Augmented renal clearance in septic and traumatized patients with normal plasma creatinine concentrations: identifying at-risk patients

Udy, Andrew A., Roberts, Jason A., Shorr, Andrew F., Boots, Robert J. and Lipman, Jeffrey (2013) Augmented renal clearance in septic and traumatized patients with normal plasma creatinine concentrations: identifying at-risk patients. Critical Care, 17 1: R35.1-R35.9. doi:10.1186/cc12544


Author Udy, Andrew A.
Roberts, Jason A.
Shorr, Andrew F.
Boots, Robert J.
Lipman, Jeffrey
Title Augmented renal clearance in septic and traumatized patients with normal plasma creatinine concentrations: identifying at-risk patients
Journal name Critical Care   Check publisher's open access policy
ISSN 1466-609X
1364-8535
Publication date 2013-01-01
Sub-type Article (original research)
DOI 10.1186/cc12544
Open Access Status DOI
Volume 17
Issue 1
Start page R35.1
End page R35.9
Total pages 9
Place of publication United Kingdom
Publisher BioMed Central
Collection year 2014
Language eng
Formatted abstract
Introduction Improved methods to optimize drug dosing in the critically ill are urgently needed. Traditional prescribing culture involves recognition of factors that mandate dose reduction (such as renal impairment), although optimizing drug exposure, through more frequent or augmented dosing, represents an evolving strategy. Elevated creatinine clearance (CLCR) has been associated with sub-therapeutic antibacterial concentrations in the critically ill, a concept termed augmented renal clearance (ARC). We aimed to determine the prevalence of ARC in a cohort of septic and traumatized critically ill patients, while also examining demographic, physiological and illness severity characteristics that may help identify this phenomenon.

Methods This prospective observational study was performed in a 30-bed tertiary level, university affiliated, adult intensive care unit. Consecutive traumatized and septic critically ill patients, receiving antibacterial therapy, with a plasma creatinine concentration ≤110 μmol/L, were eligible for enrolment. Pulse contour analysis (Vigileo / Flo Trac® system, Edwards Lifesciences, Irvine, CA, USA), was used to provide continuous cardiac index (CI) assessment over a single six-hour dosing interval. Urinary CLCR measures were obtained concurrently.

Results Seventy-one patients contributed data (sepsis n = 43, multi-trauma n = 28). Overall, 57.7% of the cohort manifested ARC, although there was a greater prevalence in trauma (85.7% versus 39.5%, P <0.001). In all patients, a weak correlation was noted between CI and CLCR (r = 0.346, P = 0.003). This was mostly driven by septic patients (r = 0.508, P = 0.001), as no correlation (r = -0.012, P = 0.951) was identified in trauma. Those manifesting ARC were younger (P <0.001), male (P = 0.012), with lower acute physiology and chronic health evaluation (APACHE) II (P= 0.008) and modified sequential organ failure assessment (SOFA) scores (P = 0.013), and higher cardiac indices (P = 0.013). In multivariate analysis, age ≤50 years, trauma, and a modified SOFA score ≤4, were identified as significant risk factors. These had greater utility in predicting ARC, compared with CI assessment alone.

Conclusions Diagnosis, illness severity and age, are likely to significantly influence renal drug elimination in the critically ill, and must be regularly considered in future study design and daily prescribing practice.
Keyword Critically-ill patients
Intensive-care-unit
Glomerular-filtration-rate
Organ blood-flow
Inadequate antimicrobial treatment
Hyperdynamic sepsis
Serum creatinine
Wave-form
Infections
Antibiotics
Q-Index Code C1
Q-Index Status Confirmed Code
Institutional Status UQ

Document type: Journal Article
Sub-type: Article (original research)
Collections: Official 2014 Collection
School of Medicine Publications
 
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