# Continuous Renal Replacement Therapy for Patients With Sepsis in a Low-Resource Medical Intensive Care Unit (MICU): Incidence, Risk Factors, and Outcomes

## TL;DR

This study examines the use of CRRT in sepsis patients with kidney injury in a low-resource ICU, finding high mortality and identifying risk factors like septic shock and poor organ function scores.

## Contribution

The study provides insights into CRRT outcomes and mortality predictors for sepsis-associated AKI in a low-resource medical ICU setting.

## Key findings

- The 28-day mortality rate was 69.8% among patients with sepsis-associated AKI treated with CRRT.
- Higher SAPS II scores at ICU admission, vasopressor use, and hypoalbuminemia at CRRT initiation were independent predictors of mortality.
- Septic shock at admission and prolonged ICU stay were significantly associated with survival outcomes.

## Abstract

Introduction

Sepsis is one of the leading causes of ICU admissions, with a substantial proportion of patients developing sepsis-associated acute kidney injury (S-AKI). In such cases, continuous renal replacement therapy (CRRT) is a cornerstone of renal supportive care; however, evidence from low-resource settings (LRS) remains limited. This study aimed to describe the demographic and clinical characteristics of patients with S-AKI treated with CRRT in an LRS medical ICU (MICU), as well as to identify predictors of mortality.

Subjects and methods

This retrospective, observational, consecutive, single-center study included adult patients admitted to the MICU between June 1, 2023, and June 1, 2024, with a diagnosis of sepsis complicated by S-AKI, and managed with CRRT. Statistical analyses were conducted using the Mann-Whitney U and Pearson χ² tests, and multinomial logistic regression was used to identify independent predictors of mortality. ORs were reported for key predictors, and Kaplan-Meier survival analysis was performed to assess time to event.

Results

A total of 96 patients with S-AKI were treated with CRRT (65 male patients, median age 64.5 years). The 28-day all-cause mortality rate was 69.8%, with a high rate of septic shock at admission among nonsurvivors (n=49, p= 0.019). Kaplan-Meier analysis demonstrated a median survival of 12 days (95%CI: 8.95-15.05). The majority of patients were admitted from hospital wards (n=59), and the most common comorbidities were hypertension (n=63), diabetes (n=38), and cardiomyopathy (n=27). Survivors had a longer MICU length of stay (p= 0.003). Nonsurvivors had a higher initial Sequential Organ Failure Assessment and Simplified Acute Physiology Score II (SAPS II) scores at MICU admission (p< 0.000), and prominent abnormalities at CRRT initiation for albumin (p= 0.004), troponine I (p= 0.032), and lactate (p= 0.004). Invasive mechanical ventilation and vasopressor therapy were predominantly used among nonsurvivors (p< 0.001). Continuous Venovenous Hemodiafiltration (CVVHDF) was the CRRT modality used for all patients (three patients used a combination of continuous and intermittent techniques), and hemoadsorption filters were used in 38 patients. The preferential indications for CVVHDF included anuria and profound metabolic acidosis, either in combination (n=51) or alone (n=17 and n=22). The most common sources of sepsis were pneumonia (n=42), urinary tract infection (n=13), multiple site infection (n=11), and abdomen (n=11). At MICU admission, blood cultures were positive in 34 patients (21 with gram-positive bacteria), urine cultures in 21 patients (12 with gram-negative bacteria), and tracheal aspirate/bronchoalveolar lavage in 39 patients (26 with gram-negative bacteria). Among the patients, 10 had a concurrent viral infection, six had candidiasis, and three had aspergillosis. Logistic regression identified an association between poor outcome and SAPS II at MICU admission (OR=1.07; 95%CI: 1.03-1.12), albumin (OR=0.89; 95%CI: 0.81-5.63), and vasopressor therapy (OR= 8.36; 95%CI: 1.51-46.33) at CRRT initiation.

Conclusion

Patients with S-AKI requiring CRRT represent a particularly vulnerable subgroup with a high risk of poor outcomes, especially when presenting with septic shock. In this single-center, low-resource MICU study, independent predictors of mortality were a high SAPS II score at MICU admission, as well as vasopressor requirement and hypoalbuminemia at CRRT initiation.