Although the optimal timing of initiation of renal replacement therapy (RRT) in critically ill patients with acute kidney injury has been extensively studied in the past, it is still unclear. In this systematic review, we searched all related randomized controlled trials (RCTs) that directly compared earlier and later RRT published prior to June 25, 2016, from PubMed, MEDLINE, and EMBASE. We extracted the study characteristics and outcomes of all-cause mortality, RRT dependence, and intensive care unit (ICU) and hospital length of stay (LOS). We identified 51 published relevant studies from 13,468 screened abstracts. Nine RCTs with 1627 participants were included in this meta-analysis. Earlier RRT was not associated with benefits in terms of mortality [relative risk (RR) 0.88, 95% confidence interval (CI) 0.68–1.14, p = 0.33] and RRT dependence (RR 0.81, 95% CI 0.46–1.42, p = 0.46). There were also no significant differences in the ICU and hospital LOS between patients who underwent earlier versus later RRT [standard means difference −0.08 (95% CI −0.26 to 0.09) and −0.11 (95% CI −0.37 to 0.16) day, respectively]. In subgroup analysis, earlier RRT was associated with a reduction in the in-hospital mortality among surgical patients (RR 0.78, 95% CI 0.64–0.96) and patients who underwent continuous renal replacement therapy (CRRT) (RR 0.80, 95% CI 0.67–0.96). Compared with later RRT, earlier initiation of RRT did not show beneficial impacts on patient outcomes. However, a lower rate of death was observed among surgical patients and in those who underwent CRRT. The included literature is highly heterogeneous and, therefore, potentially subject to bias. Further high-quality RCT studies are warranted.

The clinical conditions of critically ill patients are highly heterogeneous; therefore, nutrient requirements should be personalized based on the patient’s nutritional status. However, nutritional status is not always considered when evaluating a patient’s nutritional therapy in the medical intensive care unit (ICU). We conducted a retrospective cross-sectional study to assess the effect of ICU patients’ nutrition risk status on the association between energy intake and clinical outcomes (i.e., hospital, 14-day and 28-day mortality). The nutrition risk of critically ill patients was classified as either high- or low-nutrition risk using the modified Nutrition Risk in the Critically Ill score. There were 559 (75.3%) patients in the high nutrition risk group, while 183 patients were in the low nutrition risk group. Higher mean energy intake was associated with lower hospital, 14-day and 28-day mortality rates in patients with high nutrition risk; while there were no significant associations between mean energy intake and clinical outcomes in patients with low nutrition risk. Further examination of the association between amount of energy intake and clinical outcomes showed that patients with high nutrition risk who consumed at least 800 kcal/day had significantly lower hospital, 14-day and 28-day mortality rates. Although patients with low nutrition risk did not benefit from high energy intake, patients with high nutrition risk are suggested to consume at least 800 kcal/day in order to reduce their mortality rate in the medical ICU.

Malnutrition is common in intensive care units (ICU), and volume based feeding protocols have been proposed to increase nutrient delivery. However, the volume based approach compared to trophic feeding has not been proven entirely successful in critically ill patients. Our study aimed to compare the clinical outcomes both before and after the implementation of the feeding protocol, and to also evaluate the effects of total energy delivery on outcomes in these patients. We retrospectively collected all patient data, one year before and after the implementation of the volume-based feeding protocol, in the ICU at Taichung Veterans General Hospital. Daily actual energy intake from enteral nutritional support was recorded from the day of ICU admission until either the 7th day of ICU stay, or the day of discharge from the ICU. The energy achievement rate (%) was calculated as: (actual energy intake/estimated energy requirement) × 100%. Two-hundred fourteen patients were enrolled before the implementation of the volume-based feeding protocol (pre-FP group), while 198 patients were enrolled after the implementation of the volume-based feeding protocol (FP group). Although patients in the FP group had significantly higher actual energy intakes and achievement rates when compared with the patients in the pre-FP group, there was no significant difference in mortality rate between the two groups. Comparing survivors and non-survivors from both groups, an energy achievement rate of less than 65% was associated with an increased mortality rate after adjusting for potential confounders (odds ratio, 1.6, 95% confidence interval, 1.01–2.47). The implementation of the feeding protocol could improve energy intake for critically ill patients, however it had no beneficial effects on reducing the ICU mortality rate. Receiving at least 65% of their energy requirements is the main key point for improving clinical outcomes in patients.

Background: Clinical decisions regarding the appropriate timing of weaning off renal replacement therapy (RRT) in critically ill patients are complex and multifactorial. The aim of the current study was to identify which critical patients with acute kidney injury (AKI) may be more likely to be successfully weaned off RRT using consensus cluster analysis. Methods: In this study, critically ill patients who received RRT at three multicenter referral hospitals at several timepoints from August 2016 to July 2018 were enrolled. An unsupervised consensus clustering algorithm was used to identify distinct phenotypes. The outcomes of interest were the ability to wean off RTT and 90-day mortality. Results: A total of 124 patients with AKI requiring RRT (AKI-RRT) were enrolled. The 90-day mortality rate was 30.7% (38/124), and 49.2% (61/124) of the patients were successfully weaned off RRT for over 90 days. The consensus clustering algorithm identified three clusters from a total of 45 features. The three clusters had distinct features and could be separated according to the combination of urinary neutrophil gelatinase-associated lipocalin to creatinine ratio (uNGAL/Cr), Sequential Organ Failure Assessment (SOFA) score, and estimated glomerular filtration rate at the time of weaning off RRT. uNGAL/Cr (hazard ratio [HR] 2.43, 95% confidence interval [CI]: 1.36–4.33) and clustering phenotype (cluster 1 vs. 3, HR 2.7, 95% CI: 1.11–6.57; cluster 2 vs. 3, HR 44.5, 95% CI: 11.92–166.39) could predict 90-day mortality or re-dialysis. Conclusions: Almost half of the critical patients with AKI-RRT could wean off dialysis for over 90 days. Urinary NGAL/Cr and distinct clustering phenotypes could predict 90-day mortality or re-dialysis.

The elderly population is expanding rapidly, and that has become a major healthcare burden in terms of chronic kidney disease. The distribution patterns of kidney diseases in these elderly patients remain largely unclear. Here, we compared biopsy-based renal disease patterns between elderly and nonelderly patients. We performed a single-center, retrospective study (1992–2008) on biopsy-proven renal diseases to compare results between geriatric patients (age ≥ 65 years; n = 254) and nongeriatric patients (18 ≤ age < 65 years; n = 2592). Renal pathology was interpreted by pathologists based on light microscopy, immunofluorescence, and electron microscopy. The ages of the geriatric and nongeriatric groups were 71.8 ± 4.5 (65.1–87.3) and 39.7 ± 17.6 (18–64.9) years, respectively, and 74% and 41% of them, respectively, were men. In the geriatric group, the most frequent diagnosis was membranous nephropathy (46.1%), followed by minimal change disease/focal segmental glomerulosclerosis (16.9%), diabetic nephropathy (8.3%), hypertensive nephrosclerosis (7.5%), and IgA nephropathy (5.9%). The geriatric group had more membranous nephropathy and less lupus nephritis and IgA nephropathy than the nongeriatric group. Furthermore, the 5-year survival rate of the geriatric group was significantly low. Our results demonstrated the different distributions of renal biopsy patterns in geriatric patients diagnosed with acute or chronic progressive kidney injury and proteinuria through renal biopsy.