ETIENNE MARIA VASCONCELLOS DE MACEDO
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- Timing of Dialysis Initiation in Acute Kidney Injury and Acute-On-Chronic Renal Failure(2013) MACEDO, Etienne; MEHTA, Ravindra L.The decision to provide dialytic support and choosing the ideal moment to initiate therapy are common impasses for physicians treating patients with acute kidney injury (AKI). Although renal replacement therapy (RRT) has been extensively used in clinical practice for more than 30years, there is a paucity of evidence to guide clinicians on the optimal utilization of RRT in AKI. In the absence of traditional or urgent indications, there is no consensus on whether dialysis should be offered and when it should be started. The lack of agreed-upon parameters to guide the decision, the fear of the risk of the procedure, and the possible contribution to worse prognosis with RRT have resulted in a considerable variation in practice among physicians and centers. In this review, we summarize the evidence evaluating time of initiation of RRT and discuss possible approaches for future trials in addressing this issue.
- Targeting Recovery from Acute Kidney Injury: Incidence and Prevalence of Recovery(2014) MACEDO, Etienne; MEHTA, Ravindra L.Since the creation of Risk, Injury, Failure, Loss of Kidney Function, and End-Stage Renal Disease (RIFLE) criteria in the last 10 years, the use of a standardized definition of acute kidney injury (AKI) has made it possible for epidemiologic studies to document the increasing incidence of AKI, especially in the critical care setting [1]. In addition, several studies applying the criteria of RIFLE, Acute Kidney Injury Network, and, more recently, the Kidney Disease: Improving Global Outcome, were able to establish the association of severity of AKI with adverse clinical outcomes, including the development of chronic kidney disease (CKD) and end-stage renal disease (ESRD) [2-4]. Although, until recently, it was thought that survivors from an AKI episode frequently recover kidney function, cumulative observational data over the past decade have confirmed the association of AKI with the increased risk for permanent kidney damage, with subsequent development of CKD [5]. The epidemiological studies that we will present and discuss in this review confirm and clarify the association of AKI with the development of CKD and ESRD [6-8]. (C) 2014 S. Karger AG, Basel
- Recognition and management of acute kidney injury in the International Society of Nephrology 0by25 Global Snapshot: a multinational cross-sectional study(2016) MEHTA, Ravindra L.; BURDMANN, Emmanuel A.; CERDA, Jorge; FEEHALLY, John; FINKELSTEIN, Fredric; GARCIA-GARCIA, Guillermo; GODIN, Melanie; JHA, Vivekanand; LAMEIRE, Norbert H.; LEVIN, Nathan W.; LEWINGTON, Andrew; LOMBARDI, Raul; MACEDO, Etienne; ROCCO, Michael; ARONOFF-SPENCER, Eliah; TONELLI, Marcello; ZHANG, Jing; REMUZZI, GiuseppeBackground Epidemiological data for acute kidney injury are scarce, especially in low-income countries (LICs) and lower-middle-income countries (LMICs). We aimed to assess regional differences in acute kidney injury recognition, management, and outcomes. Methods In this multinational cross-sectional study, 322 physicians from 289 centres in 72 countries collected prospective data for paediatric and adult patients with confirmed acute kidney injury in hospital and non-hospital settings who met criteria for acute kidney injury. Signs and symptoms at presentation, comorbidities, risk factors for acute kidney injury, and process-of-care data were obtained at the start of acute kidney injury, and need for dialysis, renal recovery, and mortality recorded at 7 days, and at hospital discharge or death, whichever came earlier. We classified countries into high-income countries (HICs), upper-middle-income countries (UMICs), and combined LICs and LMICs (LLMICs) according to their 2014 gross national income per person. Findings Between Sept 29 and Dec 7, 2014, data were collected from 4018 patients. 2337 (58%) patients developed community-acquired acute kidney injury, with 889 (80%) of 1118 patients in LLMICs, 815 (51%) of 1594 in UMICs, and 663 (51%) of 1241 in HICs (for HICs vs UMICs p = 0.33; p < 0.0001 for all other comparisons). Hypotension (1615 [40%] patients) and dehydration (1536 [38%] patients) were the most common causes of acute kidney injury. Dehydration was the most frequent cause of acute kidney injury in LLMICs (526 [46%] of 1153 vs 518 [32%] of 1605 in UMICs vs 492 [39%] of 1260 in HICs) and hypotension in HICs (564 [45%] of 1260 vs 611 [38%%] of 1605 in UMICs vs 440 [38%] of 1153 LLMICs). Mortality at 7 days was 423 (11%) of 3855, and was higher in LLMICs (129 [12%] of 1076) than in HICs (125 [10%] of 1230) and UMICs (169 [11%] of 1549). Interpretation We identified common aetiological factors across all countries, which might be amenable to a standardised approach for early recognition and treatment of acute kidney injury. Study limitations include a small number of patients from outpatient settings and LICs, potentially under-representing the true burden of acute kidney injury in these areas. Additional strategies are needed to raise awareness of acute kidney injury in community healthcare settings, especially in LICs.
- Renal Recovery after Acute Kidney Injury(2016) MACEDO, Etienne; MEHTA, Ravindra L.Until recently, patients surviving an episode of acute kidney injury (AKI) were assumed to have a good renal prognosis. This belief was predominantly based on studies that used heterogeneous AKI definitions and that considered renal recovery as dialysis independence at hospital discharge. Since standardized definitions of AKI have become available, several studies have established an association between AKI and adverse clinical outcomes. It is now well recognized that while the glomerular filtration rate generally improves after AKI, the renal recovery process is often incomplete and can result in a chronic decrease in kidney function. The loss of kidney function can vary from subclinical decreases in the glomerular filtration rate to end-stage renal disease. In this chapter, we review our current understanding of renal recovery following AKI and discuss the main studies that have established associations between AKI and the development of chronic kidney disease and end-stage renal disease [1]. (C) 2016 S. Karger AG, Basel
- Continuous Dialysis Therapies: Core Curriculum 2016(2016) MACEDO, Etienne; MEHTA, Ravindra L.
- Effluent volume and dialysis dose in CRRT: time for reappraisal(2012) MACEDO, Etienne; GRANADO, Rolando Claure-Del; MEHTA, Ravindra L.The results of several studies assessing dialysis dose have dampened the enthusiasm of clinicians for considering dialysis dose as a modifiable factor influencing outcomes in patients with acute kidney injury. Powerful evidence from two large, multicenter trials indicates that increasing the dialysis dose, measured as hourly effluent volume, has no benefit in continuous renal replacement therapy (CRRT). However, some important operational characteristics that affect delivered dose were not evaluated. Effluent volume does not correspond to the actual delivered dose, as a decline in filter efficacy reduces solute removal during therapy. We believe that providing accurate parameters of delivered dose could improve the delivery of a prescribed dose and refine the assessment of the effect of dose on outcomes in critically ill patients treated with CRRT.
- Tailored Therapy: Matching the Method to the Patient(2012) MACEDO, Etienne; MEHTA, Ravindra L.Clinicians frequently have to decide when dialysis should be initiated and which modality should be used to support kidney function in critically ill patients with acute kidney injury. In most instances, these decisions are made based on the consideration of a variety of factors including patient condition, available resources and prevailing local practice experience. There is a wide variation worldwide in how these factors influence the timing of initiation and the utilization of various modalities. In this article, we review the therapeutic goals of renal support and the relative advantages and shortcomings of different dialysis techniques. We describe strategies for matching the timing of initiation to the choice of modality to individualize renal support in intensive care unit patients.
- Urine Output Assessment as a Clinical Quality Measure(2015) MACEDO, EtienneUrine output (UO) is a relevant marker of kidney function and an independent marker of serum creatinine. Although oliguria can be the result of transitory changes in volume status or due to external influences, such as drug administration, UO is currently included as a criterion to diagnose and stage acute kidney injury (AKI). In clinical practice, the potential of earlier alert of kidney injury with frequent assessment of UO can help patient screening and risk assessment. In this review, we will discuss recent studies applying UO for AKI diagnosis and prognostication and propose methods to assess UO and improve quality of care. (C) 2015 S. Karger AG, Basel
- A clinical score to predict mortality in septic acute kidney injury patients requiring continuous renal replacement therapy: the HELENICC score(2017) PASSOS, Rogerio da Hora; RAMOS, Joao Gabriel Rosa; MENDONCA, Evandro Jose Bulhoes; MIRANDA, Eva Alves; DUTRA, Fabio Ricardo Dantas; COELHO, Maria Fernanda R.; PEDROZA, Andrea C.; CORREIA, Luis Claudio L.; BATISTA, Paulo Benigno Pena; MACEDO, Etienne; DUTRA, Margarida M. D.Background: This study aimed to identify predictors of early (7-day) mortality in patients with septic acute kidney injury (AKI) who required continuous renal replacement therapy (CRRT). Methods: Prospective cohort of 186 septic AKI patients undergoing CRRT at a tertiary hospital, from October 2005 to November 2010. Results: After multivariate adjustment, five variables were associated to early mortality: norepinephrine utilization, liver failure, medical condition, lactate level, and pre-dialysis creatinine level. These variables were combined in a score, which demonstrated good discrimination, with a C-statistic of 0.82 (95% CI = 0.76-0.88), and good calibration (chi(2) = 4.3; p = 0.83). SAPS 3, APACHE II and SOFA scores demonstrated poor performance in this population. Conclusions: The HEpatic failure, LactatE, NorepInephrine, medical Condition, and Creatinine (HELENICC) score outperformed tested generic models. Future studies should further validate this score in different cohorts.
- Differential Diagnosis of AKI in Clinical Practice by Functional and Damage Biomarkers: Workgroup Statements from the Tenth Acute Dialysis Quality Initiative Consensus Conference(2013) ENDRE, Zoltan H.; KELLUM, John A.; SOMMA, Salvatore Di; DOI, Kent; GOLDSTEIN, Stuart L.; KOYNER, Jay L.; MACEDO, Etienne; MEHTA, Ravindra L.; MURRAY, Patrick T.Acute kidney injury (AKI) is a common but complex clinical syndrome with multiple etiologies. These etiologies target different sites and pathways within the kidney. Novel biomarkers of 'kidney damage' (which can be tubular or glomerular) can be used to diagnose AKI, even in the absence of an increase in serum creatinine or oliguria. These biomarkers of kidney damage can be combined with biomarkers of kidney function to facilitate classification of AKI. A comprehensive review of the literature was performed using the published methodology of the Acute Dialysis Quality Initiative (ADQI) working group and used to establish consensus statements regarding the use of biomarkers in the differential diagnosis of AKI. We recommend that the pathophysiological terms 'functional change' and 'kidney damage' be used in preference to the anatomical classification using the terms pre-renal, renal and post-renal AKI. We further recommend the use of both renal and non-renal biomarkers in establishing the specific cause of AKI as soon as possible after diagnosis. The presence of underlying CKD or of sepsis poses additional challenges in differential diagnosis, since these conditions alter both baseline biomarker excretion and biomarker performance. We recommend that biomarkers be validated within the clinical context in which they are to be used. Within that context, combinations of biomarkers may, in the future, allow differentiation of the site, mechanism and phase of injury.