Renal - AKI,CKD

Acute Coronary Syndrome- NAC

• ACT (2011): Acetylcysteine with IV contrast
  • Acetylcysteine does not prevent contrast-induced acute kidney injury in patients undergoing angiography.

Acute Kidney Injury

• ACT (2011): Acetylcysteine with IV contrast
• AKIKI (2016): Early vs. late RRT in severe AKI in ICU
  • Among ICU patients with AKI, there is no mortality difference between early or delayed RRT.
• ATN (2008): RRT intensity in ATN
  • In critically ill patients with acute tubular necrosis, more intensive renal replacement therapy does not improve all-cause mortality at 60 days compared to conventional less-intensive therapy. In the ATN study, intensive RRT did not improve renal function or nonrenal organ dysfunction, although it was associated with more frequent hypotensive episodes
• IDEAL-ICU (2018): Early vs. delayed RRT in septic shock
  • Among ICU with septic shock and AKI without urgent need for dialysis, there was no difference in 90-day all cause mortality when comparing early-initiation vs. delayed-initiation RRT strategies. Overall use of RRT was lower in the delayed-initiation strategy group.
• SALT-ED (2018): Balanced crystalloids vs. NS in non-critical ED patients
  • Among non-critically ill ED patients, initial fluid resuscitation with balanced crystalloids (Lactated Ringer's or Plasma-Lyte) does not reduce duration of hospitalization when compared to the isotonic crystalloid, normal saline. However, balanced crystalloid use is associated with a reduction in major kidney-related events

Anemia

non-dialysis–dependent CKD -ESA

• CHOIR (2006): EPO in CKD with anemia

Erythropoietin therapy targeting a higher hemoglobin level of 13.5 g/dL, as compared with 11.3 g/dL, was associated with a higher risk of death and hospitalizations for CHF among patients with non-dialysis–dependent CKD and anemia.

• TREAT (2009): Darbepoetin in CKD and T2DM
  • Targeting a hemoglobin of >13 g/dL with erythrocyte-stimulating agents does not confer a survival benefit in T2DM with CKD, but does increase the risk of stroke.
• CREATE
  • higher hemoglobin targets were associated with more rapid progression to ESRD. ESAs did not appear to influence the rate of CV events

Iron Tx in HD

• PIVOTAL (2019) -IV iron in HD pts
  • Among patients undergoing hemodialysis, a high-dose intravenous iron regimen administered proactively was superior to a low-dose regimen administered reactively and resulted in lower doses of erythropoiesis-stimulating agent being administered.

hemodialysis patients.

• NHCT - The normal HCT trial
  • targeting normal or near-normal Hgb values confer no significant clinical benefit but may in fact be associated with increased harm.