1
|
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.
Collapse
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
| |
Collapse
|
2
|
Baeg SI, Jeon J, Kang D, Na SJ, Cho J, Kim K, Yang JH, Chung CR, Lee JE, Huh W, Suh GY, Kim YG, Kim DJ, Jang HR. Impact of protocolized fluid management on electrolyte stability in patients undergoing continuous renal replacement therapy. Front Med (Lausanne) 2022; 9:915072. [PMID: 36117982 PMCID: PMC9471083 DOI: 10.3389/fmed.2022.915072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveContinuous renal replacement therapy (CRRT) is the standard treatment for critically ill patients with acute kidney injury (AKI). Electrolyte disturbance such as hypokalemia or hypophosphatemia occurs paradoxically in patients undergoing CRRT due to high clearance. We developed a fluid management protocol for dialysate and replacement fluid that depends on serum electrolytes and focuses on potassium and phosphate levels to prevent electrolyte disturbance during CRRT. The impact of our new fluid protocol on electrolyte stability was evaluated.MethodsAdult patients who received CRRT between 2013 and 2017 were included. Patients treated 2 years before (2013–2014; pre-protocol group) and 2 years following development of the fluid protocol (2016–2017; protocol group) were compared. The primary outcomes were individual coefficient of variation (CV) and abnormal event rates of serum phosphate and potassium. Secondary outcomes were frequency of electrolyte replacement and incidence of cardiac arrhythmias. Individual CV and abnormal event rates for each electrolyte were analyzed using the Wilcoxon rank-sum test and Chi-square test with Yates’ continuity correction.ResultsA total of 1,448 patients was included. Both serum phosphate and potassium were higher in the protocol group. The CVs of serum phosphate (pre-protocol vs. protocol, 0.275 [0.207–0.358] vs. 0.229 [0.169–0.304], p < 0.01) and potassium (0.104 [0.081–0.135] vs. 0.085 [0.064–0.110], p < 0.01) were significantly lower in the protocol group. The abnormal event rates of serum phosphate (rate [95% CI], 0.410 [0.400–0.415] vs. 0.280 [0.273–0.286], p < 0.01) and potassium (0.205 [0.199–0.211] vs. 0.083 [0.079–0.087], p < 0.01) were also significantly lower in the protocol group.ConclusionThe protocolized management of fluid in CRRT effectively prevented hypophosphatemia and hypokalemia by inducing excellent stability of serum phosphate and potassium levels.
Collapse
Affiliation(s)
- Song In Baeg
- Division of Nephrology, Department of Internal Medicine, Myongji Hospital, Hanyang University Medical Center, Goyang, South Korea
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Junseok Jeon
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Danbee Kang
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
- Center of Clinical Epidemiology, Samsung Medical Center, Seoul, South Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Juhee Cho
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
- Center of Clinical Epidemiology, Samsung Medical Center, Seoul, South Korea
| | - Kyunga Kim
- Statistics and Data Center, Samsung Medical Center, Seoul, South Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung Eun Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Wooseong Huh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yoon-Goo Kim
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dae Joong Kim
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hye Ryoun Jang
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
- *Correspondence: Hye Ryoun Jang,
| |
Collapse
|
3
|
Singhala M, Bell R, Cenci B, Yazdi Y, Marzinke MA, Fine DM, Parikh CR. Emergency Production and Collection of Dialysate for CVVHD During the COVID-19 Pandemic. Kidney Int Rep 2021; 6:2200-2202. [PMID: 34127951 PMCID: PMC8189730 DOI: 10.1016/j.ekir.2021.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 05/03/2021] [Accepted: 05/24/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Mohit Singhala
- Johns Hopkins University Whiting School of Engineering, Baltimore, Maryland USA
| | - Ryan Bell
- Johns Hopkins University Whiting School of Engineering, Baltimore, Maryland USA
| | - Brielle Cenci
- Johns Hopkins University Whiting School of Engineering, Baltimore, Maryland USA
| | - Youseph Yazdi
- Johns Hopkins University Whiting School of Engineering, Baltimore, Maryland USA
| | - Mark A Marzinke
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Derek M Fine
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Chirag R Parikh
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
4
|
Taliercio JJ, Nakhoul G, Vachharajani TJ, Layne M, Sedor J, Thomas G, Mehdi A, Heyka R, Demirjian S. The Production, Efficacy, and Safety of Machine-Generated Bicarbonate Solution for Continuous Venovenous Hemodialysis (CVVHD): The Cleveland Clinic Method. Kidney Med 2021; 3:353-359.e1. [PMID: 34136781 PMCID: PMC8178460 DOI: 10.1016/j.xkme.2021.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
RATIONALE & OBJECTIVE Since 1994, the Nephrology and Hypertension Department at the Cleveland Clinic has prepared and used bicarbonate-based solution for continuous venovenous hemodialysis (CVVHD) using a standard volumetric hemodialysis machine rather than purchasing from a commercial vendor. This report describes the process of producing Cleveland Clinic UltraPure Solution (CCUPS), quality and safety monitoring, economic costs, and clinical outcomes. STUDY DESIGN Retrospective study. SETTING & PARTICIPANTS CVVHD experience at Cleveland Clinic, focusing on dialysate production, institutional factors, and patients requiring continuous kidney replacement therapy. Production is shown at www.youtube.com/watch?v=WGQgephMEwA. OUTCOMES Feasibility, safety , and cost. RESULTS Of 6,426 patients treated between 2011 and 2019 with continuous kidney replacement therapy, 59% were men, 71% were White, 40% had diabetes mellitus, and 74% presented with acute kidney injury. 98% of patients were treated with CVVHD using CCUPS, while the remaining 2% were treated with either continuous venovenous hemofiltration or continuous venovenous hemodiafiltration using commercial solution. The prescribed and delivered effluent doses were 24.8 (IQR) versus 20.7 mL/kg/h (IQR), respectively. CCUPS was as effective in restoring electrolyte and serum bicarbonate levels and reducing phosphate, creatinine, and serum urea nitrogen levels as compared with packaged commercial solution over a 3-day period following initiation of dialysis, with a comparable effluent dose. Among those with acute kidney injury, mortality was similar to that predicted with the 60-day acute kidney injury predicted mortality score (r = 0.997; CI: 0.989-0.999). At our institution, the cost of production for 1 L of CCUPS is $0.67, which is considerably less than the cost of commercially purchased fluid. LIMITATIONS Observational design without a rigorous control group. CONCLUSIONS CVVHD using locally generated dialysate is safe and cost-effective.
Collapse
Affiliation(s)
- Jonathan J. Taliercio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, OH
| | - Georges Nakhoul
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, OH
| | - Tushar J. Vachharajani
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, OH
| | - Matthew Layne
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, OH
| | - John Sedor
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, OH
| | - George Thomas
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, OH
| | - Ali Mehdi
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, OH
| | - Robert Heyka
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, OH
| | - Sevag Demirjian
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, OH
| |
Collapse
|
5
|
Wright S, Meyer KB. DIY: Ultrapure Home Brew Dialysate for the ICU? Kidney Med 2021; 3:321-323. [PMID: 34136777 PMCID: PMC8178520 DOI: 10.1016/j.xkme.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Seth Wright
- William B Schwartz M.D. Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Klemens B. Meyer
- William B Schwartz M.D. Division of Nephrology, Tufts Medical Center, Boston, MA
| |
Collapse
|
6
|
Alabbas A, Kirpalani A, Morgan C, Mammen C, Licht C, Phan V, Wade A, Harvey E, Zappitelli M, Clark EG, Hiremath S, Soroka SD, Wald R, Weir MA, Chanchlani R, Lemaire M. Canadian Association of Paediatric Nephrologists COVID-19 Rapid Response: Guidelines for Management of Acute Kidney Injury in Children. Can J Kidney Health Dis 2021; 8:2054358121990135. [PMID: 33614056 PMCID: PMC7868478 DOI: 10.1177/2054358121990135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/04/2021] [Indexed: 01/08/2023] Open
Abstract
PURPOSE This article provides guidance on managing acute kidney injury (AKI) and kidney replacement therapy (KRT) in pediatrics during the COVID-19 pandemic in the Canadian context. It is adapted from recently published rapid guidelines on the management of AKI and KRT in adults, from the Canadian Society of Nephrology (CSN). The goal is to provide the best possible care for pediatric patients with kidney disease during the pandemic and ensure the health care team's safety. INFORMATION SOURCES The Canadian Association of Paediatric Nephrologists (CAPN) COVID-19 Rapid Response team derived these rapid guidelines from the CSN consensus recommendations for adult patients with AKI. We have also consulted specific documents from other national and international agencies focused on pediatric kidney health. We identified additional information by reviewing the published academic literature relevant to pediatric AKI and KRT, including recent journal articles and preprints related to COVID-19 in children. Finally, our group also sought expert opinions from pediatric nephrologists across Canada. METHODS The leadership of the CAPN, which is affiliated with the CSN, solicited a team of clinicians and researchers with expertise in pediatric AKI and acute KRT. The goal was to adapt the guidelines recently adopted for Canadian adult patients for pediatric-specific settings. These included specific COVID-19-related themes relevant to AKI and KRT in a Canadian setting, as determined by a group of kidney disease experts and leaders. An expert group of clinicians in pediatric AKI and acute KRT reviewed the revised pediatric guidelines. KEY FINDINGS (1) Current Canadian data do not suggest an imminent threat of an increase in acute KRT needs in children because of COVID-19; however, close coordination between nephrology programs and critical care programs is crucial as the pandemic continues to evolve. (2) Pediatric centers should prepare to reallocate resources to adult centers as needed based on broader health care needs during the COVID-19 pandemic. (3) Specific suggestions pertinent to the optimal management of AKI and KRT in COVID-19 patients are provided. These suggestions include but are not limited to aspects of fluid management, KRT vascular access, and KRT modality choice. (4) Considerations to ensure adequate provision of KRT if resources become scarce during the COVID-19 pandemic. LIMITATIONS We did not conduct a formal systematic review or meta-analysis. We did not evaluate our specific suggestions in the clinical environment. The local context, including how the provision of care for AKI and acute KRT is organized, may impede the implementation of many suggestions. As knowledge is advancing rapidly in the area of COVID-19, suggestions may become outdated quickly. Finally, most of the literature for AKI and KRT in COVID-19 comes from adult data, and there are few pediatric-specific studies. IMPLICATIONS Given that most acute KRT related to COVID-19 is likely to be required in the pediatric intensive care unit initial setting, close collaboration and planning between critical care and pediatric nephrology programs are needed. Our group will update these suggestions with a supplement if necessary as newer evidence becomes available that may change or add to the recommendations provided.
Collapse
Affiliation(s)
- Abdullah Alabbas
- Department of Paediatrics, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Amrit Kirpalani
- Department of Paediatrics, Division of Nephrology, Western University, London, ON, Canada
| | - Catherine Morgan
- Department of Paediatrics, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Cherry Mammen
- Department of Paediatrics, Division of Nephrology, The University of British Columbia, Vancouver, Canada
| | - Christoph Licht
- Department of Paediatrics, Division of Nephrology, University of Toronto, ON, Canada
| | - Veronique Phan
- Department of Paediatrics, Division of Nephrology, Université de Montréal, Québec, Canada
| | - Andrew Wade
- Department of Paediatrics, Division of Nephrology, University of Calgary, AB, Canada
| | - Elizabeth Harvey
- Department of Paediatrics, Division of Nephrology, University of Toronto, ON, Canada
| | - Michael Zappitelli
- Department of Paediatrics, Division of Nephrology, University of Toronto, ON, Canada
| | - Edward G. Clark
- Division of Nephrology, Department of Medicine, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Steven D. Soroka
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital and Department of Medicine, University of Toronto, ON, Canada
| | - Matthew A. Weir
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, ON, Canada
| | - Mathieu Lemaire
- Department of Paediatrics, Division of Nephrology, University of Toronto, ON, Canada
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
| |
Collapse
|
7
|
Akomeah J, Apostol A, Barnes E, Charytan C, Enriquez U, Katikaneni M, Liu F, Messina A, Neelakantappa K, Radhakrishnan J, Raichoudhury R, Ramakrishnan R, Saboor S, Sapozhnikova A, Silberzweig J, Stevens JS, Tanzi-Pfeifer S, Tutone J, Srivatana V. Optimizing Kidney Replacement Therapy During the COVID-19 Pandemic Across a Complex Healthcare System. Front Med (Lausanne) 2020; 7:604182. [PMID: 33415118 PMCID: PMC7784642 DOI: 10.3389/fmed.2020.604182] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/05/2020] [Indexed: 12/21/2022] Open
Abstract
The unprecedented surge of nephrology inpatients needing kidney replacement therapy placed hospital systems under extreme stress during the COVID-19 pandemic. In this article, we describe the formation of a cross campus "New-York Presbyterian COVID-19 Kidney Replacement Therapy Task Force" with intercampus physician, nursing, and supply chain representation. We describe several strategies including the development of novel dashboards to track supply/demand of resources, urgent start peritoneal dialysis, in-house preparation of kidney replacement fluid, the use of unconventional personnel resources to ensure the safe and continued provision of kidney replacement therapy in the face of the unanticipated surge. These approaches facilitated equitable sharing of resources across a complex healthcare-system and allowed for the rapid implementation of standardized protocols at each hospital.
Collapse
Affiliation(s)
- Jane Akomeah
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, United States
| | - Aljenica Apostol
- NewYork-Presbyterian Lower Manhattan Hospital, New York, NY, United States
| | - Esteen Barnes
- NewYork-Presbyterian Lower Manhattan Hospital, New York, NY, United States
| | - Chaim Charytan
- NewYork-Presbyterian Queens, New York, NY, United States
| | - Uvannie Enriquez
- NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY, United States
| | - Madhavi Katikaneni
- NewYork-Presbyterian Hudson Valley Hospital, Cold Spring, NY, United States
| | - Frank Liu
- NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY, United States
| | - Albert Messina
- NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, United States
| | | | - Jai Radhakrishnan
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, United States
| | | | - Ramya Ramakrishnan
- NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, United States
| | - Sadia Saboor
- NewYork-Presbyterian Lawrence Hospital, Bronxville, NY, United States
| | - Alina Sapozhnikova
- Strategic Sourcing at New York Presbyterian Hospital, New York, NY, United States
| | - Jeffrey Silberzweig
- NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY, United States
| | - Jacob S. Stevens
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, United States
| | - Susan Tanzi-Pfeifer
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, United States
| | - Jennifer Tutone
- NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, United States
| | - Vesh Srivatana
- NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY, United States
| |
Collapse
|
8
|
Clark EG, Hiremath S, Soroka SD, Wald R, Weir MA. CSN COVID-19 Rapid Review Program: Management of Acute Kidney Injury. Can J Kidney Health Dis 2020; 7:2054358120941679. [PMID: 32728473 PMCID: PMC7364799 DOI: 10.1177/2054358120941679] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 01/08/2023] Open
Abstract
PURPOSE Severe acute kidney injury (AKI) is a potential complication of COVID-19-associated critical illness. This has implications for the management of COVID-19-associated AKI and the resulting increased need for kidney replacement therapy (KRT) in the intensive care unit (ICU) and elsewhere in the hospital. The Canadian Society of Nephrology COVID-19 Rapid Review Team has sought to collate and synthesize currently available resources to inform ethically justifiable decisions. The goal is the provision of the best possible care for the largest number of patients with kidney disease while considering how best to ensure the safety of the health care team. INFORMATION SOURCES Local, provincial, national, and international guidance and planning documents related to the COVID-19 pandemic; guidance documents available from nephrology and critical care-related professional organizations; recent journal articles and preprints related to the COVID-19 pandemic; expert opinion from nephrologists from across Canada. METHODS A working group of kidney specialist physicians was established with representation from across Canada. Kidney physician specialists met via teleconference and exchanged e-mails to refine and agree on the proposed suggestions in this document. KEY FINDINGS (1) Nephrology programs should work with ICU programs to plan for the possibility that up to 30% or more of critically ill patients with COVID-19 admitted to ICU will require kidney replacement therapy (KRT). (2) Specific suggestions pertinent to the optimal management of AKI and KRT in patients with COVID-19. These suggestions include, but are not limited to, aspects of fluid management, KRT vascular access, and KRT modality choice. (3) We describe considerations related to ensuring adequate provision of KRT, should resources become scarce during the COVID-19 pandemic. LIMITATIONS A systematic review or meta-analysis was not conducted. Our suggestions have not been specifically evaluated in the clinical environment. The local context, including how the provision of acute KRT is organized, may impede the implementation of many suggestions. Knowledge is advancing rapidly in the area of COVID-19 and suggestions may become outdated quickly. IMPLICATIONS Given that most acute KRT related to COVID-19 is likely to be required initially in the ICU setting, close collaboration and planning between critical care and nephrology programs is required. Suggestions may be updated as newer evidence becomes available.
Collapse
Affiliation(s)
- Edward G. Clark
- Division of Nephrology, Department of Medicine, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Steven D. Soroka
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital and Department of Medicine, University of Toronto, ON, Canada
| | - Matthew A. Weir
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| |
Collapse
|
9
|
Kellum JA, Cerda J, Kaplan LJ, Nadim MK, Palevsky PM. Fluids for Prevention and Management of Acute Kidney Injury. Int J Artif Organs 2018; 31:96-110. [DOI: 10.1177/039139880803100204] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Fluids are the only known method of attenuating renal injury. Furthermore, whether for hydration, resuscitation or renal replacement therapy, fluid prescriptions must be tailored to the fluid and electrolyte, cardiovascular status and residual renal function of the patient. Different fluids have significantly different effects both on volume expansion as well as on the electrolyte and acid-base balance; while controversial, different fluids may even influence renal function differently. This systematic review focuses on fluids for prevention and management of acute kidney injury. We have reviewed the available evidence and have made recommendations for clinical practice and future studies.
Collapse
Affiliation(s)
- J. A. Kellum
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania - USA
| | - J. Cerda
- Division of Nephrology, Albany Medical College and Capital District Renal Physicians, Albany, New York - USA
| | - L. J. Kaplan
- Department of Surgery, Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale University School of Medicine, New Haven, Connecticut - USA
| | - M. K. Nadim
- Division of Nephrology, Department of Medicine, University of Southern California Keck School of Medicine, Los Angeles, California - USA
| | - P. M. Palevsky
- VA Pittsburgh Healthcare System, University Drive Division, Pittsburgh, Pennsylvania - USA
| |
Collapse
|
10
|
Bai ZG, Yang K, Tian JH, Ma B, Liu Y, Jiang L, Tan J, Liu TX, Chi I. Bicarbonate versus lactate solutions for acute peritoneal dialysis. Cochrane Database Syst Rev 2014; 2014:CD007034. [PMID: 24992903 PMCID: PMC10590203 DOI: 10.1002/14651858.cd007034.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The high mortality rate among critically ill patients with acute kidney injury (AKI) remains an unsolved problem in intensive care medicine, despite the use of renal replacement therapy (RRT). Increasing evidence from clinical studies in adults and children suggests that the new peritoneal dialysis (PD) fluids may allow for better long-term preservation of peritoneal morphology and function. Formation of glucose degradation products (GDPs) can be reduced and even avoided with the use of newer "biocompatible" solutions. However, it is still unclear if there are any differences in using conventional (lactate) solutions compared with low GDP (bicarbonate) solutions for acute PD. OBJECTIVES To look at the benefits and harms of bicarbonate versus lactate solutions in acute PD. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1966), EMBASE (from 1980), Latin American and Caribbean Health Sciences Literature Database LILACS (from 1982), and reference lists of articles.Date of last search: 6 May 2014. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing bicarbonate to lactate solution for acute PD. DATA COLLECTION AND ANALYSIS Two authors independently assess the methodological quality of studies. One author abstracted data onto a standard form, and a second author checked data extraction. We used the random-effects model and expressed the results as relative risk (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). MAIN RESULTS We included one study (20 patients) in this review. In shock patients, bicarbonate did not differ from lactate with respect to mortality (RR 0.50, 95% CI 0.06 to 3.91); however there were significant differences in blood lactate (MD -1.60 mmol/L, 95% CI -2.04 to -1.16), serum bicarbonate (MD 5.00 mmol/L, 95% CI 3.26 to 6.74) and blood pH (MD 0.12, 95% CI 0.06 to 0.18). In non-shock patients there was a significance difference in blood lactate (MD -0.60 mmol/L, 95% CI -0.85 to -0.35) but not in serum bicarbonate (MD 1.10 mmol/L, 95% CI -0.27 to 2.47) or blood pH (MD -0.02, 95% CI -0.02 to -0.06). Other outcomes could not be analysed because of the limited data available. AUTHORS' CONCLUSIONS There is no strong evidence that any clinical advantage for patients requiring acute PD for AKI when comparing conventional (lactate) with low GDP dialysis solutions (bicarbonate).
Collapse
Affiliation(s)
- Zheng Gang Bai
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesNo. 199, Donggang West RoadLanzhou CityGansuChina730000
- Lanzhou UniversityKey Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu ProvinceLanzhou CityChina
| | - KeHu Yang
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesNo. 199, Donggang West RoadLanzhou CityGansuChina730000
- Lanzhou UniversityKey Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu ProvinceLanzhou CityChina
| | - Jin Hui Tian
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesNo. 199, Donggang West RoadLanzhou CityGansuChina730000
- Lanzhou UniversityKey Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu ProvinceLanzhou CityChina
| | - Bin Ma
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesNo. 199, Donggang West RoadLanzhou CityGansuChina730000
| | - Yali Liu
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesNo. 199, Donggang West RoadLanzhou CityGansuChina730000
- Lanzhou UniversityKey Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu ProvinceLanzhou CityChina
| | - Lei Jiang
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesNo. 199, Donggang West RoadLanzhou CityGansuChina730000
- Lanzhou UniversityKey Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu ProvinceLanzhou CityChina
| | - Jiying Tan
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesNo. 199, Donggang West RoadLanzhou CityGansuChina730000
- Lanzhou UniversityKey Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu ProvinceLanzhou CityChina
| | - Tian Xi Liu
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesNo. 199, Donggang West RoadLanzhou CityGansuChina730000
- Lanzhou UniversityKey Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu ProvinceLanzhou CityChina
| | - Iris Chi
- University of Southern CaliforniaSchool of Social Work669 W. 34th StLos AngelesCAUSA90089‐0411
| | | |
Collapse
|
11
|
Corradi V, Cruz D, Vázquez-Rangel A, Furlan F, Grillone R, Bonaccorsi A, Cazzavillan S, de Cal M, Frisone P, Morea A, Brendolan A, Rassu M, Ronco C. Purity and stability of online-prepared hemodiafiltration fluid after storage. Blood Purif 2013; 35:112-8. [PMID: 23343555 DOI: 10.1159/000346095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Previous studies have suggested that online hemodiafiltration (OL-HDF) fluid can be used as dialysate for continuous renal replacement therapies, and thus HDF costs can be reduced. The aims of this study were to determine the purity of OL-HDF fluid and to verify the stability of the electrolyte composition and acid-base balance during its storage. METHODS OL-HDF fluid was collected in 70 individual bags and stored for up to 7 days. The following tests were performed daily in 10 bags: natural visible precipitation (macrocrystallization), sample collection for chemical analysis and fluid culture, limulus amebocyte lysate endotoxin test, standard culture of NALGENE® filters after passing of the fluid, and molecular analysis of bacterial DNA. RESULTS The values of pH and pCO(2) showed a significant change starting at 24 h (p < 0.001); after 72 h, their values were beyond the measurable range. Coefficient of variation for pCO(2) was as high as 25.7%. Electrolyte composition (Na(+), K(+), Cl(-), Ca(2+) and glucose) showed a statistically significant difference over time (p < 0.05); however, their coefficients of variation were low (1.7, 1.4, 0.6, 2.3 and 0.9%, respectively), which might not be considered clinically significant. Negative results were obtained at all points by fluid and filter cultures, endotoxin test and molecular analysis. No macrocrystallization was observed at any time point. CONCLUSIONS We demonstrate the microbiological purity of OL-HDF fluid stored for up to 7 days. The electrolyte composition was stable, except for a relevant change in pCO(2) and consequently in pH (first noted at 24 h), emphasizing the need to reassess the acid-base balance in multilayer plastic bags in future studies.
Collapse
Affiliation(s)
- V Corradi
- Department of Nephrology, San Bortolo Hospital, Vicenza, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Bai ZG, Yang K, Tian J, Ma B, Liu Y, Jiang L, Tan J, Liu TX, Chi I. Bicarbonate versus lactate solutions for acute peritoneal dialysis. Cochrane Database Syst Rev 2010:CD007034. [PMID: 20824854 DOI: 10.1002/14651858.cd007034.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The high mortality rate among critically ill patients with acute kidney injury (AKI) remains an unsolved problem in intensive care medicine, despite the use of renal replacement therapy (RRT). Increasing evidence from clinical studies in adults and children suggests that the new peritoneal dialysis (PD) fluids may allow for better long-term preservation of peritoneal morphology and function. Formation of glucose degradation products (GDPs) can be reduced and even avoided with the use of newer "biocompatible" solutions. However, it is still unclear if there are any differences in using conventional (lactate) solutions compared with low GDP (bicarbonate) solutions for acute PD. OBJECTIVES To look at the benefits and harms of bicarbonate versus lactate solutions in acute PD. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1966), EMBASE (from 1980), Latin American and Caribbean Health Sciences Literature Database LILACS (from 1982), and reference lists of articles. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing bicarbonate to lactate solution for acute PD. DATA COLLECTION AND ANALYSIS Two authors independently assess the methodological quality of studies. One author abstracted data onto a standard form, and a second author checked data extraction. We used the random-effects model and expressed the results as relative risk (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). MAIN RESULTS We included one study (20 patients) in this review. In shock patients, bicarbonate did not differ from lactate with respect to mortality (RR 0.50, 95% CI 0.06 to 3.91); however there were significant differences in blood lactate (MD -1.60 mmol/L, 95% CI -2.04 to -1.16), serum bicarbonate (MD 5.00 mmol/L, 95% CI 3.26 to 6.74) and blood pH (MD 0.12, 95% CI 0.06 to 0.18). In non-shock patients there was a significance difference in blood lactate (MD -0.60 mmol/L, 95% CI -0.85 to -0.35) but not in serum bicarbonate (MD 1.10 mmol/L, 95% CI -0.27 to 2.47) or blood pH (MD -0.02, 95% CI -0.02 to -0.06). Other outcomes could not be analysed because of the limited data available. AUTHORS' CONCLUSIONS There is no strong evidence that any clinical advantage for patients requiring acute PD for AKI when comparing conventional (lactate) with low GDP dialysis solutions (bicarbonate).
Collapse
Affiliation(s)
- Zheng Gang Bai
- a) Integrated Traditional Chinese and Western Medicine Research Institution, School of Basic Medicine Sciences of Lanzhou University, Lanzhou City, China, b) Evidence-based Medicine Centre of Lanzhou University, Lanzhou City, China c) Social Work School, University of Southern California, Los Angeles, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Rauf AA, Long KH, Gajic O, Anderson SS, Swaminathan L, Albright RC. Intermittent hemodialysis versus continuous renal replacement therapy for acute renal failure in the intensive care unit: an observational outcomes analysis. J Intensive Care Med 2008; 23:195-203. [PMID: 18474503 DOI: 10.1177/0885066608315743] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Studies have failed to show a survival difference between intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT). Comparative cost analyses are limited and fail to control for differences in patient disease severity and comorbid conditions. The authors retrospectively estimated clinical and economic outcomes associated with CRRT and IHD among critically ill patients experiencing acute renal failure (ARF) in 2 tertiary care hospitals in Rochester, Minnesota, between January 1, 2000, and December 12, 2001. METHODS 161 critically ill patients requiring dialysis for ARF were analyzed. Patient demographics, comorbid conditions, ARF etiology, mode of renal replacement therapy (RRT), renal recovery, and survival were abstracted from medical chart. APACHE II scores at dialysis initiation were calculated. Administrative data tracked length of stay (LOS) and direct medical costs from initiation of RRT to death or intensive care unit (ICU) and hospital discharge. Multivariate modeling was used to adjust outcomes for baseline differences. RESULTS 84 (52%) of the patients received CRRT and 77 (48%) received IHD. CRRT-treated patients were younger (58 vs 65 years), less likely male (58% vs 77%), had higher APACHE II scores (32 vs 27) with a higher incidence of sepsis (46% vs 30%) and respiratory disease (56% vs 39%), and were less likely to have chronic renal insufficiency (32% vs 49%). With adjustment for differences in baseline patient characteristics, the RRT method did not affect the likelihood of renal recovery, in-hospital survival, or survival during follow-up. Mean adjusted ICU LOS was 9.5 days shorter for IHD-treated than CRRT-treated patients (P< .001), and the adjusted mean difference in hospital and total costs associated with ICU stay was $56,564 and $60 827, in favor of IHD (P< .001). Mean adjusted total costs through hospital discharge were $93 611 and $140,733 among IHD-treated and CRRT-treated patients, respectively (P< .001). CONCLUSIONS This observational study suggests that costs may significantly differ by mode of RRT despite similar severity-adjusted patient outcomes. Future prospective comparisons of renal replacement modalities will need to include both clinical and economic outcomes.
Collapse
Affiliation(s)
- Anis Abdul Rauf
- Departments of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.
| | | | | | | | | | | |
Collapse
|
14
|
Continuous Renal Replacement Therapy. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50021-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
15
|
Affiliation(s)
- Ravindra L Mehta
- University of California, San Diego, San Diego, California, USA.
| |
Collapse
|
16
|
Leblanc M. Acid–base balance in acute renal failure and renal replacement therapy. Best Pract Res Clin Anaesthesiol 2004; 18:113-27. [PMID: 14760877 DOI: 10.1016/j.bpa.2003.08.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The approach to acid-base balance based on the concept of strong ions, initially proposed by Stewart, is briefly overviewed. The anion gap and the strong anion gap are both discussed. Comments are made on the strong ion difference of fluids administered to patients and their impact on acid-base status will be commented. Renal failure patients have an altered acid-base balance; most commonly, a mixed type of metabolic acidosis (hyperchloraemic, and of a high anion gap) is observed. The consequences of renal metabolic acidosis are described. Finally, the impact of renal replacement therapy on acid-base balance is exposed; different modalities of renal replacement are considered in regard to their alkalinizing performance.
Collapse
Affiliation(s)
- Martine Leblanc
- Nephrology and Critical Care, Maisonneuve-Rosemont Hospital, University of Montreal, 5415 de l'Assomption, Montreal, Que, Canada PQ H1T 2M4.
| |
Collapse
|
17
|
Tobe SW, Aujla P, Walele AA, Oliver MJ, Naimark DMJ, Perkins NJ, Beardsall M. A novel regional citrate anticoagulation protocol for CRRT using only commercially available solutions. J Crit Care 2003; 18:121-9. [PMID: 12800123 DOI: 10.1053/jcrc.2003.50006] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To describe a citrate regional anticoagulation (CRA) protocol for patients with acute renal failure and contraindications to heparin who require continuous renal replacement therapy (CRRT), using only commercially available solutions, for units that do not want or cannot prepare extemporaneously made solutions. MATERIALS AND METHODS Case report and series from a medical/surgical intensive care unit of a university teaching hospital. A CRA protocol was developed by using only commercially available solutions. Five dialysis-specific clinical parameters were identified to allow simplified measurement and control. RESULTS There was a dramatic improvement of dialysis filter survival in the index patient that was seen in the subsequent patients receiving CRA. This was accompanied by excellent control of the clinical and biochemical parameters as well as nursing acceptance and ownership of the protocol. CONCLUSION It is possible to provide safe and effective CRA with only commercially available solutions. The protocol is applicable to most patients requiring CRRT.
Collapse
Affiliation(s)
- Sheldon W Tobe
- Division of Nephrology, Sunnybrook & Women's College Health Science Centre, Toronto, Ontario, Canada
| | | | | | | | | | | | | |
Collapse
|
18
|
|
19
|
Schetz M, Leblanc M, Murray PT. The Acute Dialysis Quality Initiative--part VII: fluid composition and management in CRRT. ADVANCES IN RENAL REPLACEMENT THERAPY 2002; 9:282-9. [PMID: 12382232 DOI: 10.1053/jarr.2002.35572] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Fluid composition and management are important parts of continuous renal replacement therapy (CRRT). Most commercially available CRRT solutions are able to reestablish electrolyte homeostasis provided some phosphate supplementation is given. Supraphysiologic glucose concentrations should be avoided. Predilution fluid replacement allows higher ultrafiltration rates and can be considered as an adjunct to the anticoagulation regimen. Lactate is an effective buffer in most CRRT patients. Bicarbonate is preferred in patients with lactic acidosis and/or liver failure. When citrate is used as anticoagulant, frequent monitoring of pH is required. The clinical consequences of CRRT-induced decreases of body temperature are not clear. Substitution fluid should be sterile, but the bacteriologic requirements for CRRT dialysate are less clear. There is no consensus on the optimal parameters to monitor fluid management. Integrated balancing systems have theoretical advantages over adaptive use of intravenous fluid pumps. Although there is evidence that volume overload is associated with adverse outcome, there is no evidence that fluid removal per se improves outcome in critically ill patients with or without acute renal failure.
Collapse
Affiliation(s)
- Miet Schetz
- Department of Intensive Care, University of Leuven, Belgium.
| | | | | |
Collapse
|
20
|
Liangos O, Sakiewicz PG, Kanagasundaram NS, Hammel J, Pajouh M, Seifert T, Paganini EP. Dialyzer fiber bundle volume and kinetics of solute removal in continuous venovenous hemodialysis. Am J Kidney Dis 2002; 39:1047-53. [PMID: 11979349 DOI: 10.1053/ajkd.2002.32788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The relationship between dialyzer fiber bundle volume (FBV), dialyzer life span, and small-solute clearance has yet to be clearly defined in continuous venovenous hemodialysis (CVVHD). This study sought to define this relationship using novel ultrasound dilution technology. We studied 55 sessions in 31 intensive care unit patients on CVVHD therapy. A session was defined as the life span of a single dialyzer. The following variables were assessed every 6 hours throughout each session, starting within 1 hour of initiation of that session: FBV, access recirculation, extracorporeal blood flow rate, effluent (EUN) to blood urea nitrogen (BUN) concentration ratio, effluent creatinine to blood creatinine concentration ratio, and urea nitrogen and creatinine clearances. Data were analyzed using random-effects linear models to estimate trends. Several dialysis-related and solute-removal parameters were analyzed for association with each other. Systemic or dialysis circuit heparin was administered in 28 of 55 sessions. One hundred seventy sets of FBV, 101 sets of urea clearance, and 102 sets of creatinine clearance measurements were performed. There was a declining trend for FBV (0.8 mL/h), heart rate (0.25 beats/min/h), and measured blood flow (0.33 mL/min/h; P < 0.05). Apart from dialysate inflow rate (P = 0.044), there was no significant correlation with EUN-BUN ratio. Session duration was associated with dialysis access site; the femoral access provided longer dialysis sessions than subclavian and internal jugular accesses (P = 0.029). We conclude that small-solute removal remains stable over the course of our CVVHD system life spans despite significant loss of hemodialyzer FBV.
Collapse
Affiliation(s)
- Orfeas Liangos
- Department of Nephrology/Hypertension, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | | | | | | | | | | | | |
Collapse
|
21
|
Maccariello E, Rocha E, Dalboni MA, Ferreira AT, Draibe S, Cendoroglo M. Customized bicarbonate buffered dialysate and replacement solutions for continuous renal replacement therapies: effect of crystallization on the measured levels of electrolytes and buffer. Artif Organs 2001; 25:870-5. [PMID: 11903139 DOI: 10.1046/j.1525-1594.2001.06895.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aim of this study was to investigate the impact of the addition of calcium to bicarbonate solutions for continuous renal replacement therapy (CRRT). We tested single bag (bicarbonate and calcium mixed 24 h before testing) and double bag solutions (mixed immediately before) with and without the addition of 4 mEq/L of acetate. Prescribed calcium varied from 0 to 5 mEq/L. All test solutions containing calcium showed crystallization at light microscopy. The double bag solutions decreased but did not prevent crystallization. The addition of acetate did not interfere with crystallization. Crystallization, as measured by the weight of the crystals after filtration of the solutions, showed a significant positive correlation with the calcium deficit (prescribed minus measured) and with partial pressure of carbon dioxide. The measured level of calcium was lower than expected and correlated with crystallization. Our results suggest that the use of bicarbonate solutions containing calcium as replacement fluids for CRRT is a potentially unsafe procedure.
Collapse
Affiliation(s)
- E Maccariello
- Division of Nephrology, Universidade Federal de São Paulo (UNIFESP), Brazil.
| | | | | | | | | | | |
Collapse
|
22
|
Kanagasundaram NS, Larive AB, Paganini EP. A fractional dialysate collection method to estimate solute removal in continuous venovenous hemodialysis. Kidney Int 2000; 58:2579-84. [PMID: 11115094 DOI: 10.1046/j.1523-1755.2000.00444.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Fractional direct dialysis quantification (fDDQ), whereby a known proportion of dialysate effluent is sampled, can reliably estimate total solute removal in intermittent hemodialysis (IHD). Our study aimed to develop and test the technique in continuous venovenous hemodialysis (CVVHD). METHODS Twenty dialysate collections (mean duration 23.5 hours, range 17.25 to 26.6) were performed in 12 patients on CVVHD. An infusion pump diverted 10% of the total effluent volume to the fractional collection (fc), the remainder being channeled into the bulk collection (bc). Both fc and bc were collected on ice and assayed for urea nitrogen (UN) and creatinine (Cr). Actual solute removal (ASR) was calculated from the measured effluent volume and solute concentrations of the fc and bc. Estimated solute removal (ESR) was calculated from the product of the fc solute concentration and effluent volume. All fc/bc samples in 15 out of 20 collections underwent gram stain and aerobic/anaerobic culture. RESULTS Bland-Altman analyses suggested good agreement between ASR and ESR [absolute values of percentage differences: 95% CI = 1.73, 5.17% (UN); 1.88, 4.31% (Cr)]. Favorable concordance correlation coefficients confirmed this [rc = 0.995 (UN), 0.997 (Cr)] and were apparently unaffected by heavy pseudomonal growths in 4 out of 7 culture positive collections [rc = 0.997 (UN), 0.997 (Cr); culture negative (N = 8), rc = 0.996 (UN), 0.997 Cr)]. CONCLUSION fDDQ, using 24-hour, pump-assisted, cooled fractional dialysate sampling reliably estimates total solute removal and provides a practical alternative to total dialysate collection in assessing delivered dialysis dose.
Collapse
Affiliation(s)
- N S Kanagasundaram
- Section of Dialysis and Extracorporeal Therapy and Department of Biostatistics and Epidemiology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
| | | | | |
Collapse
|
23
|
McLean AG, Davenport A, Cox D, Sweny P. Effects of lactate-buffered and lactate-free dialysate in CAVHD patients with and without liver dysfunction. Kidney Int 2000; 58:1765-72. [PMID: 11012911 DOI: 10.1046/j.1523-1755.2000.00338.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Continuous modalities of renal replacement deplete patients of bicarbonate, which is traditionally replaced indirectly by lactate in dialysate or replacement fluids. We have compared a new lactate-free dialysate (unbuffered dialysate with separate bicarbonate replacement of dialytic bicarbonate loss) with standard lactate-buffered dialysate in terms of acid-base control, lactate accumulation, and hemodynamic stability in patients undergoing continuous renal replacement therapy in an intensive care unit. METHODS A nonrandomized crossover cohort study involving 54 patients with multi-organ failure (of whom 19 had significant hepatic dysfunction) was performed. All patients completed 24-hour continuous hemodiafiltration against both lactate-buffered and lactate-free dialysate. Arterial pH, blood gases, bicarbonate, and lactate, venous sodium, blood pressure, and inotrope requirements were measured before and at six hourly intervals during the first 24 hours of dialysis against each dialysate. RESULTS Lactate-free dialysate provided more rapid control of acidosis than lactate buffered with less total administration of buffer than that given during the lactate-buffered period (total mmol bicarbonate vs. total mmol lactate + bicarbonate). Lactate accumulation was slight in both periods, but was higher during lactate-buffered continuous venovenous hemodiafiltration (CVVHD). The mean arterial pressure rose during lactate-free dialysis with decreased inotrope doses and fell during lactate-buffered dialysis with increased inotrope requirement. Results in patients with liver dysfunction were not significantly different from those without it. CONCLUSIONS Over the time scale of 24 hours, lactate derived from continuous dialysis circuits is efficiently cleared from the blood of most patients with multi-organ failure, but with less effect on systemic acidosis than is produced by equivalent amounts of bicarbonate.
Collapse
Affiliation(s)
- A G McLean
- Centre for Nephrology, Royal Free Campus, Royal Free and University College Medical School, and Intensive Care Unit, Royal Free Hospital NHS Trust, London, England, United Kingdom.
| | | | | | | |
Collapse
|
24
|
|
25
|
Schlaeper C, Amerling R, Manns M, Levin NW. High clearance continuous renal replacement therapy with a modified dialysis machine. Kidney Int 1999. [DOI: 10.1046/j.1523-1755.56.s72.13.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
26
|
Zimmerman D, Cotman P, Ting R, Karanicolas S, Tobe SW. Continuous veno-venous haemodialysis with a novel bicarbonate dialysis solution: prospective cross-over comparison with a lactate buffered solution. Nephrol Dial Transplant 1999; 14:2387-91. [PMID: 10528662 DOI: 10.1093/ndt/14.10.2387] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To compare acid-base balance, lactate concentration and haemodynamic parameters during continuous veno-venous haemodialysis (CVVHD) using bicarbonate or a lactate buffered dialysate. METHODS DESIGN prospective randomized cross-over design; SETTING Multicentre combined adult surgical and medical intensive care units. Patients; 26 critically ill patients starting CVVHD for acute renal failure. INTERVENTIONS Each patient to receive 48 h of bicarbonate dialysate and 48 h of lactate dialysate with the order of the 48 h block randomized at trial entry. RESULTS The serum bicarbonate increased from baseline in both the lactate and bicarbonate groups over the first 48 h of treatment (16.3+/-1.53 to 22.2+/-1.41 mmol/l and 18.9+/-2.02 to 22.2+/-1.18 mmol/l, respectively) and continued to rise towards normal over the next 48 h after cross-over to the other dialysate. The H+ and pCO2 only trended higher in the lactate group. Unlike the acid base parameters, serum lactate levels varied depending on the dialysate composition. The patients initially randomized to the lactate dialysate had higher serum lactate levels and these tended to increase further after 48 h of dialysis from 2.4+/-0.8 to 2.6+/-0.4 mmol/l. However, in the following 48 h the lactate levels fell to 1.8+/-0.6 (P = 0.039) while patients were being treated with the bicarbonate dialysate. Similar results were seen in the patients initially randomized to the bicarbonate dialysate. Serum lactate remained stable over the first 48h (1.4+/-0.2 to 1.5+/-0.1 mmol/l) but after cross-over to the lactate dialysate increased to 3.1+/-0.7 mmol/l (P = 0.051). Overall, lactate levels were significantly higher during dialysis with lactate buffered solution than bicarbonate buffered solution (2.92+/-0.45 vs. 1.61+/-0.25 mmol/l P = 0.01). Mean arterial pressure trended higher during bicarbonate dialysis but did not reach statistical significance (lactate vs. bicarbonate; 71.1+/-3.1 vs. 81.3+/-5.8 mm Hg). Subgroup analysis of the patients with abnormal liver indices or increased lactate levels at initiation of dialysis (n = 15) revealed only a trend toward better bicarbonate control (lactate vs. bicarbonate; 22.00+/-1.73 vs. 22.86+/-1.09, P = 0.2). However, in this group with hepatic insufficiency elevations in serum lactate were even greater during lactate compared to the bicarbonate dialysis (3.39+/-0.68 vs. 1.78+/-0.42 P = 0.036). Patients who had elevations of lactate during lactate dialysis had a high mortality (6 of 7). These patients had an even greater disparity in lactate levels (4.3+/-1.4 vs. 1.3 +/-0.3) and blood pressure (68.0+/- 7.7 vs. 87.2+/-17.1) between lactate and bicarbonate dialysis. Due to small patient numbers these comparisons did not achieve statistical significance. CONCLUSION During continuous veno venous haemodialysis a bicarbonate buffered dialysis solution provided equal acid-base control but maintained more normal lactate levels than a lactate buffered dialysis solution.
Collapse
Affiliation(s)
- D Zimmerman
- Sunnybrook & Women's College Health Sciences Centre, University of Toronto, Ontario, Canada
| | | | | | | | | |
Collapse
|
27
|
Briglia A, Paganini EP. Acute renal failure in the intensive care unit. Therapy overview, patient risk stratification, complications of renal replacement, and special circumstances. Clin Chest Med 1999; 20:347-66, viii. [PMID: 10386261 DOI: 10.1016/s0272-5231(05)70146-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article provides a basic definition of severity scoring among patients with acute renal failure and extends the definition into the types of dialysis support that are generally used in intensive care unit acute renal failure. Acute dialysis dosing and the problems that create a difference between chronic renal failure and acute renal failure support are described, the dialytic techniques and side effects and complications of each are compared, and nonrenal-based special situations in which extracorporeal therapy has been found to be helpful are defined.
Collapse
Affiliation(s)
- A Briglia
- Division of Nephrology, University of Maryland, Baltimore, USA
| | | |
Collapse
|
28
|
Clark WR, Soltys PJ. Hemodialysis Systems for Intermittent, Semi-Continuous, and Continuous Therapies in Acute Renal Failure. ACTA ACUST UNITED AC 1998; 2:30-33. [PMID: 28466521 DOI: 10.1111/hdi.1998.2.1.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
As is the case in end-stage renal disease (ESRD), both intermittent and continuous renal replacement therapies (RRTs) are employed in acute renal failure (ARF). In fact, a continuum of treatment options is available in ARF. At one end of the ARF RRT spectrum is conventional intermittent hemodialysis (IHD), in which relatively high blood and dialysate flow rates are used (typically ≥250 and 500 mL/min, respectively). Continuous renal replacement therapies (CRRTs), which employ much lower flow rates, comprise the other end of the spectrum. Finally, hybrid therapies, which combine characteristics of both IHD and CRRT, have recently been described. These therapies' removal mechanisms for solutes over a broad molecular weight range are discussed. An understanding of these mechanisms is important when determining the amount of therapy that can be provided by any RRTs. Additional studies are required to improve the understanding of solute removal by the various RRT used in ARF.
Collapse
Affiliation(s)
- William R Clark
- Renal Division, Baxter Healthcare Corp., McGaw Park, Illinois, U.S.A.,Nephrology Division, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A
| | - Paul J Soltys
- Renal Division, Baxter Healthcare Corp., McGaw Park, Illinois, U.S.A
| |
Collapse
|