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Background Acute kidney injury (AKI) is associated with significant morbidity and mortality in critically ill patients. However, data on AKI in coronary care units (CCU) remain limited, particularly in low- and middle-income countries. This study aimed to determine the incidence, etiology, risk factors, and outcomes of AKI in a CCU setting in Thailand. Methods In this retrospective cohort study, we analyzed 209 patients admitted to a tertiary hospital CCU between January 2019 and September 2020. We collected data on baseline characteristics, comorbidities, medications, clinical parameters, and outcomes. Risk factors were assessed using multivariable logistic regression analysis. Results AKI occurred in 30.6% of patients, with multifactorial etiologies being the most common (42.2%). AKI was associated with significantly higher mortality at both 30 days (35.9% vs. 3.4%, p  < 0.001) and 90 days (43.8% vs. 6.9%, p  < 0.001). Independent risk factors for AKI included pre-existing chronic kidney disease (adjusted OR 3.47), reduced left ventricular ejection fraction (OR 3.19), mechanical ventilation (OR 3.08), and vasopressor use (OR 2.84). Independent predictors of kidney replacement therapy were mechanical ventilation (OR 11.26) and vasopressor use (OR 5.61). Conclusions AKI is a frequent and severe complication among CCU patients in a low- to middle-income country, significantly increasing short-term mortality and hospital stay. Early identification of high-risk patients may improve outcomes through timely intervention and monitoring.

Inflammatory cytokines play a pivotal role in septic shock, driving tissue injury and circulatory failure. Hemoadsorption has been proposed as an extracorporeal strategy that removes inflammatory mediators. Patient selection and treatment timing may be integral to clinical benefit. To determine whether adjunctive hemoadsorption with the HA-330 cytokine adsorber reduces 28-day mortality in patients with septic shock requiring high-dose vasopressors, compared with standard treatment alone. This multicenter, randomized controlled trial enrolled patients with septic shock requiring norepinephrine ≥ 0.2 mcg/kg/min at two tertiary care centers in Thailand. Participants were assigned 1:1 to standard treatment alone (ST group) or standard treatment with two 3-hour sessions of hemoadsorption using HA-330 (HA group). The primary outcome was 28-day mortality. The trial was terminated early at the second pre-planned interim analysis due to slow recruitment and funding constraints before reaching the planned sample size of 206 participants. A total of 128 participants were enrolled; 65 were assigned to the ST group and 63 to the HA group. The median age was 67 years, and baseline characteristics were largely comparable between groups. By day 28, 38 of 65 (58%) participants in the ST group and 28 of 63 (44%) in the HA group had died (relative risk, 0.76; 95% CI, 0.54-1.07; P = 0.16; hazard ratio, 0.68; 95% CI, 0.44-1.07; P = 0.09). No significant differences were observed in organ support-free days, shock reversal, vasopressor doses, or inflammatory markers. In a post-hoc Cox model adjusted for IL-6 (log-transformed) and VIS at hour 0, the hazard ratio for 28-day mortality was 0.62 (95% CI, 0.39-0.97; P = 0.037). No serious adverse events were reported in either group. In this randomized trial which was terminated early, adjunctive hemoadsorption with HA-330 in patients with septic shock requiring high-dose vasopressors did not statistically reduce 28-day mortality. ClinicalTrials.gov (NCT05136183); registered November 29, 2021.

Background Optimal fluid management in critically ill patients varies across different phases of care. This study examined the feasibility of adding a restrictive fluid strategy with early de-escalation to standard care for patients with circulatory shock. Methods We performed a single-center, feasibility, randomized controlled trial, involving patients with shock who required fluid resuscitation and were admitted in the medical intensive care unit. After initial fluid resuscitation, patients were randomly assigned (1:1) to either a restrictive fluid strategy or usual care. The restrictive group targeted a near-zero fluid balance over 3 days by limiting fluid intake and using diuretics or mechanical fluid removal when needed. The primary outcome was cumulative fluid balance at day 3. The secondary outcomes were the lengths of stay in the intensive care unit and the hospital, the mechanical ventilation duration, acute kidney injury, renal replacement therapy, and mortality. Results We enrolled 100 patients, assigning 50 to the restrictive strategy and 50 to usual care. By day 3, the restrictive group showed a lower cumulative fluid balance than usual care (‒2353 mL vs. 793 mL, p  < 0.001). This trend continued to day 7 (‒3032 mL vs. 1125 mL, p  < 0.001). The restrictive group also had shorter stays in the intensive care unit and the hospital (7 vs. 10 days, p  = 0.006; 16 vs. 22 days, p  = 0.02). There were no statistically significant differences in hospital or 30-day mortality rates between the groups (18% vs. 38%, p  = 0.05; 12% vs. 30%, p  = 0.05, respectively). Similarly, no significant differences were observed in the incidence of acute kidney injury or the use of renal replacement therapy. Conclusions A restrictive fluid strategy with early de-escalation and de-resuscitation is feasible and may reduce fluid accumulation and showed a signal for reduced hospital stay without increasing adverse events in critically ill patients following acute fluid resuscitation. Trial registration TCTR20220719002 (The trial has been reviewed and approved by TCTR committee on July 16th, 2022). Key messages A restrictive fluid strategy that employs a protocol-based intervention to achieve a target fluid balance after initial resuscitation in patients with sepsis appears feasible, does not increase harm, and may improve outcomes.