Overview. Aims & Methods Incidence of RRT for AKI Characteristics - RRT patients - RRT treatment Outcome Factors asssociated with outcome

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1 RRT in Finland Suvi Vaara, MD Intensive Care Units, Division of Anaesthesiology and Intensive Care Medicine Helsinki University Central Hospital Finland

2 Overview Aims & Methods Incidence of RRT for AKI Characteristics - RRT patients - RRT treatment Outcome Factors asssociated with outcome

3 Aims of the study Describe RRT treatment in Finland Study factors associated with 90-day mortality - fluid accumulation

4 Study flow chart 5853 admissions to ICUs from to admissions with RRT 308 patients 296 study patients 95 admissions excluded - 44 with end-stage renal disease -22 readmitted with previous RRT - 12 no consent - 2 not permanently living in Finland - 4 intermediate care - 4 elective admission <24h - 7 else 12 patients excluded - 9 RRT for intoxication only - 3 plasmapheresis

5 RRT incidence Proportion of included ICU patients 296 of 2901 (10.2%; 95% CI %) Population-based incidence 19.4 ( ) per 100,000 adults per year Reference population 3.67 million = 85 % of the Finnish adult population

6 Yearly population-based incidence per 100,000 (95% CI) * * * * *

7 Patient characteristics I APACHE III diagnosis groups N (%) of 296 Non-operative 203 (68.6) Renal disease 51 (25.1) Sepsis 38 (18.7) Metabolic 32 (15.8) Gastrointestinal disease 32 (15.8) Cardiovascular 25 (12.3) Other 25 (12.3) Operative 93 (31.4) Cardiovascular 51 (54.8) Gastrointestinal disease 35 (37.6) Other 7 (7.5)

8 Elderly patients N=296 Median (IQR) 64 (55-73) years N Age (years)

9 Severity of illness N=296 Median (IQR) 51 (40-65) N

10 Patient characteristics II Characteristic Male gender 197 (67%) N (%) / Median (IQR) Baseline creatinine 91 (72-103) Emergency admission 271 (93%) Vasoactives 216 (75%) Severe sepsis 142 (48%) Diuretics prior to RRT 163 (55%) Treatment restrictions 95 (32%)

11 Indications for RRT - Median (IQR) number of indications 3 (2-4) Indication N (%) Oliguria 223 (78) High creatinine 196 (70) Acidosis 181 (65) Fluid accumulation 116 (43) Hyperkalemia 72 (26) Rhabdomyolysis 34 (13) Intoxication 19 (7) Other 16 (6) 175 (51-509) ml/24h 335 ( ) umol/l ph 7.22( ) BE ( ) mmol/l

12 RRT was initiated early -Median (IQR) time to RRT 14.0 ( ) hours N=296

13 Initial RRT modality N=11 3.7% N=4 1.4% N=4 1.4% N= % N=11 3.7% -91% predilution N= % N= % -95% predilution

14 CRRT anticoagulation

15 Initial CRRT dose N=215 N Median (IQR) 35.3 ( ) ml/kg/h Daily median (IQR) duration of CRRT 19.0 ( ) h (680 treatment days) Dose after adjusting for duration ->27.9 ml/kg/h

16 Reasons for interruptions 51% 137 CRRT treatment days

17 Lenght of stay Median (IQR), days ICU 5.5 ( ) Hospital 14.5 ( ) N N

18 Mortality Hospital % (95% CI; %) 90-day % ( %) SAPS II standardized mortality ratio 0.64 ( )

19 Studies with 90-day mortality Retro Prosp RCT

20 RRT initiation day & mortality 90-day mortality (%) P=0.511 % Time from ICU admission (h) Survivors 10.9 ( ) vs. non-survivors:19.2 ( ) P=0.044

21 Parameters at RRT initiation Survivors N=180 Non-survivors N=116 Urine output / 24h (ml) 510 ( ) 150 (35-496) Creatinine umol/l 279 ( ) 237 ( ) Lactate mmol/l 1.8 ( ) 3.8 ( ) Base excess mmol/l -7.6 ( ) ( ) Vasoactives N (%) 121 (69.5) 95 (81.9) Cumulative balance (L) 3.1 ( ) 6.2 ( ) Fluid accumulation % of weight 3.6 ( ) 8.0 ( ) All P-values <0.05. Continuous variables presented as median (IQR).

22 Fluid accumulation from admission to RRT <10% N=207 -> no fluid overload >10% N=76 ->fluid overload Median (IQR) 5.1 ( ) N=283 N

23 Fluid accumulation & mortality P<

24 Logistic regression for 90-day mortality OR (95% CI) P-value Age /year 1.05 ( ) <0.001 SAPS II without age /point 1.05 ( ) <0.001 Non-renal SOFA score on RRT initiation day /point 1.23 ( ) Time from admission to RRT /day 1.22 ( ) Fluid overload 2.53 ( ) Non-significant factors -Initial RRT modality -severe sepsis (yes/no) -Urine output on RRT initiation day, diuretics use prior to RRT -Lactate, crea, BE prior to RRT

25 90-day survival No fluid overload Fluid overload 68.6% 40.8% Log-rank test P<0.001

26 Conclusions Population-based incidence 19.4 per 100,000 adults per year RRT initiated early 90-day mortality 39% Fluid overload-> worse outcome

27 Manuscript Fluid accumulation is associated with increased risk for 90-day mortality in patients receiving renal replacement therapy Suvi T. Vaara, Anna-Maija Korhonen, Kirsi-Maija Kaukonen, Sara Nisula, Outi Inkinen, Sanna Hoppu, Jouko J. Laurila, Leena Mildh, Matti Reinikainen, Vesa Lund, Ilkka Parviainen, Ville Pettilä, and the FINNAKI study group

28 The FINNAKI Study Group Central Finland Central Hospital: Raili Laru-Sompa, Anni Pulkkinen, Minna Saarelainen, Mikko Reilama, Sinikka Tolmunen, Ulla Rantalainen, Marja Miettinen East Savo Central Hospital: Markku Suvela, Katrine Pesola, Pekka Saastamoinen, Sirpa Kauppinen Helsinki University Central Hospital: Ville Pettilä, Kirsi-Maija Kaukonen, Anna-Maija Korhonen, Sara Nisula, Suvi Vaara, Raili Suojaranta-Ylinen, Leena Mildh, Mikko Haapio, Laura Nurminen, Sari Sutinen, Leena Pettilä, Helinä Laitinen, Heidi Syrjä, Kirsi Henttonen, Elina Lappi, Hillevi Boman Jorvi Central Hospital: Tero Varpula, Päivi Porkka, Mirka Sivula Mira Rahkonen, Anne Tsurkka, Taina Nieminen, Niina Prittinen. Kanta-Häme Central hospital: Ari Alaspää, Hanna Juntunen, Teija Sanisalo Kuopio University Hospital: Ilkka Parviainen, Ari Uusaro, Esko Ruokonen, Stepani Bendel, Niina Rissanen, Maarit Lång, Sari Rahikainen, Saija Rissanen, Merja Ahonen, Elina Halonen, Eija Vaskelainen Lapland Central Hospital: Meri Poukkanen, Esa Lintula, Sirpa Suominen Länsi Pohja Central Hospital: Jorma Heikkinen, Timo Lavander, Kirsi Heinonen, Anne-Mari Juopperi, Middle Ostrobothnia Central Hospital: Tadeusz Kaminski, Fiia Gäddnäs, Tuija Kuusela, Jane Roiko North Karelia Central Hospital: Sari Karlsson, Matti Reinikainen, Tero Surakka, Helena Jyrkönen, Tanja Eiserbeck, Jaana Kallinen Satakunta Hospital district: Vesa Lund, Päivi Tuominen, Pauliina Perkola, Riikka Tuominen, Marika Hietaranta, Satu Johansson South Karelia Central Hospital: Seppo Hovilehto, Anne Kirsi, Pekka Tiainen, Tuija Myllärinen, Pirjo Leino, Anne Toropainen Tampere University Hospital: Anne Kuitunen, Jyrki Tenhunen, Ilona Leppänen, Markus Levoranta, Sanna Hoppu, Jukka Sauranen, Atte Kukkurainen, Samuli Kortelainen, Simo Varila Turku University Hospital: Outi Inkinen, Niina Koivuviita, Jutta Kotamäki, Anu Laine Oulu University Hospital: Tero Ala-Kokko, Jouko Laurila, Sinikka Sälkiö Vaasa Central Hospital: Simo-Pekka Koivisto, Raku Hautamäki, Maria Skinnar

29 Thank you!

30 Treatment restrictions 95 (32%) had restrictions 53 (18%) were withdrawn of RRT 2605 patients who never received RRT (6%) were restricted outside RRT

31 Daily fluid balance Survivors Non-survivors Day number

32 Fluid accumulation from admission to RRT Median (IQR) 5.1 ( ) N=283 N Fluid accumulation <10% N=207 -> no fluid overload >10% N=76 ->fluid overload