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Lee YF, Lin PR, Wu SH, Hsu HH, Yang SY, Kor CT. Impact of the prognostic nutritional index on renal replacement therapy-free survival and mortality in patients on continuous renal replacement therapy. Ren Fail 2024; 46:2365394. [PMID: 38874108 PMCID: PMC11232640 DOI: 10.1080/0886022x.2024.2365394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 06/03/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND The survival of critically ill patients with acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT) is highly dependent on their nutritional status. OBJECTIVES The prognostic nutritional index (PNI) is an indicator used to assess nutritional status and is calculated as: PNI = (serum albumin in g/dL) × 10 + (total lymphocyte count in/mm3) × 0.005. In this retrospective study, we investigated the correlation between this index and clinical outcomes in critically ill patients with AKI receiving CRRT. METHODS We analyzed data from 2076 critically ill patients admitted to the intensive care unit at Changhua Christian Hospital, a tertiary hospital in central Taiwan, between January 1, 2010, and April 30, 2021. All these patients met the inclusion criteria of the study. The relationship between PNI and renal replacement therapy-free survival (RRTFS) and mortality was examined using logistic regression models, Cox proportional hazard models, and propensity score matching. High utilization rate of parenteral nutrition (PN) was observed in our study. Subgroup analysis was performed to explore the interaction effect between PNI and PN on mortality. RESULTS Patients with higher PNI levels exhibited a greater likelihood of achieving RRTFS, with an adjusted odds ratio of 2.43 (95% confidence interval [CI]: 1.98-2.97, p-value < 0.001). Additionally, these patients demonstrated higher survival rates, with an adjusted hazard ratio of 0.84 (95% CI: 0.72-0.98) for 28-day mortality and 0.80 (95% CI: 0.69-0.92) for 90-day mortality (all p-values < 0.05), compared to those in the low PNI group. While a high utilization rate of parenteral nutrition (PN) was observed, with 78.86% of CRRT patients receiving PN, subgroup analysis showed that high PNI had an independent protective effect on mortality outcomes in AKI patients receiving CRRT, regardless of their PN status. CONCLUSIONS PNI can serve as an easy, simple, and efficient measure of lymphocytes and albumin levels to predict RRTFS and mortality in AKI patients with require CRRT.
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Affiliation(s)
- Yu-Fu Lee
- Division of Critical Care Internal Medicine, Department of Emergency Medicine and Critical Care, Changhua Christian Hospital, Changhua, Taiwan
| | - Pei-Ru Lin
- Big Data Center, Changhua Christian Hospital, Changhua, Taiwan
- Graduate Institute of Statistics and Information Science, National Changhua University of Education, Changhua, Taiwan
| | - Shin-Hwar Wu
- Division of Critical Care Internal Medicine, Department of Emergency Medicine and Critical Care, Changhua Christian Hospital, Changhua, Taiwan
| | - Hsin-Hui Hsu
- Division of Critical Care Internal Medicine, Department of Emergency Medicine and Critical Care, Changhua Christian Hospital, Changhua, Taiwan
| | - Shu-Yun Yang
- Division of Critical Care Internal Medicine, Department of Emergency Medicine and Critical Care, Changhua Christian Hospital, Changhua, Taiwan
| | - Chew-Teng Kor
- Big Data Center, Changhua Christian Hospital, Changhua, Taiwan
- Graduate Institute of Statistics and Information Science, National Changhua University of Education, Changhua, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
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Zeng Z, Shen Y, Wan L, Yang X, Liang Z, He M. Risk factors for unplanned weaning of continuous renal replacement therapy in ICU patients: a meta-analysis. Ren Fail 2024; 46:2387431. [PMID: 39135545 PMCID: PMC11328600 DOI: 10.1080/0886022x.2024.2387431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 07/21/2024] [Accepted: 07/29/2024] [Indexed: 08/18/2024] Open
Abstract
OBJECTIVE To systematically review the risk factors for unplanned weaning during continuous renal replacement therapy in ICU patients. METHODS A combination of subject words + free words was used to search the relevant literature published in CNKI, Wanfang, VIP, CBM, PubMed, EMbase, Web of Science, Cochrane Library, Mediline and other databases. The search period was from the establishment of the databases to June 25, 2024. Revman 5.4 software and Stata15.0 software was used to meta-analyze the risk factors for unplanned weaning during continuous renal replacement therapy in ICU patients. RESULTS A total of 23 studies were included in this meta-analysis, describing 15 variables, 3793 patients, and using 7197 filters. Meta-analysis results showed that risk factors for unplanned weaning during continuous renal replacement therapy in ICU patients were as follows: Low mean arterial pressure [OR = 1.02, 95%CI (1.00, 1.03), p < 0.05], hypothermia [OR = 3.40, 95%CI (1.78, 6.47), p < 0.05], age (≥60 years) [OR = 4.45, 95%CI (3.18, 6.22), p < 0.05], comorbid underlying disease [OR = 3.63, 95%CI (2.70, 4.88), p < 0.05], agitation [OR = 4.97, 95%CI (3.20, 7.74), p < 0.05], no anticoagulant use [OR = 1.65, 95%CI (1.25, 2.17), p < 0.05], short activated partial prothrombin time [OR = 1.23, 95%CI (1.13, 1.34), p < 0.05], hyper-hematocrit [OR = 1.73, 95%CI (1.13, 2.66), p = 0.01], low ionized calcium concentration [OR = 1.48, 95% CI (1.08, 2.02), p = 0.01], CRRT that was treated at a high dose [OR = 1.42, 95%CI (1.14, 1.76), p < 0.05], mechanical ventilation [OR = 4.25, 95%CI (2.67, 6.77), p < 0.05], and lack of dedicated care [OR = 5.08, 95%CI (2.51, 10.28), p < 0.05]. However, it is unclear whether platelet count, prothrombin activity, and blood flow velocity are risk factors for unplanned weaning during CRRT in ICU patients, and more studies are needed for further validation. CONCLUSION Available evidence suggests that a variety of factors contribute to unplanned weaning of CRRT in ICU patients. Early detection of these risk factors is essential for healthcare professionals to develop preventive and curative strategies. REGISTRATION This study is registered on the PROSERO website under registration number CRD42024543554.
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Affiliation(s)
- Zhi Zeng
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Yuqi Shen
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Li Wan
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Xiuru Yang
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Zhenghua Liang
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Mei He
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
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Zhang Q, Ding D, Wang C, Lu J, Zhu Q, Ding F. Automated regional citrate anticoagulation system based on individualized dosing models in nonliver failure patients undergoing PIRRT therapy. Ren Fail 2024; 46:2387207. [PMID: 39238242 DOI: 10.1080/0886022x.2024.2387207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 07/01/2024] [Accepted: 07/28/2024] [Indexed: 09/07/2024] Open
Abstract
INTRODUCTION Regional citrate anticoagulation is a preferred option for renal replacement therapy in critically ill patients. However, current implementations ignore individual differences that may exist in the fluctuation of patients' ionized calcium levels. To address this problem, individualized citrate and calcium supplementation models were established based on the pharmacokinetic and clearance characteristics of citrate, and an automated regional citrate anticoagulation system was built with these models as its core to facilitate the treatment of clinical patients. This study was designed to preliminarily evaluate the safety and efficacy of this system, the SuperbMed® RCA-SP100 automated regional citrate anticoagulation system, in prolonged intermittent renal replacement therapy. METHODS Seven patients undergoing prolonged intermittent renal replacement therapy completed treatment with the SuperbMed® RCA-SP100 system. In vivo and in vitro ionized calcium levels were measured every hour before and after the start of dialysis. The accuracy and alarm sensitivity of the pumps were also monitored. RESULTS During seven treatments, the average extracorporeal ionized calcium level was 0.34 ± 0.02 mmol/L, and the mean ionized calcium level in vivo was 1.09 ± 0.07 mmol/L. No patient required intervention, and there was no filter coagulation. The pumps all had an absolute accuracy less than 5%, and alarms could be triggered precisely. CONCLUSIONS We reported on an automated system that allows for individualized citrate and calcium supplementation in prolonged intermittent renal replacement therapy and enables the precise and secure implementation of regional citrate anticoagulation.
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Affiliation(s)
- Qi Zhang
- Division of Nephrology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Damin Ding
- Shanghai Superb Medical Technology Co., Ltd, Shanghai, China
| | - Chaobin Wang
- Shanghai Superb Medical Technology Co., Ltd, Shanghai, China
| | - Jianxin Lu
- Division of Nephrology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qin Zhu
- Division of Nephrology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Feng Ding
- Division of Nephrology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Yang E, Wang Q, Guo J, Wei J, Zhang C, Zhao W, He X, Bo E, Mao Y, Yang H. Development and external validation of a prediction model for the premature circuit clotting of continuous renal replacement therapy in critically ill patients. Intensive Crit Care Nurs 2024; 84:103703. [PMID: 38704337 DOI: 10.1016/j.iccn.2024.103703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/11/2024] [Accepted: 04/03/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVE This study aimed to develop and validate a prediction model for premature circuit clotting of continuous renal replacement therapy (CRRT) in critically ill patients. DESIGN A retrospective cohort study was conducted on ICU patients undergoing CRRT. The Medical Information Mart for Intensive Care-III Clinical Database CareVue subset and Medical Information Mart for Intensive Care-IV were utilized for model development, while the eICU Collaborative Research Database was employed for external validation. Predictive factors were selected through Least Absolute Shrinkage and Selection Operator Regression and univariate logistic regression. A prediction model was then developed using binary logistic regression. Internal and external validations assessed the model's discrimination, calibration, and clinical net benefit. RESULTS This study encompassed 2531 patients overall, with a premature circuit clotting rate of 31.88 %. The prediction model comprises five variables: body temperature, anticoagulation, mean arterial pressure, maximum transmembrane pressure change within two hours, and vasopressor. The model demonstrated robust predictive performance, achieving an area under the receiver operating characteristic curve of 0.897 (95 % CI: 0.879-0.915) in the training set and 0.877 (95 % CI: 0.852-0.902) in the external validation set. Internal validation yielded a Brier score of 0.087, while external validation showed a Brier score of 0.120. Calibration curves indicated good model calibration for both validations. The decision curve analysis indicates that the model yields a clinical net benefit across a wide range of decision thresholds. CONCLUSION The model demonstrates robust discrimination, calibration, and clinical net benefit, with readily available variables indicating substantial potential for valuable clinical applications. IMPLICATIONS FOR CLINICAL PRACTICE Healthcare providers in the ICU can leverage the model to evaluate the risk of premature circuit clotting in critically ill patients undergoing continuous renal replacement therapy, facilitating timely intervention to mitigate its incidence.
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Affiliation(s)
- Erming Yang
- School of Nursing, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Qiaohong Wang
- Department of Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Jing Guo
- Department of Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Jilin Wei
- Department of Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Chiyu Zhang
- Department of Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Wenfang Zhao
- Department of Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xingyue He
- School of Nursing, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Enhui Bo
- School of Nursing, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Ya Mao
- School of Nursing, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Hui Yang
- School of Nursing, Shanxi Medical University, Taiyuan, Shanxi, China; The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China.
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Tang S, Yu Y, Tang S, Liu T, Wu H, Liu Y, Zhao L, Lu R, Zhang P, Bai M. Regional citrate anticoagulation versus LMWH anticoagulation for CRRT in liver failure patients without increased bleeding risk. Int J Artif Organs 2024:3913988241269492. [PMID: 39180396 DOI: 10.1177/03913988241269492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2024]
Abstract
BACKGROUND The optimal anticoagulation regimen for continuous renal replacement therapy (CRRT) in liver failure (LF) patients without increased bleeding risk remains controversial. Therefore, we conducted a monocentric retrospective study to evaluate the efficacy and safety of the regional citrate anticoagulation (RCA) versus low molecular weight heparin (LMWH) anticoagulation for CRRT in LF without increased bleeding risk. METHOD According to the anticoagulation strategy for CRRT, patients were divided into the RCA and LMWH-anticoagulation groups. The evaluated endpoints were patient survival, filter lifespan, bleeding, citrate accumulation, and totCa/ionCa ratio. RESULT Totally 167 and 164 filters were used in the RCA and LMWH group, respectively. The median filter lifespan was significantly longer in the RCA group (34 h (IQR = 24-54) versus 24 h (IQR = 18-45.5) [95%CI, 24.5-33]; p < 0.001). The 4-week mortality rate was significantly higher in the LMWH-anticoagulation group (71 (57.72%) vs 53 (40.46%); p = 0.006). After adjusted the important parameters in the multivariate COX regression model, the mortality risk was significantly reduced in the RCA group (HR = 0.668 [95%CI, 0.468-0.955]; p = 0.027). In the LMWH group, 30 bleeding episodes (24,19%) were observed, whereas only 7 (5.34%) occurred in the RCA group (p < 0.001). Two patients (1.5%) in the RCA group occurred citrate accumulation. CONCLUSIONS In LF patients without increased bleeding risk who underwent CRRT, RCA significantly extended the filter lifespan and improved patient survival rate. There was no significant difference in the rate of adverse events between the two groups.
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Affiliation(s)
- Siyan Tang
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
- Department of Postgraduate Student, Xi'an Medical University, Xi'an, China
| | - Yan Yu
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Siwei Tang
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
- Department of Postgraduate Student, Xi'an Medical University, Xi'an, China
| | - Tong Liu
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Hao Wu
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
- Department of Postgraduate Student, Xi'an Medical University, Xi'an, China
| | - Yi Liu
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
- Department of Postgraduate Student, Xi'an Medical University, Xi'an, China
| | - Lijuan Zhao
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Rui Lu
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Peng Zhang
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Hu C, Shui P, Zhang B, Xu X, Wang Z, Wang B, Yang J, Xiang Y, Zhang J, Ni H, Hong Y, Zhang Z. How to safeguard the continuous renal replacement therapy circuit: a narrative review. Front Med (Lausanne) 2024; 11:1442065. [PMID: 39234046 PMCID: PMC11373359 DOI: 10.3389/fmed.2024.1442065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Accepted: 07/30/2024] [Indexed: 09/06/2024] Open
Abstract
The high prevalence of acute kidney injury (AKI) in ICU patients emphasizes the need to understand factors influencing continuous renal replacement therapy (CRRT) circuit lifespan for optimal outcomes. This review examines key pharmacological interventions-citrate (especially in regional citrate anticoagulation), unfractionated heparin (UFH), low molecular weight heparin (LMWH), and nafamostat mesylate (NM)-and their effects on filter longevity. Citrate shows efficacy with lower bleeding risks, while UFH remains cost-effective, particularly in COVID-19 cases. LMWH is effective but associated with higher bleeding risks. NM is promising for high-bleeding risk scenarios. The review advocates for non-tunneled, non-cuffed temporary catheters, especially bedside-inserted ones, and discusses the advantages of surface-modified dual-lumen catheters. Material composition, such as polysulfone membranes, impacts filter lifespan. The choice of treatment modality, such as Continuous Veno-Venous Hemodialysis (CVVHD) or Continuous Veno-Venous Hemofiltration with Dialysis (CVVHDF), along with the management of effluent volume, blood flow rates, and downtime, are critical in prolonging filter longevity in CRRT. Patient-specific conditions, particularly the type of underlying disease, and the implementation of early mobilization strategies during CRRT are identified as influential factors that can extend the lifespan of CRRT filters. In conclusion, this review offers insights into factors influencing CRRT circuit longevity, supporting evidence-based practices and suggesting further multicenter studies to guide ICU clinical decisions.
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Affiliation(s)
- Chaomin Hu
- Department of Emergency Medicine, Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou, China
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Pengfei Shui
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bo Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xin Xu
- Department of Emergency Medicine, Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou, China
| | - Zhengquan Wang
- Department of Emergency Medicine, Yuyao City People's Hospital, Yuyao, China
| | - Bin Wang
- Department of Emergency Medicine, Anji People's Hospital, Anji, China
| | - Jie Yang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yang Xiang
- Department of Emergency Medicine, Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou, China
| | - Jun Zhang
- Department of Emergency Medicine, Yuyao City People's Hospital, Yuyao, China
| | - Hongying Ni
- Department of Critical Care Medicine, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- School of Medicine, Shaoxing University, Shaoxing, Zhejiang, China
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7
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Chen Y, Feng F, Guo H, Zhang L, Liu J. Study on the application of a segmented sodium citrate solution anticoagulation strategy in critically ill patients receiving CRRT: a prospective, randomized controlled study. Trials 2024; 25:542. [PMID: 39152492 PMCID: PMC11328445 DOI: 10.1186/s13063-024-08370-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 08/05/2024] [Indexed: 08/19/2024] Open
Abstract
BACKGROUND To explore the feasibility and effectiveness of a segmented sodium citrate solution anticoagulation strategy in patients receiving CRRT. METHODS A prospective, randomized controlled study was conducted. RESULTS According to the inclusion and exclusion criteria, 80 patients were included and randomly divided into two groups. Moreover, coagulation indices, liver function indices, renal function indices, and SOFA and APACHE II scores did not significantly differ between the two groups (P > 0.05). The coagulation grade of the venous ports in the experimental group was lower than that in the control group and the two groups of filters, but the difference was not statistically significant (P = 0.337). Both sodium citrate solution infusion methods maintained a low blood calcium concentration (0.25-0.45 mmol/L) in the peripheral circulation pathway, and no patient developed hypocalcaemia (< 1.0 mmol/L). The lifespans of the extracorporeal circulation tube in the experimental group and the control group were 69.43 ± 1.49 h and 49.39 ± 2.44 h, respectively (t = 13.316, P = 0.001). CONCLUSION The segmented citrate solution anticoagulation strategy could extend the lifespan of the extracorporeal circulation tube and improve CRRT efficacy. TRIAL REGISTRATION The Chinese Clinical Trial Registry number is ChiCTR2200057272. Registered on March 5, 2022.
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Affiliation(s)
- Yu Chen
- Intensive Care Unit, The 1st School of Clinical Medicine of Lanzhou University, Lanzhou, 730000, Gansu, China
| | - Fang Feng
- Intensive Care Unit, Lanzhou University Second Hospital, Lanzhou, 730000, Gansu, China
| | - Hong Guo
- Intensive Care Unit, The 1st School of Clinical Medicine of Lanzhou University, Lanzhou, 730000, Gansu, China
| | - Lu Zhang
- Intensive Care Unit, The 1st School of Clinical Medicine of Lanzhou University, Lanzhou, 730000, Gansu, China
| | - Jian Liu
- Intensive Care Unit, The 1st School of Clinical Medicine of Lanzhou University, Lanzhou, 730000, Gansu, China.
- Intensive Care Unit, Gansu Provincial Central Hospital, Lanzhou, 730000, Gansu, China.
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8
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Gorard D. Magnesium Disorders. N Engl J Med 2024; 391:668. [PMID: 39141870 DOI: 10.1056/nejmc2408312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
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Post A, Heijkoop ÈRH, Diebels LLM, Post A, van Meurs M, van der Voort PHJ, Franssen CFM, Volbeda M. Further improvement of circuit survival in citrate based continuous renal replacement therapy. Clin Kidney J 2024; 17:sfae187. [PMID: 39099560 PMCID: PMC11292220 DOI: 10.1093/ckj/sfae187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Indexed: 08/06/2024] Open
Abstract
Background Continuous renal replacement therapy (CRRT) is the most frequently used modality of renal replacement therapy (RRT) in critical care patients with acute kidney injury (AKI). Adequate CRRT delivery can be challenging, due to problems with circuit patency. To improve circuit patency, we developed a new CRRT protocol using continuous veno-venous hemodiafiltration (CVVHDF) with 3.0 mmol/l regional citrate anticoagulation (CVVHDF/RCA3.0) as our first choice RRT modality. Methods Retrospective comparison of efficacy and safety of a CVVHDF/RCA3.0 protocol with our former continuous veno-venous hemofiltration protocol with 2.2 regional citrate anticoagulation (CVVH/RCA2.2) in adult critically ill patients with AKI requiring CRRT between 25 April 2020 and 24 October 2021. Results In total, 56 patients (257 circuits) and 66 patients (290 circuits) were included in the CVVH/RCA2.2 and CVVHDF/RCA3.0 groups, respectively. Median circuit survival was significantly higher in patients treated with CVVHDF/RCA3.0 (39.6 (IQR 19.5-67.3) hours) compared to patients treated with CVVH/RCA2.2 (22.9 (IQR 11.3-48.6) hours) (P < .001). Higher body weight and higher convective flow were associated with a lower circuit survival. Metabolic control was similar, except for metabolic alkalosis that occurred less frequently during CVVHDF/RCA3.0 (19% of patients) compared to CVVH/RCA2.2 (46% of patients) (P = .006). Conclusions CRRT circuit survival was longer with CVVHDF/RCA3.0 compared to CVVH/RCA2.2. CRRT circuit survival was negatively associated with higher body weight and higher convective flow.
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Affiliation(s)
- Alena Post
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Èmese R H Heijkoop
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Lotte L M Diebels
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Adrian Post
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Matijs van Meurs
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter H J van der Voort
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Casper F M Franssen
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Meint Volbeda
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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10
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Hasan MS, Jamaludin MA, Mohd Azman SA, Atan R, Yap MH, Lee ZY, Mohd Yunos N. Early experience of using regional citrate anticoagulation for continuous renal replacement therapy in critically ill patients in a resource-limited setting. Nephrology (Carlton) 2024; 29:528-536. [PMID: 38830816 DOI: 10.1111/nep.14330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/22/2024] [Accepted: 05/23/2024] [Indexed: 06/05/2024]
Abstract
AIM Despite the superiority of regional citrate anticoagulation (RCA) in continuous renal replacement therapy (CRRT), its application is limited in resource-limited settings. We aim to explore the cost and safety of RCA for CRRT in critically ill patients, compared to usual care. METHODS This prospective observational study included patients requiring CRRT in a tertiary intensive care unit (ICU) from February 2022 to January 2023. They were classified to either the RCA or usual care groups based on the anticoagulation technique chosen by the treating physician, considering contraindications. The CRRT prescription follows the institutional protocol. All relevant data were obtained from the ICU CRRT-RCA charts and electronic medical records. A cost analysis was performed. RESULTS A total of 54 patients (27 per group) were included, with no demographic differences. Sequential Organ Failure Assessment score and lactate levels were significantly higher in the usual care group. The number of filters used were comparable (p = .108). The median filter duration in the RCA group was numerically longer (35.00 [15.50-56.00] vs. 23.00 [17.00-29.00] h), but not statistically significant (p = .253). The duration of mechanical ventilation, vasopressor requirement, and mortality were similar, but the RCA group had a significantly longer ICU stay. The rate of adverse events was similar, with four severe metabolic alkalosis cases in the RCA group. The RCA group had higher total cost per patient per day (USD 611 vs. 408; p = .013). CONCLUSION In this resource-limited setting, RCA for CRRT appeared safe and had clinically longer filter lifespan compared with usual care, albeit the increased cost.
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Affiliation(s)
- M Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- Department of Anaesthesiology, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Muhammad Afif Jamaludin
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | | | - Rafidah Atan
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- Department of Anaesthesiology, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Mei Hoon Yap
- Department of Anaesthesiology, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Nor'azim Mohd Yunos
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- Department of Anaesthesiology, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia
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11
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Deja A, Guzzo I, Cappoli A, Labbadia R, Bayazit AK, Yildizdas D, Schmitt CP, Tkaczyk M, Cvetkovic M, Kostic M, Hayes W, Shroff R, Jankauskiene A, Virsilas E, Longo G, Vidal E, Mir S, Bulut IK, Pasini A, Paglialonga F, Montini G, Yilmaz E, Costa LC, Teixeira A, Schaefer F. Factors influencing circuit lifetime in paediatric continuous kidney replacement therapies - results from the EurAKId registry. Pediatr Nephrol 2024:10.1007/s00467-024-06459-6. [PMID: 39023538 DOI: 10.1007/s00467-024-06459-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 06/22/2024] [Accepted: 06/24/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Continuous kidney replacement therapy (CKRT) has recently become the preferred kidney replacement modality for children with acute kidney injury (AKI). We hypothesise that CKRT technical parameters and treatment settings in addition to the clinical characteristics of patients may influence the circuit lifetime in children. METHODS The study involved children included in the EurAKId registry (NCT02960867), who underwent CKRT treatment. We analysed patient characteristics and CKRT parameters. The primary end point was mean circuit lifetime (MCL). Secondary end points were number of elective circuit changes and occurrence of dialysis-related complications. RESULTS The analysis was composed of 247 children who underwent 37,562 h of CKRT (median 78, IQR 37-165 h per patient). A total of 1357 circuits were utilised (3, IQR 2-6 per patient). MCL was longer in regional citrate anticoagulation (RCA), compared to heparin (HA) and no anticoagulation (NA) (42, IQR 32-58 h; 24, IQR 14-34 h; 18, IQR 12-24 h, respectively, p < 0.001). RCA was associated with longer MCL regardless of the patient's age or dialyser surface. In multivariate analysis, MCL correlated with dialyser surface area (beta = 0.14, p = 0.016), left internal jugular vein vascular access site (beta = -0.37, p = 0.027), and the use of HA (beta = -0.14, p = 0.038) or NA (beta = -0.37, p < 0.001) vs. RCA. RCA was associated with the highest ratio of elective circuit changes and the lowest incidence of complications. CONCLUSION Anticoagulation modality, dialyser surface, and vascular access site influence MCL. RCA should be considered when choosing first-line anticoagulation for CKRT in children. Further efforts should focus on developing guidelines and clinical practice recommendations for paediatric CKRT.
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Affiliation(s)
- Anna Deja
- Department of Paediatrics and Nephrology, Medical University of Warsaw, Warsaw, Poland.
| | - Isabella Guzzo
- Division of Nephrology, Dialysis and Transplant Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Andrea Cappoli
- Division of Nephrology, Dialysis and Transplant Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Raffaella Labbadia
- Division of Nephrology, Dialysis and Transplant Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Aysun Karabay Bayazit
- Department of Pediatric Nephrology, Cukurova University, Faculty of Medicine, Adana, Turkey
| | - Dincer Yildizdas
- Department of Pediatric Nephrology, Cukurova University, Faculty of Medicine, Adana, Turkey
| | - Claus Peter Schmitt
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Marcin Tkaczyk
- Department of Pediatrics and Immunology, Nephrology Division, Polish Mothers Memorial Hospital Research Institute, Lodz, Poland
| | - Mirjana Cvetkovic
- Department of Nephrology, University Children Hospital, Belgrade, Serbia
| | - Mirjana Kostic
- Department of Nephrology, University Children Hospital, Belgrade, Serbia
| | - Wesley Hayes
- Department of Pediatric Nephrology, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Rukshana Shroff
- Department of Pediatric Nephrology, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Augustina Jankauskiene
- Clinic of Pediatrics, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Ernestas Virsilas
- Clinic of Pediatrics, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Germana Longo
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Woman's and Children's Health, University of Padua, Padua, Italy
| | - Enrico Vidal
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Woman's and Children's Health, University of Padua, Padua, Italy
| | - Sevgi Mir
- Department of Pediatric Nephrology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Ipek Kaplan Bulut
- Department of Pediatric Nephrology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Andrea Pasini
- Pediatric Nephrology and Dialysis, Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Fabio Paglialonga
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Grande IRRCS, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Grande IRRCS, Ospedale Maggiore Policlinico, Milan, Italy
| | - Ebru Yilmaz
- Department of Pediatric Nephrology, Dr Behcet Children Research and Education Hospital, Izmir, Turkey
| | - Liane Correia Costa
- Department of Pediatric Nephrology, Centro Materno-Infantil Do Norte, Porto, Portugal
| | - Ana Teixeira
- Department of Pediatric Nephrology, Centro Materno-Infantil Do Norte, Porto, Portugal
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
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12
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Dimski T, Brandenburger T, Vollmer C, Kindgen-Milles D. A safe and effective protocol for postdilution hemofiltration with regional citrate anticoagulation. BMC Nephrol 2024; 25:218. [PMID: 38982339 PMCID: PMC11234626 DOI: 10.1186/s12882-024-03659-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 07/01/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) is recommended during continuous renal replacement therapy. Compared to systemic anticoagulation, RCA provides a longer filter lifespan with the risk of metabolic alkalosis and impaired calcium homeostasis. Surprisingly, most RCA protocols are designed for continuous veno-venous hemodialysis or hemodiafiltration. Effective protocols for continuous veno-venous hemofiltration (CVVH) are rare, although CVVH is a standard treatment for high-molecular-weight clearance. Therefore, we evaluated a new RCA protocol for postdilution CVVH. METHODS This is a monocentric prospective interventional study to evaluate a new RCA protocol for postdilution CVVH. We recruited surgical patients with stage III acute kidney injury who needed renal replacement therapy. We recorded dialysis and RCA data and hemodynamic and laboratory parameters during treatment sessions of 72 h. The primary endpoint was filter patency at 72 h. The major safety parameters were metabolic alkalosis and severe hypocalcemia at any time. RESULTS We included 38 patients who underwent 66 treatment sessions. The mean filter lifespan was 66 ± 12 h, and 44 of 66 (66%) filters were patent at 72 h. After censoring for non-CVVH-related cessation of treatment, 83% of all filters were patent at 72 h. The delivered dialysis dose was 28 ± 5 ml/kgBW/h. The serum levels of creatinine, urea and beta2-microglobulin decreased significantly from day 0 to day 3. Metabolic alkalosis occurred in one patient. An iCa++ below 1.0 mmol/L occurred in four patients. Citrate accumulation did not occur. CONCLUSIONS We describe a safe, effective, and easy-to-use RCA protocol for postdilution CVVH. This protocol provides a long and sustained filter lifespan without serious adverse effects. The risk of metabolic alkalosis and hypocalcemia is low. Using this protocol, a recommended dialysis dose can be safely administered with effective clearance of low- and middle-molecular-weight molecules. TRIAL REGISTRATION The study was approved by the medical ethics committee of Heinrich-Heine University Duesseldorf (No. 2018-82KFogU). The trial was registered in the local study register of the university (No: 2018044660) on 07/04/2018 and was retrospectively registered at ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT03969966) on 31/05/2019.
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Affiliation(s)
- Thomas Dimski
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstr. 5, Duesseldorf, 40225, Germany.
| | - Timo Brandenburger
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstr. 5, Duesseldorf, 40225, Germany
| | - Christian Vollmer
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstr. 5, Duesseldorf, 40225, Germany
| | - Detlef Kindgen-Milles
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstr. 5, Duesseldorf, 40225, Germany
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13
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Yin R, Ding L, Jing X, Zhang Y. Risk factors of hypotension in patients undergoing CRRT: A meta-analysis. Asian J Surg 2024:S1015-9584(24)01230-2. [PMID: 38944612 DOI: 10.1016/j.asjsur.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 05/24/2024] [Accepted: 06/13/2024] [Indexed: 07/01/2024] Open
Affiliation(s)
- Rong Yin
- Department of Anesthesiology, Changzhou First People's Hospital, Jiangsu, China
| | - Lei Ding
- Department of Gastroenterology, Changzhou Maternal and Child Health Care Hospital, Jiangsu, China
| | - Xinhua Jing
- Department of Anesthesiology, Changzhou First People's Hospital, Jiangsu, China.
| | - Yun Zhang
- Department of Anesthesiology, Changzhou First People's Hospital, Jiangsu, China.
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14
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Corbu A, Terrec F, Malvezzi P, Jouzier A, Jouve T, Rostaing L, Naciri Bennani H. Calcium-Free Dialysate Hemodialysis: A Simplified Approach. J Pers Med 2024; 14:660. [PMID: 38929882 PMCID: PMC11204440 DOI: 10.3390/jpm14060660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 06/11/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
Intermittent hemodialysis (HD) in high-bleeding-risk patients presents a challenge as circuit anticoagulation using heparin is contraindicated in such cases. Recently, the use of calcium-free citrate-containing dialysate with calcium supplementation emerged as a viable alternative to heparin-circuit anticoagulation. This is a retrospective, monocentric study to evaluate dialysis efficacy using calcium-free citrate-containing dialysate with calcium reinjection into the venous line in hemodialysis patients at risk of bleeding. A total of 53 patients were analyzed: 52 had a temporary contraindication to systemic anticoagulation (active bleeding or surgical intervention), and 1 chronic HD patient had prolonged bleeding time due to inoperable arteriovenous fistula stenosis. Only 7 out of 79 dialysis sessions performed were prematurely terminated (vascular access dysfunction). The median dialysis time was 240 min (range: 150-300). The chronic dialysis patient had 108 sessions with no premature termination. Frequent monitoring of ionized calcium was performed throughout the dialysis sessions: levels remained stable at T0 and T + 60 min (1.08 ± 0.08 mmol/L) and slightly increased at the end of the dialysis session (1.19 ± 0.13 mmol/L), remaining within normal limits. Target postfilter ionized calcium <0.4 mmol/L was achieved in all sessions (0.31 ± 0.07 mmol/L). There were no cases of symptomatic hypo-/hypercalcemia and no need for calcium infusion rate adjustment throughout the sessions. Hemodialysis with calcium-free citrate-containing dialysate and calcium reinjection into the venous line is efficient and safe in HD patients with contraindications to systemic anticoagulation.
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Affiliation(s)
- Alexandra Corbu
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
| | - Florian Terrec
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
| | - Paolo Malvezzi
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
| | - Arnaud Jouzier
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
| | - Thomas Jouve
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
- Univ. Grenoble Alpes Inserm U 1209, CNRS UMR 5309, Team Epigenetics, Immunity, Metabolism, Cell Signaling and Cancer, Institute for Advanced Biosciences, 38000 Grenoble, France
| | - Lionel Rostaing
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
- Univ. Grenoble Alpes Inserm U 1209, CNRS UMR 5309, Team Epigenetics, Immunity, Metabolism, Cell Signaling and Cancer, Institute for Advanced Biosciences, 38000 Grenoble, France
| | - Hamza Naciri Bennani
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
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15
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Zhu D, He J, Xiao Z, Zhou X, Zhang X. Citrate and low-dose heparin combined anticoagulation in pediatric continuous renal replacement therapy. Sci Rep 2024; 14:13504. [PMID: 38866989 PMCID: PMC11169537 DOI: 10.1038/s41598-024-64433-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 06/10/2024] [Indexed: 06/14/2024] Open
Abstract
There remains no optimal anticoagulation protocol for continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) in pediatric patients with elevated D-dimer levels. We aimed to assess the effects of different anticoagulation strategies on the risk of CRRT filter clotting in these patients. Pediatric patients undergoing CRRT were retrospectively grouped based on pre-CRRT D-dimer levels and anticoagulant: D-RCA group (normal D-dimer, RCA only, n = 22), D+ RCA group (elevated D-dimer, RCA only, n = 50), and D+ RCA+ systemic heparin anticoagulation (SHA) group (elevated D-dimer, RCA combined with SHA, n = 55). The risk of filter clotting and incidence of bleeding were compared among the groups. Among the groups, the D+ RCA+ SHA group had the longest filter lifespan; further, the incidence of bleeding was not increased by concurrent use of low-dose heparin for anticoagulation. Moreover, concurrent heparin anticoagulation was associated with a decreased risk of filter clotting. Contrastingly, high pre-CRRT hemoglobin and D-dimer levels and post-filter ionized calcium level > 0.4 mmol/L were associated with an increased risk of filter clotting. RCA combined with low-dose heparin anticoagulation could reduce the risk of filter clotting and prolong filter lifespan without increasing the risk of bleeding in patients with elevated D-dimer levels undergoing CRRT.
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Affiliation(s)
- Desheng Zhu
- Pediatric Intensive Care Unit, The Affiliated Children's Hospital of Xiangya School of Medicine, Central South University (Hunan Children's Hospital), No. 86 Ziyuan Rd, Yuhua District, Changsha, 410007, Hunan, China
| | - Jie He
- Pediatric Intensive Care Unit, The Affiliated Children's Hospital of Xiangya School of Medicine, Central South University (Hunan Children's Hospital), No. 86 Ziyuan Rd, Yuhua District, Changsha, 410007, Hunan, China
| | - Zhenghui Xiao
- Pediatric Intensive Care Unit, The Affiliated Children's Hospital of Xiangya School of Medicine, Central South University (Hunan Children's Hospital), No. 86 Ziyuan Rd, Yuhua District, Changsha, 410007, Hunan, China
| | - Xiong Zhou
- Pediatric Intensive Care Unit, The Affiliated Children's Hospital of Xiangya School of Medicine, Central South University (Hunan Children's Hospital), No. 86 Ziyuan Rd, Yuhua District, Changsha, 410007, Hunan, China
| | - Xinping Zhang
- Pediatric Intensive Care Unit, The Affiliated Children's Hospital of Xiangya School of Medicine, Central South University (Hunan Children's Hospital), No. 86 Ziyuan Rd, Yuhua District, Changsha, 410007, Hunan, China.
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16
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Volbeda M, Franssen CFM. Meta-analysis of regional citrate versus heparin anticoagulation for continuous renal replacement therapy. Ther Apher Dial 2024; 28:475-476. [PMID: 38173140 DOI: 10.1111/1744-9987.14104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/21/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Meint Volbeda
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Casper F M Franssen
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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17
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Walker HGM, Brown AJ, Vaz IP, Reed R, Schofield MA, Shao J, Nanjayya VB, Udy AA, Jeffcote T. Composite outcome measures in high-impact critical care randomised controlled trials: a systematic review. Crit Care 2024; 28:184. [PMID: 38807143 PMCID: PMC11134769 DOI: 10.1186/s13054-024-04967-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/22/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND The use of composite outcome measures (COM) in clinical trials is increasing. Whilst their use is associated with benefits, several limitations have been highlighted and there is limited literature exploring their use within critical care. The primary aim of this study was to evaluate the use of COM in high-impact critical care trials, and compare study parameters (including sample size, statistical significance, and consistency of effect estimates) in trials using composite versus non-composite outcomes. METHODS A systematic review of 16 high-impact journals was conducted. Randomised controlled trials published between 2012 and 2022 reporting a patient important outcome and involving critical care patients, were included. RESULTS 8271 trials were screened, and 194 included. 39.1% of all trials used a COM and this increased over time. Of those using a COM, only 52.6% explicitly described the outcome as composite. The median number of components was 2 (IQR 2-3). Trials using a COM recruited fewer participants (409 (198.8-851.5) vs 584 (300-1566, p = 0.004), and their use was not associated with increased rates of statistical significance (19.7% vs 17.8%, p = 0.380). Predicted effect sizes were overestimated in all but 6 trials. For studies using a COM the effect estimates were consistent across all components in 43.4% of trials. 93% of COM included components that were not patient important. CONCLUSIONS COM are increasingly used in critical care trials; however effect estimates are frequently inconsistent across COM components confounding outcome interpretations. The use of COM was associated with smaller sample sizes, and no increased likelihood of statistically significant results. Many of the limitations inherent to the use of COM are relevant to critical care research.
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Affiliation(s)
- Humphrey G M Walker
- Department of Critical Care, St Vincent's Hospital, Melbourne, VIC, Australia.
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Australia.
| | - Alastair J Brown
- Department of Critical Care, St Vincent's Hospital, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Ines P Vaz
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Australia
| | - Rebecca Reed
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Australia
| | - Max A Schofield
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Australia
| | | | - Vinodh B Nanjayya
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, VIC, Australia
| | - Andrew A Udy
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, VIC, Australia
| | - Toby Jeffcote
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, VIC, Australia
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18
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Ray PE. Continuous kidney replacement therapy in critically ill children: heparin vs citrate. Pediatr Res 2024:10.1038/s41390-024-03238-9. [PMID: 38740869 DOI: 10.1038/s41390-024-03238-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 04/11/2024] [Indexed: 05/16/2024]
Affiliation(s)
- Patricio E Ray
- Department of Pediatrics and Child Health Research Center, University of Virginia School of Medicine, Charlottesville, VA, USA.
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19
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Yu X, Ouyang L, Li J, Peng Y, Zhong D, Yang H, Zhou Y. Knowledge, attitude, practice, needs, and implementation status of intensive care unit staff toward continuous renal replacement therapy: a survey of 66 hospitals in central and South China. BMC Nurs 2024; 23:281. [PMID: 38671501 PMCID: PMC11055233 DOI: 10.1186/s12912-024-01953-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/19/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) is a commonly utilized form of renal replacement therapy (RRT) in the intensive care unit (ICU). A specialized CRRT team (SCT, composed of physicians and nurses) engage playing pivotal roles in administering CRRT, but there is paucity of evidence-based research on joint training and management strategies. This study armed to evaluate the knowledge, attitude, and practice (KAP) of ICU staff toward CRRT, and to identify education pathways, needs, and the current status of CRRT implementation. METHODS This study was performed from February 6 to March 20, 2023. A self-made structured questionnaire was used for data collection. Descriptive statistics, T-tests, Analysis of variance (ANOVA), multiple linear regression, and Pearson correlation coefficient tests (α = 0.05) were employed. RESULTS A total of 405 ICU staff from 66 hospitals in Central and South China participated in this study, yielding 395 valid questionnaires. The mean knowledge score was 51.46 ± 5.96 (61.8% scored highly). The mean attitude score was 58.71 ± 2.19 (73.9% scored highly). The mean practice score was 18.15 ± 0.98 (85.1% scored highly). Multiple linear regression analysis indicated that gender, age, years of CRRT practice, ICU category, and CRRT specialist panel membership independently affected the knowledge score; Educational level, years of CRRT practice, and CRRT specialist panel membership independently affected the attitude score; Education level and teaching hospital employment independently affected the practice score. The most effective method for ICU staff to undergo training and daily work experience is within the department. CONCLUSION ICU staff exhibit good knowledge, a positive attitude and appropriately practiced CRRT. Extended CRRT practice time in CRRT, further training in a general ICU or teaching hospital, joining a CRRT specialist panel, and upgraded education can improve CRRT professional level. Considering the convenience of training programs will enhance ICU staff participation. Training should focus on basic CRRT principles, liquid management, and alarm handling.
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Affiliation(s)
- Xiaoyan Yu
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China
| | - Lin Ouyang
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China
| | - Jinxiu Li
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China
| | - Ying Peng
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China
| | - Dingming Zhong
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China
| | - Huan Yang
- Blood Purification Center, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China
| | - Yanyan Zhou
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China.
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20
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Musalem P, Pedreros-Rosales C, Müller-Ortiz H. Anticoagulation in renal replacement therapies: Why heparin should be abandoned in critical ill patients? Int Urol Nephrol 2024; 56:1383-1393. [PMID: 37755609 DOI: 10.1007/s11255-023-03805-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/13/2023] [Indexed: 09/28/2023]
Abstract
Extracorporeal circuits used in renal replacement therapy (RRT) can develop thrombosis, leading to downtimes and reduced therapy efficiency. To prevent this, anticoagulation is used, but the optimal anticoagulant has not yet been identified. Heparin is the most widely used anticoagulant in RRT, but it has limitations, such as unpredictable pharmacokinetics, nonspecific binding to plasma proteins and cells, and the possibility of suboptimal anticoagulation or bleeding complications, specifically in critically ill patients with acute renal failure who are already at high risk of bleeding. Citrate anticoagulation is a better alternative, being considered a standard for continuous renal replacement therapy, since it is associated with a lower risk of bleeding complications and better efficacy, even in patients with acute renal failure or liver disease. The aim of this article is to provide an updated review of the different strategies of anticoagulation in renal replacement therapies that can be implemented in critical scenarios, focusing on the advantages and disadvantages of each one and the beneficial aspects of using citrate over heparin in critical ill patients.
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Affiliation(s)
- Pilar Musalem
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile
- Nephrology, Dialysis and Transplantation Service, Hospital Las Higueras, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile
| | - Cristian Pedreros-Rosales
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile.
- Nephrology, Dialysis and Transplantation Service, Hospital Las Higueras, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile.
| | - Hans Müller-Ortiz
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile
- Nephrology, Dialysis and Transplantation Service, Hospital Las Higueras, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile
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21
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Atis SK, Duyu M, Karakaya Z, Yilmaz A. Citrate anticoagulation and systemic heparin anticoagulation during continuous renal replacement therapy among critically-ill children. Pediatr Res 2024:10.1038/s41390-024-03163-x. [PMID: 38555381 DOI: 10.1038/s41390-024-03163-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/23/2024] [Accepted: 03/01/2024] [Indexed: 04/02/2024]
Abstract
BAKCGROUND The aim of this study was to evaluate the efficacy and safety of citrate versus heparin anticoagulation for CRRT in critically-ill children. METHODS This retrospective comparative cohort reviewed the clinical records of critically-ill children undergoing CRRT with either RCA or systemic heparin anticoagulation. The primary outcome measure was hemofilter survival time. Secondary outcomes included the comparison of complications and metabolic disorders. RESULTS A total of 131 patients (55 RCA and 76 systemic heparin) were included, in which a cumulative number of 280 hemofilters were used (115 in RCA with 5762 h total CRRT time, and 165 in systemic heparin with 6230 h total CRRT time). Hemofilter survival was significantly longer for RCA (51.0 h; IQR: 24-67 h) compared to systemic heparin (29.5 h; IQR, 17-48 h) (p = 0.002). Clotting-related hemofilter failure occurred in 9.6% of the RCA group compared to 19.6% in the systemic heparin group (p = 0.038). Citrate accumulation occurred in 4 (3.5%) of 115 RCA sessions. Hypocalcemia and metabolic alkalosis episodes were significantly more frequent in RCA recipients (35.7% vs 15.2%, p < 0.0001; 33.0% vs 19.4%, p = 0.009). CONCLUSION RCA is a safe and effective anticoagulation method for CRRT in critically-ill children and it prolongs hemofilter survival. IMPACT RCA is superior to systemic heparin for the prolongation of circuit survival (overall and for clotting-related loss) during CRRT. These data indicate that RCA can be used to maximize the effective delivery of CRRT in critically-ill patients admitted to the PICU. There are potential cost-saving implications from our results owing to benefits such as less circuit downtime and fewer circuit changes.
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Affiliation(s)
- Seyma Koksal Atis
- Department of Pediatrics, Istanbul Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey.
| | - Muhterem Duyu
- Pediatric Intensive Care Unit, Istanbul Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey
| | - Zeynep Karakaya
- Department of Pediatrics, Istanbul Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey
| | - Alev Yilmaz
- Department of Pediatrics, Division of Pediatric Nephrology, Istanbul University Faculty of Medicine, Istanbul, Turkey
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22
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de Fallois J, Scharm R, Lindner TH, Scharf C, Petros S, Weidhase L. Kidney replacement and conservative therapies in rhabdomyolysis: a retrospective analysis. BMC Nephrol 2024; 25:96. [PMID: 38486159 PMCID: PMC10938657 DOI: 10.1186/s12882-024-03536-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/06/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Toxic renal effects of myoglobin following rhabdomyolysis can cause acute kidney injury (AKI) with the necessity of kidney replacement therapy (KRT). Fast elimination of myoglobin seems notable to save kidney function and intensify kidney repair. Clinical data regarding efficacy of KRT in critical care patients with rhabdomyolysis and AKI are limited. This retrospective analysis aimed to identify differences between conservative therapy and different modalities of KRT regarding myoglobin elimination and clinical outcome. METHODS This systematic, retrospective, single-center study analyzed 328 critical care patients with rhabdomyolysis (myoglobin > 1000 µg/l). Median reduction rate of myoglobin after starting KRT was calculated and compared for different modalities. Multivariate logistic regression models were established to identify potential confounder on hospital mortality. Filter lifetime of the various extracorporeal circuits was analyzed by Kaplan-Meier curves. RESULTS From 328 included patients 171 required KRT. Health condition at admission of this group was more critical compared to patient with conservative therapy. Myoglobin reduction rate did not differ between the groups (KRT 49% [30.8%; 72.2%] vs. conservative treatment (CT) 61% [38.5%; 73.5%]; p = 0.082). Comparison between various extracorporeal procedures concerning mortality showed no significant differences. Hospital mortality was 55.6% among patients with KRT and 18.5% with CT (p < 0.001). Multivariate logistic regression model identified requirement for KRT (OR: 2.163; CI: 1.061-4.407); p = 0.034) and the SOFA Score (OR: 1.111; CI: 1.004-1.228; p = 0.041) as independent predictive factors for hospital mortality. When comparing specific KRT using multivariate regression, no benefit was demonstrated for any treatment modality. Life span of the extracorporeal circuit was shorter with CVVH compared to that of others (log-Rank p = 0.017). CONCLUSIONS This study emphasizes that AKI requiring KRT following rhabdomyolysis is accompanied by high mortality rate. Differences in myoglobin reduction rate between various KRTs could not be confirmed, but CVVH was associated with reduced filter lifetime compared to other KRTs, which enable myoglobin elimination, too.
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Affiliation(s)
- Jonathan de Fallois
- Medical Department III, Division of Nephrology, University of Leipzig Medical Center, Leipzig, Germany
| | - Robert Scharm
- Medical Intensive Care Unit, Medical ICU, University of Leipzig Medical Center, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Tom H Lindner
- Medical Department III, Division of Nephrology, University of Leipzig Medical Center, Leipzig, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Sirak Petros
- Medical Intensive Care Unit, Medical ICU, University of Leipzig Medical Center, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Lorenz Weidhase
- Medical Intensive Care Unit, Medical ICU, University of Leipzig Medical Center, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
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23
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Pelusio C, Endres P, Neyra JA, Allegretti AS. Renal Replacement Therapy in Cirrhosis: A Contemporary Review. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:133-138. [PMID: 38649217 PMCID: PMC11103613 DOI: 10.1053/j.akdh.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 12/20/2023] [Accepted: 01/02/2024] [Indexed: 04/25/2024]
Abstract
Acute kidney injury is a common complication of decompensated cirrhosis, frequently requires hospitalization, and carries a high short-term mortality. This population experiences several characteristic types of acute kidney injury: hypovolemic-mediated (prerenal), ischemic/nephrotoxic-mediated (acute-tubular necrosis), and hepatorenal syndrome. Prerenal acute kidney injury is treated with volume resuscitation. Acute-tubular necrosis is treated by optimizing perfusion pressure and discontinuing the offending agent. Hepatorenal syndrome, a unique physiology of decreased effective arterial circulation leading to renal vasoconstriction and ultimately acute kidney injury, is treated with plasma expansion with albumin and splanchnic vasoconstrictors such as terlipressin or norepinephrine. Common acute stressors such as bleeding, infection, and volume depletion often contribute to multifactorial acute kidney injury. Even with optimal medical management, many clinicians are faced with the challenge of initiating renal replacement therapy in these patients. This article reviews the epidemiology, indications, and complex considerations of renal replacement therapy for acute kidney injury in decompensated cirrhosis.
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Affiliation(s)
- Caterina Pelusio
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy; Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Paul Endres
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA.
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24
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Di Marco GS, Chasan AI, Boeckel GR, Beul K, Pavenstädt H, Roth J, Brand M. Monocytes as Targets for Immunomodulation by Regional Citrate Anticoagulation. Int J Mol Sci 2024; 25:2900. [PMID: 38474146 DOI: 10.3390/ijms25052900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 03/14/2024] Open
Abstract
Immune alterations in end-stage renal patients receiving hemodialysis are complex and predispose patients to infections. Anticoagulation may also play an immunomodulatory role in addition to the accumulation of uremic toxins and the effects of the dialysis procedure. Accordingly, it has been recently shown that the infection rate increases in patients under regional citrate anticoagulation (RCA) compared with systemic heparin anticoagulation (SHA). We hypothesized that RCA affects the immune status of hemodialysis patients by targeting monocytes. In a cohort of 38 end-stage renal patients undergoing hemodialysis, we demonstrated that whole blood monocytes of patients receiving RCA-but not SHA-failed to upregulate surface activation markers, like human leukocyte antigen class II (HLA-DR), after stressful insults, indicating a state of deactivation during and immediately after dialysis. Additionally, RNA sequencing (RNA-seq) data and gene set enrichment analysis of pre-dialysis monocytes evidenced a great and complex difference between the groups given that, in the RCA group, monocytes displayed a dramatic transcriptional change with increased expression of genes related to the cell cycle regulation, cellular metabolism, and cytokine signaling, compatible with the reprogramming of the immune response. Transcriptomic changes in pre-dialysis monocytes signalize the lasting nature of the RCA-related effects, suggesting that monocytes are affected even beyond the dialysis session. Furthermore, these findings demonstrate that RCA-but not SHA-impairs the response of monocytes to activation stimuli and alters the immune status of these patients with potential clinical implications.
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Affiliation(s)
- Giovana Seno Di Marco
- Department of Internal Medicine D, University Hospital Muenster, 48149 Muenster, Germany
| | - Achmet Imam Chasan
- Institute of Immunology, University of Muenster, 48149 Muenster, Germany
| | - Göran Ramin Boeckel
- Department of Internal Medicine D, University Hospital Muenster, 48149 Muenster, Germany
| | - Katrin Beul
- Department of Internal Medicine D, University Hospital Muenster, 48149 Muenster, Germany
| | - Hermann Pavenstädt
- Department of Internal Medicine D, University Hospital Muenster, 48149 Muenster, Germany
| | - Johannes Roth
- Institute of Immunology, University of Muenster, 48149 Muenster, Germany
| | - Marcus Brand
- Department of Internal Medicine D, University Hospital Muenster, 48149 Muenster, Germany
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25
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Israni A, Goldfarb DS. Let's stop talking about 'citrate toxicity'. Curr Opin Nephrol Hypertens 2024; 33:181-185. [PMID: 37962170 DOI: 10.1097/mnh.0000000000000953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
PURPOSE OF REVIEW Continuous renal replacement therapy (CRRT) is a vital medical intervention used in critically ill patients with acute kidney injury (AKI). One of the key components of adequate clearance with CRRT is the use of anticoagulants to prevent clotting of the extracorporeal circuit. Regional citrate anticoagulation is the most often recommended modality. The term 'citrate toxicity' is used to describe potential adverse effects of accumulation of citrate and subsequent hypocalcemia. However, citrate is itself not inherently toxic. The term and diagnosis of citrate toxicity are questioned in this review. RECENT FINDINGS Citrate is being increasingly used for regional anticoagulation of the CRRT circuit. Citrate accumulation is infrequent and can cause hypocalcemia and metabolic alkalosis, which are potential adverse effects. Citrate itself, however, is not a toxic molecule. The term 'citrate toxicity' has been used to denote hypocalcemia and metabolic acidosis. However, citrate administration is well known to cause systemic and urinary alkalinization and under certain circumstances, metabolic alkalosis, but is not associated itself with any 'toxic' effects.We review the existing literature and debunk the perceived toxicity of citrate. We delve into the metabolism and clearance of citrate and question current data suggesting metabolic acidosis occurs as the result of citrate accumulation. SUMMARY In conclusion, this article calls into question prevailing concerns about 'citrate toxicity'. We emphasize the need for a more nuanced understanding of its safety profile. We recommend discarding the term 'citrate toxicity' in favor of another frequently used, but more meaningful term: 'citrate accumulation'.
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Affiliation(s)
- Avantika Israni
- Nephrology Division, NYU Grossman School of Medicine and Nephrology Section, NY Harbor VA Healthcare System, New York, New York, USA
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26
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Kameda S, Maeda A, Maeda S, Inoue Y, Takahashi K, Kageyama A, Doi K, Fujii T. Dose of nafamostat mesylate during continuous kidney replacement therapy in critically ill patients: a two-centre observational study. BMC Nephrol 2024; 25:69. [PMID: 38408970 PMCID: PMC10895744 DOI: 10.1186/s12882-024-03506-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/16/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Nafamostat mesylate is an anticoagulant used for critically ill patients during continuous kidney replacement therapy (CKRT), characterised by its short half-life. However, its optimal dosage remains unclear. This study aimed to explore the optimal dosage of nafamostat mesylate during CKRT. METHODS We conducted a two-centre observational study. We screened all critically ill adult patients who required CKRT in the intensive care unit (ICU) from September 2013 to August 2021; we included patients aged ≥ 18 years who received nafamostat mesylate during CKRT. The primary outcome was filter life, defined as the time from CKRT initiation to the end of the first filter use due to filter clotting. The secondary outcomes included safety and other clinical outcomes. The survival analysis of filter patency by the nafamostat mesylate dosage adjusted for bleeding risk and haemofiltration was performed using a Cox proportional hazards model. RESULTS We included 269 patients. The mean dose of nafamostat mesylate was 15.8 mg/hr (Standard deviation (SD), 8.8; range, 5.0 to 30.0), and the median filter life was 18.3 h (Interquartile range (IQR), 9.28 to 36.7). The filter survival analysis showed no significant association between the filter life and nafamostat mesylate dosage (hazard ratio 1.12; 95 CI 0.74-1.69, p = 0.60) after adjustment for bleeding risk and addition of haemofiltration to haemodialysis. CONCLUSIONS We observed no dose-response relationship between the dose of nafamostat mesylate (range: 5 to 30 mg/h) and the filter life during CKRT in critically ill patients. The optimal dose to prevent filter clotting safely needs further study in randomised controlled trials. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Shinya Kameda
- Intensive Care Unit, The Jikei University Hospital, 3-19-18 Nishi-Shimbashi, Minato-ku, 105-8471, Tokyo, Japan.
| | - Akinori Maeda
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo, Japan
| | - Shun Maeda
- Intensive Care Unit, The Jikei University Hospital, 3-19-18 Nishi-Shimbashi, Minato-ku, 105-8471, Tokyo, Japan
| | - Yutaro Inoue
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazunari Takahashi
- Intensive Care Unit, The Jikei University Hospital, 3-19-18 Nishi-Shimbashi, Minato-ku, 105-8471, Tokyo, Japan
| | - Akira Kageyama
- Department of Pharmacy, The Jikei University Hospital, Tokyo, Japan
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomoko Fujii
- Intensive Care Unit, The Jikei University Hospital, 3-19-18 Nishi-Shimbashi, Minato-ku, 105-8471, Tokyo, Japan
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27
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Tao Z, Feng Y, Wang J, Zhou Y, Yang J. Global Scientific Trends in Continuous Renal Replacement Therapy from 2000 to 2023: A Bibliometric and Visual Analysis. Blood Purif 2024; 53:436-464. [PMID: 38310853 DOI: 10.1159/000536312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/08/2024] [Indexed: 02/06/2024]
Abstract
INTRODUCTION Continuous renal replacement therapy (CRRT) is one of the most widely used blood purification and organ support methods in the ICU. However, the development process, the current status, hotspots, and future trends of CRRT remain unclear. METHOD The WoSCC database was used to analyze CRRT research evolution and theme trends. VOSviewer was used to construct coauthorship, co-occurrence, co-citation, and network visualizations. CiteSpace is used to detect bursts for co-occurrence items. Several important subtopics were reviewed and discussed in more detail. RESULTS Global publications increased from 56 in 2000 to 398 in 2023, a 710.71% increase. Blood Purification published the most manuscripts, followed by the International Journal of Artificial Organs. The USA, the San Bortolo Hospital, and Bellomo were the most productive and impactful institution, country, and author, respectively. Based on co-occurrence cluster analysis, five clusters emerged: (1) clinical applications and management of CRRT; (2) sepsis and CRRT; (3) CRRT anticoagulant management; (4) CRRT and antibiotic pharmacokinetics and pharmacodynamics; and (5) comparison of CRRT and intermittent hemodialysis. COVID-19, initiation, ECOMO, cefepime, guidelines, cardiogenic shock, biomarker, and outcome were the latest high-frequency keywords or strongest bursts, indicating the emerging frontiers of CRRT. CONCLUSIONS There has been widespread publication and citation of CRRT research in the past 2 decades. We provide an overview of current trends, global collaboration patterns, basic knowledge, research hotspots, and emerging frontiers.
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Affiliation(s)
- ZhongBin Tao
- Department of Pediatrics, The First Hospital of Lanzhou University, Lanzhou, China
| | - YanDong Feng
- Department of Pediatrics, The First Hospital of Lanzhou University, Lanzhou, China
| | - Jie Wang
- Department of Pediatrics, The Second People's Hospital of Gansu Province, Lanzhou, China
| | - YongKang Zhou
- Department of Pediatrics, The First Hospital of Lanzhou University, Lanzhou, China
| | - JunQiang Yang
- Department of Pediatrics, The First Hospital of Lanzhou University, Lanzhou, China
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28
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Xinping Z, Jie H, Zhenya Y, Desheng Z, Xiong Z. Citrate anticoagulation in plasma exchange followed by continuous renal replacement therapy in critically ill children. Int J Artif Organs 2024; 47:85-95. [PMID: 38229209 DOI: 10.1177/03913988231223375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
OBJECTIVE To investigate the effectiveness and safety of regional citrate-anticoagulated (RCA) plasma exchange (PE) and whether citrate-related metabolic disorders can be improved by sequential RCA continuous renal replacement therapy (CRRT). METHODS This retrospective, single-center observational study included 79 critically ill children requiring PE followed by CRRT (June 2018 to June 2021) at the Pediatric Intensive Care Unit of Hunan Children's Hospital, China. Patients were divided into the RCA-PE (n = 30) and systemic heparin anticoagulation (SHA-PE) (n = 49) groups. Filter level comparison post-PE assessed RCA-PE efficacy, and metabolic changes occurring pre- and post-PE and CRRT were used to evaluate the effect of CRRT on RCA-based anticoagulation safety. RESULTS The RCA-PE group had a better overall filter performance than the SHA-PE group. Two hours after PE, pH and HCO₃- levels increased more significantly for the RCA-PE than the SHA-PE group. The RCA-PE incidence of metabolic alkalosis was 48.3%, higher by 4.2% (p < 0.001) compared to the SHA-PE group. In the RCA-PE group, pH and HCO₃- decreased significantly 4 h after CRRT; the metabolic alkalosis caused by RCA-PE decreased to 13.8% (p = 0.005). No significant difference in pH, HCO₃-, and metabolic alkalosis incidence was observed between the two groups 4 h after CRRT. CONCLUSIONS The overall filtration performance of RCA-PE is superior to that of SHA-PE followed by CRRT. The metabolic complications associated with RCA-PE are mainly metabolic alkalosis that can be improved by using CRRT after RCA-PE and this is a better alternative for anticoagulation during PE in critically ill children.
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Affiliation(s)
- Zhang Xinping
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
| | - He Jie
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
| | - Yao Zhenya
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
| | - Zhu Desheng
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
| | - Zhou Xiong
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
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29
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Bai M, Yu Y, Zhao L, Tian X, Zhou M, Jiao J, Liu Y, Li Y, Yue Y, Wei L, Jing R, Li Y, Ma F, Liang Y, Sun S. Regional Citrate Anticoagulation versus No Anticoagulation for CKRT in Patients with Liver Failure with Increased Bleeding Risk. Clin J Am Soc Nephrol 2024; 19:151-160. [PMID: 37990929 PMCID: PMC10861105 DOI: 10.2215/cjn.0000000000000351] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 10/31/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND The opinions on the efficacy and safety of no anticoagulation versus regional citrate anticoagulation for continuous KRT (CKRT) were controversial in patients with severe liver failure with a higher bleeding risk. We performed a randomized controlled trial to assess no anticoagulation versus regional citrate anticoagulation for CKRT in these patients. METHODS Adult patients with liver failure with a higher bleeding risk who required CKRT were considered candidates. The included participants were randomized to receive regional citrate anticoagulation or no-anticoagulation CKRT. The primary end point was filter failure. RESULTS Of the included participants, 44 and 45 were randomized to receive regional citrate anticoagulation and no-anticoagulation CKRT, respectively. The no-anticoagulation group had a significantly higher filter failure rate (25 [56%] versus 12 [27%], P = 0.003), which was confirmed by cumulative incidence function analysis and sensitive analysis including only the first CKRT sessions. In the cumulative incidence function analysis, the cumulative filter failure rates at 24, 48, and 72 hours of the no-anticoagulation and regional citrate anticoagulation groups were 31%, 58%, and 76% and 11%, 23%, and 35%, respectively. Participants in the regional citrate anticoagulation group had significantly higher incidences of Ca 2+tot /Ca 2+ion >2.5 (7% versus 57%, P < 0.001), hypocalcemia (51% versus 82%, P = 0.002), and severe hypocalcemia (13% versus 77%, P < 0.001). However, most (73%) of the increased Ca 2+tot /Ca 2+ion ratios were normalized after the upregulation of the calcium substitution rate. In the regional citrate anticoagulation group, there was no significant additional increase in the systemic citrate concentration after 6 hours. CONCLUSIONS For patients with liver failure with a higher bleeding risk who required CKRT, regional citrate anticoagulation resulted in significantly longer filter lifespan than no anticoagulation. However, regional citrate anticoagulation in patients with liver failure was associated with a significantly higher risk of hypocalcemia, severe hypocalcemia, and Ca 2+tot /Ca 2+ion >2.5. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER RCA for CRRT in Liver Failure and High Risk Bleeding Patients, NCT03791190 .
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Affiliation(s)
- Ming Bai
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yan Yu
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Lijuan Zhao
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Xiujuan Tian
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Meilan Zhou
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Jing Jiao
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yi Liu
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yajuan Li
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yuan Yue
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Lei Wei
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Rui Jing
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yangping Li
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Feng Ma
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Ying Liang
- Department of Health Statistics, the Fourth Military Medical University, Xi'an, China
| | - Shiren Sun
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
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30
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Hong Q, Chen S, He Y, Chen J, Zhang P. Construction and validation of a prediction model for the risk of citrate accumulation in patients with hepatic insufficiency receiving continuous renal replacement therapy with citrate anticoagulation. BMC Nephrol 2024; 25:27. [PMID: 38254020 PMCID: PMC10804492 DOI: 10.1186/s12882-024-03462-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND To construct and validate a prediction model of the risk of citrate accumulation in patients with hepatic dysfunction receiving continuous renal replacement therapy with regional citrate anticoagulation (RCA-CRRT), which reduces the risk of citrate accumulation. METHODS All patients who received RCA-CRRT from 2021 to 2022 and were hospitalized in the First Affiliated Hospital of Zhejiang University were considered for study participation. Logistic regression analysis was used to identify the risk factors for citrate accumulation, based on which a nomogram model was constructed and validated in the validation group. RESULTS Six factors were finally identified, from which a nomogram was created to predict the risk of citrate accumulation. The area under the curve of the prediction model was 0.814 in the training group and 0.819 in the validation group, and the model showed acceptable agreement between the actual and predicted probabilities. Decision curve analysis also demonstrated that the model was clinically useful. CONCLUSIONS The model constructed from six factors reliably predicted the risk of citrate accumulation in patients with hepatic insufficiency who received RCA-CRRT.
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Affiliation(s)
- Quxia Hong
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China
- Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, Zhejiang, China
- Department of Nephrology, Tiantai People's Hospital, Taizhou, Zhejiang, China
| | - Siyu Chen
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China
- Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, Zhejiang, China
| | - Yongchun He
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China
- Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, Zhejiang, China
| | - Jianghua Chen
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China
- Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, Zhejiang, China
| | - Ping Zhang
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China.
- Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China.
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, Zhejiang, China.
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Wang F, Zhang M, Li X, Sun X, He X, Guan M, Chen Z, Lin L, Tang X, Zhang L. An evaluation of different dilution modes on circuit lifespan during continuous veno-venous hemodiafiltration without anticoagulation. Semin Dial 2024; 37:52-58. [PMID: 36808647 DOI: 10.1111/sdi.13147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 02/08/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Circuit clotting remains a major problem during continuous kidney replacement therapy (CKRT), particularly in patients with contraindications to anticoagulant use. We hypothesized that the different options of alternative replacement fluid infusion sites might affect circuit lifespan. However, research-based evidence supporting an optimal replacement fluid infusion strategy is limited. Therefore, we aimed to evaluate the effect of three dilution modes (pre-dilution, post-dilution, and pre- to post-dilution) on circuit lifespan during continuous veno-venous hemodiafiltration (CVVHDF). METHODS This prospective cohort study was conducted between December 2019 and December 2020. Patients requiring CKRT were enrolled to receive pre-dilution, post-dilution, or pre- to post-dilution fluid infusion with CVVHDF. The primary endpoint was circuit lifespan, and the secondary outcomes included the clinical parameters of patients, such as changes in serum creatinine (Scr) and blood urea nitrogen (BUN) levels, 28-day all-cause mortality, and length of stay. For all patients included in this study, only the first circuit used was recorded. RESULTS Among the 132 patients enrolled in this study, 40 were in the pre-dilution mode, 42 were in the post-dilution mode, and 50 were in the pre- to post-dilution mode. The mean circuit lifespan was significantly longer in the pre- to post-dilution group (45.72 h, 95% CI, 39.75-51.69 h) than in the pre-dilution group (31.58 h, 95% CI, 26.33-36.82 h) and the post-dilution group (35.20 h, 95% CI, 29.62-40.78 h). There was no significant difference between the pre- and post-dilution group circuit lifespan (p > 0.05). Kaplan-Meier survival analysis revealed a significant difference between the three dilution modes (p = 0.001). No significant differences were observed in terms of changes in the Scr and BUN levels, admission day, and 28-day all-cause mortality among the three dilution groups (p > 0.05). CONCLUSION The pre- to post-dilution mode significantly prolonged circuit lifespan but did not reduce Scr and BUN levels, compared with the pre-dilution and post-dilution modes during CVVHDF when no anticoagulants were used.
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Affiliation(s)
- Fang Wang
- Department of Nephrology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Min Zhang
- Department of Nephrology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Xu Li
- Department of Nephrology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Xiankun Sun
- Department of Nephrology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Xuanchen He
- Department of Nephrology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Mingjing Guan
- Department of Nephrology, Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Zhiwen Chen
- Department of Nephrology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Li Lin
- Department of Nephrology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Xue Tang
- Department of Nephrology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Ling Zhang
- Department of Nephrology, Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, China
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Boldt D, Busse L, Chawla LS, Flannery AH, Khanna A, Neyra JA, Palmer P, Wilson J, Yessayan L. Anticoagulation practices for continuous renal replacement therapy: a survey of physicians from the United States. Ren Fail 2023; 45:2290932. [PMID: 38073554 PMCID: PMC11001369 DOI: 10.1080/0886022x.2023.2290932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND During continuous renal replacement therapy (CRRT), anticoagulants are recommended for patients at low risk of bleeding and not already receiving systemic anticoagulants. Current anticoagulants used in CRRT in the US are systemic heparins or regional citrate. To better understand use of anticoagulants for CRRT in the US, we surveyed nephrologists and critical care medicine (CCM) specialists. METHODS The survey contained 30 questions. Respondents were board certified and worked in intensive care units of academic medical centers or community hospitals. RESULTS 150 physicians (70 nephrologists and 80 CCM) completed the survey. Mean number of CRRT machines in use increased ∼30% from the pre-pandemic era to 2022. Unfractionated heparin was the most used anticoagulant (43% of estimated patients) followed by citrate (28%). Respondents reported 29% of patients received no anticoagulant. Risk of hypocalcemia (52%) and citrate safety (42%) were the predominant reasons given for using no anticoagulant instead of citrate in heparin-intolerant patients. 84% said filter clogging was a problem when no anticoagulant was used, and almost 25% said increased transfusions were necessary. Respondents using heparin (n = 131) considered it inexpensive and easily obtainable, although of moderate safety, citing concerns of heparin-induced thrombocytopenia and bleeding. Anticoagulant citrate dextrose solution was the most used citrate. Respondents estimated that 37% of patients receiving citrate develop hypocalcemia and 17% citrate lock. CONCLUSIONS Given the increased use of CRRT and the lack of approved, safe, and effective anticoagulant choices for CRRT in the US, effective use of current and other anticoagulant options needs to be evaluated.
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Affiliation(s)
- David Boldt
- Department of Anesthesiology and Perioperative Medicine, UCLA Healthcare System and David Geffen School of Medicine, Los Angeles, CA, USA
| | - Laurence Busse
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA, USA
| | | | - Alexander H. Flannery
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Ashish Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, School of Medicine, Wake Forest University, Winston-Salem, NC, USA
- Perioperative Outcomes and Informatics Collaborative, Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Javier A. Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - James Wilson
- Department of Nephrology, UCLA Healthcare System and David Geffen School of Medicine, Los Angeles, CA, USA
| | - Lenar Yessayan
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Platnich J, Kung JY, Romanovsky AS, Ostermann M, Wald R, Pannu N, Bagshaw SM. A Systematic Bibliometric Analysis of High-Impact Articles in Critical Care Nephrology. Blood Purif 2023; 53:243-267. [PMID: 38052181 PMCID: PMC10997269 DOI: 10.1159/000535558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 11/24/2023] [Indexed: 12/07/2023]
Abstract
INTRODUCTION Critical care nephrology is a subspecialty that merges critical care and nephrology in response to shared pathobiology, clinical care, and technological innovations. To date, there has been no description of the highest impact articles. Accordingly, we systematically identified high impact articles in critical care nephrology. METHODS This was a bibliometric analysis. The search was developed by a research librarian. Web of Science was searched for articles published between January 1, 2000 and December 31, 2020. Articles required a minimum of 30 citations, publication in English language, and reporting of primary (or secondary) original data. Articles were screened by two reviewers for eligibility and further adjudicated by three experts. The "Top 100" articles were hierarchically ranked by adjudication, citations in the 2 years following publication and journal impact factor (IF). For each article, we extracted detailed bibliometric data. Risk of bias was assessed for randomized trials by the Cochrane Risk of Bias tool. Analyses were descriptive. RESULTS The search yielded 2,805 articles. Following initial screening, 307 articles were selected for full review and adjudication. The Top 100 articles were published across 20 journals (median [IQR] IF 10.6 [8.9-56.3]), 38% were published in the 5 years ending in 2020 and 62% were open access. The agreement between adjudicators was excellent (intraclass correlation, 0.96; 95% CI, 0.84-0.99). Of the Top 100, 44% were randomized trials, 35% were observational, 14% were systematic reviews, 6% were nonrandomized interventional studies and one article was a consensus document. The risk of bias among randomized trials was low. Common subgroup themes were RRT (42%), AKI (30%), fluids/resuscitation (14%), pediatrics (10%), interventions (8%), and perioperative care (6%). The citations for the Top 100 articles were 175 (95-393) and 9 were cited >1,000 times. CONCLUSION Critical care nephrology has matured as an important subspecialty of critical care and nephrology. These high impact papers have focused largely on original studies, mostly clinical trials, within a few core themes. This list can be leveraged for curricula development, to stimulate research, and for quality assurance.
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Affiliation(s)
- Jaye Platnich
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| | - Janice Y. Kung
- Geoffrey & Robyn Sperber Health Sciences Library, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Adam S. Romanovsky
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| | - Marlies Ostermann
- Department of Critical Care Medicine, King’s College London, Guy’s & St Thomas’ Hospital, London, UK
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital and the University of Toronto and the Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Neesh Pannu
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
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Assefi M, Leurent A, Blanchard F, Quemeneur C, Deransy R, Monsel A, Constantin JM. Impact of increasing post-filter ionized calcium target on filter lifespan in renal replacement therapy with regional citrate anticoagulation: A before-and-after study. J Crit Care 2023; 78:154364. [PMID: 37379797 DOI: 10.1016/j.jcrc.2023.154364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Regional citrate anticoagulation (RCA) is the recommended method for anticoagulation in continuous renal replacement therapy (CRRT). However, the optimal post-filter ionized calcium (iCa) target level remains unclear. This study aims to assess the effect of increasing the post-filter iCa target level from 0.25-0.35 mmol/L to 0.30-0.40 mmol/L on filter lifespan until clotting during RCA-CRRT. METHODS This before-and-after single-center study included patients who underwent RCA-CRRT sessions without systemic anticoagulation during two periods. The first period included patients with a post-filter iCa target between 0.25 and 0.35 mmol/L, while the second period included those with a target between 0.30 and 0.40 mmol/L. The primary outcome was filter lifespan until clotting. RESULTS A total of 1037 CRRT sessions were analyzed, with 610 sessions in the first period and 427 sessions in the second period. After adjusting for confounding factors, there was no significant difference in filter lifespan until clotting between the two groups (hazard ratio, 1.020 [0.703; 1.481]; p = 0.92). CONCLUSION Increasing the post-filter iCa target level from 0.25-0.35 mmol/L to 0.30-0.40 mmol/L during RCA-CRRT does not reduce filter lifespan until clotting and may decrease unnecessary citrate exposure. However, the optimal post-filter iCa target should be individualized according to the patient's clinical and biological status.
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Affiliation(s)
- Mona Assefi
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France.
| | - Alix Leurent
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Florian Blanchard
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Cyril Quemeneur
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Romain Deransy
- Université de Nantes, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, France
| | - Antoine Monsel
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France; Sorbonne University-INSERM UMRS_959, Immunology-Immunopathology-Immunotherapy (I3), 75013 Paris, France
| | - Jean-Michel Constantin
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
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See KC, Wong WK. Acute kidney injury and kidney replacement therapy in adults. Singapore Med J 2023; 64:751-757. [PMID: 38047331 PMCID: PMC10775300 DOI: 10.4103/singaporemedj.smj-2022-191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/09/2023] [Indexed: 12/05/2023]
Affiliation(s)
- Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore
| | - Weng Kin Wong
- One Future Kidney Care, Mount Elizabeth Hospital, Singapore
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Vieira JAM, Reinheimer IC, Dos Santos AC, Halperin FK, Susin LA, Staub LP, Ribeiro RJE, da Silveira JB, Fontoura LF, de Souza DC, Nunes KP, de Souza VC, da Silva Selistre L, Poli-de-Figueiredo CE. Quality indicators in prolonged hemodialysis with regional citrate anticoagulation with the genius system: retrospective cohort of critical patients with acute kidney injury. BMC Nephrol 2023; 24:353. [PMID: 38036951 PMCID: PMC10691098 DOI: 10.1186/s12882-023-03342-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 09/21/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Prolonged hemodialysis (HD) is performed from 6 to 12 h and can last up to 24 h. To prevent system clotting some studies suggest that Regional Citrate Anticoagulation (RCA) use reduces bleeding rates relative to systemic heparin. However, there may be difficulties in the patient's clinical management and completing the prescribed HD with Genius system using RCA. OBJECTIVE To analyze safety Quality Indicators (IQs) and follow up on prolonged HD with 4% sodium citrate solution in a Genius® hybrid system. METHODS This is a retrospective cohort conducted in an intensive care unit. RESULTS 53 random sessions of prolonged HD with 4% sodium citrate solution of critically ill patients with AKI assessed. Evaluated safety indicators were dysnatremia and metabolic alkalosis, observed in 15% and 9.4% of the sessions, respectively. Indicators of effectiveness were system clotting which occurred in 17.3%, and the minimum completion of the prescribed HD time, which was 75.5%. CONCLUSION The assessment of the indicators showed that the use of RCA with a 4% sodium citrate solution in prolonged HD with the Genius system in critically ill patients with AKI can be performed in a simple, safe, and effective way.
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Affiliation(s)
- Jorge Alberto Menegasso Vieira
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil.
| | - Isabel Cristina Reinheimer
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
| | - Amanda Corrêa Dos Santos
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
| | - Fernando Kowarick Halperin
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
| | - Luiza Aguirre Susin
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
| | - Lia Portella Staub
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
| | - Raquel Jaqueline Eder Ribeiro
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
| | - Julia Braga da Silveira
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
| | - Lucas Friedrich Fontoura
- Academic Master's and Doctorate Degree in Health Sciences, Universidade de Caxias do Sul (UCS), Street Francisco Getúlio Vargas, 1130, Caxias do Sul, Rio Grande do Sul, 95070-560, Brazil
| | - Diego Candido de Souza
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
| | - Karen Patrícia Nunes
- Academic Master's and Doctorate Degree in Health Sciences, Universidade de Caxias do Sul (UCS), Street Francisco Getúlio Vargas, 1130, Caxias do Sul, Rio Grande do Sul, 95070-560, Brazil
| | - Vandrea Carla de Souza
- Academic Master's and Doctorate Degree in Health Sciences, Universidade de Caxias do Sul (UCS), Street Francisco Getúlio Vargas, 1130, Caxias do Sul, Rio Grande do Sul, 95070-560, Brazil
| | - Luciano da Silva Selistre
- Academic Master's and Doctorate Degree in Health Sciences, Universidade de Caxias do Sul (UCS), Street Francisco Getúlio Vargas, 1130, Caxias do Sul, Rio Grande do Sul, 95070-560, Brazil
| | - Carlos Eduardo Poli-de-Figueiredo
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
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Demuynck T, Grooteman M, Ter Wee P, Cozzolino M, Meijers B. Regional Citrate Anticoagulation: A Tale of More Than Two Stories. Semin Nephrol 2023; 43:151481. [PMID: 38212212 DOI: 10.1016/j.semnephrol.2023.151481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Calcium is a key clotting factor, and several inorganic molecules that bind to calcium have been found to reduce the clotting propensity of blood. Citrate, a calcium chelator, is used as inhibitor of the coagulation cascade in blood transfusion. Also, it is used as an anaticoagulant during dialysis to maintain patency of the extracorporeal circuit, known as regional citrate anticoagulation (RCA). The amount of citrate should be chosen such that ionized calcium concentrations in the extracorporeal circuit are reduced enough to minimize propagation of the coagulation cascade. The dialytic removal of the calcium-citrate complexes combined with reduced ionized calcium concentrations makes necessary calcium supplementation of the blood returning to the patient. This can be achieved in different ways. In classical RCA, citrate and calcium are infused in the afferent and efferent tubing, respectively, whereas the dialysate does not contain calcium. This setup has been shown to be highly efficacious with a very low clotting propensity. Strict monitoring of blood electrolytes is required. Alternatively, the use of a high-calcium dialysate leads to calcium loading, obviating the need for a separate calcium infusion pump. The main advantages are simplified delivery of RCA and less fluctuation of systemic calcium concentrations. Currently, citric acid is sometimes added to the acid concentrate as a replacement for acetic acid. Differences and similarities between RCA and citrate-containing dialysate are discussed. RCA is an excellent alternative to heparin for patients at high risk of bleeding.
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Affiliation(s)
- Thomas Demuynck
- Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Muriel Grooteman
- Department of Nephrology, Amsterdam UMC, Amsterdam, Netherlands; Diabetes and Metabolism, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Piet Ter Wee
- Department of Nephrology, Amsterdam UMC, Amsterdam, Netherlands; Diabetes and Metabolism, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Mario Cozzolino
- Renal Division, Department of Health Sciences, University of Milan, Milan, Italy
| | - Björn Meijers
- Department of Nephrology, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.
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Qiu Z, Pang X, Xiang Q, Cui Y. The Crosstalk between Nephropathy and Coagulation Disorder: Pathogenesis, Treatment, and Dilemmas. J Am Soc Nephrol 2023; 34:1793-1811. [PMID: 37487015 PMCID: PMC10631605 DOI: 10.1681/asn.0000000000000199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 07/10/2023] [Indexed: 07/26/2023] Open
Abstract
ABSTRACT The interaction between the kidney and the coagulation system greatly affects each other because of the abundant vessel distribution and blood perfusion in the kidney. Clinically, the risks of complicated thrombosis and bleeding have become important concerns in the treatment of nephropathies, especially nephrotic syndrome, CKD, ESKD, and patients with nephropathy undergoing RRTs. Adverse effects of anticoagulant or procoagulant therapies in patients with nephropathy, especially anticoagulation-related nephropathy, heparin-induced thrombocytopenia, and bleeding, seriously worsen the prognosis of patients, which have become challenges for clinicians. Over the decades, the interaction between the kidney and the coagulation system has been widely studied. However, the effects of the kidney on the coagulation system have not been systematically investigated. Although some coagulation-related proteins and signaling pathways have been shown to improve coagulation abnormalities while avoiding additional kidney damage in certain kidney diseases, their potential as anticoagulation targets in nephropathy requires further investigation. Here, we review the progression of research on the crosstalk between the coagulation system and kidney diseases and systematically analyze the significance and shortcomings of previous studies to provide new sight into future research. In addition, we highlight the status of clinical treatment for coagulation disorder and nephropathy caused by each other, indicating guidance for the formulation of therapeutic strategies or drug development.
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Affiliation(s)
- Zhiwei Qiu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
| | - Xiaocong Pang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
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Di Mario F, Sabatino A, Regolisti G, Pacchiarini MC, Greco P, Maccari C, Vizzini G, Italiano C, Pistolesi V, Morabito S, Fiaccadori E. Simplified regional citrate anticoagulation protocol for CVVH, CVVHDF and SLED focused on the prevention of KRT-related hypophosphatemia while optimizing acid-base balance. Nephrol Dial Transplant 2023; 38:2298-2309. [PMID: 37037771 PMCID: PMC10547235 DOI: 10.1093/ndt/gfad068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND Hypophosphatemia is a common electrolyte disorder in critically ill patients undergoing prolonged kidney replacement therapy (KRT). We evaluated the efficacy and safety of a simplified regional citrate anticoagulation (RCA) protocol for continuous venovenous hemofiltration (CVVH), continuous venovenous hemodiafiltration (CVVHDF) and sustained low-efficiency dialysis filtration (SLED-f). We aimed at preventing KRT-related hypophosphatemia while optimizing acid-base equilibrium. METHODS KRT was performed by the Prismax system (Baxter) and polyacrylonitrile AN69 filters (ST 150, 1.5 m2, Baxter), combining a 18 mmol/L pre-dilution citrate solution (Regiocit 18/0, Baxter) with a phosphate-containing solution (HPO42- 1.0 mmol/L, HCO3- 22.0 mmol/L; Biphozyl, Baxter). When needed, phosphate loss was replaced with sodium glycerophosphate pentahydrate (Glycophos™ 20 mmol/20 mL, Fresenius Kabi Norge AS, Halden, Norway). Serum citrate measurements were scheduled during each treatment. We analyzed data from three consecutive daily 8-h SLED-f sessions, as well as single 72-h CVVH or 72-h CVVHDF sessions. We used analysis of variance (ANOVA) for repeated measures to evaluate differences in variables means (i.e. serum phosphate, citrate). Because some patients received phosphate supplementation, we performed analysis of covariance (ANCOVA) for repeated measures modelling phosphate supplementation as a covariate. RESULTS Forty-seven patients with acute kidney injury (AKI) or end stage kidney disease (ESKD) requiring KRT were included [11 CVVH, 11 CVVHDF and 25 SLED-f sessions; mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score 25 ± 7.0]. Interruptions for irreversible filter clotting were negligible. The overall incidence of hypophosphatemia (s-P levels <2.5 mg/dL) was 6.6%, and s-P levels were kept in the normality range irrespective of baseline values and the KRT modality. The acid-base balance was preserved, with no episode of citrate accumulation. CONCLUSIONS Our data obtained with a new simplified RCA protocol suggest that it is effective and safe for CVVH, CVVHDF and SLED, allowing to prevent KRT-related hypophosphatemia and maintain the acid-base balance without citrate accumulation. TRIAL REGISTRATION NCT03976440 (registered 6 June 2019).
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Affiliation(s)
- Francesca Di Mario
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Alice Sabatino
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Giuseppe Regolisti
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
- UO Clinica e Immunologia Medica, Azienda Ospedaliero-Universitaria, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Maria Chiara Pacchiarini
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Paolo Greco
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Caterina Maccari
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Giuseppe Vizzini
- Laboratorio di Immunopatologia Renale “Luigi Migone”, Università degli Studi di Parma, Parma, Italy
| | - Chiara Italiano
- Laboratorio di Immunopatologia Renale “Luigi Migone”, Università degli Studi di Parma, Parma, Italy
| | - Valentina Pistolesi
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, “Sapienza” Università̀ di Roma, Rome, Italy
| | - Santo Morabito
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, “Sapienza” Università̀ di Roma, Rome, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
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Brunoni B, Zadek F, Mulazzani F, Verza G, Marrazzo F, Spina S, Protti A, Fumagalli R, Langer T. Calcium-Citrate Anticoagulation during Continuous Renal Replacement Therapy in Patients with Metformin Intoxication: A Case Series, Mathematical Estimation of Citrate Accumulation, and Literature Review. Blood Purif 2023; 52:802-811. [PMID: 37673054 DOI: 10.1159/000531953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 06/29/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION Metformin intoxication causes lactic acidosis by inhibiting Krebs' cycle and oxidative phosphorylation. Continuous renal replacement therapy (CRRT) is recommended for metformin removal in critically ill patients. According to current guidelines, regional citrate anticoagulation (RCA) is the first-line strategy. However, since metformin also inhibits citrate metabolism, a risk of citrate accumulation could be hypothesized. In the present study, we monitored the potential citrate accumulation in metformin-associated lactic acidosis (MALA) patients treated with CRRT and RCA using the physical-chemical approach to acid-base interpretation. METHODS We collected a case series of 3 patients with MALA. Patients were treated with continuous venovenous hemofiltration (CVVH), and RCA was performed with diluted citrate solution. Citrate accumulation was monitored through two methods: the ratio between total and ionized plasma calcium concentrations (T/I calcium ratio) above 2.5 and the strong ion gap (SIG) to identify an increased concentration of unmeasured anions. Lastly, a mathematical model was developed to estimate the expected citrate accumulation during CVVH and RCA. RESULTS All 3 patients showed a resolution of MALA after the treatment with CVVH. The T/I calcium ratio was consistently below 2.5, and SIG decreased, reaching values lower than 6 mEq/L after 48 h of CVVH treatment. According to the mathematical model, the estimated SIG without citrate metabolism should have been around 21 mEq/L due to citrate accumulation. CONCLUSIONS In our clinical management, no signs of citrate accumulation were recorded in MALA patients during treatment with CVVH and RCA. Our data support the safe use of diluted citrate to perform RCA during metformin intoxication.
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Affiliation(s)
- Beatrice Brunoni
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Francesco Zadek
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Francesca Mulazzani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Giovanni Verza
- INFN, Sezione di Padova, Padova, Italy
- Dipartimento di Fisica e Astronomia "G. Galilei", Università Degli Studi di Padova, Padova, Italy
| | - Francesco Marrazzo
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milano, Italy
| | - Stefano Spina
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milano, Italy
| | - Alessandro Protti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milano, Italy
| | - Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milano, Italy
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Price N, Wood AF. Acute kidney injury in the critical care setting. Nurs Stand 2023; 38:45-50. [PMID: 37458070 DOI: 10.7748/ns.2023.e12063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 07/18/2023]
Abstract
Acute kidney injury is a sudden reduction in renal function which impairs the kidneys' ability to maintain fluid, electrolyte and acid-base balance. The syndrome often develops secondary to severe illness and is associated with a significant increase in morbidity and mortality rate in critically ill patients. This article gives an overview of the pathophysiology and aetiology of acute kidney injury, as well as the associated complications and clinical diagnostic signs. The authors also describe some common causes of the syndrome in critically ill patients, specifically sepsis, liver failure and cardiac failure, and discuss patient management in the critical care setting, with a focus on haemodynamic support and continuous renal replacement therapy.
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Affiliation(s)
- Natasha Price
- division of nursing and paramedic science, school of health sciences, Queen Margaret University, Edinburgh, Scotland
| | - Alison Fiona Wood
- programme lead for independent prescribing, division of nursing and paramedic science, school of health sciences, Queen Margaret University, Edinburgh, Scotland
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Xu J, Fang L, Chen J, Chen X, Yang H, Zhang W, Wu L, Chen D. Real-life effects, complications, and outcomes in 39 critically ill neonates receiving continuous kidney replacement therapy. Pediatr Nephrol 2023; 38:3145-3152. [PMID: 36988692 DOI: 10.1007/s00467-023-05944-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 03/01/2023] [Accepted: 03/09/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Continuous kidney replacement therapy (CKRT) has been expanded from simple kidney replacement therapy to the field of critical illness in children. However, CKRT is rarely used in critically ill neonates in the neonatal intensive care unit (NICU). This study aimed to describe patients' clinical characteristics at admission and CKRT initiation, CKRT effects, short-term outcomes, and predictors of death in critically ill neonates. METHODS A 7-year single-center retrospective study in a tertiary NICU. RESULTS Thirty-nine critically ill neonates received CKRT between May 2015 and April 2022 with a mortality rate of 35.9%. The most common primary diagnosis was neonatal sepsis in 15 cases (38.5%). Continuous veno-venous hemodiafiltration and continuous veno-venous hemofiltration were applied in 43.6% and 56.4% of neonates, respectively. The duration of CKRT was 44 (18, 72) h. Thirty-one patients (79.5%) had complications due to CKRT-related adverse events, and the most common complication was thrombocytopenia. Approximately 12 h after the CKRT initiation, urine volume, mean arterial pressure, and pH were increased, and serum creatinine, blood urea nitrogen, and blood lactate were decreased. In the multivariate logistic regression analysis, neonatal critical illness score [odds ratio 0.886 (0.786 ~ 0.998), P = 0.046] was an independent risk factor for death in critically ill neonates who received CKRT. CONCLUSIONS CKRT can be an effective and feasible technique in critically ill neonates, but the overall mortality and CKRT-related complications are relatively high. Furthermore, the probability of death is greater among neonates with greater severity of illness at CKRT initiation. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Jinglin Xu
- Department of Neonatology, Fujian Province, Quanzhou Maternity and Children's Hospital, Fengze Street, No 700, Quanzhou, 362000, China
| | - Lingyu Fang
- Department of Neonatology, Fujian Province, Quanzhou Maternity and Children's Hospital, Fengze Street, No 700, Quanzhou, 362000, China
| | - Jiangbin Chen
- Department of Neonatology, Fujian Province, Quanzhou Maternity and Children's Hospital, Fengze Street, No 700, Quanzhou, 362000, China
| | - Xinhua Chen
- Department of Neonatology, Fujian Province, Quanzhou Maternity and Children's Hospital, Fengze Street, No 700, Quanzhou, 362000, China
| | - Hansong Yang
- Department of Neonatology, Fujian Province, Quanzhou Maternity and Children's Hospital, Fengze Street, No 700, Quanzhou, 362000, China
| | - Weifeng Zhang
- Department of Neonatology, Fujian Province, Quanzhou Maternity and Children's Hospital, Fengze Street, No 700, Quanzhou, 362000, China
| | - Lianqiang Wu
- Department of Neonatology, Fujian Province, Quanzhou Maternity and Children's Hospital, Fengze Street, No 700, Quanzhou, 362000, China
| | - Dongmei Chen
- Department of Neonatology, Fujian Province, Quanzhou Maternity and Children's Hospital, Fengze Street, No 700, Quanzhou, 362000, China.
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Zhang K, Liu C, Zhao H. Meta-analysis of haematocrit and activated partial thromboplastin time as risk factors for unplanned interruptions in patients undergoing continuous renal replacement therapy. Int J Artif Organs 2023; 46:498-506. [PMID: 37376844 DOI: 10.1177/03913988231180639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
OBJECTIVE Although continuous renal replacement therapy (CRRT) is common, unplanned interruptions often limit its usefulness. Unplanned interruption refers to the forced interruption of blood purification treatment, the failure to complete blood purification treatment goals or the failure to meet blood purification schedule times. This study aimed to evaluate the effect of haematocrit and activated partial thromboplastin time (APTT) on the incidence of unplanned interruptions in critical patients with CRRT. METHODS A systematic review and a meta-analysis were performed by searching the databases of China National Knowledge Infrastructure, Wanfang, VIP, China Biomedical Literature, Cochrane Library, PubMed, Web of Science and Embase from their inception to 31st March 2022 for all studies with a comparator or independent variable relating to the unplanned interruption of CRRT. RESULTS Nine studies involving 1165 participants were included. Haematocrit and APTT were independent risk factors for the unplanned interruption of CRRT. The higher the haematocrit level, the greater the risk of unplanned CRRT interruptions (relative risk ratio [RR] = 1.04, 95% confidence interval [CI]: 1.02, 1.07, Z = 4.27, p < 0.001). The prolongation of APPT reduced the risk of unplanned CRRT interruptions (RR = 0.94, 95% CI: 0.92, 0.96, Z = 6.10, p < 0.001). CONCLUSION Haematocrit and APTT are the influencing factors on the incidence of unplanned interruptions in critical patients undergoing CRRT.
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Affiliation(s)
- Kun Zhang
- Department of Critical Care Medicine, Hebei General Hospital, Shijiazhuang, China
| | - Chunxia Liu
- Department of Critical Care Medicine, Hebei General Hospital, Shijiazhuang, China
| | - Heling Zhao
- Department of Critical Care Medicine, Hebei General Hospital, Shijiazhuang, China
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Thanapongsatorn P, Sinjira T, Kaewdoungtien P, Kusirisin P, Kulvichit W, Sirivongrangson P, Peerapornratana S, Lumlertgul N, Srisawat N. Standard versus no post-filter ionized calcium monitoring in regional citrate anticoagulation for continuous renal replacement therapy (NPC trial). Clin Kidney J 2023; 16:1469-1479. [PMID: 37664560 PMCID: PMC10468745 DOI: 10.1093/ckj/sfad069] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Indexed: 09/05/2023] Open
Abstract
Background Current guidelines recommend monitoring of post-filter ionized calcium (pfCa) when using regional citrate anticoagulation during continuous renal replacement therapy (RCA-CRRT) to determine citrate efficiency for the prevention of filter clotting. However, the reliability of pfCa raises the question of whether routine monitoring is required. Reducing the frequency of pfCa monitoring could potentially reduce costs and workload. Our objective was to test the efficacy and safety of no pfCa monitoring among critically ill patients receiving RCA-CRRT. Methods This study was a non-inferiority randomized controlled trial conducted between January 2021 and October 2021 at King Chulalongkorn Memorial Hospital, Thailand. Critically ill patients who were treated with RCA-CRRT were randomized to receive either standard pfCa monitoring (aiming pfCa level of 0.25-0.35 mmol/L), or no pfCa monitoring, in which a constant rate of citrate infusion was maintained at pre-determined citrate concentrations of 4 mmol/L with blinding of pfCa levels to treating clinicians. The primary outcome was the filter lifespan. Non-inferiority would be demonstrated if the upper limit of the 95% confidence interval (CI) for the difference in filter lifespan between the groups was less than 20 h. Results Fifty patients were randomized to the standard pfCa monitoring group (n = 25) or no pfCa monitoring group (n = 25). The mean filter lifespan was 54 ± 20 h in the standard pfCa monitoring group and 47 ± 23 h in the no pfCa monitoring group (absolute difference 7.1 h; 95% CI -5.3, 19.5, P = .25). When restricting the analysis to circuits reaching the maximum duration of circuit lifespan at 72 h and clotted filters, the filter lifespan was 61 ± 17 h in the standard pfCa group vs 60 ± 19 h in the no pfCa monitoring group (absolute difference 0.9 h; 95% CI -11.5, 13.4, P = .88). Compared with the no pfCa monitoring group, the standard pfCa monitoring group had a significantly higher mean citrate concentrations (4.43 ± 0.32 vs 4 mmol/L, P < .001) and a higher rate of severe hypocalcemia (44% vs 20%, P = .13). No statistical differences were found in filter clotting, citrate accumulation, citrate overload and mortality between the two groups. Conclusions Among critically ill patients receiving RCA-CRRT, no pfCa monitoring by maintaining the citrate concentrations of 4 mmol/L is feasible. Larger randomized controlled trials should be conducted to ensure the efficacy, safety and cost-effectiveness of this strategy. Trial registration ClinicalTrials.gov: NCT04792424 (registered 11 March 2021).
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Affiliation(s)
- Peerapat Thanapongsatorn
- Department of Medicine, Central Chest Institute of Thailand, Nonthaburi, Thailand
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Tanyapim Sinjira
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Piyanut Kaewdoungtien
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Prit Kusirisin
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Win Kulvichit
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Sadudee Peerapornratana
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Laboratory Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nuttha Lumlertgul
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nattachai Srisawat
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Academy of Science, Royal Society of Thailand, Bangkok, Thailand
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Lau YH, Li AY, Lim SL, Woo KL, Ramanathan K, Chua HR, Akalya K, Tan AY, Phua J, Tan JJ, Puah SH, Chia YW, Loh SC, Ahmed Khan F, Chatterjee S, Kaushik M, See KC. Association of anticoagulation use during continuous kidney replacement therapy and 90-day outcomes: A multicentre study. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:390-397. [PMID: 38920170 DOI: 10.47102/annals-acadmedsg.202337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction Anticoagulation is recommended during continuous kidney replacement therapy (CKRT) to prolong the filter lifespan for optimal filter performance. We aimed to evaluate the effect of anticoagulation during CKRT on dialysis dependence and mortality within 90 days of intensive care unit (ICU) admission. Method Our retrospective observational study evaluated the first CKRT session in critically ill adults with acute kidney injury (AKI) in Singapore from April to September 2017. The primary outcome was a composite of dialysis dependence or death within 90 days of ICU admission; the main exposure variable was anticoagulation use (regional citrate anticoagulation [RCA] or systemic heparin). Multivariable logistic regression was performed to adjust for possible confounders: age, female sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, liver dysfunction, coagulopathy (international normalised ratio[INR] >1.5) and platelet counts of less than 100,000/uL). Results The study cohort included 276 patients from 14 participating adult ICUs, of whom 176 (63.8%) experienced dialysis dependence or death within 90 days of ICU admission (19 dialysis dependence, 157 death). Anticoagulation significantly reduced the odds of the primary outcome (adjusted odds ratio [AOR] 0.47, 95% confidence interval [CI] 0.27-0.83, P=0.009). Logistic regression analysis using anticoagulation as a 3-level indicator variable demonstrated that RCA was associated with mortality reduction (AOR 0.46, 95% CI 0.25-0.83, P=0.011), with heparin having a consistent trend (AOR 0.51, 95% CI 0.23-1.14, P=0.102). Conclusion Among critically ill patients with AKI, anticoagulation use during CKRT was associated with reduced dialysis or death at 90 days post-ICU admission, which was statistically significant for regional citrate anticoagulation and trended in the same direction of benefit for systemic heparin anticoagulation. Anticoagulation during CKRT should be considered whenever possible.
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Affiliation(s)
- Yie Hui Lau
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | - Andrew Y Li
- Department of Respiratory Service, Department of Medicine, Woodlands Health Campus, Singapore
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Kai Lee Woo
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | | | - Horng-Ruey Chua
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore
| | - K Akalya
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore
| | - Addy Yh Tan
- Department of Anaesthesia, National University Hospital Singapore
| | - Jason Phua
- Fast and Chronic programmes, Alexandra Hospital, National University Health System; Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Jonathan Je Tan
- Anaesthesia, Intensive Care, Mount Elizabeth Novena Hospital, Singapore
| | - Ser Hon Puah
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Yew Woon Chia
- Department of Cardiology, Tan Tock Seng Hospital, Singapore
| | - Sean Ch Loh
- Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | | | | | | | - Kay Choong See
- Division of Respiratory and Critical Care Medicine, National University Hospital Singapore
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Teixeira JP, Saa L, Kaucher KA, Villanueva RD, Shieh M, Baca CR, Harmon B, Owen ZJ, Mendez Majalca I, Schmidt DW, Singh N, Shaffi SK, Xu ZQ, Roha T, Mitchell JA, Demirjian S, Argyropoulos CP. Rapid implementation of an emergency on-site CKRT dialysate production system during the COVID-19 pandemic. BMC Nephrol 2023; 24:245. [PMID: 37608357 PMCID: PMC10463836 DOI: 10.1186/s12882-023-03260-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 06/29/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND On December 29, 2021, during the delta wave of the Coronavirus Disease 2019 (COVID-19) pandemic, the stock of premanufactured solutions used for continuous kidney replacement therapy (CKRT) at the University of New Mexico Hospital (UNMH) was nearly exhausted with no resupply anticipated due to supply chain disruptions. Within hours, a backup plan, devised and tested 18 months prior, to locally produce CKRT dialysate was implemented. This report describes the emergency implementation and outcomes of this on-site CKRT dialysate production system. METHODS This is a single-center retrospective case series and narrative report describing and reporting the outcomes of the implementation of an on-site CKRT dialysate production system. All adults treated with locally produced CKRT dialysate in December 2021 and January 2022 at UNMH were included. CKRT dialysate was produced locally using intermittent hemodialysis machines, hemodialysis concentrate, sterile parenteral nutrition bags, and connectors made of 3-D printed biocompatible rigid material. Outcomes analyzed included dialysate testing for composition and microbiologic contamination, CKRT prescription components, patient mortality, sequential organ failure assessment (SOFA) scores, and catheter-associated bloodstream infections (CLABSIs). RESULTS Over 13 days, 22 patients were treated with 3,645 L of locally produced dialysate with a mean dose of 20.0 mL/kg/h. Fluid sample testing at 48 h revealed appropriate electrolyte composition and endotoxin levels and bacterial colony counts at or below the lower limit of detection. No CLABSIs occurred within 7 days of exposure to locally produced dialysate. In-hospital mortality was 81.8% and 28-day mortality was 68.2%, though illness severity was high, with a mean SOFA score of 14.5. CONCLUSIONS Though producing CKRT fluid with IHD machines is not novel, this report represents the first description of the rapid and successful implementation of a backup plan for local CKRT dialysate production at a large academic medical center in the U.S. during the COVID-19 pandemic. Though conclusions are limited by the retrospective design and limited sample size of our analysis, our experience could serve as a guide for other centers navigating similar severe supply constraints in the future.
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Affiliation(s)
- J Pedro Teixeira
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA.
- Center for Adult Critical Care, UNM Hospital, Albuquerque, NM, USA.
- Acute Dialysis and CRRT Program, UNM Hospital, Albuquerque, NM, USA.
| | - Lisa Saa
- Department of Internal Medicine, UNM School of Medicine, Albuquerque, NM, USA
| | | | | | - Michelle Shieh
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
- Center for Adult Critical Care, UNM Hospital, Albuquerque, NM, USA
| | - Crystal R Baca
- Acute Dialysis and CRRT Program, UNM Hospital, Albuquerque, NM, USA
| | - Brittany Harmon
- Acute Dialysis and CRRT Program, UNM Hospital, Albuquerque, NM, USA
| | - Zanna J Owen
- Acute Dialysis and CRRT Program, UNM Hospital, Albuquerque, NM, USA
| | | | - Darren W Schmidt
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Namita Singh
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Saeed K Shaffi
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Zhi Q Xu
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
- Acute Dialysis and CRRT Program, UNM Hospital, Albuquerque, NM, USA
| | - Thomas Roha
- Center for Adult Critical Care, UNM Hospital, Albuquerque, NM, USA
| | - Jessica A Mitchell
- Center for Adult Critical Care, UNM Hospital, Albuquerque, NM, USA
- Department of Emergency Medicine, UNM School of Medicine, Albuquerque, NM, USA
| | - Sevag Demirjian
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH, USA
| | - Christos P Argyropoulos
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
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Nalesso F, Bettin E, Bogo M, Cacciapuoti M, Cattarin L, Scaparrotta G, Calò LA. Safety of Citrate Anticoagulation in CKRT: Monocentric Experience of a Dynamic Protocol of Calcium Monitoring. J Clin Med 2023; 12:5201. [PMID: 37629242 PMCID: PMC10455350 DOI: 10.3390/jcm12165201] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/05/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Regional Citrate Anticoagulation (RCA) is considered the first-line anticoagulation for Continuous Kidney Replacement Therapy (CKRT). The RCA requires strict protocols and trained staff to avoid unsafe use and ensure its benefit. We have analyzed all our CKRT prescriptions from December 2020 to April 2022 anonymously, collecting data on CKRT, lab tests, clinical conditions, and complications of RCA. In addition, in order to better detect citrate accumulation, we have performed an RCA protocol by reducing the CaTot/Ca2+ ratio cut-off from 2.50 to 2.40 and increasing the number of calcium checks according to its trend. Among the 374 patients in CKRT, 104 received RCA prescriptions, of which 11 (10.6%) were discontinued: 4 for the suspicion of citrate accumulation, 1 for the development of metabolic alkalosis, 1 for the shift to a different CKRT procedure due to the need for a higher bicarbonate dose, 4 for the elevation of hepatocytolysis indexes, and 1 due to a preemptive discontinuation following massive post-surgery bleeding. None of the patients have had citrate toxicity as indicated by a CaTot/Ca2+ greater than 2.50, and our protocol has allowed the early identification of patients who might develop clinical citrate toxicity.
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Affiliation(s)
- Federico Nalesso
- Department of Medicine, Nephrology, Dialysis and Transplant, University of Padua, 35128 Padua, Italy (L.A.C.)
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von Groote T, Albert F, Meersch M, Koch R, Gerss J, Arlt B, Sadjadi M, Porschen C, Pickkers P, Zarbock A. Evaluation of Proenkephalin A 119-159 for liberation from renal replacement therapy: an external, multicenter pilot study in critically ill patients with acute kidney injury. Crit Care 2023; 27:276. [PMID: 37430375 DOI: 10.1186/s13054-023-04556-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 06/28/2023] [Indexed: 07/12/2023] Open
Abstract
INTRODUCTION Recent evidence suggests an association of plasma Proenkephalin A 119-159 (penKid) with early and successful liberation from continuous renal replacement therapy (CRRT) in critically ill patients with acute kidney injury. However, these exploratory results are derived from a monocentric trial and therefore require external validation in a multicenter cohort. METHODS Data and plasma samples from the "Effect of Regional Citrate Anticoagulation versus Systemic Heparin Anticoagulation During Continuous Kidney Replacement Therapy on Dialysis Filter Life Span and Mortality Among Critically Ill Patients With Acute Kidney Injury-A Randomized Clinical Trial" (RICH Trial) were used for this validation study. PenKid was measured in all plasma samples available at CRRT initiation and at day 3 of CRRT. Patients were categorized into low and high penKid groups with a cutoff at 100 pmol/l. Competing-risk time-to-event analyses were performed. Competing risk endpoints were successful and unsuccessful liberation from CRRT, the latter meaning death or initiation of a new RRT within one week of discontinuation of primary CRRT. Then penKid was compared to urinary output. RESULTS Low pre-CRRT penKid levels at CRRT initiation were not associated with early and successful liberation from CRRT compared to patients with high pre-CRRT penKid levels [subdistribution hazard ratio (sHR) 1.01, 95% CI 0.73-1.40, p = 0.945]. However, the landmark analysis on day 3 of ongoing CRRT demonstrated an association between low penKid levels and successful liberation from CRRT (sHR 2.35, 95% CI 1.45-3.81, p < 0.001) and an association between high penKid levels and unsuccessful liberation (sHR 0.46, 95% CI 0.26-0.80, p = 0.007). High daily urinary output (> 436 ml/d) was even stronger associated with successful liberation (sHR 2.91, 95% CI 1.80-4.73, p < 0.001) compared to penKid. DISCUSSION This study suggests that penKid may be a competent biomarker to monitor the recovery of kidney function during CRRT. This is in line with previous findings and investigated this concept in a multicenter cohort. Again, low penKid was associated with early and successful CRRT liberation, but was outperformed by high daily urinary output. The findings of this study now warrant further evaluation in prospective studies or a randomized controlled trial. Trial registration The RICH Trial was registered at clinicaltrials.gov: NCT02669589. Registered 01 February 2016.
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Affiliation(s)
- Thilo von Groote
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Felix Albert
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Melanie Meersch
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Raphael Koch
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | | | - Mahan Sadjadi
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Christian Porschen
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
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Zhou Z, Liu C, Yang Y, Wang F, Zhang L, Fu P. Anticoagulation options for continuous renal replacement therapy in critically ill patients: a systematic review and network meta-analysis of randomized controlled trials. Crit Care 2023; 27:222. [PMID: 37287084 DOI: 10.1186/s13054-023-04519-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 06/02/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) is a widely used standard therapy for critically ill patients with acute kidney injury (AKI). Despite its effectiveness, treatment is often interrupted due to clot formation in the extracorporeal circuits. Anticoagulation is a crucial strategy for preventing extracorporeal circuit clotting during CRRT. While various anticoagulation options are available, there were still no studies synthetically comparing the efficacy and safety of these anticoagulation options. METHODS Electronic databases (PubMed, Embase, Web of Science, and the Cochrane database) were searched from inception to October 31, 2022. All randomized controlled trials (RCTs) that examined the following outcomes were included: filter lifespan, all-cause mortality, length of stay, duration of CRRT, recovery of kidney function, adverse events and costs. RESULTS Thirty-seven RCTs from 38 articles, comprising 2648 participants with 14 comparisons, were included in this network meta-analysis (NMA). Unfractionated heparin (UFH) and regional citrate anticoagulation (RCA) are the most frequently used anticoagulants. Compared to UFH, RCA was found to be more effective in prolonging filter lifespan (MD 12.0, 95% CI 3.8 to 20.2) and reducing the risk of bleeding. Regional-UFH plus Prostaglandin I2 (Regional-UFH + PGI2) appeared to outperform RCA (MD 37.0, 95% CI 12.0 to 62.0), LMWH (MD 41.3, 95% CI 15.6 to 67.0), and other evaluated anticoagulation options in prolonging filter lifespan. However, only a single included RCT with 46 participants had evaluated Regional-UFH + PGI2. No statistically significant difference was observed in terms of length of ICU stay, all-cause mortality, duration of CRRT, recovery of kidney function, and adverse events among most evaluated anticoagulation options. CONCLUSIONS Compared to UFH, RCA is the preferred anticoagulant for critically ill patients requiring CRRT. The SUCRA analysis and forest plot of Regional-UFH + PGI2 are limited, as only a single study was included. Additional high-quality studies are necessary before any recommendation of Regional-UFH + PGI2. Further larger high-quality RCTs are desirable to strengthen the evidence on the best choice of anticoagulation options to reduce all-cause mortality and adverse events and promote the recovery of kidney function. Trial registration The protocol of this network meta-analysis was registered on PROSPERO ( CRD42022360263 ). Registered 26 September 2022.
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Affiliation(s)
- Zhifeng Zhou
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Chen Liu
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yingying Yang
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Fang Wang
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Ling Zhang
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, 610041, China.
| | - Ping Fu
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, 610041, China
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Griffin BR. The Promise of Continuous Kidney Replacement Therapy Optimization to Improve Patient Outcomes and Reduce Resource Utilization. Kidney Med 2023; 5:100665. [PMID: 37250501 PMCID: PMC10220390 DOI: 10.1016/j.xkme.2023.100665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Affiliation(s)
- Benjamin R. Griffin
- Address for Correspondence: Benjamin R. Griffin, MD, Department of Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Dr, UIHC – Int Med T310, Iowa City, IA 52242.
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