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Samimi MN, Hale A, Schults J, Fischer A, Roberts JA, Dhanani J. Clinical guidance for unfractionated heparin dosing and monitoring in critically ill patients. Expert Opin Pharmacother 2024. [PMID: 38825778 DOI: 10.1080/14656566.2024.2364057] [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: 01/29/2024] [Accepted: 05/31/2024] [Indexed: 06/04/2024]
Abstract
INTRODUCTION Unfractionated heparin is a widely used anticoagulant in critically ill patients. It has a well-established safety profile and remains an attractive option for clinicians due to its short half-life and reversibility. Heparin has a unique pharmacokinetic profile, which contributes to significant inter-patient and intra-patient variability in effect. The variability in anticoagulant effect combined with heparin's short half-life mean close monitoring is required for clinical efficacy and preventing adverse effects. To optimize heparin use in critically ill patients effective monitoring assays and dose adjustment strategies are needed. AREAS COVERED This paper explores the use of heparin as an anticoagulant and optimal approaches to monitoring in critically ill patients. EXPERT OPINION Conventional monitoring assays for heparin dosing have significant limitations. Emerging data appears to favor using anti-Xa assay monitoring for heparin anticoagulation which many centers have successfully adopted as the standard. The anti-Xa assay appears have important benefits relative to the aPTT for heparin monitoring in critically ill patients, and should be considered for broader use.
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Affiliation(s)
- May N Samimi
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Andrew Hale
- Discipline of Pharmacy, School of Clinical Sciences, Queensland University of Technology
| | - Jessica Schults
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Andreas Fischer
- Pharmacy Department, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Jayesh Dhanani
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Figueiredo MA, Andrade NS, Blanco Carrión A, Medina JB, Gallottini M, Ortega KL. Bleeding during tooth extraction in patients with chronic kidney disease: A cross-sectional pilot study. Oral Dis 2024; 30:2617-2624. [PMID: 37575013 DOI: 10.1111/odi.14709] [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: 04/05/2023] [Revised: 07/13/2023] [Accepted: 07/29/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE This work measures the intra-operative bleeding in end-stage renal disease patients and assesses whether laboratory coagulation tests and nitrogenous compounds are related to a higher bleeding risk. METHODS Laboratory tests were performed on the day of surgery and some patients with thrombocytopenia and values above the normal levels of international normalised ratio (INR), thrombin time (TT) and activated partial thromboplastin time (aPTT) were identified. RESULTS Haemostatic time ranged from 2 to 35 min (mean of 8.51 min) after suture. Bleeding volume ranged from 0.02 to 67.06 mL (mean of 4.38 mL) and the bleeding volume per minute ranged from 0.05 to 2.10 mL/min (median of 0.6 mL/min). Only seven patients (16.27%) had abnormal bleeding (more than 0.6 mL/min). Spearman's coefficient showed weak correlations between bleeding volume (mL/min) and serum urea (r = 0.226), TT (r = 0.227), plasma urea (r = 0.148) and creatinine (r = 146), as well as very weak correlations with all other variables (r < 0.140) such as age, haemodialysis time, glycaemia, glycated haemoglobin, platelets, INR, aPTT and fibrinogen. CONCLUSION It was not possible to associate any laboratory test or nitrogenous compounds present in the blood and saliva with an increased bleeding.
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Affiliation(s)
| | - Natalia Silva Andrade
- Special Care Dentistry Centre, School of Dentistry, University of São Paulo, Sao Paulo, Brazil
- Department of Dentistry, Federal University of Sergipe, Lagarto, Brazil
| | - Andrés Blanco Carrión
- Oral Medicine, Oral Surgery and Implantology Unit (MedOralRes), Faculty of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Janaina Braga Medina
- Special Care Dentistry Centre, School of Dentistry, University of São Paulo, Sao Paulo, Brazil
- Oral Medicine, Oral Surgery and Implantology Unit (MedOralRes), Faculty of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Marina Gallottini
- Special Care Dentistry Centre, School of Dentistry, University of São Paulo, Sao Paulo, Brazil
- Department of Stomatology, School of Dentistry, University of São Paulo, Sao Paulo, Brazil
| | - Karem L Ortega
- Special Care Dentistry Centre, School of Dentistry, University of São Paulo, Sao Paulo, Brazil
- Oral Medicine, Oral Surgery and Implantology Unit (MedOralRes), Faculty of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela, Spain
- Department of Stomatology, School of Dentistry, University of São Paulo, Sao Paulo, Brazil
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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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Liu D, Zhao J, Xia H, Dong S, Yan S, Zhuang Y, Chen Y, Peng H. Nafamostat mesylate versus regional citrate anticoagulation for continuous renal replacement therapy in patients at high risk of bleeding: a retrospective single-center study. Eur J Med Res 2024; 29:72. [PMID: 38245802 PMCID: PMC10799389 DOI: 10.1186/s40001-024-01660-7] [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: 11/14/2023] [Accepted: 01/11/2024] [Indexed: 01/22/2024] Open
Abstract
PURPOSE The choice of continuous renal replacement therapy (CRRT) anticoagulation program for patients at high risk of bleeding has always been a complex problem in clinical practice. Clinical regimens include regional citrate anticoagulation (RCA) and nafamostat mesylate (NM). This study aimed to evaluate the efficacy and safety of these two anticoagulants for CRRT in patients at high risk of bleeding to guide their clinical use better. PATIENTS AND METHODS Between January 2021 and December 2022, 307 patients were screened for this study. Forty-six patients were finally enrolled: 22 in the regional citrate anticoagulation group and 24 in the nafamostat mesylate group. We collected patients' baseline characteristics, laboratory indicators before CRRT, and CRRT-related data. We then performed a statistical analysis of the data from both groups of patients. RESULTS In our study, the baseline characteristics did not differ significantly between the two groups; the baseline laboratory indicators before CRRT of patients in the two groups were not significantly different. The duration of CRRT was 600 min in the regional citrate anticoagulation (RCA) group, 615 min in the nafamostat mesylate (NM) group; the success rate was 90.7% in the RCA group, and 85.6% in the NM group, the anticoagulant efficacy between the two groups was comparable. There was no significant difference in the safety of anticoagulation between the two groups. We used Generalized Estimating Equations (GEE) to test whether different anticoagulation methods significantly affected the success rate of CRRT and found no statistical difference between RCA and NM. CONCLUSION Our study suggests that nafamostat mesylate's anticoagulant efficacy and safety are not inferior to regional citrate anticoagulation for continuous renal replacement therapy in patients at high risk of bleeding.
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Affiliation(s)
- Dan Liu
- Department of Emergency, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Middle Road, Jingan District, Shanghai, People's Republic of China
| | - Jian Zhao
- Department of Emergency, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Middle Road, Jingan District, Shanghai, People's Republic of China
| | - Hui Xia
- Department of Emergency, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Middle Road, Jingan District, Shanghai, People's Republic of China
| | - Shi Dong
- Department of Emergency, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Middle Road, Jingan District, Shanghai, People's Republic of China
| | - Songjuan Yan
- Department of Emergency, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Middle Road, Jingan District, Shanghai, People's Republic of China
| | - Yugang Zhuang
- Department of Emergency, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Middle Road, Jingan District, Shanghai, People's Republic of China
| | - Yuanzhuo Chen
- Department of Emergency, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Middle Road, Jingan District, Shanghai, People's Republic of China.
| | - Hu Peng
- Department of Emergency, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Middle Road, Jingan District, Shanghai, People's Republic of China.
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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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Huang F, Cao WX, Yan YY, Mao TT, Wang XW, Huang D, Qiu YS, Lu WJ, Li DJ, Zhuang YG. Influence of continuous renal replacement therapy on the plasma concentration of tigecycline in patients with septic shock: A prospective observational study. Front Pharmacol 2023; 14:1118788. [PMID: 36969878 PMCID: PMC10034132 DOI: 10.3389/fphar.2023.1118788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 02/22/2023] [Indexed: 03/12/2023] Open
Abstract
Objective: The influence of continuous renal replacement therapy (CRRT) on the steady-state plasma concentration of high-dose tigecycline was investigated in septic shock patients to provide references for drug dosing.Methods: In this prospective observational study, 17 septic shock patients presenting with severe infections needing a broad-spectrum antibiotic therapy with high-dose tigecycline (100 mg per 12 h) in the intensive care unit were included and divided into CRRT group (n = 6) or non-CRRT group (n = 11). The blood samples were collected and plasma drug concentration was determined by SHIMADZU LC-20A and SHIMADZU LCMS 8040. The steady-state plasma concentration was compared between groups using unpaired t-test. Furthermore, between-groups comparisons adjusted for baseline value was also done using multivariate linear regression model.Results: Peak concentration (Cmax) of tigecycline was increased in CRRT group compared to non-CRRT group, but there were no statistical differences (505.11 ± 143.84 vs. 406.29 ± 108.00 ng/mL, p-value: 0.129). Trough concentration (Cmin) of tigecycline was significantly higher in CRRT group than in non-CRRT group, with statistical differences (287.92 ± 41.91 vs. 174.79 ± 33.15 ng/mL, p-value: 0.000, adjusted p-value: 0.000). In safety, Cmin was reported to be a useful predictor of hepatotoxicity with a cut-off of 474.8 ng/mL. In our studies, Cmin of all patients in CRRT group was lower than 474.8 ng/mL.Conclusion: The plasma concentration of tigecycline was increased in septic shock patients with CRRT treatment and only Cmin shown statistical differences. No dose adjustment seems needed in the view of hepatotoxicity.Clinical Trial Registration:https://www.chictr.org.cn/, identifier ChiCTR2000037475.
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Affiliation(s)
- Fang Huang
- Department of Pharmacy, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wen-Xiang Cao
- Department of Pharmacy, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yu-Ying Yan
- School of Pharmacy, Nanjing Medical University, Nanjing, China
| | - Tian-Tian Mao
- Department of Emergency Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xian-Wen Wang
- Department of Emergency Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Dan Huang
- Department of Emergency Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yu-Shuang Qiu
- Department of Pharmacy, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wen-Jie Lu
- Department of Pharmacy, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Dong-Jie Li
- Department of Pharmacy, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Dong-Jie Li, ; Yu-Gang Zhuang,
| | - Yu-Gang Zhuang
- Department of Emergency Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Dong-Jie Li, ; Yu-Gang Zhuang,
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Roberts SH, Goodwin ML, Bobba CM, Al-Qudsi O, Satyapriya SV, Tripathi RS, Papadimos TJ, Whitson BA. Continuous renal replacement therapy and extracorporeal membrane oxygenation: implications in the COVID-19 era. Perfusion 2023; 38:18-27. [PMID: 34494489 DOI: 10.1177/02676591211042561] [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] [Indexed: 01/24/2023]
Abstract
The novel severe acute respiratory syndrome coronavirus 2, SARS-CoV-2 (coronavirus Disease 19 (COVID-19)) was identified as the causative agent of viral pneumonias in Wuhan, China in December 2019, and has emerged as a pandemic causing acute respiratory distress syndrome (ARDS) and multiple organ dysfunction. Interim guidance by the World Health Organization states that extracorporeal membrane oxygenation (ECMO) should be considered as a rescue therapy in COVID-19-related ARDS. International registries tracking ECMO in COVID-19 patients reveal a 21%-70% incidence of acute renal injury requiring renal replacement therapy (RRT) during ECMO support. The indications for initiating RRT in patients on ECMO are similar to those for patients not requiring ECMO. RRT can be administered during ECMO via a temporary dialysis catheter, placement of a circuit in-line hemofilter, or direct connection of continuous RRT in-line with the ECMO circuit. Here we review methods for RRT during ECMO, RRT initiation and timing during ECMO, anticoagulation strategies, and novel cytokine filtration approaches to minimize COVID-19's pathophysiological impact.
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Affiliation(s)
- Sophia H Roberts
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,The Ohio State University College of Medicine, Columbus, OH, USA
| | - Matthew L Goodwin
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Christopher M Bobba
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,The Ohio State University College of Medicine, Columbus, OH, USA
| | - Omar Al-Qudsi
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - S Veena Satyapriya
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ravi S Tripathi
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Thomas J Papadimos
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Anticoagulation in patients with acute kidney injury undergoing kidney replacement therapy. Pediatr Nephrol 2022; 37:2303-2330. [PMID: 34668064 DOI: 10.1007/s00467-021-05020-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/13/2020] [Accepted: 02/18/2021] [Indexed: 10/20/2022]
Abstract
Kidney replacement therapy (KRT) is used to provide supportive therapy for critically ill patients with severe acute kidney injury and various other non-renal indications. Modalities of KRT include continuous KRT (CKRT), intermittent hemodialysis (HD), and sustained low efficiency daily dialysis (SLED). However, circuit clotting is a major complication that has been investigated extensively. Extracorporeal circuit clotting can cause reduction in solute clearances and can cause blood loss, leading to an upsurge in treatment costs and a rise in workload intensity. In this educational review, we discuss the pathophysiology of the clotting cascade within an extracorporeal circuit and the use of various types of anticoagulant methods in various pediatric KRT modalities.
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Double Pump Sequential Constant Citrate Anticoagulation in General Hemodialysis. Appl Bionics Biomech 2022; 2022:6047074. [PMID: 35928576 PMCID: PMC9345715 DOI: 10.1155/2022/6047074] [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: 02/17/2022] [Revised: 04/19/2022] [Accepted: 05/03/2022] [Indexed: 11/17/2022] Open
Abstract
Objective To investigate the safety and efficacy of single-pump and double-pump sequential anticoagulation in general hemodialysis under the condition of constant citrate. Methods A total of 32 patients with end-stage renal disease complicated with hemorrhage admitted by Zigong Third People's Hospital from December 2019 to December 2020 were collected. Randomly divided into single pump group (n = 17) and double pump group (n = 15). The coagulation of dialyzer and intravenous pot was compared between the two groups. Then, the changes of serum calcium before treatment, after 2 h treatment, and after the completion of the treatment, and the front of the blood pump and intravenous pot, as well as behind the intravenous pot were observed and recorded in the two groups. Then, single-pool clearance of urea/volume (spKt/V) was compared between the two groups. Results There were few differences in dialyzer coagulation between the single pump group and double pump group. However, the single pump group had a significant increase in the number of intravenous pot coagulations than the double pump group. At 2 h for dialysis, the serum calcium level behind the intravenous pot in the double pump group was notably lower than that in the single pump group. And after the completion of dialysis, the serum calcium returned to pretreatment level. The Kt/v in both groups reached the normal standard without statistically significant difference. And there were no adverse reactions in the patients of both groups after dialysis. Conclusion For hemodialysis patients with bleeding, dual-pump segmented anticoagulation is superior to single-pump anticoagulation in intravenous pot anticoagulation. Double pump segmented sequential constant citrate anticoagulation can be utilized as a new simple and effective anticoagulation method for clinical hemodialysis.
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A Cohort Study on the Safety and Efficacy of Warfarin and Rivaroxaban in Anticoagulant Therapy in Patients with Atrial Fibrillation Study. BIOMED RESEARCH INTERNATIONAL 2022; 2022:4611383. [PMID: 35845939 PMCID: PMC9283039 DOI: 10.1155/2022/4611383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/22/2022] [Accepted: 05/24/2022] [Indexed: 11/17/2022]
Abstract
Objective. To observe the safety and efficacy of warfarin and rivaroxaban in anticoagulation therapy in patients with atrial fibrillation (AF). Methods. A total of 96 patients with AF treated in our hospital from June 2019 to February 2021 were enrolled in this study. According to the different modes of drug administration, the patients were divided into the warfarin group and rivaroxaban group. Demographic and clinical data such as age, body weight, and previous drug use were collected. The blood routine, liver and kidney function, blood coagulation routine, and cardiac color ultrasound were accessed. The valvular atrial fibrillation and anticoagulant taboos were excluded, and the risk of embolism and bleeding was evaluated. Among them, 48 patients in the warfarin group were given warfarin once a day, and the international ratio (INR) was used to adjust the dose, and the INR was controlled between 2.0 and 3.0. In contrast, 48 patients in the rivaroxaban group received a fixed dose of rivaroxaban 20 mg or 15 mg once a day. After administration, regular telephone or outpatient follow-up was given once a month, to monitor patients’ drug compliance and ask if there was bleeding, and to detect blood routine, urine routine, fecal routine+occult blood, and liver and kidney function. In addition, at the beginning of 3, 6, and 12 months of follow-up, each patient was given cardiac color Doppler ultrasound, peripheral vascular color ultrasound, and brain CT to determine whether there were mural thrombosis, stroke, and peripheral arterial thromboembolism. The INR attainment rate, coagulation index, thromboembolism, bleeding, and adverse reactions were compared between the two groups. Results. There was no significant difference in serum Dmurd and NT-proBNP levels between the two groups before treatment and 3, 6, and 9 months after treatment. There was no significant difference in the number of venous embolism, pulmonary embolism, cerebral embolism, and total embolism between the two groups (
). There was no significant difference in the number of mild, moderate, and severe bleeding between the two groups (
), but the total number of bleeding in the rivaroxaban group was lower than that in the warfarin group (
). During the treatment, side effects such as nausea and vomiting, elevated transaminase, glutamyl transpeptidase, and diarrhea occurred between the two groups, and there was no significant difference in the number of adverse reactions between the two groups (
). Conclusion. Compared with warfarin, rivaroxaban anticoagulant therapy has the same advantage in tolerance and prevention of thromboembolism in patients with AF, but rivaroxaban can effectively reduce the risk of bleeding in patients with AF.
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11
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Anticoagulación en circuitos de terapias continuas de reemplazo renal. ENFERMERÍA INTENSIVA 2022. [DOI: 10.1016/j.enfi.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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12
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Li R, Gao X, Zhou T, Li Y, Wang J, Zhang P. Regional citrate versus heparin anticoagulation for CRRT in critically ill patients: a meta-analysis of RCTS. Ther Apher Dial 2022; 26:1086-1097. [PMID: 35385216 DOI: 10.1111/1744-9987.13850] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/30/2022] [Accepted: 04/02/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION This study aimed to compare the efficacy and safety of citrate and heparin in continuous renal replacement therapy (CRRT) for critically ill patients. METHODS Searched in PubMed, Embase, and Cochrane Library databases. RESULTS Analyses showed that there no difference existed in mortality, metabolic alkalosis, circuit loss, and the number of transfused between the two group(RR=0.95, P=0.40; RR=1.73, P=0.40; RR=0.64, P=0.09; RR=1.05, P=0.70). The filter life of the citrate group was longer than heparin group(MD=16.98, P<0.0001). The risk of bleeding and HIT was significantly lower in the citrate(RR=0.32, P<0.00001; RR=0.55, P=0.04). The citrate group was more susceptible to hypocalcemia(RR=4.85, P=0.0004). CONCLUSION Citrate anticoagulant therapy should have priority for CRRT in most critically ill patients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Rui Li
- Weifang Medical University, Weifang, China
| | - Xiang Gao
- Weifang Medical University, Weifang, China
| | - Tao Zhou
- Department of Critical Care Medicine, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Yunjie Li
- Weifang Medical University, Weifang, China
| | | | - Peirong Zhang
- Department of Critical Care Medicine, Affiliated Hospital of Weifang Medical University, Weifang, China
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13
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Gould DW, Doidge J, Sadique MZ, Borthwick M, Hatch R, Caskey FJ, Forni L, Lawrence RF, MacEwen C, Ostermann M, Mouncey PR, Harrison DA, Rowan KM, Young JD, Watkinson PJ. Heparin versus citrate anticoagulation for continuous renal replacement therapy in intensive care: the RRAM observational study. Health Technol Assess 2022; 26:1-58. [PMID: 35212260 DOI: 10.3310/zxhi9396] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In the UK, 10% of admissions to intensive care units receive continuous renal replacement therapy with regional citrate anticoagulation replacing systemic heparin anticoagulation over the last decade. Regional citrate anticoagulation is now used in > 50% of intensive care units, despite little evidence of safety or effectiveness. AIM The aim of the Renal Replacement Anticoagulant Management study was to evaluate the clinical and health economic impacts of intensive care units moving from systemic heparin anticoagulation to regional citrate anticoagulation for continuous renal replacement therapy. DESIGN This was an observational comparative effectiveness study. SETTING The setting was NHS adult general intensive care units in England and Wales. PARTICIPANTS Participants were adults receiving continuous renal replacement therapy in an intensive care unit participating in the Intensive Care National Audit & Research Centre Case Mix Programme national clinical audit between 1 April 2009 and 31 March 2017. INTERVENTIONS Exposure - continuous renal replacement therapy in an intensive care unit after completion of transition to regional citrate anticoagulation. Comparator - continuous renal replacement therapy in an intensive care unit before starting transition to regional citrate anticoagulation or had not transitioned. OUTCOME MEASURES Primary effectiveness - all-cause mortality at 90 days. Primary economic - incremental net monetary benefit at 1 year. Secondary outcomes - mortality at hospital discharge, 30 days and 1 year; days of renal, cardiovascular and advanced respiratory support in intensive care unit; length of stay in intensive care unit and hospital; bleeding and thromboembolic events; prevalence of end-stage renal disease at 1 year; and estimated lifetime incremental net monetary benefit. DATA SOURCES Individual patient data from the Intensive Care National Audit & Research Centre Case Mix Programme were linked with the UK Renal Registry, Hospital Episode Statistics (for England), Patient Episodes Data for Wales and Civil Registrations (Deaths) data sets, and combined with identified periods of systemic heparin anticoagulation and regional citrate anticoagulation (survey of intensive care units). Staff time and consumables were obtained from micro-costing. Continuous renal replacement therapy system failures were estimated from the Post-Intensive Care Risk-adjusted Alerting and Monitoring data set. EuroQol-3 Dimensions, three-level version, health-related quality of life was obtained from the Intensive Care Outcomes Network study. RESULTS Out of the 188 (94.9%) units that responded to the survey, 182 (96.8%) use continuous renal replacement therapy. After linkage, data were available from 69,001 patients across 181 intensive care units (60,416 during periods of systemic heparin anticoagulation use and 8585 during regional citrate anticoagulation use). The change to regional citrate anticoagulation was not associated with a step change in 90-day mortality (odds ratio 0.98, 95% confidence interval 0.89 to 1.08). Secondary outcomes showed step increases in days of renal support (difference in means 0.53 days, 95% confidence interval 0.28 to 0.79 days), advanced cardiovascular support (difference in means 0.23 days, 95% confidence interval 0.09 to 0.38 days) and advanced respiratory support (difference in means, 0.53 days, 95% CI 0.03 to 1.03 days) with a trend toward fewer bleeding episodes (odds ratio 0.90, 95% confidence interval 0.76 to 1.06) with transition to regional citrate anticoagulation. The micro-costing study indicated that regional citrate anticoagulation was more expensive and was associated with an estimated incremental net monetary loss (step change) of -£2376 (95% confidence interval -£1912 to £911). The estimated likelihood of cost-effectiveness at 1 year was less than 0.1%. LIMITATIONS Lack of patient-level treatment data means that the results represent average effects of changing to regional citrate anticoagulation in intensive care units. Administrative data are subject to variation in data quality over time, which may contribute to observed trends. CONCLUSIONS The introduction of regional citrate anticoagulation has not improved outcomes for patients and is likely to have substantially increased costs. This study demonstrates the feasibility of evaluating effects of changes in practice using routinely collected data. FUTURE WORK (1) Prioritise other changes in clinical practice for evaluation and (2) methodological research to understand potential implications of trends in data quality. TRIAL REGISTRATION This trial is registered as ClinicalTrials.gov NCT03545750. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 13. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Doug W Gould
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - James Doidge
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - M Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Mark Borthwick
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Robert Hatch
- Kadoorie Centre for Critical Care Research and Education, NIHR Biomedical Research Centre, Oxford, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Fergus J Caskey
- UK Renal Registry, Bristol, UK.,Population Health Sciences, University of Bristol, Bristol, UK
| | - Lui Forni
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, Guildford, UK.,Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | | | - Clare MacEwen
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Marlies Ostermann
- Department of Intensive Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - J Duncan Young
- Kadoorie Centre for Critical Care Research and Education, NIHR Biomedical Research Centre, Oxford, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Peter J Watkinson
- Kadoorie Centre for Critical Care Research and Education, NIHR Biomedical Research Centre, Oxford, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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14
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Raina R, Sethi S, Khooblall A, Kher V, Deshpande S, Yerigeri K, Pandya A, Nair N, Datla N, McCulloch M, Bunchman T, Davenport A. Non-anticoagulation pediatric continuous renal replacement therapy methods to increase circuit life. Hemodial Int 2022; 26:147-159. [PMID: 34989465 DOI: 10.1111/hdi.13003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Acute kidney injury (AKI) is a clinical condition characterized by an abrupt increase in serum creatinine levels due to functional changes in the kidneys from a newfound insult or injury. For supportive treatment, continuous renal replacement therapy (CRRT) is one of the most widely used modalities due to its precise control of fluid balance over extended periods of time. However, its complications include circuit clotting, the most frequent cause for CRRT interruption. Vascular access and circuit management were found to be major determinants of performance efficiency. Anticoagulation required to prevent clotting has the downside of increasing the risk of bleeding, especially in the setting of overdosage. Hence, a delicate balance needs to be maintained consistently. METHODS This study explores the adequacy of non-anticoagulation measures in the prevention of circuit clotting. A comprehensive literature search was conducted using PubMed/Medline and Embase databases to include all relevant studies. FINDINGS The most-effective CRRT catheter would be made of nonthrombogenic material, noncuffed and nontunneled with separate lumens for arterial and venous blood. Further, studies show that blood flow during the process is optimized at 200 ml/min, which can be lowered in the pediatric population due to more narrow catheters. Platelet count and hematocrit need to be closely monitored as levels above 450,000 × 106 /L and 0.40, respectively, increase risk of clotting. Predilution is a non-anticoagulation technique to reduce the risk of clotting by returning replacement solution to the blood before it reaches the filter. Also, biocompatible membranes such as polyacrylonitrile or polysulfone activate the coagulation cascade significantly less than the conventional cellulose-based membranes, thereby reducing clotting chances. DISCUSSIONS With the advent of such techniques and maneuvers, anticoagulation can be efficiently maintained in patients undergoing CRRT without increasing the risk of bleeding.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Sidharth Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Amrit Khooblall
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Vijay Kher
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Shweta Deshpande
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Keval Yerigeri
- Department of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Aadi Pandya
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Nikhil Nair
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Nithin Datla
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Mignon McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Timothy Bunchman
- Pediatric Nephrology & Transplantation, Children's Hospital of Richmond at VCU, Richmond, Virginia, USA
| | - Andrew Davenport
- University College London Centre for Nephrology, Division of Medicine, University College London Medical School, Royal Free Hospital, London, UK
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15
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The importance of anticoagulation in COVID-19-related acute kidney injury requiring continuous renal replacement therapy. SRP ARK CELOK LEK 2022. [DOI: 10.2298/sarh200918011k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Introduction/Objective. In Serbia, the pandemic of the coronavirus disease
2019 (COVID-19) began in early March 2020. The aim of this study is to
summarize clinical experience in the treatment of COVID-19-associated acute
kidney injury (AKI) by methods of continuous renal replacement therapy
(CRRT) with the focus on the amount of the administered dose of
unfractionated heparin (UFH). Methods. The study covers 12 patients treated
with CRRT at the Clinic for Infectious Diseases at the Clinical Center of
Vojvodina from March 6, 2020 to May 20, 2020. Antithrombotic prophylaxis,
risk of venous thromboembolism (VTE), applied therapy, biochemical
parameters before and after CRRT, anticoagulation and other CRRT parameters
were analyzed. Results. The mean age of the patients was 61.54 ? 10.37
years and seven (58.3%) were men. All the patients received standard
thromboprophylaxis. Nine (75%) patients had Padua Prediction Score for Risk
of VTE ? 4, but none developed a thrombotic event. Seven critically ill
patients with multi-organic dysfunction developed AKI dependent on CRRT. The
mean CRRT dose was 36.6 ml/kg/h, the mean bolus dose of unfractionated
heparin was 3250 ? 1138.18IU, and the continuous dose was 1112.5 ?
334.48IU/kg/h. Discontinuation of CRRT due to the clotting circuit was
necessary in only one patient. The values of leukocytes, AST, ALT, GGT,
aPTT, PT were significantly higher after CRRT compared to urea, creatinine,
potassium, chlorine and magnesium, whose values were significantly lower.
Conclusion. In our COVID-19 patients who had high inflammatory parameters
and D-dimer and an estimated risk of developing DVT, the implementation
pre-dilution CVVHDF with antithrombotic membrane and 1/3 to 1/2 higher UFH
doses than the recommended one, the filter life lasted longer with no
complications.
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16
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Radu RI, Ben Gal T, Abdelhamid M, Antohi E, Adamo M, Ambrosy AP, Geavlete O, Lopatin Y, Lyon A, Miro O, Metra M, Parissis J, Collins SP, Anker SD, Chioncel O. Antithrombotic and anticoagulation therapies in cardiogenic shock: a critical review of the published literature. ESC Heart Fail 2021; 8:4717-4736. [PMID: 34664409 PMCID: PMC8712803 DOI: 10.1002/ehf2.13643] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/08/2021] [Accepted: 09/19/2021] [Indexed: 01/09/2023] Open
Abstract
Cardiogenic shock (CS) is a complex multifactorial clinical syndrome, developing as a continuum, and progressing from the initial insult (underlying cause) to the subsequent occurrence of organ failure and death. There is a large phenotypic variability in CS, as a result of the diverse aetiologies, pathogenetic mechanisms, haemodynamics, and stages of severity. Although early revascularization remains the most important intervention for CS in settings of acute myocardial infarction, the administration of timely and effective antithrombotic therapy is critical to improving outcomes in these patients. In addition, other clinical settings or non-acute myocardial infarction aetiologies, associated with high thrombotic risk, may require specific regimens of short-term or long-term antithrombotic therapy. In CS, altered tissue perfusion, inflammation, and multi-organ dysfunction induce unpredictable alterations to antithrombotic drugs' pharmacokinetics and pharmacodynamics. Other interventions used in the management of CS, such as mechanical circulatory support, renal replacement therapies, or targeted temperature management, influence both thrombotic and bleeding risks and may require specific antithrombotic strategies. In order to optimize safety and efficacy of these therapies in CS, antithrombotic management should be more adapted to CS clinical scenario or specific device, with individualized antithrombotic regimens in terms of type of treatment, dose, and duration. In addition, patients with CS require a close and appropriate monitoring of antithrombotic therapies to safely balance the increased risk of bleeding and thrombosis.
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Affiliation(s)
- Razvan I. Radu
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
| | - Tuvia Ben Gal
- Department of Cardiology, Rabin Medical Center (Beilinson Campus), Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
| | - Magdy Abdelhamid
- Cardiology Department, Kasr Alainy School of MedicineCairo UniversityCairoEgypt
| | - Elena‐Laura Antohi
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
- University for Medicine and Pharmacy ‘Carol Davila’ BucharestBucharestRomania
| | - Marianna Adamo
- Cardiothoracic Department, Civil Hospitals and Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Andrew P. Ambrosy
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
- Division of Research, Kaiser Permanente Northern CaliforniaOaklandCAUSA
| | - Oliviana Geavlete
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
- University for Medicine and Pharmacy ‘Carol Davila’ BucharestBucharestRomania
| | - Yuri Lopatin
- Cardiology CentreVolgograd Medical UniversityVolgogradRussian Federation
| | - Alexander Lyon
- Cardio‐Oncology ServiceRoyal Brompton Hospital and Imperial College LondonLondonUK
| | - Oscar Miro
- Emergency Department, Hospital Clínic de BarcelonaUniversity of BarcelonaBarcelonaSpain
| | - Marco Metra
- Cardiology, Cardiothoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - John Parissis
- Second Department of Cardiology, Attikon University HospitalNational and Kapodistrian University of AthensAthensGreece
| | - Sean P. Collins
- Department of Emergency Medicine; Vanderbilt University Medical CentreNashvilleTNUSA
| | - Stefan D. Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site BerlinCharité—Universitätsmedizin BerlinBerlinGermany
| | - Ovidiu Chioncel
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
- University for Medicine and Pharmacy ‘Carol Davila’ BucharestBucharestRomania
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17
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Zhang W, Bai M, Zhang L, Yu Y, Li Y, Zhao L, Yue Y, Li Y, Zhang M, Fu P, Sun S, Chen X. Development and External Validation of a Model for Predicting Sufficient Filter Lifespan in Anticoagulation-Free Continuous Renal Replacement Therapy Patients. Blood Purif 2021; 51:668-678. [PMID: 34673634 PMCID: PMC9501746 DOI: 10.1159/000519409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/18/2021] [Indexed: 02/05/2023]
Abstract
Background Anticoagulation-free continuous renal replacement therapy (CRRT) was recommended by the current clinical guideline for patients with increased bleeding risk and contraindications of citrate. Nevertheless, anticoagulation-free CRRT yielded heterogeneous filter lifespan. Furthermore, the specific cutoff values for traditional coagulation parameters to predict sufficient filter lifespan of anticoagulation-free CRRT have not yet been determined. The purpose of our present study was to develop and validate a model for predicting sufficient filter lifespan in anticoagulation-free CRRT patients. Methods Patients who underwent anticoagulation-free CRRT in our center between June 2013 and June 2019 were retrospectively included. The primary outcome was sufficient filter lifespan (≥24 h). Thirty-seven predictors were included for modeling based on their clinical significance and previous reports. The final model was developed by using multivariable logistic regression analysis and was validated in a separate external cohort. Results The development cohort included 170 patients. Sufficient filter lifespan was observed in 80 patients. Thirteen variables were independent predictors for sufficient filter lifespan by logistic regression: body temperature, mean arterial pressure, activated partial thromboplastin time, direct bilirubin, alkaline phosphatase, blood urea nitrogen, vasopressor use, body mass index, white blood cell, platelet count, D-dimer, uric acid, and pH. The area under the curve (AUC) of the stepwise model and internal validation model was 0.82 (95% confidence interval [CI] [0.76–0.88]) and 0.8 (95% CI [0.74–0.87]), respectively. The positive predictive value and the negative predictive value of the stepwise model were 0.77 and 0.79, respectively. The validation cohort included 44 eligible patients and the AUC of the external validation model was 0.82 (95% CI [0.69–0.96]). Conclusions The use of a prediction model instead of an assessment based only on coagulation parameters could facilitate the identification of the patients with filter lifespan of ≥24 h when they accepted anticoagulation-free CRRT.
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Affiliation(s)
- Wei Zhang
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China.,Nephrology Institute of the Chinese People's Liberation Army, Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Ling Zhang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Yu
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Yangping Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Lijuan Zhao
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Yuan Yue
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Yajuan Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Min Zhang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Ping Fu
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Xiangmei Chen
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China.,Nephrology Institute of the Chinese People's Liberation Army, Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
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18
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Zang S, Chen Q, Zhang Y, Xu L, Chen J. Comparison of the Clinical Effectiveness of AN69-oXiris versus AN69-ST Filter in Septic Patients: A Single-Centre Study. Blood Purif 2021; 51:617-629. [PMID: 34610595 DOI: 10.1159/000519166] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 08/22/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The clinical effectiveness of AN69-oXiris remains unclear. This study aimed to compare the effects of AN69-oXiris and AN69-ST filters on cytokine levels and clinical improvement in septic patients. METHODS This prospective observational study recruited septic patients who underwent blood purification in the First Affiliated Hospital of Soochow University between December 2019 and May 2020. Patients were assigned to an AN69-oXiris (oXiris) or AN69-ST (ST) group based on their preferred filter. Patients' clinical data, cytokine levels, and prognostic indicators were analysed at baseline (T0), 24 h after treatment (T1), and at the end of the treatment (T2). RESULTS Forty-four patients participated in this study (22 patients in each group). Participants in both groups showed improvements in mean arterial pressure (MAP) values, oxygenation indices, and urinary output, and decreased vasoactive-inotropic scores (VISs), heart rates, lactic acid levels, and serum creatinine levels after blood purification. Reductions in cytokine levels were observed at T1 in both groups. Improvement the haemodynamic status was higher in the oXiris group than in the ST group at T2 (MAP: 79.0 [76.0, 85.0] vs. 77.0 [72.75, 79.25] mm Hg, p = 0.04; VISs: 9.10 [0.00, 16.69] vs. 19.05 [10.60, 26.33], p = 0.03, respectively). Patients in the oXiris group also had lower cytokine levels than those in the ST group at T1 (tumour necrosis factor-α: 24.55 [16.9, 30.15] vs. 30.15 [23.38, 34.13] pg/mL, p = 0.04; interleukin (IL)-6: 66.63 [46.21, 102.20] vs. 125.48 [79.73, 167.97] pg/mL, p = 0.01; IL-8: 53.59 [35.10, 66.01] vs. 63.60 [45.58, 83.37] pg/mL, p = 0.04; IL-10: 13.50 [10.35, 18.68] vs. 17.15 [13.80, 21.95] pg/mL, p = 0.04, respectively). There were no significant differences between the 2 groups regarding hospital mortality, intensive care unit length of stay (LOS), and hospital LOS. CONCLUSION Blood purification using the AN69-oXiris or AN69-ST filter proved useful for septic patients, which was associated with reduced cytokine levels and improved clinical condition. Patients treated with AN69-oXiris had a more remarkable improvement in haemodynamic status and lower cytokine levels than those treated with AN69-ST filter, but there were no differences in clinical outcomes. Further investigations are needed to prove this finding.
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Affiliation(s)
- Shouhua Zang
- Department of Surgical Intensive Care Unit of Anesthesiology, First Hospital Affiliated to Soochow University, Suzhou, China,
| | - Qing Chen
- Department of Surgical Intensive Care Unit of Anesthesiology, First Hospital Affiliated to Soochow University, Suzhou, China
| | - Yukun Zhang
- Department of Surgical Intensive Care Unit of Anesthesiology, First Hospital Affiliated to Soochow University, Suzhou, China
| | - Li Xu
- Department of Surgical Intensive Care Unit of Anesthesiology, First Hospital Affiliated to Soochow University, Suzhou, China
| | - Jun Chen
- Department of Surgical Intensive Care Unit of Anesthesiology, First Hospital Affiliated to Soochow University, Suzhou, China
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Valle EDO, Cabrera CPS, Albuquerque CCCD, Silva GVD, Oliveira MFAD, Sales GTM, Smolentzov I, Reichert BV, Andrade L, Seabra VF, Lins PRG, Rodrigues CE. Continuous renal replacement therapy in COVID-19-associated AKI: adding heparin to citrate to extend filter life-a retrospective cohort study. Crit Care 2021; 25:299. [PMID: 34412667 PMCID: PMC8375288 DOI: 10.1186/s13054-021-03729-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 08/12/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) may predispose patients to thrombotic events. The best anticoagulation strategy for continuous renal replacement therapy (CRRT) in such patients is still under debate. The purpose of this study was to evaluate the impact that different anticoagulation protocols have on filter clotting risk. METHODS This was a retrospective observational study comparing two different anticoagulation strategies (citrate only and citrate plus intravenous infusion of unfractionated heparin) in patients with acute kidney injury (AKI), associated or not with COVID-19 (COV + AKI and COV - AKI, respectively), who were submitted to CRRT. Filter clotting risks were compared among groups. RESULTS Between January 2019 and July 2020, 238 patients were evaluated: 188 in the COV + AKI group and 50 in the COV - AKI group. Filter clotting during the first filter use occurred in 111 patients (46.6%). Heparin use conferred protection against filter clotting (HR = 0.37, 95% CI 0.25-0.55), resulting in longer filter survival. Bleeding events and the need for blood transfusion were similar between the citrate only and citrate plus unfractionated heparin strategies. In-hospital mortality was higher among the COV + AKI patients than among the COV - AKI patients, although it was similar between the COV + AKI patients who received heparin and those who did not. Filter clotting was more common in patients with D-dimer levels above the median (5990 ng/ml). In the multivariate analysis, heparin was associated with a lower risk of filter clotting (HR = 0.28, 95% CI 0.18-0.43), whereas an elevated D-dimer level and high hemoglobin were found to be risk factors for circuit clotting. A diagnosis of COVID-19 was marginally associated with an increased risk of circuit clotting (HR = 2.15, 95% CI 0.99-4.68). CONCLUSIONS In COV + AKI patients, adding systemic heparin to standard regional citrate anticoagulation may prolong CRRT filter patency by reducing clotting risk with a low risk of complications.
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Affiliation(s)
- Eduardo de Oliveira Valle
- Hospital das Clínicas, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455, 3º andar, sala 3310, São Paulo, SP, CEP 01246-903, Brazil
| | - Carla Paulina Sandoval Cabrera
- Hospital das Clínicas, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455, 3º andar, sala 3310, São Paulo, SP, CEP 01246-903, Brazil
| | - Claudia Coimbra César de Albuquerque
- Hospital das Clínicas, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455, 3º andar, sala 3310, São Paulo, SP, CEP 01246-903, Brazil
| | - Giovanio Vieira da Silva
- Hospital das Clínicas, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455, 3º andar, sala 3310, São Paulo, SP, CEP 01246-903, Brazil
| | - Márcia Fernanda Arantes de Oliveira
- Hospital das Clínicas, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455, 3º andar, sala 3310, São Paulo, SP, CEP 01246-903, Brazil
| | - Gabriel Teixeira Montezuma Sales
- Hospital das Clínicas, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455, 3º andar, sala 3310, São Paulo, SP, CEP 01246-903, Brazil
| | - Igor Smolentzov
- Hospital das Clínicas, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455, 3º andar, sala 3310, São Paulo, SP, CEP 01246-903, Brazil
| | - Bernardo Vergara Reichert
- Hospital das Clínicas, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455, 3º andar, sala 3310, São Paulo, SP, CEP 01246-903, Brazil
| | - Lucia Andrade
- Hospital das Clínicas, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455, 3º andar, sala 3310, São Paulo, SP, CEP 01246-903, Brazil
| | - Victor Faria Seabra
- Hospital das Clínicas, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455, 3º andar, sala 3310, São Paulo, SP, CEP 01246-903, Brazil
| | - Paulo Ricardo Gessolo Lins
- Hospital das Clínicas, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455, 3º andar, sala 3310, São Paulo, SP, CEP 01246-903, Brazil
| | - Camila Eleuterio Rodrigues
- Hospital das Clínicas, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455, 3º andar, sala 3310, São Paulo, SP, CEP 01246-903, Brazil.
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20
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Influence of recombinant human-soluble thrombomodulin on extracorporeal circuit clotting in septic patients undergoing blood purification: a propensity-matched cohort study. J Artif Organs 2021; 24:485-491. [PMID: 33856580 DOI: 10.1007/s10047-021-01268-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
Blood purification has been widely performed for critically ill patients, even in cases without renal failure. Effective anticoagulation of the extracorporeal circuit is necessary to prevent circuit clotting. We hypothesized that administration of recombinant human-soluble thrombomodulin (rhsTM) to septic patients undergoing blood purification may prevent circuit clotting, because this agent regulates coagulation. We performed a retrospective, single-center, propensity-matched cohort study in the intensive care unit of Nishichita General Hospital. We included septic patients admitted to the intensive care unit from May 2015 to August 2020 who underwent blood purification. Patients who received rhsTM during intensive care unit admission to the end of the first blood purification (rhsTM group) were matched 1:1 with other patients (control group). The primary outcome was the occurrence of circuit clotting during the first blood purification. A total of 138 patients were included in the study [43 patients (31%) in the rhsTM group and 95 patients (69%) in the control group]. After propensity score matching, 42 pairs of patients were selected, and patients in the rhsTM group had a lower incidence of circuit clotting (21 vs. 55%, P = 0.003). One case of major bleeding occurred in the rhsTM group, but there was no difference in the incidence of major bleeding between groups (2 vs. 0%, P = 1.0). In conclusion, this propensity-matched cohort study indicated that the administration of rhsTM to septic patients undergoing blood purification may prevent extracorporeal circuit clotting.
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21
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Raina R, Agrawal N, Kusumi K, Pandey A, Tibrewal A, Botsch A. A Meta-Analysis of Extracorporeal Anticoagulants in Pediatric Continuous Kidney Replacement Therapy. J Intensive Care Med 2021; 37:577-594. [PMID: 33688766 DOI: 10.1177/0885066621992751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Continuous kidney replacement therapy (CKRT) is the primary therapeutic modality utilized in hemodynamically unstable patients with severe acute kidney injury. As the circuit is extracorporeal, it poses an increased risk of blood clotting and circuit loss; frequent circuit losses affect the provider's ability to provide optimal treatment. The objective of this meta-analysis is to evaluate the safety and efficacy of the extracorporeal anticoagulants in the pediatric CKRT population. DATA SOURCES We conducted a literature search on PubMed/Medline and Embase for relevant citations. STUDY SELECTION Studies were included if they involved patients under the age of 18 years undergoing CKRT, with the use of anticoagulation (heparin, citrate, or prostacyclin) as a part of therapy. Only English articles were included in the study. DATA EXTRACTION Initial search yielded 58 articles and a total of 24 articles were included and reviewed. A meta-analysis was performed focusing on the safety and effectiveness of regional citrate anticoagulation (RCA) vs unfractionated heparin (UFH) anticoagulants in children. DATA SYNTHESIS RCA had statistically significantly longer circuit life of 50.65 hours vs. UFH of 42.10 hours. Two major adverse effects metabolic alkalosis and electrolyte imbalance seen more commonly in RCA compared to UFH. There was not a significant difference in the risk of systemic bleeding when comparing RCA vs. UFH. CONCLUSION RCA is the preferred anticoagulant over UFH due to its significantly longer circuit life, although vigilant circuit monitoring is required due to the increased risk of electrolyte disturbances. Prostacyclin was not included in the meta-analysis due to the lack of data in pediatric patients. Additional studies are needed to strengthen the study results further.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Nirav Agrawal
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.,Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Kirsten Kusumi
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Avisha Pandey
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Abhishek Tibrewal
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Alexander Botsch
- Division of Critical Care Medicine, Summa Health, Akron, OH, USA
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22
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Anstey CM, Russell FD. Measurement of the Concentration of Citrate in Human Biofluids in Patients Undergoing Continuous Renal Replacement Therapy Using Regional Citrate Anticoagulation: Application of a Two-Step Enzymatic Assay. Blood Purif 2021; 50:848-856. [PMID: 33550280 DOI: 10.1159/000513150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 11/17/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) is now commonly used to treat acute kidney injury in critically ill patients. The concentration of citrate is not routinely measured, with citrate accumulation and/or toxicity primarily assessed using surrogate measures. OBJECTIVES The aim of this study was to measure the concentration of citrate in plasma and ultrafiltrate in patients receiving CRRT with RCA using a modified commercial enzymatic assay. METHODS After meeting inclusion criteria, blood was sampled from 20 patients before, during, and after episodes of filtration. Using spectrophotometry, samples were tested for citrate concentration. Demographic and other clinical and biochemical data were also collected. Throughout, a 15 mmol/L solution of trisodium citrate was used as the prefilter anticoagulant. Results were analysed using STATA (v15.0) and presented as mean (SD), median (IQR), or simple proportion. Comparisons were made using either the Student t test or the Wilcoxon rank-sum test. Correlation was assessed using Pearson's r. RESULTS Twenty patients (17 males) were enrolled in the study. Mean (SD) age was 63.7 years (9.9). Median (IQR) ICU length of stay was 281 h (199, 422) with 85% undergoing intermittent positive pressure ventilation. Median APACHE 3 score was 95 (87, 117) with an overall 30% mortality rate. Median filtration time was 85 h (46, 149). No difference was found between pre- and post-filtration plasma citrate concentrations (79 µmol/L [50] vs. 71 µmol/L [42], p = 0.65). Mean citrate concentration during filtration was 508 µmol/L (221) with a maximum of 1,070 µmol/L. This was significantly higher than the pre/post levels (p < 0.001). CONCLUSIONS Plasma concentrations of citrate rose significantly during episodes of CRRT using RCA returning back to normal after cessation of treatment.
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Affiliation(s)
- Chris M Anstey
- School of Medicine, Sunshine Coast Campus, Griffith University, Birtinya, Queensland, Australia,
| | - Fraser D Russell
- Genecology Research Centre, School of Health and Sport Sciences, University of the Sunshine Coast, Maroochydore, Queensland, Australia
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23
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Precision renal replacement therapy. Curr Opin Crit Care 2021; 26:574-580. [PMID: 33002973 DOI: 10.1097/mcc.0000000000000776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This article reviews the current evidence supporting the use of precision medicine in the delivery of acute renal replacement therapy (RRT) to critically ill patients, focusing on timing, solute control, anticoagulation and technologic innovation. RECENT FINDINGS Precision medicine is most applicable to the timing of RRT in critically ill patients. As recent randomized controlled trials have failed to provide consensus on when to initiate acute RRT, the decision to start acute RRT should be based on individual patient clinical characteristics (e.g. severity of the disease, evolution of clinical parameters) and logistic considerations (e.g. organizational issues, availability of machines and disposables). The delivery of a dynamic dialytic dose is another application of precision medicine, as patients may require different and varying dialysis doses depending on individual patient factors and clinical course. Although regional citrate anticoagulation (RCA) is recommended as first-line anticoagulation for continuous RRT, modifications to RCA protocols and consideration of other anticoagulants should be individualized to the patient's clinical condition. Finally, the evolution of RRT technology has improved precision in dialysis delivery through increased machine accuracy, connectivity to the electronic medical record and automated reduction of downtime. SUMMARY RRT has become a complex treatment for critically ill patients, which allows for the prescription to be precisely tailored to the different clinical requirements.
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24
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Yuan F, Li Z, Li X, Liu H. Application of regional citrate anticoagulation in membrane therapeutic plasma exchange. Int Urol Nephrol 2020; 52:2379-2384. [PMID: 32740788 DOI: 10.1007/s11255-020-02581-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/25/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Both regional citrate anticoagulation (RCA) and heparin are used as anticoagulants during membrane therapeutic plasma exchange (mTPE). However, there are few reports of comparisons of the two methods. The aim of this study was to compare different anticoagulants in mTPE and observe the effectiveness, safety, and advantages of RCA. METHODS We retrospectively included 85 patients who underwent mTPE in the past 1 year, and divided them into three groups. Patients with no bleeding tendency were administered heparin anticoagulation; patients with bleeding tendency/with liver dysfunction/who had undergone an operation were treated with RCA, or did not receive anticoagulation. In the heparin group, low-dose heparin anticoagulation was administered; in the RCA group, 4% sodium citrate solution was administered, and 10% calcium gluconate solution was pumped from the venous circuit tube. The peripheral blood platelet count, prothrombin time (PT), activated partial thromboplastin time (APTT), and electrolytes were detected before and after treatment in all patients. RESULTS A total of 255 sessions of mTPE were performed in 85 patients (2-7 times/case) with 120 sessions of heparin anticoagulation, 93 sessions of RCA, and 42 sessions of no anticoagulation. Compared with pretreatment values, the platelet count decreased by 53.7% and the PT and APTT increased (p < 0.05) in the heparin group after treatment. There were no differences in platelet count and PT before and after treatment in the RCA group. In the RCA group, the patients did not experience hypocalcemia or hypercalcemia, and no separator clotting occurred. CONCLUSION RCA is safe, feasible, and effective in mTPE, especially for patients with bleeding tendency and frequent monitoring is needed. It is worth widely developing and applying it in clinical practice.
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Affiliation(s)
- Fang Yuan
- Department of Nephrology, ESRD Center of the Second Xiangya Hospital, Central South University, Changsha, 410011, China
| | - Zheng Li
- Department of Nephrology, ESRD Center of the Second Xiangya Hospital, Central South University, Changsha, 410011, China
| | - Xiejia Li
- Department of Nephrology, ESRD Center of the Second Xiangya Hospital, Central South University, Changsha, 410011, China
| | - Hong Liu
- Department of Nephrology, ESRD Center of the Second Xiangya Hospital, Central South University, Changsha, 410011, China.
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25
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Anton FI, Rus PA, Hagau N. Monitoring Anticoagulation with Unfractionated Heparin on Renal Replacement Therapy. Which is the Best aPTT Sampling Site? J Crit Care Med (Targu Mures) 2020; 6:159-166. [PMID: 32864461 PMCID: PMC7430360 DOI: 10.2478/jccm-2020-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 06/26/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Controlled anticoagulation is key to maintaining continuous blood filtration therapies. Objective: The study aimed to compare different blood sampling sites for activated partial thromboplastin time (aPTT) to evaluate anticoagulation with unfractionated heparin (UFH) in continuous renal replacement therapy (CRRT) and identify the most appropriate sampling site for safe patient anticoagulation and increased filter life span. METHOD The study was a prospective observational single-centre investigation targeting intensive care unit (ICU) patients on CRRT using an anticoagulation protocol based on patient characteristics and a weight-based modified nomogram. Eighty-four patients were included in the study. Four sampling sites were assessed: heparin free central venous nondialysis catheter (CVC), an arterial line with heparinised flush (Artery), a circuit access line (Access), and a circuit return line (Postfilter). Blood was sampled from each of four different sites on every patient, four hours after the first heparin bolus. aPTT was determined using a rapid clot detector, point of care device. RESULTS A high positive correlation was obtained for aPTT values between CVC and Access sampling sites (r (84) =0.72; p <0 .05) and a low positive correlation between CVC and Arterial sampling site (r (84) =0.46, p < 0.05). When correlated by artery age, the young Artery (1-3 day old) correlates with CVC, Access and Postfilter (r (45) = 0.74, p >0.05). The aPTT values were significantly higher at Postfilter and Arterial sampling site, older than three days, compared to the CVC sampling site (p<0.05). CONCLUSION Considering patient bleeding risks and filter life span, the optimal sampling sites for safe assessment of unfractionated heparin anticoagulation on CRRT during CVVHDF were the central venous catheter using heparin free lavage saline solution, a heparinised flushed arterial catheter not older than three days, and a circuit access line.
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Affiliation(s)
| | - Paul Adrian Rus
- Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Emergency Clinical County Hospital, Cluj-Napoca, Romania
| | - Natalia Hagau
- Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Regina Maria Hospital, Cluj-Napoca, Romania
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26
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Schaubroeck HA, Gevaert S, Bagshaw SM, Kellum JA, Hoste EA. Acute cardiorenal syndrome in acute heart failure: focus on renal replacement therapy. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:802-811. [PMID: 32597679 DOI: 10.1177/2048872620936371] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Almost half of hospitalised patients with acute heart failure develop acute cardiorenal syndrome. Treatment consists of optimisation of fluid status and haemodynamics, targeted therapy for the underlying cardiac disease, optimisation of heart failure treatment and preventive measures such as avoidance of nephrotoxic agents. Renal replacement therapy may be temporarily needed to support kidney function, mostly in case of diuretic resistant fluid overload or severe metabolic derangement. The best timing to initiate renal replacement therapy and the best modality in acute heart failure are still under debate. Several modalities are available such as intermittent and continuous renal replacement therapy as well as hybrid techniques, based on two main principles: haemofiltration and haemodialysis. Although continuous techniques have been associated with less haemodynamic instability and a greater chance of renal recovery, cohort data are conflicting and randomised controlled trials have not shown a difference in recovery or mortality. In the presence of diuretic resistance, isolated ultrafiltration with individualisation of ultrafiltration rates is a valid option for decongestion in acute heart failure patients. Practical tools to optimise the use of renal replacement therapy in acute heart failure-related acute cardiorenal syndrome were discussed.
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Affiliation(s)
| | - Sofie Gevaert
- Department of Cardiology, Ghent University Hospital, Belgium
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta, Canada
| | - John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh, USA
| | - Eric Aj Hoste
- Intensive Care Unit, Ghent University Hospital, Belgium.,Research Foundation-Flanders (FWO), Brussels, Belgium
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27
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Dimski T, Brandenburger T, MacKenzie C, Kindgen-Milles D. Elimination of glycopeptide antibiotics by cytokine hemoadsorption in patients with septic shock: A study of three cases. Int J Artif Organs 2020; 43:753-757. [DOI: 10.1177/0391398820917151] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Sepsis and septic shock are characterized by a release of cytokines into the circulation. These mediators contribute to the detrimental hemodynamic and metabolic effects in the early phase of septic shock. Recently, a new polystyrene-based hemoadsorption device was introduced into clinical practice (CytoSorb®). The adsorber binds a variety of molecules including cytokines and removes them from the circulation. Studies in septic patients have shown an improved clinical course following hemoadsorption but no increased survival. We hypothesize that not only cytokines but also antibiotics may be removed which potentially may negate any beneficial effect of the adsorber. To test this hypothesis, we performed polystyrene-based hemoadsorption in three patients in septic shock and analysed glycopeptide elimination by measuring serum levels pre- and post-adsorber. We administered both teicoplanin and vancomycin via a 60-min infusion and vancomycin via continuous infusion, additionally. When applied as 60 min infusion, vancomycin and teicoplanin were removed immediately by the adsorber. However, the adsorptive capacity of the device was saturable. Serum levels of vancomycin, but not teicoplanin, decreased to subtherapeutic levels. With continuous infusion of vancomycin, removal was less and serum levels remained in the therapeutic range. In conclusion, we show effective glycopeptide adsorption using a polystyrene-based hemoadsorber in septic patients. The dose of these antibiotics should be adjusted appropriately and early therapeutic drug monitoring is highly recommended.
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Affiliation(s)
- Thomas Dimski
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Timo Brandenburger
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Colin MacKenzie
- Institute of Medical Microbiology and Hospital Hygiene, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Detlef Kindgen-Milles
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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28
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Therapeutic Anticoagulation with Argatroban and Heparins Reduces Granulocyte Migration: Possible Impact on ECLS-Therapy? Cardiovasc Ther 2020; 2020:9783630. [PMID: 32405324 PMCID: PMC7196999 DOI: 10.1155/2020/9783630] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/09/2020] [Indexed: 02/06/2023] Open
Abstract
Introduction Anticoagulants such as argatroban and heparins (low-molecular-weight and unfractionated) play an immense role in preventing thromboembolic complications in clinical practice. Nevertheless, they can also have a negative effect on the immune system. This study is aimed at investigating the influence of these substances on polymorphonuclear neutrophils (PMNs), whose nonspecific defense mechanisms can promote thrombogenesis. Methods Blood samples from 30 healthy volunteers were investigated, whereby PMNs were isolated by density gradient centrifugation and incubated with 0.8 μg/mL of argatroban, 1.0 U/mL of low-molecular-weight heparin (LMWH), 1.0 U/mL of unfractionated heparin (UFH), or without drug (control). A collagen-cell mixture was prepared and filled into 3D μ-slide chemotaxis chambers (IBIDI® GmbH, Germany). Stimulation was initiated by using a chemokine gradient of n-formyl-methionine-leucyl-phenylalanine (fMLP), and microscopic observation was conducted for 4.5 hours. The cells' track length and track straightness, as well as the number of attracted granulocytes, level of ROS (reactive oxygen species) production, and NET (neutrophil extracellular traps) formation, were analyzed and categorized into migration distances and time periods. Results All three anticoagulants led to significantly reduced PMN track lengths, with UFH having the biggest impact. The number of tracks observed in the UFH group were significantly reduced compared to the control group. Additionally, the UFH group demonstrated a significantly lower track straightness compared to the control. ROS production and NET formation were unaffected. Conclusion Our data provide evidence that anticoagulants have an inhibitory effect on the extent of PMN migration and chemotactic migration efficiency, thus indicating their potential immune-modulatory and prothrombotic effects.
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29
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Gould DW, Doidge J, Zia Sadique M, Borthwick M, Caskey FJ, Forni L, Lawrence RF, MacEwen C, Mouncey PR, Ostermann M, Harrison DA, Rowan KM, Duncan Young J, Watkinson PJ. Renal replacement anticoagulant management: Protocol and analysis plan for an observational comparative effectiveness study of linked data sources. J Intensive Care Soc 2020; 23:311-317. [DOI: 10.1177/1751143720913417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Acute kidney injury is common in critical illness. In patients with severe acute kidney injury, renal replacement therapy is needed to prevent harm from metabolic and electrolyte disturbances and fluid overload. In the UK, continuous renal replacement therapy (CRRT) is the preferred modality, which requires anticoagulation. Over the last decade, conventional systemic heparin anticoagulation has started being replaced by regional citrate anticoagulation for CRRT, which is now used in approximately 50% of ICUs. This shift towards regional citrate anticoagulation for CRRT is occurring with little evidence of safety or longer term effectiveness. Renal replacement anticoagulant management (RRAM) is an observational comparative effectiveness study, utilising existing data sources to address the clinical and cost-effectiveness of the change to regional citrate anticoagulation for CRRT in UK ICUs. The study will use data from approximately 85,000 patients who were treated in adult, general ICUs participating in the case mix programme national clinical audit between 1 April 2009 and 31 March 2017. A survey of health service providers’ anticoagulation practices will be combined with treatment and hospital outcome data from the case mix programme and linked with long-term outcomes from the Civil Registrations (deaths), Hospital Episodes Statistics for England, Patient Episodes Data for Wales, and the UK Renal Registry datasets. The primary clinical effectiveness outcome is all-cause mortality at 90-days. The study will incorporate an economic evaluation with micro-costing of both regional citrate anticoagulation and systemic heparin anticoagulation. Study registration: NCT03545750
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Affiliation(s)
- Doug W Gould
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - James Doidge
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - M Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Mark Borthwick
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, England, UK
| | - Fergus J Caskey
- United Kingdom Renal Registry, Bristol, UK and Population Health Sciences, University of Bristol, Bristol, UK
| | - Lui Forni
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, UK
- Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | | | - Clare MacEwen
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, England, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Marlies Ostermann
- Department of Intensive Care, Guy's and St Thomas' Hospital, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - J Duncan Young
- Kadoorie Centre for Critical Care Research and Education, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Peter J Watkinson
- Kadoorie Centre for Critical Care Research and Education, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Aygun F. Evaluation of continuous renal replacement therapy and risk factors in the pediatric intensive care unit. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2020; 31:53-61. [DOI: 10.4103/1319-2442.279961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
PURPOSE OF REVIEW The delivery of an effective dialysis dose in continuous renal replacement therapy (CRRT) depends on adequate anticoagulation of the extracorporeal circuit. In most patients, either systemic heparin anticoagulation (SHA) or regional citrate anticoagulation (RCA) is used. This review will outline the basics and rationale of RCA and summarize data on safety and efficacy of both techniques. RECENT FINDINGS The basic principle of RCA is to reduce the level of ionized calcium in the extracorporeal circuit via infusion of citrate. This way, effective anticoagulation restricted to the extracorporeal circuit is achieved. SHA and RCA were compared in a variety of studies. RCA significantly prolonged filter lifetime, reduced bleeding complications and provided excellent control of uremia and acid-base status. RCA was also safe in the majority of patients with impaired liver function, whereas caution must be exerted in those with severe multiorgan failure and persistent hyperlactatemia. SUMMARY RCA per se is safe and effective for anticoagulation of CRRT. Compared to SHA, efficacy of anticoagulation is improved and adverse effects are reduced. RCA can be recommended as the anticoagulation mode of choice for CRRT in most ICU patients.
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Dimski T, Brandenburger T, Slowinski T, Kindgen-Milles D. Feasibility and safety of combined cytokine adsorption and continuous veno-venous hemodialysis with regional citrate anticoagulation in patients with septic shock. Int J Artif Organs 2019; 43:10-16. [PMID: 31379256 DOI: 10.1177/0391398819866459] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Septic shock is characterized by severe metabolic and hemodynamic alterations. It is often accompanied by acute kidney injury. A new adjunct treatment is hemoadsorption using a cytokine adsorber in line with continuous veno-venous renal replacement therapy. We studied the feasibility, efficacy, and safety of cytokine adsorption with citrate-anticoagulated continuous veno-venous hemodialysis (regional citrate anticoagulation-continuous veno-venous hemodialysis). METHODS In 11 patients with septic shock and acute kidney injury stage 3, we studied 12 cycles of cytokine adsorption and regional citrate anticoagulation-continuous veno-venous hemodialysis. We monitored parameters of citrate anticoagulation, circuit lifetime, laboratory parameters, hemodynamics, and vasopressor demand. RESULTS Ten out of 12 adsorber/continuous veno-venous hemodialysis circuits reached the target lifetime of 24 h for the adsorber. One system clotted and one was stopped for non-device-related reasons. Nine of the remaining continuous renal replacement therapy circuits reached 72 h lifetime. With default settings for regional citrate anticoagulation, serum ionized calcium and pH were in the normal range. Urea and creatinine were reduced significantly, and norepinephrine dose decreased from 0.47 (±0.09) to 0.16 (±0.04) µg/kg/min (p = 0.016) after 24 h. DISCUSSION We show that combined cytokine adsorption/continuous veno-venous hemodialysis is effective to control pH, to reduce urea and creatinine, and to improve hemodynamics by reducing norepinephrine doses in patients with septic shock. It can be applied safely with standard settings of regional citrate anticoagulation rendering sufficiently long filter lifetimes for the adsorber and the continuous veno-venous hemodialysis circuit. Further studies are on the way to investigate whether these effects translate into improved outcomes in septic shock patients.
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Affiliation(s)
- Thomas Dimski
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Timo Brandenburger
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Torsten Slowinski
- Department of Nephrology, University Hospital Charité, Berlin, Germany
| | - Detlef Kindgen-Milles
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Borisov AS, Malov AA, Kolesnikov SV, Lomivorotov VV. Renal Replacement Therapy in Adult Patients After Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:2273-2286. [PMID: 30871949 DOI: 10.1053/j.jvca.2019.02.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 02/04/2019] [Accepted: 02/08/2019] [Indexed: 01/28/2023]
Affiliation(s)
- Alexander S Borisov
- Department of Anaesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Andrey A Malov
- Department of Anaesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Sergey V Kolesnikov
- Department of Anaesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Vladimir V Lomivorotov
- Department of Anaesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia; Novosibirsk State University, Novosibirsk, Russia.
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Renal replacement therapy: a practical update. Can J Anaesth 2019; 66:593-604. [PMID: 30725343 DOI: 10.1007/s12630-019-01306-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 12/19/2018] [Accepted: 12/19/2018] [Indexed: 12/20/2022] Open
Abstract
Acute kidney injury (AKI) is defined as an abrupt decrease in kidney function, with the most severe form requiring some method of renal replacement therapy (RRT). The use of RRT is required in 5-10% of critically ill patients who develop severe AKI. Renal replacement therapy can be provided as either intermittent hemodialysis or one of the various modes of continuous renal replacement therapy (CRRT), with CRRT potentially conferring an advantage with respect to renal recovery and dialysis independence. There is no difference in mortality when comparing low (< 25 mL·kg-1·hr-1) vs high (> 40 mL·kg-1·hr-1) RRT dosing. Continuous renal replacement therapy may be run in different modes of increasing complexity depending on a given patient's clinical needs. Regional citrate anticoagulation is recommended as the therapy of choice for the majority of critically ill patients requiring CRRT.
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Broeker A, Wicha SG, Dorn C, Kratzer A, Schleibinger M, Kees F, Heininger A, Kees MG, Häberle H. Tigecycline in critically ill patients on continuous renal replacement therapy: a population pharmacokinetic study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:341. [PMID: 30558639 PMCID: PMC6296114 DOI: 10.1186/s13054-018-2278-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 11/26/2018] [Indexed: 01/03/2023]
Abstract
Background Tigecycline is a vital antibiotic treatment option for infections caused by multiresistant bacteria in the intensive care unit (ICU). Acute kidney injury (AKI) is a common complication in the ICU requiring continuous renal replacement therapy (CRRT), but pharmacokinetic data for tigecycline in patients receiving CRRT are lacking. Methods Eleven patients mainly with intra-abdominal infections receiving either continuous veno-venous hemodialysis (CVVHD, n = 8) or hemodiafiltration (CVVHDF, n = 3) were enrolled, and plasma as well as effluent samples were collected according to a rich sampling schedule. Total and free tigecycline was determined by ultrafiltration and high-performance liquid chromatography (HPLC)-UV. Population pharmacokinetic modeling using NONMEM® 7.4 was used to determine the pharmacokinetic parameters as well as the clearance of CVVHD and CVVHDF. Pharmacokinetic/pharmacodynamic target attainment analyses were performed to explore the potential need for dose adjustments of tigecycline in CRRT. Results A two-compartment population pharmacokinetic (PK) model was suitable to simultaneously describe the plasma PK and effluent measurements of tigecycline. Tigecycline dialysability was high, as indicated by the high mean saturation coefficients of 0.79 and 0.90 for CVVHD and CVVHDF, respectively, and in range of the concentration-dependent unbound fraction of tigecycline (45–94%). However, the contribution of CRRT to tigecycline clearance (CL) was only moderate (CLCVVHD: 1.69 L/h, CLCVVHDF: 2.71 L/h) in comparison with CLbody (physiological part of the total clearance) of 18.3 L/h. Bilirubin was identified as a covariate on CLbody in our collective, reducing the observed interindividual variability on CLbody from 58.6% to 43.6%. The probability of target attainment under CRRT for abdominal infections was ≥ 0.88 for minimal inhibitory concentration (MIC) values ≤ 0.5 mg/L and similar to patients without AKI. Conclusions Despite high dialysability, dialysis clearance displayed only a minor contribution to tigecycline elimination, being in the range of renal elimination in patients without AKI. No dose adjustment of tigecycline seems necessary in CRRT. Trial registration EudraCT, 2012–005617-39. Registered on 7 August 2013. Electronic supplementary material The online version of this article (10.1186/s13054-018-2278-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A Broeker
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstraße 45, 20146, Hamburg, Germany
| | - S G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstraße 45, 20146, Hamburg, Germany.
| | - C Dorn
- Institute of Pharmacy, University of Regensburg, Universitätstr. 31, 93053, Regensburg, Germany
| | - A Kratzer
- Hospital Pharmacy, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - M Schleibinger
- Department of Orthopaedics and Trauma, Hospital Ingolstadt, Krumenauerstraße 25, 85049, Ingolstadt, Germany
| | - F Kees
- Department of Pharmacology and Toxicology, University of Regensburg, Universitätsstr. 31, 93053, Regensburg, Germany
| | - A Heininger
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Division Hospital and Environmental Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany
| | - M G Kees
- Department of Anesthesiology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - H Häberle
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
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