricular ring to right ventricular ring, were most closely associated with changes in plasma volume as measured by hematocrit levels. Monitoring these specific impedance vectors may help more accurately guide volume reduction therapy by tracking changes in the intravascular fluid compartment.
This study reviewed 7 previous studies to investigate whether a 90 minute door-to-balloon time (DTB) metric improves outcomes for STEMI patients undergoing percutaneous coronary intervention (PCI). The results of the studies were mixed, with some showing decreased mortality for shorter DTB times below 2 hours, while others found no significant change in mortality even as DTB times decreased. The authors concluded that while DTB is important and any treatment delay can increase mortality, it is not the sole determining factor and total ischemic time must also be considered. Efforts to improve outcomes should focus on decreasing time from symptom onset to hospital presentation as well as time to treatment.
This study analyzed 96 renal transplant patients to evaluate aortic stiffness and its relationship to renal function. The study found:
1) Aortic pulse wave velocity (APWV), a measure of aortic stiffness, was inversely correlated with estimated glomerular filtration rate (eGFR), a measure of renal function - the poorer the renal function, the higher the aortic stiffness.
2) APWV increased with more advanced stages of chronic kidney disease (CKD), based on eGFR levels.
3) APWV was positively correlated with blood pressure levels.
The study concludes that aortic stiffness, as measured by APWV, is related to renal graft dysfunction as reflected by decreased e
This study reviewed the management of 1432 grown-up congenital heart disease patients over 10 years at a tertiary hospital in India. It found a early morbidity rate of 5.2% and identified previous sternotomy, emergency procedures, cross-clamp time over 45 minutes, and cyanotic disease as significant risk factors. Outcomes were generally good with a mortality rate of 1.4% and 86% follow-up completeness. However, the study was limited by its single center retrospective design and loss to follow-up of simpler cases.
1) Radial artery spasm is a common complication of transradial catheterization and is caused by contraction of smooth muscle cells in response to catecholamines and mechanical stimuli.
2) Predictors of radial artery spasm include multiple puncture attempts and use of a 7F or larger sheath.
3) Strategies to prevent radial artery spasm include the use of intra-arterial, topical, or subcutaneous vasodilators like verapamil, nitroglycerin, and lidocaine. Moderate sedation with opioids and benzodiazepines can also help reduce spasm rates.
4) Verapamil 2.5mg appears to be the most effective
- The PIONEER AF-PCI trial compared the effectiveness and safety of different anticoagulation and antiplatelet therapy combinations in patients with atrial fibrillation undergoing percutaneous coronary intervention with stent placement.
- Patients were randomized to receive either rivaroxaban plus a single antiplatelet, rivaroxaban plus dual antiplatelet therapy, or warfarin plus dual antiplatelet therapy.
- The trial found that rivaroxaban-based regimens resulted in lower rates of clinically significant bleeding than warfarin-based standard therapy, while rates of cardiovascular events were similar across groups.
Thrombectomy in Stroke: DAWN and DEFUSE3 trial dataSCGH ED CME
The document summarizes key findings from several recent clinical trials evaluating endovascular thrombectomy for acute ischemic stroke:
1. The HERMES meta-analysis of 5 randomized controlled trials from 2010-2015 found endovascular thrombectomy plus standard care significantly reduced disability at 90 days compared to standard care alone.
2. The DEFUSE3 trial of 182 patients found endovascular therapy plus medical therapy improved functional outcomes and reduced mortality compared to medical therapy alone for strokes 6-16 hours.
3. The DAWN trial of 206 patients found the same benefits for strokes 6-24 hours when a clinical-radiological mismatch was present. Both DEFUSE3 and DAWN saw no increase in serious adverse events.
2. continuous renal replacement therapy recent advances and future researchEdleo13
The document summarizes two large randomized controlled trials that provide new evidence to guide clinicians on the use of continuous renal replacement therapy (CRRT) for acute kidney injury (AKI) in intensive care units (ICUs). The ATN and RENAL trials investigated different intensities of CRRT and found that effluent flow rates above 25 ml/kg per hour do not improve outcomes. The trials also established CRRT as the most appropriate treatment for vasopressor-dependent AKI patients in the ICU. However, questions remain regarding optimal initiation thresholds and timing of CRRT.
1) The VISSIT trial compared outcomes of 112 patients with symptomatic intracranial stenosis randomized to balloon-expandable stent plus medical therapy or medical therapy alone. At 1 year, the stent group had a higher risk of stroke or TIA compared to the medical therapy group.
2) The CADISS trial randomized 250 patients with carotid or vertebral artery dissection to antiplatelet drugs or anticoagulant drugs for 3 months. Both groups had low risks of stroke, with no significant difference between treatments.
3) The ATTEST trial compared tenecteplase to alteplase in 104 patients with acute ischemic stroke within 4.5 hours of onset. There were no significant differences in pen
This document discusses dialytic support for patients with acute kidney injury (AKI). It begins by outlining classifications and definitions of AKI severity. It then addresses many open questions regarding renal replacement therapy (RRT) for AKI, such as when to start, what modality to use, and when to stop. The document reviews various RRT modalities and considerations for their use. It provides guidelines on determining when to initiate RRT based on lab values and clinical criteria. Overall, the document aims to help clinicians navigate the many decisions that must be made in providing RRT for AKI patients.
Monitoring and surveillance_of_vascular_accessNaveen Kumar
This document discusses surveillance of vascular access in hemodialysis patients. It notes that while arteriovenous fistulas and grafts are superior to catheters, vascular access complications are common. Guidelines suggest various surveillance methods to maintain access patency, including monitoring physical signs and using tests like access flow measurements and ultrasound imaging to detect stenosis early. Randomized controlled trials on the benefits of surveillance vs monitoring alone have shown conflicting results, but surveillance is generally associated with fewer thrombotic events, hospitalizations, and missed treatments. However, there is no conclusive evidence yet that surveillance prolongs overall access lifespan.
This document provides an overview and discussion of recent literature on renal replacement therapy (RRT) in intensive care. It summarizes key findings from two important studies from 2008 and 2009 that compared higher vs lower intensity RRT and found no difference in outcomes. It also discusses ongoing questions around optimal timing of RRT initiation and potential roles of biomarkers like NGAL. Modes of RRT like SLED are presented as alternatives to CRRT. While high volume hemofiltration was theorized to help modulate the immune response in sepsis, studies found no clear benefit and it cannot be recommended as standard practice. Ongoing research on biomarkers and optimal dosing and timing is still needed.
This document discusses hemodynamic monitoring and blood flow measurement. It notes that physical assessment of patients is often inaccurate and slow to change. While blood pressure is commonly measured, blood flow and pressure do not always correlate as compensatory mechanisms can keep blood pressure normal even when blood flow declines. The document advocates measuring stroke volume as a more direct indicator of blood flow status. It reviews various techniques for measuring stroke volume, noting that esophageal Doppler monitoring has the most evidence from randomized controlled trials showing it can reduce length of hospital stay when used for intraoperative fluid optimization in high-risk patients.
This document discusses hemodynamic monitoring and blood flow measurement. It notes that physical assessment of patients is often inaccurate and slow to change. While blood pressure is commonly measured, blood flow and pressure do not always correlate as compensatory mechanisms can keep blood pressure normal even when blood flow declines. The document advocates measuring stroke volume as a more direct indicator of blood flow status. It reviews various techniques for measuring stroke volume, noting that esophageal Doppler monitoring has the most evidence from randomized controlled trials showing it can reduce length of hospital stay when used to guide fluid administration in surgical patients.
BLOOD TRANSFUSIONS ARE ASSOCIATED WITH MORTALITY IN PEDIATRIC PATIENTS WITH S...Texas Children's Hospital
Restrictive thresholds for red blood cell (RBC) transfusion have not been shown to be inferior to liberal transfusion thresholds after cardiac surgery in pediatric or adult patients.1,2
RBC transfusions are associated with readmission due to heart failure (HF) in adults after aortic valve replacements, and with increased risk of right ventricle-pulmonary artery conduit failure in pediatric patients.3,4
Data are limited about RBC transfusions in pediatric patients with HF.
Novel strategies to improve diastolic functiondrucsamal
This document summarizes Gerd Hasenfuss's presentation on novel strategies to improve diastolic function and reduce elevated left atrial pressure in patients with heart failure with preserved ejection fraction (HFpEF). It discusses an inter-atrial shunt device that creates a small permanent connection between the atria, baroreceptor activation therapy, the Aldo-DHF trial which found spironolactone improved diastolic function in HFpEF, and a study showing exercise training improved exercise capacity and quality of life in HFpEF. The presentation emphasizes that high left atrial pressure is a key factor in morbidity and mortality for HFpEF and these strategies aim to reduce left atrial pressure.
This document summarizes the outcomes of an emerging pediatric cardiac surgery program's experience with surgical palliation of hypoplastic left heart syndrome (HLHS) and related anomalies between 2010-2014. The program achieved an overall hospital survival rate of 81% by utilizing different surgical strategies including the Norwood procedure, hybrid procedure, and salvage hybrid-bridge-to-Norwood procedure based on individual patient factors. Cardiac comorbidities such as obstructed pulmonary venous return influenced the choice to use a hybrid or salvage strategy. The program's flexible approach and matching of surgical strategy to patient characteristics helped achieve outcomes comparable to benchmark data, despite being a new program.
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?SMACC Conference
This document discusses the goals of early goal directed therapy (EGDT) for sepsis patients and questions whether all patients should have the same goals. It outlines the goals of EGDT - oxygen saturation, central venous pressure, mean arterial pressure, and central venous oxygen saturation. It notes that sepsis patients often have comorbidities that need to be considered when setting goals. While the treatments to achieve the goals can have adverse effects, EGDT may provide a mortality benefit through a multifaceted quality improvement approach. The conclusion is that rigid targets should be avoided for septic patients and further high quality evidence is still needed.
Surgery vs conservative strategy in aortic stenosisShivani Rao
1) This study compared outcomes of an initial aortic valve replacement (AVR) strategy versus a conservative watchful waiting strategy in asymptomatic patients with severe aortic stenosis using data from a large Japanese multicenter registry.
2) They found that the initial AVR strategy was associated with significantly lower risks of all-cause death, cardiovascular death, aortic valve-related death, and heart failure hospitalization at 5 years compared to the conservative strategy.
3) The benefits of initial AVR over conservative watchful waiting were seen both in propensity score-matched analyses and analyses of the full cohort adjusted for baseline differences, suggesting initial AVR may improve long-term outcomes in asymptomatic severe aortic stenosis.
Peritoneal dialysis (PD) is associated with better preservation of residual kidney function compared to hemodialysis (HD). PD also has advantages such as lower infection risks and improved quality of life through increased employment rates and lifestyle flexibility compared to HD. However, PD remains underutilized in many countries despite its benefits. Factors contributing to underutilization include modality preferences of nephrologists, lack of patient education, and system-related barriers. Integrated care approaches emphasizing early referral and shared modality decision-making between patients and nephrologists are optimal for end-stage renal disease treatment.
This study reviewed the management of 1432 grown-up congenital heart disease patients over 10 years at a tertiary hospital in India. It found a early morbidity rate of 5.2% and identified previous sternotomy, emergency procedures, cross-clamp time over 45 minutes, and cyanotic disease as significant risk factors. Outcomes were generally good with a mortality rate of 1.4% and 86% follow-up completeness. However, the study was limited by its single center retrospective design and loss to follow-up of simpler cases.
1) Radial artery spasm is a common complication of transradial catheterization and is caused by contraction of smooth muscle cells in response to catecholamines and mechanical stimuli.
2) Predictors of radial artery spasm include multiple puncture attempts and use of a 7F or larger sheath.
3) Strategies to prevent radial artery spasm include the use of intra-arterial, topical, or subcutaneous vasodilators like verapamil, nitroglycerin, and lidocaine. Moderate sedation with opioids and benzodiazepines can also help reduce spasm rates.
4) Verapamil 2.5mg appears to be the most effective
- The PIONEER AF-PCI trial compared the effectiveness and safety of different anticoagulation and antiplatelet therapy combinations in patients with atrial fibrillation undergoing percutaneous coronary intervention with stent placement.
- Patients were randomized to receive either rivaroxaban plus a single antiplatelet, rivaroxaban plus dual antiplatelet therapy, or warfarin plus dual antiplatelet therapy.
- The trial found that rivaroxaban-based regimens resulted in lower rates of clinically significant bleeding than warfarin-based standard therapy, while rates of cardiovascular events were similar across groups.
Thrombectomy in Stroke: DAWN and DEFUSE3 trial dataSCGH ED CME
The document summarizes key findings from several recent clinical trials evaluating endovascular thrombectomy for acute ischemic stroke:
1. The HERMES meta-analysis of 5 randomized controlled trials from 2010-2015 found endovascular thrombectomy plus standard care significantly reduced disability at 90 days compared to standard care alone.
2. The DEFUSE3 trial of 182 patients found endovascular therapy plus medical therapy improved functional outcomes and reduced mortality compared to medical therapy alone for strokes 6-16 hours.
3. The DAWN trial of 206 patients found the same benefits for strokes 6-24 hours when a clinical-radiological mismatch was present. Both DEFUSE3 and DAWN saw no increase in serious adverse events.
2. continuous renal replacement therapy recent advances and future researchEdleo13
The document summarizes two large randomized controlled trials that provide new evidence to guide clinicians on the use of continuous renal replacement therapy (CRRT) for acute kidney injury (AKI) in intensive care units (ICUs). The ATN and RENAL trials investigated different intensities of CRRT and found that effluent flow rates above 25 ml/kg per hour do not improve outcomes. The trials also established CRRT as the most appropriate treatment for vasopressor-dependent AKI patients in the ICU. However, questions remain regarding optimal initiation thresholds and timing of CRRT.
1) The VISSIT trial compared outcomes of 112 patients with symptomatic intracranial stenosis randomized to balloon-expandable stent plus medical therapy or medical therapy alone. At 1 year, the stent group had a higher risk of stroke or TIA compared to the medical therapy group.
2) The CADISS trial randomized 250 patients with carotid or vertebral artery dissection to antiplatelet drugs or anticoagulant drugs for 3 months. Both groups had low risks of stroke, with no significant difference between treatments.
3) The ATTEST trial compared tenecteplase to alteplase in 104 patients with acute ischemic stroke within 4.5 hours of onset. There were no significant differences in pen
This document discusses dialytic support for patients with acute kidney injury (AKI). It begins by outlining classifications and definitions of AKI severity. It then addresses many open questions regarding renal replacement therapy (RRT) for AKI, such as when to start, what modality to use, and when to stop. The document reviews various RRT modalities and considerations for their use. It provides guidelines on determining when to initiate RRT based on lab values and clinical criteria. Overall, the document aims to help clinicians navigate the many decisions that must be made in providing RRT for AKI patients.
Monitoring and surveillance_of_vascular_accessNaveen Kumar
This document discusses surveillance of vascular access in hemodialysis patients. It notes that while arteriovenous fistulas and grafts are superior to catheters, vascular access complications are common. Guidelines suggest various surveillance methods to maintain access patency, including monitoring physical signs and using tests like access flow measurements and ultrasound imaging to detect stenosis early. Randomized controlled trials on the benefits of surveillance vs monitoring alone have shown conflicting results, but surveillance is generally associated with fewer thrombotic events, hospitalizations, and missed treatments. However, there is no conclusive evidence yet that surveillance prolongs overall access lifespan.
This document provides an overview and discussion of recent literature on renal replacement therapy (RRT) in intensive care. It summarizes key findings from two important studies from 2008 and 2009 that compared higher vs lower intensity RRT and found no difference in outcomes. It also discusses ongoing questions around optimal timing of RRT initiation and potential roles of biomarkers like NGAL. Modes of RRT like SLED are presented as alternatives to CRRT. While high volume hemofiltration was theorized to help modulate the immune response in sepsis, studies found no clear benefit and it cannot be recommended as standard practice. Ongoing research on biomarkers and optimal dosing and timing is still needed.
This document discusses hemodynamic monitoring and blood flow measurement. It notes that physical assessment of patients is often inaccurate and slow to change. While blood pressure is commonly measured, blood flow and pressure do not always correlate as compensatory mechanisms can keep blood pressure normal even when blood flow declines. The document advocates measuring stroke volume as a more direct indicator of blood flow status. It reviews various techniques for measuring stroke volume, noting that esophageal Doppler monitoring has the most evidence from randomized controlled trials showing it can reduce length of hospital stay when used for intraoperative fluid optimization in high-risk patients.
This document discusses hemodynamic monitoring and blood flow measurement. It notes that physical assessment of patients is often inaccurate and slow to change. While blood pressure is commonly measured, blood flow and pressure do not always correlate as compensatory mechanisms can keep blood pressure normal even when blood flow declines. The document advocates measuring stroke volume as a more direct indicator of blood flow status. It reviews various techniques for measuring stroke volume, noting that esophageal Doppler monitoring has the most evidence from randomized controlled trials showing it can reduce length of hospital stay when used to guide fluid administration in surgical patients.
BLOOD TRANSFUSIONS ARE ASSOCIATED WITH MORTALITY IN PEDIATRIC PATIENTS WITH S...Texas Children's Hospital
Restrictive thresholds for red blood cell (RBC) transfusion have not been shown to be inferior to liberal transfusion thresholds after cardiac surgery in pediatric or adult patients.1,2
RBC transfusions are associated with readmission due to heart failure (HF) in adults after aortic valve replacements, and with increased risk of right ventricle-pulmonary artery conduit failure in pediatric patients.3,4
Data are limited about RBC transfusions in pediatric patients with HF.
Novel strategies to improve diastolic functiondrucsamal
This document summarizes Gerd Hasenfuss's presentation on novel strategies to improve diastolic function and reduce elevated left atrial pressure in patients with heart failure with preserved ejection fraction (HFpEF). It discusses an inter-atrial shunt device that creates a small permanent connection between the atria, baroreceptor activation therapy, the Aldo-DHF trial which found spironolactone improved diastolic function in HFpEF, and a study showing exercise training improved exercise capacity and quality of life in HFpEF. The presentation emphasizes that high left atrial pressure is a key factor in morbidity and mortality for HFpEF and these strategies aim to reduce left atrial pressure.
This document summarizes the outcomes of an emerging pediatric cardiac surgery program's experience with surgical palliation of hypoplastic left heart syndrome (HLHS) and related anomalies between 2010-2014. The program achieved an overall hospital survival rate of 81% by utilizing different surgical strategies including the Norwood procedure, hybrid procedure, and salvage hybrid-bridge-to-Norwood procedure based on individual patient factors. Cardiac comorbidities such as obstructed pulmonary venous return influenced the choice to use a hybrid or salvage strategy. The program's flexible approach and matching of surgical strategy to patient characteristics helped achieve outcomes comparable to benchmark data, despite being a new program.
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?SMACC Conference
This document discusses the goals of early goal directed therapy (EGDT) for sepsis patients and questions whether all patients should have the same goals. It outlines the goals of EGDT - oxygen saturation, central venous pressure, mean arterial pressure, and central venous oxygen saturation. It notes that sepsis patients often have comorbidities that need to be considered when setting goals. While the treatments to achieve the goals can have adverse effects, EGDT may provide a mortality benefit through a multifaceted quality improvement approach. The conclusion is that rigid targets should be avoided for septic patients and further high quality evidence is still needed.
Surgery vs conservative strategy in aortic stenosisShivani Rao
1) This study compared outcomes of an initial aortic valve replacement (AVR) strategy versus a conservative watchful waiting strategy in asymptomatic patients with severe aortic stenosis using data from a large Japanese multicenter registry.
2) They found that the initial AVR strategy was associated with significantly lower risks of all-cause death, cardiovascular death, aortic valve-related death, and heart failure hospitalization at 5 years compared to the conservative strategy.
3) The benefits of initial AVR over conservative watchful waiting were seen both in propensity score-matched analyses and analyses of the full cohort adjusted for baseline differences, suggesting initial AVR may improve long-term outcomes in asymptomatic severe aortic stenosis.
Peritoneal dialysis (PD) is associated with better preservation of residual kidney function compared to hemodialysis (HD). PD also has advantages such as lower infection risks and improved quality of life through increased employment rates and lifestyle flexibility compared to HD. However, PD remains underutilized in many countries despite its benefits. Factors contributing to underutilization include modality preferences of nephrologists, lack of patient education, and system-related barriers. Integrated care approaches emphasizing early referral and shared modality decision-making between patients and nephrologists are optimal for end-stage renal disease treatment.
This document outlines principles of continuous renal replacement therapy (CRRT) for acute kidney injury (AKI) management, including patient selection and prescription details. It discusses CRRT modalities and when each is appropriate. Regarding timing of CRRT initiation, early initiation may help mitigate AKI complications, though defining "early" remains challenging. Biomarkers like NGAL show promise in predicting AKI severity and prognosis but require more research. Overall CRRT aims to optimize fluid, electrolyte and acid-base balance for hemodynamically unstable AKI patients.
This document discusses continuous renal replacement therapy (CRRT) for acute kidney injury (AKI). It begins by defining CRRT and describing its indications, including life-threatening conditions like hyperkalemia and pulmonary edema. It recommends starting CRRT early in AKI and discusses modalities like CVVH, CVVHD, and CVVHDF. The document provides details on how to perform CRRT, such as catheter placement and settings. It also addresses complications and suggests using bicarbonate-based fluids and biocompatible membranes. In summary, the document provides a comprehensive overview of CRRT for AKI, including indications, modalities, procedures, and recommendations to optimize outcomes.
Rrt in icu dr said khamis zagazig april 2018 latestFarragBahbah
The document provides an overview of renal replacement therapy (RRT) modalities for critically ill patients with acute kidney injury (AKI). It discusses the history and evolution of RRT, including intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT). The pros and cons of IHD and CRRT are presented. Key considerations for RRT include which modality to use, anticoagulation options, dialysate buffers, and membranes. Guidelines for determining therapy dose and duration and criteria for discontinuing RRT are summarized. Outcomes with IHD versus CRRT remain unclear due to limitations of existing studies. Overall, the document reviews best practices for delivering RRT to critically ill AK
This document discusses peritoneal dialysis (PD) as a treatment for acute kidney injury (AKI) and end-stage renal disease (ESRD). It provides the following key points:
- PD can be used as a continuous renal replacement therapy for AKI and is a suitable method for correcting metabolic and electrolyte disturbances caused by AKI.
- For ESRD, an integrated care approach using PD first when medically suitable is optimal. PD preservation of residual kidney function and reduced infection risks provide initial survival benefits over hemodialysis.
- However, PD programs in many countries are underutilized due to factors including lack of education, physician preference, and system barriers. Increased support from various
1) The document discusses acute kidney injury (AKI) and cardiorenal syndrome (CRS) which are increasingly prevalent in patients with cardiovascular disease and associated with poor outcomes.
2) Continuous renal replacement therapy (CRRT) is a growing treatment for critically ill cardiac patients with AKI and refractory CRS in cardiac intensive care units (CICU).
3) Successful CRRT requires an integrated multidisciplinary team approach and further research is needed to improve management and outcomes for these high-risk cardiac patients.
The document discusses renal replacement therapy options for patients with end-stage renal disease, including hemodialysis, peritoneal dialysis, and kidney transplantation. It provides details on each treatment modality and emphasizes the importance of early referral to a nephrologist to allow time for vascular access placement, transplant evaluation, and patient education. The best vascular access for hemodialysis is an arteriovenous fistula due to its lower risk of infection and greater longevity. All statements regarding kidney transplantation timing and criteria are correct. Screening for malignancies is important in transplant recipients due to higher cancer risks with immunosuppression.
Dr. Osama El-Shahat discusses various aspects of acute kidney injury (AKI) management including staging, modalities of renal replacement therapy, and general principles. The document covers (1) staging systems like RIFLE and AKIN to classify AKI severity, (2) modalities like intermittent hemodialysis, slow continuous ultrafiltration, and continuous renal replacement therapy, and (3) general guidelines around initiating renal replacement therapy, vascular access, solutions, anticoagulation, and dose of therapy. The overall message is that managing AKI requires an individualized approach and more high-quality research is still needed.
This document provides an introduction, history, and indications for continuous renal replacement therapy (CRRT). It summarizes that CRRT was developed as an alternative to intermittent hemodialysis for critically ill patients. CRRT allows for slow, continuous removal of waste and fluid over many hours compared to brief, intermittent hemodialysis sessions. The document reviews the components of CRRT systems and indications for its use in critically ill patients with conditions like fluid overload, acidosis, hyperkalemia, or multi-organ dysfunction.
This randomized trial compared outcomes of 1-month dual antiplatelet therapy (DAPT) followed by aspirin monotherapy to 6-12 months of DAPT after stent implantation. 3,020 patients receiving polymer-free drug-coated stents or biodegradable polymer drug-eluting stents were randomly assigned to 1 of the 2 DAPT duration groups. The primary outcome of death, myocardial infarction, revascularization, stroke or major bleeding within 1 year occurred in similar rates between groups, demonstrating noninferiority of 1-month DAPT. No differences in individual components of the primary outcome or major bleeding were observed between groups. Thus, 1-month DAPT followed by aspirin monotherapy
1) The document discusses different modalities for providing dialytic support for acute kidney injury (AKI) patients, including intermittent and continuous renal replacement therapies.
2) It compares the pros and cons of different modalities and notes there is no clear evidence of differences in mortality or renal recovery between intermittent and continuous therapies.
3) Guidelines recommend considering patient hemodynamic stability and using continuous renal replacement therapy for unstable patients or those with brain injury, and emphasize starting renal replacement therapy based on clinical criteria rather than a single laboratory value.
This document discusses current methods for treating deep vein thrombosis (DVT) and the impact of post-thrombotic syndrome (PTS). It provides statistics on the prevalence and costs of DVT and PTS in the US. The document reviews changes to DVT treatment guidelines supporting early thrombus removal through pharmacomechanical thrombolysis. Clinical studies demonstrate pharmacomechanical thrombolysis improves outcomes over anticoagulation alone by increasing patency and reducing long-term PTS symptoms. The document concludes that early thrombus removal through pharmacomechanical techniques is the new standard of care for proximal DVT due to decreased complications and improved patient outcomes compared to anticoagulation or catheter-directed thrombolysis alone.
AKI, or acute kidney injury, occurs in 18% of hospital admissions and can be caused by sepsis, hypovolemia, drugs, acute glomerulonephritis, or obstruction. Early signs include increased serum creatinine, low blood pressure under 90, and low urine output under 500ml in 24 hours. Treatment focuses on fluid management and supportive care; starting renal replacement therapy is based on fluid overload and high blood urea levels. Continuous renal replacement therapy is preferred for hemodynamic instability while intermittent hemodialysis enables faster clearance but is riskier for unstable patients.
Outcome After Procedures for Retained Blood Syndrome in Coronary SurgeryPaul Molloy
OBJECTIVES:
Incomplete drainage of blood from around the heart and lungs can lead to retained blood syndrome (RBS) after cardiac sur-
gery. The aim of this study was to assess the incidence of and the outcome after procedures for RBS in patients undergoing isolated coronary artery bypass grafting (CABG)-
- An arteriovenous fistula is associated with better outcomes for patients undergoing hemodialysis compared to other types of vascular access.
- Patients with chronic kidney disease can be referred to a transplant center when their glomerular filtration rate (GFR) falls below 20 mL/min/1.73m2. Pre-emptive and live donor kidney transplants are associated with better graft survival compared to other types of transplants.
- Primary care providers play an important role in managing patients with kidney disease and those undergoing renal replacement therapies like dialysis and transplantation. This includes educating patients about treatment options and managing comorbidities.
1) The document describes a randomized controlled trial called ISCHEMIA-CKD that compared an invasive strategy (PCI or CABG) to a conservative strategy in patients with stable coronary disease, advanced chronic kidney disease, and moderate or severe ischemia.
2) The trial found that an initial invasive strategy did not result in a lower rate of death or nonfatal myocardial infarction compared to an initial conservative strategy.
3) Limitations of the trial included exclusion of very symptomatic patients and lower than expected event rates, reducing the power to detect differences between strategies.
Intraoperative oesophageal Doppler monitoring (ODM) guided fluid management was compared to standard central venous pressure (CVP) guided fluids in a randomized controlled trial of 128 colorectal surgery patients. ODM guided fluid optimization resulted in significantly shorter hospital length of stay, earlier return of gut function, fewer postoperative complications, and cost savings compared to CVP-guided fluids. ODM provided a more reliable assessment of intravascular volume status and cardiac preload than CVP alone.
1. Modifying the Highest Mortality Rate
in the Major AKI Adverse Outcome
Other than Death
LossESRD &
Incident Hemodialysis
EVA QI Program
&
AKI to ESRD Predictive Analytics
To Target Mortality & Hospitalization
Kevin Ho, M.D.
Renal-Electrolyte Division
UPMC & University of Pittsburgh
The Acute Kidney Injury Group
KH 09/12/12
2. Vascular Access is the Largest Modifiable
Mortality Risk Factor in Hemodialysis
During 1st
Year
Importance of early permanent vascular access
placement (arteriovenous fistula / AVF,
arteriovenous graft / AVG) and early discontinuation
of tunneled dialysis catheter (TDC) use
KH 09/12/12
3. Risk of Death is Highest During 1st
120 Days
• One-half of deaths (46%) occur within the 1st
120 days
• Dialysis catheters account for largest attributable fraction of
mortality risk during Year 1 (≤120 d and >120 d) on HD among
modifiable risk factors
• Primary cause of death = Cardiac
Bradbury BD et al. Clin J Am Soc Nephrol 2007; 2: 89-99.
Dialysis Outcomes & Practice Patterns Study (DOPPS), 1996-2004
n = 4,802 incident HD patients (U.S.)
27.5 (≤120 d) vs 21.9 deaths (>120 d) /100 pers-yrs
CARD INF
120 d
DeathRateper100person-yrs
0 d
Days at Risk
330 d
KH 09/12/12
4. Converting Vascular Access Affects Mortality
• Conversion of vascular
access in prior 4 months
resulted in a change in
mortality risk during next 8
months
• In 70,852 prevalent HD patients
Converting TDC to AVF/AVG:
29% decrease in mortality risk
• In 3,904 incident HD patients
Conversion of TDC to
AVF: 50% decrease in
mortality risk
TDC to AVF/AVG:
15% decrease in risk
Lacson Jr E et al. AJKD 2009; 54:912-921
Fresenius Medical Care, North America
Prevalent
Incident
HRforMortalityHRforMortality
TDC
AVG AVFAVF/G
TDC
AVG AVFAVF/G
KH 09/12/12
5. Hypothesis
Prediction of Incident ESRD following AKI &
Implementation of Early Vascular Access
Planning with Early AV Fistula Placement
Will Improve Survival when Mortality Risk is
Greatest During Year 1 of Hemodialysis
KH 09/12/12
6. Dialysis Catheter to Permanent Vascular Access in Incident HD
Inpatients who Transition to Outpatient Hemodialysis
• Critical observation: Of 175 incident UPP hemodialysis patients
(Presbyterian Hospital) referred to outpatient dialysis units (4/08-12/08)
85.1% initiated hemodialysis acutely as inpatients (149 of 175)
May contribute to low observed rate of pre-ESRD nephrology care
• Current national vascular access guidelines (Fistula First) address
only progression of CKD to ESRD in outpatients initiating
hemodialysis (Stage 4 CKD: eGFR 15 – 29 ml/min/1.73m2
)
• Baseline data (4/08-6/10): 826 patients initiated on hemodialysis,
459 patients were discharged on hemodialysis to outpatient dialysis units
• Of these incident HD inpatients, we examined a subset of 84 patients
discharged on hemodialysis to 8 of 18 JV dialysis units
90.5% initiated hemodialysis using a TDC
vs only 13.6% with pre-existing AVF/AVG
Andersen S…Ho K. Amer J Kidney Dis 2011; 57(4): A21, P-19KH 09/12/12
7. Inpatient Hemodialysis Initiation
826 consecutive adult inpatients* initiated on HD over 26 months;
466 dialysis-dependent at hospital discharge.
[*includes pre-existing ESRD (renal transplant, peritoneal dialysis)
not on HD during preceding 12 mo.]
Andersen S…Ho K. Amer J Kidney Dis 2011; 57(4): A21, P-19
Subset of 84 incident HD inpatients
discharged on HD to 8 dialysis units
Inpatient Subset (n=84)
Incident HD Inpatients n (%)
Non-ESRD 54 (64%)
ESRD:
Peritoneal Dialysis
13 (16%)
ESRD:
Prior Renal Transplant
17 (20%)
26 Months
(4/08 – 6/10)
Initiate
Inpatient HD
n=826
Inpatient
Death
n=214 (25.9%)
Discharge
To Outpatient Dialysis
n=466 (56.4%)
Inpatient
Renal Recovery
n=146 (17.7%)
Outpatient HD
Other Dialysis Units
n=375
Outpatient HD
Affiliated DCI Units
n=84
Outpatient PD
n=4
Lost to followup
n=3
KH 09/12/12
8. Vascular Access Conversion During 1st
HD Year
Bradbury BD et al. AJKD 2009; 53:804-814
CumulativeProbability
ofAccessConversion
100 200 300 4000
0.2
0.0
0.4
0.6
0.8
1.0
AVF
AVG
TDC
Follow-up Time (days)
59.0% Cumulative Prob of Conversion in 1st
HD Yr
Median time to AVF = 105 days
In our subset of incident HD inpatients, conversion from TDC
to permanent vascular access required a median time = 101 days
Comparable to 4,532 U.S. incident HD patients (<30d) in DOPPS Study I, II
KH 09/12/12
9. Dialysis Catheter to Permanent Vascular Access in Incident
HD Inpatients who Transition to Outpatient Hemodialysis
Inpatient
(Pre-Discharge)
Outpatient
(Post-Discharge)
Inpatient
Hemodialysis Initiation
Initial Vascular Access
Used for Inpatient HD
90.5% TDC 9.5% AVF
12.2% Pts
mean 5 d
median 7 d
87.8% Pts
mean 92.4 d
median 67.5 d
DISCHARGE
Outpatient
Hemodialysis Units
AV Fistula (AV Graft)
Surgery/Creation
Ultrasound
Vein Mapping
AV Fistula (AV Graft)
Surgery/Creation
Ultrasound
Vein Mapping
4/08-6/10
826 Inpatients
Initiate HD
459 Inpatients
Discharged on HD
Subset of
Incident HD
Inpatients
n=84
11.6% Pts
mean 2.8 d
median 2 d
88.4% Pts
mean 112 d
median 105.4 d
13.1% Pts
Pre-existing
AVFs
54% Pts
Initiating HD with TDC
Received AVF/AVG
Andersen S…Ho K. Amer J Kidney
Dis 2011; 57(4): A21, P-19
10. Are There Data to Justify Early Vascular Access
Planning in Inpatients?
Are there data predicting which inpatients acutely
initiated on hemodialysis for AKI will require
outpatient hemodialysis 3 months later for ESRD?
Yes.
Inpatient vascular access planning for incident HD inpatients is
clinically appropriate if specific patients can be predicted early on
to remain dialysis-dependent with no renal recovery at 3 months
following dialysis initiation, thereby fulfilling the CMS definition of
ESRD
KH 09/12/12
11. THE KEY: Low Renal Recovery in Inpatients Starting
Hemodialysis Transitioning to Outpatient Hemodialysis
54 Inpatients Known CKD Status in Prior 1 Yr
(no ESRD/CKD-T) Initiated on Hemodialysis
Subset of
Incident HD
Inpatients
n=84
4/08-6/10
Incident HD
Inpatients
Discharged
on HD
n=459
Clinical Basis for Early Vascular Access Planning Initiative in Inpatients
Andersen S…Ho K. J Am Soc Nephrol 2011; 22: 788A, P-2914
Total
Patients
Prior
Renal
Care
Renal Recovery
at 3 Months
Post-I nitiation
Pre-Admission
CKD Stage
(GFR ml/min/1.73m2
)
n n (%) n (%)
No CKD 6 n/a 2 (33)
Stage 1 (≥90) 1 0 (0) 0 (0)
Stage 2 (60 to <90) 0 n/a n/a
Stage 3A (30 to <45) 7 2 (29) 0 (0)
Stage 3B (45 to <60 14 6 (43) 0 (0)
Stage 4 (15 to <30) 19 15 (79) 0 (0)
Stage 5 (<15) 7 6 (86) 0 (0)
Total CKD Stages 1-5 48 29 (60) 0 (0)
Pre-Admission CKD Stage: Determined within 1 Yr prior to
admission - nephrology documentation > other MD
documentation > average of ≥ 3 baseline Cr values.
Prior Renal Care: Nephrology followup (including renal
transplantation followup for CKD-T)
Renal Recovery at 3 Months: Discontinuation of hemodialysis
as a result of improved renal function within 90 days of initiating
hemodialysis as inpatient
39% CKD 3A+3B
35% CKD 4
13% CKD 5
11% No CKD
KH 09/12/12
12. Inpatient AKI-on-CKD Leads to ESRD
• Multicenter, observational study of 9,425 Taiwanese post-surgical
inpatients admitted to surgical ICU and surviving to hospital discharge
– CKD = baseline eGFR <45ml/min/1.73m2
(Stage 3B+4+5)
• Risk of ESRD in AKI-on-CKD vs AKI-without-CKD, AHR = 19.8
Wu V-C et al. Kidney Int
2011(Dec);80:1222-1230
FreedomfromDialysis
+ AKI / + CKD
– AKI / – CKD
+ AKI R / – CKD
+ AKI I / – CKD
+ AKI F / – CKD
– AKI / + CKD
CKD status AKI status Long-term dialysis, HR (95% CI)
No prior CKD No AKI 1 (reference)
+ AKI 4.64 (2.51-8.56)*
+ Prior CKD No AKI 40.86 (20.01-83.50)*
+ AKI 91.6 (49.3-170.1)*
KH 09/12/12
13. • Functional measure of outpatient TDC use,
Defined: HDTDC = [(No. outpatient HD treatments using TDC) / (No. of total outpatient
HD treatments)] during time interval (HDTDC is inverse to AVF/G use)
• EARLY AVF/G group exhibited lower TDC use with mean HDTDC values of 57% and
33% for months 3 to 6 months and months 6 to 12, respectively, in comparison to
91% and 74% for the LATE AVF/G group
Andersen S…Ho K. J Am Soc Nephrol 2011; 22: 787A, P-2910
Early AVF placement
≤ 90 days (n=29)
Late AVF placement
> 90 days (n=38)
p=0.0004
p=0.0004
Does Earlier AVF Placement Translate to Earlier AVF Use
& Fewer TDC-Associated Treatments in Year 1?
KH 09/12/12
14. Early Vascular Access Planning Initiative
New Paradigm: EVA
What is our proposed QI approach?
Early Vascular Access Planning Initiative aims to:
Reduce conversion time from TDC to permanent
vascular access & reduce hospitalization and mortality
of hemodialysis patients in Year 1
KH 09/12/12
15. Shifting & Modifying Access Conversion Curve
Hypothesis: Early Vascular Access Conversion
Reduces Mortality in Year 1
TDC to Permanent Vascular Access Conversion
%PatientswithAVF(AVG)
Time (months)
Discharge
EVA Usual
MortalityRate
KH 09/12/12
16. Early Vascular Access (EVA) Planning Initiative
Dialysis Provider
Dialysis Unit start date
Form 2728 data
HD: incenter, SNF, home
ethnicity, race
medical insurance type
employment status
prior erythropoietin use
+
Vasc Access Data
Initial vasc access type
1st
AVF (AVG) use date
TDC treatment days
AVF (AVG) treatment days
Renal recovery, death
Dialysis Provider
Hospitalization Data
hospital days / mo
admission diagnosis
The Renal Network
& Dialysis Provider
Mortality Data
date of death
deaths/patient days at risk
Post-Discharge
1-Y Outpatient Data
Data Sharing
Agreements
Dialysis Data
Renal replacement initiation
date
1st
acute hemodialysis date
9999903 billing code
1st
CVVHD date
Renal Recovery
Death, CMO
HD Vasc Access Data
TDC (1st
) insertion date
(existing AVF/AVG?)
Renal RN education date
Vein mapping date
Vascular Surg Consult date
AVF (AVG) surgery date
Conversion time TDC to VA
TDC (last) removal date
Triggers
Data
Collection
EVA Mechanism
EMR EVA
Activation
Renal RN
Educator
Vascular Surg
RN Coordinator
Vein
Mapping
AVF (AVG)
Placement
Cerner Patient
Tracking List
Vascular
Access
Database
Discharge &
Admission
to Outpatient
Dialysis Unit
KH 09/12/12
17. Effect of Inpatient Early Vascular Access Planning on Outpatient Hemodialysis
Vascular Access Outcomes, Hospitalization, Mortality
EVA QI Measures
• Pre-implementation baseline status of inpatient vascular access planning
• Evaluate post-discharge outpatient effectiveness of QI mechanism
Data-sharing agreements: The Renal Network, DCI and FMC dialysis providers
• Primary Measures
EVA planning event occurrence (vein mapping, Vascular Surgery consultation,
vascular surgery, followup visit)
Conversion time from initial inpatient TDC placement to (a) initial AVF/AVG
placement (inpatient or outpatient) and (b) initial AVF/AVG use (two-needle) in
outpatient dialysis center setting
Hospitalization & mortality rates of incident HD inpatient patients during the
first 6 months and 12 months post-index hospital discharge
- date of initial TDC placement
- date of vein mapping procedure
- date of Vascular Surgery inpatient / outpatient consultation
- date of Vascular Surgery outpatient follow-up appointment
- date of initial AVF/AVG placement (inpatient or outpatient)
- date of conversion from TDC use to AVF/AVG use for outpatient HD treatments
- duration of pre-ESRD nephrology care prior to hemodialysis initiation
- occurrence of pre-dialysis erythropoiesis stimulating agent (ESA) therapy
- total hospital days post-index hospitalization within 1 year
- mortality events post-index hospitalization within 1 year
KH 09/12/12
18. “Non-recovery of renal function after AKI may be an important
contributor to growth in the number of incident end-stage renal disease
(ESRD) cases out of proportion to the increase in the prevalence of
CKD.” (Wu V-C et al. Kidney Int 2011;80:1222-1230)
An analytical system to Predict which Inpatients --
Develop Acute Kidney Injury (AKI),
initiate on hemodialysis, then Transition to ESRD
AKI to ESRD
Predictive Analytics
KH 09/12/12
19. AKI to ESRD Predictive Analytics Data Capture
Dialysis Provider
Dialysis Unit start date
Form 2728 data
HD: incenter, SNF, home
ethnicity, race
medical insurance type
employment status
prior erythropoietin use
+
Vasc Access Data
Initial vasc access type
1st
AVF (AVG) use date
TDC treatment days
AVF (AVG) treatment days
Renal recovery, death
Dialysis Provider
Hospitalization Data
hospital days / mo
admission diagnosis
ESRD Renal Network
& Dialysis Provider
Mortality Data
date of death
deaths/patient days at risk
Post-Discharge
1-Y Outpatient Data
Discharge &
Admission
to Outpatient
Dialysis Unit
Triggers
Data
Collection
Data Sharing
Agreements
Goal: Real-Time Data Capture
KH 09/12/12
20. AKI to ESRD Predictive Analytics
AKI Risk Factors (HITS), Biomarkers, EVA, Disposition
Acute
Precipitating
Factor(s)
Pre-Existing
Risk Factor(s)
Admission
Hospitalization
AKI Evolution
Inpatient
Outpatient
Outpatient
AMPLIFY
DEVELOP
MODEL
BASELINE
FACTORS
MODEL
PRECIPITATING
FACTORS
MODEL
AMPLIFYING
FACTORS
Acute
IHD1st
HIT 2nd
HIT
ESRD
Resolve
No
Recovery
EVA
Resolve
3RD
HIT
CKD
ESRD
CKD
Develop / Use
Biomarkers
KH 09/12/12
21. AKI to ESRD Predictive Analytics
InpatientOutpatient OutpatientAKI Evolution
Admission
Hospitalization
DEVELOP
Acute
IHD1st
HIT 2nd
HIT ESRD
No
Recovery
3RD
HIT
Analytic
Hierarchy
Process
Analytic
Hierarchy
Process
Analytic
Hierarchy
Process
Acute
Precipitating
Factor(s)
Pre-Existing
Risk Factor(s)
Amplifying
Factor(s)
Age
Albuminuria
Proteinuria
Chronic Kidney Disease
ESLD
Hyperuricemia
Genomics
Acute MI
CHF
Sepsis
Hemodynamics
Cardiac Surgery
IV Contrast
Medications
AKI Severity
AKI Duration
AKI Recurrence
KH 09/12/12
22. Decision Analysis: Analytic Hierarchy Process
• Computer decision support analytics to predict risk of -- AKI, initiation of acute
hemodialysis, long-term dialysis requirement (ESRD) – will utilize AHP for
decision analysis
• Analytic Hierarch Process (AHP) developed by Thomas Saaty (Katz
Grad School of Business, Univ. of Pittsburgh) is a structured method for
organizing multiple factors to analyze complex decisions by creating a
hierarchy of sub-problems
– Elements of the hierarchy consist of careful measurements or rough
approximations, tangible or intangible factors, understood or poorly
understood qualities
– At each level, pairwise comparisons are organized into a matrix and
weights are derived for each element of the hierarchy
– Analysis uses these pairwise comparisons to measure the impact of
items from one level of the hierarchy on elements belonging to the
next higher level
– The hierarchy structure is based on Goal, Alternatives to reach the
Goal, Criteria against which each Alternative needs to be measured
KH 09/12/12
23. Italian NEFROINT Prospective Database
• Italian multicenter prospective data collection to study AKI
• NEFROINT database
– Interactive, web-based, full-stack web application framework (Ruby
on Rails utilizing Ruby programming language)
– Data entry via electronic case report forms
– Eight data sections:
• Demographics, anthropometrics, admission diagnoses
• Comorbidities (including nephrotoxin expsoure)
• Initial ICU day data (calculates APACHE II, SAPS II, SOFA scores)
• Vital signs, urine output, laboratory values (daily)
• Sepsis
• AKI (daily RIFLE/AKIN stage defined); alert for RIFLE class, Risk
• Renal replacement therapy
• Outcomes (ICU/hospital mortality, renal outcomes at ICU
discharge/death)
• Test: Prospective data collection for 576 consecutive, non-
ESRD incident patients in ten ICUs (9/09 – 4/10)
– AKI defined = RIFLE class, Risk
– Baseline Cr defined = lowest SCr in preceding 3 mo.
(or estimated based on MDRD eGFR=75ml/min/1.73m2, ADQI
Working Group)
Garzotto F et al. Blood Purif 2011;31:159-171KH 09/12/12