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Raina R, Sethi SK, Filler G, Menon S, Mittal A, Khooblall A, Khooblall P, Chakraborty R, Adnani H, Vijayvargiya N, Teo S, Bhatt G, Koh LJ, Mourani C, de Sousa Tavares M, Alhasan K, Forbes M, Dhaliwal M, Raghunathan V, Broering D, Sultana A, Montini G, Brophy P, McCulloch M, Bunchman T, Yap HK, Topalglu R, Díaz-González de Ferris M. PCRRT Expert Committee ICONIC Position Paper on Prescribing Kidney Replacement Therapy in Critically Sick Children With Acute Liver Failure. Front Pediatr 2021; 9:833205. [PMID: 35186830 PMCID: PMC8849201 DOI: 10.3389/fped.2021.833205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 12/29/2021] [Indexed: 12/30/2022] Open
Abstract
Management of acute liver failure (ALF) and acute on chronic liver failure (ACLF) in the pediatric population can be challenging. Kidney manifestations of liver failure, such as hepatorenal syndrome (HRS) and acute kidney injury (AKI), are increasingly prevalent and may portend a poor prognosis. The overall incidence of AKI in children with ALF has not been well-established, partially due to the difficulty of precisely estimating kidney function in these patients. The true incidence of AKI in pediatric patients may still be underestimated due to decreased creatinine production in patients with advanced liver dysfunction and those with critical conditions including shock and cardiovascular compromise with poor kidney perfusion. Current treatment for kidney dysfunction secondary to liver failure include conservative management, intravenous fluids, and kidney replacement therapy (KRT). Despite the paucity of evidence-based recommendations concerning the application of KRT in children with kidney dysfunction in the setting of ALF, expert clinical opinions have been evaluated regarding the optimal modalities and timing of KRT, dialysis/replacement solutions, blood and dialysate flow rates and dialysis dose, and anticoagulation methods.
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Affiliation(s)
- Rupesh Raina
- Cleveland Clinic Akron General Medical Center, Akron, OH, United States.,Department of Nephrology, Akron Children's Hospital, Akron, OH, United States
| | - Sidharth K Sethi
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Guido Filler
- Division of Paediatric Nephrology, Department of Paediatrics, Western University, London, ON, Canada
| | - Shina Menon
- Division of Pediatric Nephrology, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States
| | - Aliza Mittal
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, India
| | - Amrit Khooblall
- Cleveland Clinic Akron General Medical Center, Akron, OH, United States.,Department of Nephrology, Akron Children's Hospital, Akron, OH, United States.,Akron Nephrology Associates, Akron, OH, United States
| | - Prajit Khooblall
- Akron Nephrology Associates, Akron, OH, United States.,Department of Medicine, Northeast Ohio Medical University, Rootstown, OH, United States
| | - Ronith Chakraborty
- Cleveland Clinic Akron General Medical Center, Akron, OH, United States.,Department of Nephrology, Akron Children's Hospital, Akron, OH, United States.,Akron Nephrology Associates, Akron, OH, United States
| | - Harsha Adnani
- Anne Arundel Medical Center, Annapolis, MD, United States
| | - Nina Vijayvargiya
- Cleveland Clinic Akron General Medical Center, Akron, OH, United States.,Akron Nephrology Associates, Akron, OH, United States
| | - Sharon Teo
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Girish Bhatt
- Department of Pediatrics, ISN-SRC, Pediatric Nephrology, All India Institute of Medical Sciences (AIIMS), Bhopal, India
| | - Lee Jin Koh
- Department of Paediatric Nephrology, Starship Children's Hospital, Auckland, New Zealand
| | - Chebl Mourani
- Pediatrics, Hôtel-Dieu de France Hospital (HDF), Beirut, Lebanon
| | | | - Khalid Alhasan
- Pediatric Nephrology, King Saud University College of Medicine, Riyadh, Saudi Arabia
| | - Michael Forbes
- Department of Pediatric Critical Care, Akron Children's Hospital, Akron, OH, United States
| | - Maninder Dhaliwal
- Department of Pediatric Critical Care, Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, India
| | - Veena Raghunathan
- Department of Pediatric Critical Care, Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, India
| | - Dieter Broering
- Klinik für Allgemeine und Thoraxchirurgie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Azmeri Sultana
- Department of Pediatric Nephrology, Dr. M R Khan Shishu Hospital & Institute of Child Health, Dhaka, Bangladesh
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Istituto di Ricerca e Cura a Carattere Scientifico Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Patrick Brophy
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY, United States
| | - Mignon McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Timothy Bunchman
- Pediatric Nephrology and Transplantation, Children's Hospital of Richmond, Virginia Commonwealth University (VCU), Richmond, VA, United States
| | - Hui Kim Yap
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore.,Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Rezan Topalglu
- Department of Pediatric Nephrology, School of Medicine, Hacettepe University, Ankara, Turkey
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Kato C, Oakes M, Kim M, Desai A, Olson SR, Raghunathan V, Shatzel JJ. Anticoagulation strategies in extracorporeal circulatory devices in adult populations. Eur J Haematol 2020; 106:19-31. [PMID: 32946632 DOI: 10.1111/ejh.13520] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/27/2020] [Accepted: 08/31/2020] [Indexed: 12/16/2022]
Abstract
Extracorporeal circulatory devices such as hemodialysis and extracorporeal membrane oxygenation can be lifesaving; however, they are also prone to pathologic events including device failure, venous and arterial thrombosis, hemorrhage, and an accelerated risk for atherosclerotic disease due to interactions between blood components and device surfaces of varying biocompatibility. While extracorporeal devices may be used acutely for limited periods of time (eg, extracorporeal membrane oxygenation, continuous venovenous hemofiltration, therapeutic apheresis), some patients require chronic use of these technologies (eg, intermittent hemodialysis and left ventricular assist devices). Given the substantial thrombotic risks associated with extracorporeal devices, multiple antiplatelet and anticoagulation strategies-including unfractionated heparin, low-molecular-weight heparin, citrate, direct thrombin inhibitors, and direct oral anticoagulants, have been used to mitigate the thrombotic milieu within the patient and device. In the following manuscript, we outline the current data on anticoagulation strategies for commonly used extracorporeal circulatory devices, highlighting the potential benefits and complications involved with each.
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Affiliation(s)
- Catherine Kato
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Michael Oakes
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Morris Kim
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Anish Desai
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Sven R Olson
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA.,Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Vikram Raghunathan
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Joseph J Shatzel
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA.,Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
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Honore PM, Rimmelé T. Total-to-ionized calcium ratio, taken alone, is no longer valid to diagnose citrate accumulation! What additional parameters should we consider to strengthen the utility of this ratio? J Crit Care 2020; 59:172-175. [PMID: 32679468 DOI: 10.1016/j.jcrc.2020.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Patrick M Honore
- Professor of Medicine, ICU Department, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium.
| | - Thomas Rimmelé
- Professor of Medicine, Head of Anesthesiology and Criticial Care Medicine Department, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France.
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Yu Y, Bai M, Ma F, Zhang W, Li Y, Zhao L, Li L, Zhou M, Li L, Sun S. Regional citrate anticoagulation versus no-anticoagulation for continuous venovenous hemofiltration in patients with liver failure and increased bleeding risk: A retrospective case-control study. PLoS One 2020; 15:e0232516. [PMID: 32369523 PMCID: PMC7199954 DOI: 10.1371/journal.pone.0232516] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 04/16/2020] [Indexed: 01/01/2023] Open
Abstract
Objective There are controversial opinions on anticoagulation for continuous venovenous hemofiltration (CVVH) in patients with liver failure (LF) and increased bleeding risk. Therefore, we conducted a retrospective study to evaluate the efficacy and safety of regional citrate anticoagulation (RCA) versus no-anticoagulation for CVVH in these patients. Methods The included patients were divided into RCA and no-anticoagulation group according to the CVVH anticoagulation strategy they accepted for CVVH. Filter lifespan, bleeding, citrate accumulation, catheter occlusion, and totCa/ionCa ratio were evaluated as outcomes. Results In the original cohort, the filter lifespan of the RCA group (41 patients, 79 filters) was significantly longer than the no-anticoagulation group (62 patients, 162 filters) (> 72 hours vs 39.5 hours (IQR 31.2–47.8), P = 0.002). The adjusted results demonstrated that RCA could significantly reduce the risk of filter failure (HR = 0.459, 95%CI 0.26–0.82, P = 0.008). Four episodes of totCa/ionCa > 2.5 were observed in the RCA group and continuously accepted RCA-CVVH after the reduction of citrate dose and blood flow. No obvious citrate accumulation was observed in these patients. In the matched cohort, the filter lifespan of the RCA group was significantly longer than the no-anticoagulation group (P = 0.013) as well. No significant difference in the episodes of totCa/ionCa > 2.5 was observed between the two matched groups (P = 0.074). Both in the original cohort and the matched cohort, the bleeding, acidosis, alkalosis, and catheter occlusion incidences were not significantly different between the two groups. Conclusions In LF patients with increased bleeding risk who underwent CVVH, RCA could prolong the filter lifespan and be safely used with careful blood gas monitoring and citrate dose adjusting. Further prospective, randomized, control studies are warranted to obtain robust evidences.
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Affiliation(s)
- Yan Yu
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
- * E-mail: (MB); (SS)
| | - Feng Ma
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Wei Zhang
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Yangping Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Lijuan Zhao
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Li Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Meilan Zhou
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Lu Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
- * E-mail: (MB); (SS)
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Honore PM, Mugisha A, David C, Attou R, Redant S, Gallerani A, De Bels D. In severe liver disease, citrate can be used safely: the question remains-by which mechanism. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:63. [PMID: 32093726 PMCID: PMC7038605 DOI: 10.1186/s13054-020-2801-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/18/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Patrick M Honore
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium.
| | - Aurore Mugisha
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Cristina David
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Rachid Attou
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Sebastien Redant
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Andrea Gallerani
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - David De Bels
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
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56
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Inducible metabolic pathway for citrate metabolism in case of major liver dysfunction: fact or fiction? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:166. [PMID: 31088498 PMCID: PMC6515620 DOI: 10.1186/s13054-019-2432-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/10/2019] [Indexed: 11/10/2022]
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García-Hernández R, Espigares-López MI, García-Palacios MV, Gámiz Sánchez R, Miralles-Aguiar F, Calderón Seoane E, Pernia Romero A, Torres LM. A pilot study into the use of Continuous Venous Hyperfiltration to manage patients in a critical state with dysregulated inflammation. ACTA ACUST UNITED AC 2019; 66:370-380. [PMID: 31084978 DOI: 10.1016/j.redar.2019.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Haemofiltration paradigms used to manage critically ill patients with a dysregulated inflammatory response (DIR) assess kidney function to monitor its onset, adaptation, and completion. A Continuous Venous Hyperfiltration (CONVEHY) protocol is presented, in which a non-specific adsorption membrane (AN69-ST-Heparin Grafted) is used with citrate as an anticoagulant and substitution fluid. CONVEHY uses tools readily available to achieve kidney related and non-related objectives, and it is guided by the monitoring of pathophysiological responses. OBJECTIVES To compare the response to an AN69-ST-HG membrane when heparin (He, n=5: Standard protocol) or citrate (Ci, n=6: CONVEHY protocol) was used to evaluate whether a larger study into the benefits of this protocol would be feasible. MATERIALS AND METHODS In a retrospective pilot study, the benefits of the CONVEHY protocol to manage patients with a DIR in a surgical critical care unit (CCUs) were assessed by evaluating the SOFA (Sequential Organ Failure Assessment) (He 11 ± 2.35; Ci 11 ± 3.63: p=0.54) and APACHE II (He 28.60 ± 9.40; Ci 24 ± 8.46: p=0.93) scores. RESULTS Nights in hospital (He 35.2 ± 16.3 nights; Ci 9 ± 2.53: p=0.004), hospital admission after discharge from the CCUs (He 40.25 ± 21.82; Ci 13.2 ± 4.09: p=0.063), patients hospitalised >20 days (He 80%; Ci 0%: p=0.048), days requiring mechanical ventilation (He 16 ± 5.66; Ci 4 ± 1.72: p=0.004), and the predicted (55.39 ± 26.13%) versus real mortality in both groups (9.1%: p=0.004). CONCLUSIONS The CONVEHY protocol improves the clinical responses of patients with DIR, highlighting the potential value of performing larger and confirmatory studies.
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Affiliation(s)
- R García-Hernández
- Facultativo especialista de Área de Anestesiología y Reanimación, H.U. Puerta del Mar, Cádiz, España.
| | - M I Espigares-López
- Facultativo especialista de Área de Anestesiología y Reanimación, H.U. Puerta del Mar, Cádiz, España
| | - M V García-Palacios
- Facultativo especialista de Área de Medicina Preventiva, H.U. Puerta del Mar, Cádiz, España
| | - R Gámiz Sánchez
- Facultativo especialista de Área de Anestesiología y Reanimación, H.U. Puerta del Mar, Cádiz, España
| | - F Miralles-Aguiar
- Residente de Anestesiología y Reanimación. Médico especialista en Medicina Intensiva. H.U. Puerta del Mar, Cádiz, España
| | - E Calderón Seoane
- Facultativo especialista de Área de Anestesiología y Reanimación, H.U. Puerta del Mar, Cádiz, España
| | - A Pernia Romero
- Facultativo especialista de Área de Anestesiología y Reanimación, H.U. Puerta del Mar, Cádiz, España
| | - L M Torres
- Facultativo especialista de Área de Anestesiología y Reanimación, H.U. Puerta del Mar, Cádiz, España
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