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Teixeira JP, Zeidman A, Beaubien-Souligny W, Cerdá J, Connor MJ, Eggleston K, Juncos LA, da Silva JR, Wells C, Yessayan L, Barker AB, McConville W, Speer R, Wille KM, Neyra JA, Tolwani A. Proceedings of the 2022 UAB CRRT Academy: Non-Invasive Hemodynamic Monitoring to Guide Fluid Removal with CRRT and Proliferation of Extracorporeal Blood Purification Devices. Blood Purif 2023; 52:857-879. [PMID: 37742622 DOI: 10.1159/000533573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/29/2023] [Indexed: 09/26/2023]
Abstract
In 2022, we celebrated the 15th anniversary of the University of Alabama at Birmingham (UAB) Continuous Renal Replacement Therapy (CRRT) Academy, a 2-day conference attended yearly by an international audience of over 100 nephrology, critical care, and multidisciplinary trainees and practitioners. This year, we introduce the proceedings of the UAB CRRT Academy, a yearly review of select emerging topics in the field of critical care nephrology that feature prominently in the conference. First, we review the rapidly evolving field of non-invasive hemodynamic monitoring and its potential to guide fluid removal by renal replacement therapy (RRT). We begin by summarizing the accumulating data associating fluid overload with harm in critical illness and the potential for harm from end-organ hypoperfusion caused by excessive fluid removal with RRT, underscoring the importance of accurate, dynamic assessment of volume status. We describe four applications of point-of-care ultrasound used to identify patients in need of urgent fluid removal or likely to tolerate fluid removal: lung ultrasound, inferior vena cava ultrasound, venous excess ultrasonography, and Doppler of the left ventricular outflow track to estimate stroke volume. We briefly introduce other minimally invasive hemodynamic monitoring technologies before concluding that additional prospective data are urgently needed to adapt these technologies to the specific task of fluid removal by RRT and to learn how best to integrate them into practical fluid-management strategies. Second, we focus on the growth of novel extracorporeal blood purification devices, starting with brief reviews of the inflammatory underpinnings of multiorgan dysfunction and the specific applications of pathogen, endotoxin, and/or cytokine removal and immunomodulation. Finally, we review a series of specific adsorptive technologies, several of which have seen substantial clinical use during the COVID-19 pandemic, describing their mechanisms of target removal, the limited existing data supporting their efficacy, ongoing and future studies, and the need for additional prospective trials.
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Affiliation(s)
- J Pedro Teixeira
- Division of Nephrology and Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Amanda Zeidman
- Division of Nephrology, Department of Medicine, Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Jorge Cerdá
- Department of Medicine, Nephrology, Albany Medical College, Albany, New York, USA
| | - Michael J Connor
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine and Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - Luis A Juncos
- Division of Nephrology, Department of Internal Medicine, Central Arkansas Veterans' Healthcare System, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | | | - Catherine Wells
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew B Barker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Wendy McConville
- School of Nursing, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Rajesh Speer
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Keith M Wille
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Ashita Tolwani
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
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White KC, Nasser A, Gatton ML, Laupland KB. Current management of fluid balance in critically ill patients with acute kidney injury: A scoping review. CRIT CARE RESUSC 2023; 25:126-135. [PMID: 37876369 PMCID: PMC10581269 DOI: 10.1016/j.ccrj.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objective The overall objective of this scoping review is to assess the extent of the literature related to the fluid management of critically ill patients with acute kidney injury (AKI). Introduction AKI is common in critically ill patients where fluid therapy is a mainstay of treatment. An association between fluid balance (FB) and adverse patient-centred outcomes in critically ill patients with AKI regardless of severity has been demonstrated. The evidence for the prospective intervention of FB and its impact on outcomes is unknown. Inclusion criteria All studies investigating FB in patients with AKI admitted to an intensive care unit were included. Literature not related to FB in the critically ill patient with AKI population was excluded. Methods We searched MEDLINE, EMBASE, and CINAHL from January 1st, 2012, onwards. We included primary research studies, experimental and observational, recruiting adult participants admitted to an intensive care unit who had an AKI. We extracted data on study and patient characteristics, as well as FB, renal-based outcomes, and patient-centred outcomes. Two reviewers independently screened citations for eligible studies and performed data extraction. Results Of the 13,767 studies reviewed, 22 met the inclusion criteria. Two studies examined manipulation of fluid input, 18 studies assessed enhancing fluid removal, and two studies applied a restrictive fluid protocol. Sixteen studies examined patients receiving renal replacement therapy, five studies included non-renal replacement therapy patients, and one study included both. Current evidence is broad with varied approaches to managing fluid input and fluid removal. The studies did not demonstrate a consensus approach for any aspect of the fluid management of critically ill patients. There was a limited application of a restrictive fluid protocol with no conclusions possible. Conclusions The current body of evidence for the management of FB in critically ill patients with AKI is limited in nature. The current quality of evidence is unable to guide current clinical practice. The key outcome of this review is to highlight areas for future research.
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Affiliation(s)
- Kyle C. White
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- Intensive Care Unit, Queen Elizabeth II Jubilee Hospital, Coopers Plains, Queensland, Australia
| | - Ahmad Nasser
- Intensive Care Unit, Queen Elizabeth II Jubilee Hospital, Coopers Plains, Queensland, Australia
- Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Michelle L. Gatton
- Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Kevin B. Laupland
- Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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