Thiamine and Renal Failure in Septic Shock Patients

Every possible option to decreased morbidity, mortality, and costs are worth looking at in my book. The study that I am reviewing at this moment was published in 2017. I am ashamed that I had not run into it until today. It's challenging to stay up to date in everything. I digress.

Some would quickly bash this study for it being small (n=70) and a post-hoc secondary analysis of a pilot study. I am not going to do that. Why not? Well first of all, I do not participate in research myself. Just reading and enjoying these studies. Also, thiamine has no side effects described in the literature. Third, it is an inexpensive medication. Fourth, if it does turn out to decrease the incidence of acute kidney injury and the need for renal replacement therapy, aren't you going to feel guilty for not adopting these strategies for your patients? I hate resorting to that but my responsibility is for patients. What happens if this data is wrong? Nothing. What happens if this data is right and no one does anything for several years? Many patients may suffer.

This article is completely free and I encourage you to download it and read it for yourself. Amongst the points illustrated by the authors, they mention that it's not only perfusion that injures the kidneys during sepsis. There are other factors listed in the article. The way that it is postulated that thiamine works for these patients is by assisting in the mitochondrial dysfunction. Data that I have found not listed in this article shows that thiamine deficiency could have an incidence between 20-70% of critically ill patients. 

What they found was 21% of the patients in the placebo arm of the trial went on to need dialysis. Just one patient, or 3% in the thiamine group went on to require this. The authors note that acidosis was the primary indication for dialysis in 66% of the patients who required it. I personally would like to dig deeper into these numbers as there is some data that thiamine administration helps decrease lactic acidosis. 

This data should make you wonder if the strategy that many clinicians take of providing more IV fluids to patients whose renal function deteriorates is the correct strategy. Are we going to look in the mirror in a decade and want to punch our past selves in the face?   

- EJ

Link to Abstract

Link to Full Article

ADDENDUM: The prospective RCT is going to be completed in July 2022. Here is the link to clinicaltrials.gov's study details here: LINK

Moskowitz A, Andersen LW, Cocchi MN, Karlsson M, Patel PV, Donnino MW. Thiamine as a renal protective agent in septic shock. A secondary analysis of a randomized, double-blind, placebo-controlled trial. Anns Am Thorac Soc. 2017;14(5):737–41.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Hyperchloremia: We've known it is harmful to the kidneys since 2012

It has been 7 years since this study came out, and many since. Here we are still using saline like it's benign. Part of the problem is that clinicians get set in their ways and just don't read. Sorry if that offends anyone, but it's true. Some say, "this has always worked and I haven't seen a problem with it" so they keep doing what they're doing. Our job is to cause no harm. I'm trying my best to minimize that but after all, we are all human. Being lazy is no excuse, though.

This article from 2012 shows a study that was performed on 12 healthy volunteers. It was a randomized, double blind, cross over study. I bet they were either college students or medical students; the mean age was 22. This was not disclosed in the article, of course. The participants received either 2L of 0.9% NaCl or plasma-lyte over an hour on separate occasions 7 to 10 days apart. If you still don't know what Plasma-lyte is, you must be new here. They did some bloodwork as well as MRI's. They must have had some good funding here.

Amongst the results, they found a significant difference in the serum chloride, as expected (p < 0.0001) and a much lower strong ion difference (p = 0.025) in the saline group. All the other electrolytes were unremarkable. From the MRI results, they found lower mean renal artery flow velocity (p = 0.045) and lower renal cortical tissue perfusion (p = 0.008) in the saline group. This proves that hyperchloremic metabolic acidosis is not benign.

A hat tip to the authors.

-EJ




Link to the article: 

Chowdhury AH, Cox EF, Francis ST, et al. A Randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers. Ann Surg 2012; 256: 18–24.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Hyperchloremic Metabolic Acidosis and Acute Kidney Injury

Hyperchloremia and moderate increase in serum chloride are associated with acute kidney injury in severe sepsis and septic shock patients

A lot of the research I do on my own time to be a better doctor includes the simple basics of critical care. I don’t delve too much into the esoteric things bc it doesn’t impact as many lives as what I do on a DAILY basis. That’s the reason why I’m obsessed with fluids and sharing what I’ve learned along the way leading to how my practice has changed. Keep in mind that even LR could lead to an increase in the serum Cl (nl 98-109 and LR has 109mmol/L). I have made a video on YouTube describing the different fluids side by side that I made when I was a fellow. Since then, I have made individual videos covering NS, LR, and Plasma-Lyte. I really hope that some of you are benefitting from these posts. I appreciate the feedback I’ve received. Hat tip to the authors.

-EJ 



Link to Abstract

Link to PDF

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Lithium Toxicity: To Dialyze or to Monitor?

(Hypothetical) Case scenario: Patient comes in, accidental overdose of lithium, HD stable, physical exam unremarkable, labs pristine, lithium level of 2.x. Poison control called. ED interventions performed flawlessly. Nephro consulted in the ED and recommends HD if level is above (insert arbitrary number here). On recheck several hours later, pt looks GREAT clinically but the lithium value has increased closer to (insert arbitrary number here). 

Now, I'm an intensivist and make my living off of placing vascular catheters but only if there's appropriate data behind it. It is time to look up the data. No, I won't even pretend to know everything. 

Hey, look! There's a Cochrane review about it!
Full (free) article: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007951.pub2/epdf

Here are a couple things that caught my attention regarding this review: 

"No randomized controlled trials of hemodialysis therapy for lithium poisoning were identified."

This is definitely reasonable. I mean, imagine the complexity of consenting these patients who are on lithium already for an unfortunate reason and have overdosed for one reason or another where their capacity may be questioned. IRB permission, sigh.  

Hence, after a very thorough review of all the data including the more recent (2015) Extracorporeal Treatments in Poisoning (EXTRIP) workgroup systematic review, the author concludes that: 
"Although the use of hemodialysis to enhance the elimination of lithium in patients with lithium poisoning is logical, there is no research from randomized controlled trials on its benefits and harms in patients with lithium poisoning. Most patients with lithium poisoning recover fully, but the available data do not provide a reliable way to predict which patients will have a good or poor outcome. Until higher-quality evidence can be developed, the decision to use hemodialysis in addition to standard therapy with intravenous fluids will continue to be based on clinical judgment. Hemodialysis treatment should ideally be given as part of a randomized controlled trial."
This conclusion is to be expected, we like data, any good data, and we just don't have it here. 

The fine investigators in the EXTRIP workgroup published this fine piece of work which gave way to the table listed below. 
Full (free) article:http://docs.wixstatic.com/ugd/363318_f36816033c994d129d7663213a31ea71.pdf

This makes a lot more sense. Choosing an arbitrary number has no data behind it. Fortunately, my patient has great renal function, a stable mental status, and her heart is lovable. Let's hold off on HD. At least that's what I'm going to do, for now. 

In the words of one of my favorite attending physicians during my fellowship, sometimes you have to just "do something". I'm not going to listen to him this time. 

A big hat tip to the researchers involved because I just dislike doing research. 

-EJ

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.