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Kunz JV, Hansmann H, Fähndrich M, Pigorsch M, Bethke N, Peters H, Krüger A, Schroeder T, Marcy F, Magomedov A, Müller-Redetzky H, Eckardt KU, Khadzhynov D, Enghard P. Standard vs. carbone dioxide adapted kidney replacement therapy in hypercapnic ARDS patients: a randomized controlled pilot trial (BigBIC). Crit Care 2024; 28:198. [PMID: 38863072 PMCID: PMC11167756 DOI: 10.1186/s13054-024-04979-z] [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: 03/08/2024] [Accepted: 06/03/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Current continuous kidney replacement therapy (CKRT) protocols ignore physiological renal compensation for hypercapnia. This study aimed to explore feasibility, safety, and clinical benefits of pCO2-adapted CKRT for hypercapnic acute respiratory distress syndrome (ARDS) patients with indication for CKRT. METHODS We enrolled mechanically ventilated hypercapnic ARDS patients (pCO2 > 7.33 kPa) receiving regional citrate anticoagulation (RCA) based CKRT in a prospective, randomized-controlled pilot-study across five intensive care units at the Charité-Universitätsmedizin Berlin, Germany. Patients were randomly assigned 1:1 to the control group with bicarbonate targeted to 24 mmol/l or pCO2-adapted-CKRT with target bicarbonate corresponding to physiological renal compensation. Study duration was six days. Primary outcome was bicarbonate after 72 h. Secondary endpoints included safety and clinical endpoints. Endpoints were assessed in all patients receiving treatment. RESULTS From September 2021 to May 2023 40 patients (80% male) were enrolled. 19 patients were randomized to the control group, 21 patients were randomized to pCO2-adapted-CKRT. Five patients were excluded before receiving treatment: three in the control group (consent withdrawal, lack of inclusion criteria fulfillment (n = 2)) and two in the intervention group (lack of inclusion criteria fulfillment, sudden unexpected death) and were therefore not included in the analysis. Median plasma bicarbonate 72 h after randomization was significantly higher in the intervention group (30.70 mmol/l (IQR 29.48; 31.93)) than in the control group (26.40 mmol/l (IQR 25.63; 26.88); p < 0.0001). More patients in the intervention group received lung protective ventilation defined as tidal volume < 8 ml/kg predicted body weight. Thirty-day mortality was 10/16 (63%) in the control group vs. 8/19 (42%) in the intervention group (p = 0.26). CONCLUSION Tailoring CKRT to physiological renal compensation of respiratory acidosis appears feasible and safe with the potential to improve patient care in hypercapnic ARDS. TRIAL REGISTRATION The trial was registered in the German Clinical Trials Register (DRKS00026177) on September 9, 2021 and is now closed.
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Affiliation(s)
- Julius Valentin Kunz
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Helena Hansmann
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
- Department of Nephrology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Mareike Fähndrich
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Mareen Pigorsch
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Charité-Platz 1, 10117, Berlin, Germany
| | - Nicole Bethke
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
- Department of Nephrology, Vivantes Klinikum Friedrichshain, Berlin, Germany
| | - Harm Peters
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Anne Krüger
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Tim Schroeder
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Florian Marcy
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Abakar Magomedov
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Holger Müller-Redetzky
- Department of Infectious Diseases, Pneumology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Charité-Platz 1, 10117, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Dmytro Khadzhynov
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
- Kuratorium for Dialysis and Transplantation (KfH) Renal Unit Berlin-Mitte, Große Hamburger Str. 5-11, Berlin, Germany
| | - Philipp Enghard
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.
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Cortina G, Daverio M, Demirkol D, Chanchlani R, Deep A. Continuous renal replacement therapy in neonates and children: what does the pediatrician need to know? An overview from the Critical Care Nephrology Section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). Eur J Pediatr 2024; 183:529-541. [PMID: 37975941 PMCID: PMC10912166 DOI: 10.1007/s00431-023-05318-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/13/2023] [Accepted: 10/28/2023] [Indexed: 11/19/2023]
Abstract
Continuous renal replacement therapy (CRRT) is the preferred method for renal support in critically ill and hemodynamically unstable children in the pediatric intensive care unit (PICU) as it allows for gentle removal of fluids and solutes. The most frequent indications for CRRT include acute kidney injury (AKI) and fluid overload (FO) as well as non-renal indications such as removal of toxic metabolites in acute liver failure, inborn errors of metabolism, and intoxications and removal of inflammatory mediators in sepsis. AKI and/or FO are common in critically ill children and their presence is associated with worse outcomes. Therefore, early recognition of AKI and FO is important and timely transfer of patients who might require CRRT to a center with institutional expertise should be considered. Although CRRT has been increasingly used in the critical care setting, due to the lack of standardized recommendations, wide practice variations exist regarding the main aspects of CRRT application in critically ill children. Conclusion: In this review, from the Critical Care Nephrology section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC), we summarize the key aspects of CRRT delivery and highlight the importance of adequate follow up among AKI survivors which might be of relevance for the general pediatric community. What is Known: • CRRT is the preferred method of renal support in critically ill and hemodynamically unstable children in the PICU as it allows for gentle removal of fluids and solutes. • Although CRRT has become an important and integral part of modern pediatric critical care, wide practice variations exist in all aspects of CRRT. What is New: • Given the lack of literature on guidance for a general pediatrician on when to refer a child for CRRT, we recommend timely transfer to a center with institutional expertise in CRRT, as both worsening AKI and FO have been associated with increased mortality. • Adequate follow-up of PICU patients with AKI and CRRT is highlighted as recent findings demonstrate that these children are at increased risk for adverse long-term outcomes.
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Affiliation(s)
- Gerard Cortina
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Marco Daverio
- Pediatric Intensive Care Unit, University Hospital of Padua, Padua, Italy
| | - Demet Demirkol
- Pediatric Intensive Care Unit, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - Akash Deep
- Pediatric Intensive Care Unit, Kings College London, London, UK.
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Wang B, Peng M, Wei H, Liu C, Wang J, Jiang L, Fang F, Wang Y, Shen Y. The benefits of early continuous renal replacement therapy in critically ill patients with acute kidney injury at high-altitude areas: a retrospective multi-center cohort study. Sci Rep 2023; 13:14882. [PMID: 37689800 PMCID: PMC10492831 DOI: 10.1038/s41598-023-42003-6] [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: 03/12/2023] [Accepted: 09/04/2023] [Indexed: 09/11/2023] Open
Abstract
Severe hypoxia would aggravate the acute kidney injury (AKI) in high-altitude areas and continuous renal replacement therapy (CRRT) has been used to treat critically ill patients with AKI. However, the characteristics and outcomes of CRRT in critically ill patients at AKI in high altitudes and the optimal timing of CRRT initiation remain unclear. 1124 patients were diagnosed with AKI and treated with CRRT in the ICU, comprising a high-altitude group (n = 648) and low-altitude group (n = 476). Compared with the low-altitude group, patients with AKI at high altitude showed longer CRRT (4.8 vs. 3.7, P = 0.036) and more rapid progression of AKI stages (P < 0.01), but without any significant minor or major bleeding episodes (P > 0.05). Referring to the analysis of survival and kidney recovery curves, a higher mortality but a lower possibility of renal recovery was observed in the high-altitude group (P < 0.001). However, in the high-altitude group, the survival rate of early CRRT initiation was significantly higher than that of delayed CRRT initiation (P < 0.001). The findings showed poorer clinical outcomes in patients undergoing CRRT for AKI at high altitudes. CRRT at high altitudes was unlikely to increase the adverse events. Moreover, early CRRT initiation might reduce the mortality and promote renal recovery in high-altitude patients.
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Affiliation(s)
- Bowen Wang
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
| | - Mengjia Peng
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
| | - Hui Wei
- Intensive Care Center, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, Chengdu, 610041, Sichuan, China
| | - Chang Liu
- Intensive Care Center, People's Hospital of Tibet Autonomous Region, Lhasa, 850000, Tibet, China
| | - Juan Wang
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
| | - Liheng Jiang
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
| | - Fei Fang
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
| | - Yuliang Wang
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China.
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China.
| | - Yuandi Shen
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China.
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China.
- Department of Emergency, Naval Medical Center of PLA, Shanghai, 200052, China.
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Yu D, Tang X, Xue H, Ao Y, Xie Y, Li X. Paraneoplastic syndrome in malignant lymphoma: A case report. Heliyon 2023; 9:e18968. [PMID: 37636455 PMCID: PMC10458334 DOI: 10.1016/j.heliyon.2023.e18968] [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: 11/27/2022] [Revised: 07/12/2023] [Accepted: 08/03/2023] [Indexed: 08/29/2023] Open
Abstract
Hypercalcaemia associated with malignancy is a complication of advanced tumors. Lactic acidosis is also an extremely rare paraneoplastic syndrome of malignancy, and the presence of both usually indicates an extremely poor prognosis for the tumour. Diffuse large B-cell lymphoma is the most common type of non-Hodgkin's lymphoma and is also a common aggressive lymphoma. It is extremely rare for patients with diffuse large B-cell lymphoma to develop both hypercalcaemia and severe lactic acidosis. In this article, we report a case of CD5 positive diffuse large B-cell lymphoma with hypercalcaemic crisis and persistent lactic acidosis, in which calcium was rapidly reduced to normal after rehydration, diuresis, calcitonin and zoledronate, and continuous renal replacement therapy (CRRT). After correction of acidosis with sodium bicarbonate, diuresis, vitamin B1 and CRRT, the patient's lactate remained at a high level. The aim of this article is to analyse the experience of the combination of hypercalcaemia and intractable lactic acidosis, which should be considered as a serious electrolyte disorder possibly associated with abnormal metabolism of malignant tumors, and to identify and treat the primary lesion as early as possible.
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Affiliation(s)
- Dian Yu
- Lianyungang Clinical College of Nanjing Medical University, China
- Department of Emergency and Critical Care Medicine, The First People's Hospital of Lianyungang, China
- Clinical College of Guizhou Medical University, China
| | - Xinyi Tang
- Lianyungang Clinical College of Nanjing Medical University, China
- Department of Emergency and Critical Care Medicine, The First People's Hospital of Lianyungang, China
| | - Haoyue Xue
- Department of Emergency and Critical Care Medicine, The First People's Hospital of Lianyungang, China
- Lianyungang Clinical College of Xuzhou Medical University, China
| | - Yongfeng Ao
- Clinical College of Guizhou Medical University, China
| | - Yongpeng Xie
- Lianyungang Clinical College of Nanjing Medical University, China
- Department of Emergency and Critical Care Medicine, The First People's Hospital of Lianyungang, China
- Lianyungang Clinical College of Xuzhou Medical University, China
| | - Xiaomin Li
- Lianyungang Clinical College of Nanjing Medical University, China
- Department of Emergency and Critical Care Medicine, The First People's Hospital of Lianyungang, China
- Lianyungang Clinical College of Xuzhou Medical University, China
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Jacobs R, Verbrugghe W, Dams K, Roelant E, Couttenye MM, Devroey D, Jorens P. Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy: Is Metabolic Fear the Enemy of Logic? A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Life (Basel) 2023; 13:life13051198. [PMID: 37240843 DOI: 10.3390/life13051198] [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: 03/13/2023] [Revised: 03/31/2023] [Accepted: 04/05/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Anticoagulation is recommended to maintain the patency of the circuit in continuous renal replacement therapy (CRRT). However, anticoagulation-associated complications can occur. We performed a systematic review and meta-analysis to compare the efficacy and safety of citrate anticoagulation to heparin anticoagulation in critically ill patients treated with CRRT. METHODS Randomised controlled trials (RCTs) evaluating the safety and efficacy of citrate anticoagulation and heparin in CRRT were included. Articles not describing the incidence of metabolic and/or electrolyte disturbances induced by the anticoagulation strategy were excluded. The PubMed, Embase, and MEDLINE electronic databases were searched. The last search was performed on 18 February 2022. RESULTS Twelve articles comprising 1592 patients met the inclusion criteria. There was no significant difference between the groups in the development of metabolic alkalosis (RR = 1.46; (95% CI (0.52-4.11); p = 0.470)) or metabolic acidosis (RR = 1.71, (95% CI (0.99-2.93); p = 0.054)). Patients in the citrate group developed hypocalcaemia more frequently (RR = 3.81; 95% CI (1.67-8.66); p = 0.001). Bleeding complications in patients randomised to the citrate group were significantly lower than those in the heparin group (RR 0.32 (95% CI (0.22-0.47); p < 0.0001)). Citrate showed a significantly longer filter lifespan of 14.52 h (95% CI (7.22-21.83); p < 0.0001), compared to heparin. There was no significant difference between the groups for 28-day mortality (RR = 1.08 (95% CI (0.89-1.31); p = 0.424) or 90-day mortality (RR 0.9 (95% CI (0.8-1.02); p = 0.110). CONCLUSION regional citrate anticoagulation is a safe anticoagulant for critically ill patients who require CRRT, as no significant differences were found in metabolic complications between the groups. Additionally, citrate has a lower risk of bleeding and circuit loss than heparin.
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Affiliation(s)
- Rita Jacobs
- Intensive Care Department, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Walter Verbrugghe
- Intensive Care Department, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Karolien Dams
- Intensive Care Department, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Ella Roelant
- Clinical Trial Center (CTC), Antwerp University Hospital, 2650 Edegem, Belgium
| | - Marie Madeleine Couttenye
- Department of Nephrology and Hypertension, Antwerp University Hospital, 2650 Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics (LEMP), 2000 Antwerpen, Belgium
| | - Dirk Devroey
- Deparmtment of Family Medicine and Chronic Care, Faculty of Medicine and Framacy, Vrije Universiteit Brussels (VUB), 1090 Brussels, Belgium
| | - Philippe Jorens
- Intensive Care Department, Antwerp University Hospital, 2650 Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics (LEMP), 2000 Antwerpen, Belgium
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Zanza C, Facelli V, Romenskaya T, Bottinelli M, Caputo G, Piccioni A, Franceschi F, Saviano A, Ojetti V, Savioli G, Longhitano Y. Lactic Acidosis Related to Pharmacotherapy and Human Diseases. Pharmaceuticals (Basel) 2022; 15:ph15121496. [PMID: 36558947 PMCID: PMC9787936 DOI: 10.3390/ph15121496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 12/02/2022] Open
Abstract
Lactic acidosis represents one of the most common conditions that can compromise the health of intensive care unit (ICU) patients, increasing the mortality of patients with high levels of Lactate who do not receive a proper treatment within the first 6 h of hospitalization. There are two enantiomers of lactic acid: L-lactic acid (when the concentration increases, it can lead to a state of severe acidemia risking cardiovascular collapse, causing an increase in mortality in ICU patients) and D lactic acid (produced in the human organism by microbiota and its production increases during some pathological status). Generally, increased levels of serum lactic acid could be due to numerous factors, including hypoxia (caused for example by septic/cardiogenic/hypovolemic or obstructive shock), specific pathologies (e.g., liver disease), use of some drugs (e.g., metformin), presence of toxins, and trauma. Since the underlying cause could be fatal for the ICU patient, it is important to understand the root of this clinical status with a view to correct it and prevent the risk of a poor clinical outcome. Prevention and early treatment are the keys to control the negative clinical consequences. The aim of this review is to revise the scientific literature for further confirmation about the importance of early identification of acidotic statuses and to underline how an early diagnosis can prevent the worst clinical outcome, especially for ICU patients who are more fragile compared to the general population.
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Affiliation(s)
- Christian Zanza
- Foundation “Ospedale Alba-Bra Onlus,” Department of Emergency Medicine, Anesthesia and Critical Care Medicine, Michele and Pietro Ferrero Hospital,12060 Verduno, Italy
- Department of Emergency Medicine, Policlinico Agostino Gemelli, Catholic University of Sacred Heart, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-334-326-1277
| | - Valentina Facelli
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliera “SS Antonio e Biagio e C. Arrigo”, 15121 Alessandria, Italy
| | - Tastiana Romenskaya
- Department of Physiology and Pharmacology, Sapienza University of Rome, 00185 Rome, Italy
| | - Maria Bottinelli
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliera “SS Antonio e Biagio e C. Arrigo”, 15121 Alessandria, Italy
| | - Giorgia Caputo
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliera “SS Antonio e Biagio e C. Arrigo”, 15121 Alessandria, Italy
| | - Andrea Piccioni
- Department of Emergency Medicine, Policlinico Agostino Gemelli, Catholic University of Sacred Heart, 00168 Rome, Italy
| | - Francesco Franceschi
- Department of Emergency Medicine, Policlinico Agostino Gemelli, Catholic University of Sacred Heart, 00168 Rome, Italy
| | - Angela Saviano
- Department of Emergency Medicine, Policlinico Agostino Gemelli, Catholic University of Sacred Heart, 00168 Rome, Italy
| | - Veronica Ojetti
- Department of Emergency Medicine, Policlinico Agostino Gemelli, Catholic University of Sacred Heart, 00168 Rome, Italy
| | - Gabriele Savioli
- Emergency Department, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
- PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Yaroslava Longhitano
- Foundation “Ospedale Alba-Bra Onlus,” Department of Emergency Medicine, Anesthesia and Critical Care Medicine, Michele and Pietro Ferrero Hospital,12060 Verduno, Italy
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliera “SS Antonio e Biagio e C. Arrigo”, 15121 Alessandria, Italy
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Affiliation(s)
- Stéphane Gaudry
- From INSERM, UMR_S1155, Common and Rare Kidney Diseases, Hôpital Tenon, Sorbonne Université (S.G., D.D.), and Université de Paris (D.D.), Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, and the Health Care Simulation Center, UFR SMBH, Université Paris 13, Sorbonne Paris Cité, Bobigny (S.G.), and Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Hôpital Louis Mourier, Colombes (D.D.) - all in France; and the Kidney Medicine Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, and the Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh - both in Pittsburgh (P.M.P.)
| | - Paul M Palevsky
- From INSERM, UMR_S1155, Common and Rare Kidney Diseases, Hôpital Tenon, Sorbonne Université (S.G., D.D.), and Université de Paris (D.D.), Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, and the Health Care Simulation Center, UFR SMBH, Université Paris 13, Sorbonne Paris Cité, Bobigny (S.G.), and Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Hôpital Louis Mourier, Colombes (D.D.) - all in France; and the Kidney Medicine Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, and the Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh - both in Pittsburgh (P.M.P.)
| | - Didier Dreyfuss
- From INSERM, UMR_S1155, Common and Rare Kidney Diseases, Hôpital Tenon, Sorbonne Université (S.G., D.D.), and Université de Paris (D.D.), Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, and the Health Care Simulation Center, UFR SMBH, Université Paris 13, Sorbonne Paris Cité, Bobigny (S.G.), and Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Hôpital Louis Mourier, Colombes (D.D.) - all in France; and the Kidney Medicine Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, and the Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh - both in Pittsburgh (P.M.P.)
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Cronin B, O'Brien EO. Intraoperative Renal Replacement Therapy: Practical Information for Anesthesiologists. J Cardiothorac Vasc Anesth 2021; 36:2656-2668. [PMID: 34750060 DOI: 10.1053/j.jvca.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 09/02/2021] [Accepted: 10/01/2021] [Indexed: 11/11/2022]
Abstract
Previous publications regarding perioperative renal replacement therapy (RRT) have focused on the general care of the RRT-dependent patient and provided a broad overview of the various RRT modalities. The goal of this review article is to provide anesthesiologists with specific practical information regarding the possible intraoperative advantages and limitations of each modality, mandatory equipment to institute intraoperative therapy, and background knowledge necessary to communicate effectively with nephrologists and/or support staff regarding the intraoperative RRT goals.
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Affiliation(s)
- Brett Cronin
- Department of Anesthesiology, University of California, San Diego, UCSD Medical Center, San Diego, CA.
| | - E Orestes O'Brien
- Department of Anesthesiology, University of California, San Diego, UCSD Medical Center, San Diego, CA.
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Nalesso F, Garzotto F, Cattarin L, Innico G, Gobbi L, Calò LA. Impact of different hemodiafiltration solutions on ionemia in long-term CRRT. Int J Artif Organs 2021; 44:807-815. [PMID: 34472996 DOI: 10.1177/03913988211043203] [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] [Indexed: 11/15/2022]
Abstract
Critical patients with Acute Kidney Injury (AKI) requiring renal replacement therapy are in most cases eligible only for continuous modalities where the electrolyte balance control is a critical issue. The standard solutions used for hemodiafiltration, containing potassium at 2 mmol/L and no phosphorus, determines during the extended renal replacement therapy hypokalemia and hypophosphatemia. Therefore, solutions containing potassium and phosphate in physiological concentrations were formulated to avoid electrolyte imbalances and reduce ion alterations in prolonged treatments, these solutions are not routinely used in the standard clinical practice. To avoid electrolyte imbalances, we have first introduced in our practice two different solutions and then we have retrospectively analyzed the electrolyte balance upon these two solutions in order to identity the impact of these solutions on potassium and phosphate according to our clinical practice. We retrospectively analyzed 96 patients treated with Continuous Renal Replacement Therapy (CRRT) in the intensive care units (ICU) at Padua's University Hospital to evaluate the role on electrolyte balance of Phoxilium® and Prismasol 2® that differ in their composition and the need for electrolytes infusions. In the Phoxilium group the frequency of hypokalemia, hypophosphatemia, and the need of potassium and phosphate replacement were significantly reduced resulting in a reduction in complications, workload, and clinical risk associated with infusions of electrolytes. Our data demonstrated that the use of these two different hemodiafiltration solutions can reduce the occurrence of hypokalemia and hypophosphatemia during CRRT performing personalized treatments without the use of potassium and phosphate infusions.
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Affiliation(s)
- Federico Nalesso
- Department of Medicine, Nephrology, University of Padua, Padua, Italy
| | | | - Leda Cattarin
- Department of Medicine, Nephrology, University of Padua, Padua, Italy
| | - Georgie Innico
- Department of Medicine, Nephrology, University of Padua, Padua, Italy
| | - Laura Gobbi
- Department of Medicine, Nephrology, University of Padua, Padua, Italy
| | - Lorenzo A Calò
- Department of Medicine, Nephrology, University of Padua, Padua, Italy
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10
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Lactate measurements in an integrated perfusion machine for human livers. Nat Biotechnol 2020; 38:1259. [DOI: 10.1038/s41587-020-0626-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 09/08/2020] [Indexed: 01/01/2023]
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11
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Kamel KS, Oh MS, Halperin ML. L-lactic acidosis: pathophysiology, classification, and causes; emphasis on biochemical and metabolic basis. Kidney Int 2020; 97:75-88. [DOI: 10.1016/j.kint.2019.08.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/01/2019] [Accepted: 08/20/2019] [Indexed: 11/30/2022]
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Tandukar S, Palevsky PM. Continuous Renal Replacement Therapy: Who, When, Why, and How. Chest 2018; 155:626-638. [PMID: 30266628 DOI: 10.1016/j.chest.2018.09.004] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/29/2018] [Accepted: 09/12/2018] [Indexed: 01/31/2023] Open
Abstract
Continuous renal replacement therapy (CRRT) is commonly used to provide renal support for critically ill patients with acute kidney injury, particularly patients who are hemodynamically unstable. A variety of techniques that differ in their mode of solute clearance may be used, including continuous venovenous hemofiltration with predominantly convective solute clearance, continuous venovenous hemodialysis with predominantly diffusive solute clearance, and continuous venovenous hemodiafiltration, which combines both dialysis and hemofiltration. The present article compares CRRT with other modalities of renal support and reviews indications for initiation of renal replacement therapy, as well as dosing and technical aspects in the management of CRRT.
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Affiliation(s)
- Srijan Tandukar
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Paul M Palevsky
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Renal Section, Medical Service, VA Pittsburgh Healthcare System, Pittsburgh, PA.
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Hamdi T, Palmer BF. Review of Extracorporeal Membrane Oxygenation and Dialysis-Based Liver Support Devices for the Use of Nephrologists. Am J Nephrol 2017; 46:139-149. [PMID: 28738354 DOI: 10.1159/000479342] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Acute kidney injury in the intensive care unit (ICU) is a manifestation of an underlying severe illness that commonly involves other organ systems. Pulmonary, cardiac, and hepatic failures are the most prevalent. This article provides a simplified review of the technical aspects of extracorporeal cardiopulmonary and liver support devices used in the adult ICU patient, as well as a summary of the most relevant and up-to-date clinical evidence that supports their use.
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Affiliation(s)
- Tamim Hamdi
- Department of Internal Medicine, Division of Nephrology, UT Southwestern, Dallas, TX, USA
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14
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Kraut JA, Madias NE. Lactic Acidosis: Current Treatments and Future Directions. Am J Kidney Dis 2016; 68:473-82. [DOI: 10.1053/j.ajkd.2016.04.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 04/01/2016] [Indexed: 11/11/2022]
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15
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Outcome of patients on combined extracorporeal membrane oxygenation and continuous renal replacement therapy: a retrospective study. Int J Artif Organs 2015; 38:133-7. [PMID: 25656009 DOI: 10.5301/ijao.5000381] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a lifesaving therapy used in the management of cardiopulmonary failure. Continuous renal replacement therapy (CRRT) is often added to the treatment for the correction of fluid and electrolyte imbalance in patients with acute kidney injury. Most of the literature on the use of combined ECMO and CRRT has been on pediatric patients. There are limited outcome data on the use of these combined modalities in adult patients. METHODS This is a retrospective analysis of all the patients above the age of 18 years who underwent combined ECMO and CRRT at a tertiary care medical center during the period January 2007 to January 2012. The primary outcomes measured were mortality at one year and renal recovery or dialysis dependence at one month. RESULTS A total of 40 patients who were treated concurrently with ECMO and CRRT were identified. The mean age was 47.01 ± 18.29 years. The most common indications for initiation of CRRT were combined fluid overload and electrolyte imbalance. Mortality at one month was (32/40) 80%. Among the 8 survivors (20%), 3 patients required continuation of hemodialysis and 5 patients were independent of dialysis at 30 days. CONCLUSIONS Mortality of patients treated with combined ECMO and CRRT is high. Initiation of CRRT in these patients is simply an indicator of severity of illness and fatality. Younger age, higher arterial pH, left ventricular dysfunction and use of VA ECMO are associated with improved survival in these patients.
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John SG, William P, Murugapandian S, Thajudeen B. Outcome of Patients with Infective Endocarditis who were Treated with Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy. Clin Pract 2014; 4:670. [PMID: 25568769 PMCID: PMC4274487 DOI: 10.4081/cp.2014.670] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 09/21/2014] [Accepted: 09/30/2014] [Indexed: 11/25/2022] Open
Abstract
Infective endocarditis is a potentially life threatening condition. It is associated with high mortality and morbidity resulting mostly due to cardiorespiratory failure. Extracorporeal membrane oxygenation is a modality of treatment used to support hypoxic respiratory failure especially in patients who are already on mechanical ventilation. Continuous renal replacement therapy is added mainly for maintaining fluid and electrolyte balance. Here we report a case series of patients diagnosed with infective endocarditis who were treated with combined extracorporeal membrane oxygenation and continuous renal replacement therapy. Three patients in the age group 20-60 years were admitted with clinical features suggestive of infective endocarditis. During the course of hospital stay they developed cardiorespiratory failure requiring mechanical ventilation and extracorporeal membrane oxygenation support for refractory hypoxia. It was complicated by heart failure, renal failure and fluid overload which required initiation of continuous renal replacement therapy. All the three patients succumbed in spite of the aggressive treatment. In addition to the role played by each complication, delayed start of continuous renal replacement therapy might have also contributed to the high mortality. Early initiation of continuous renal replacement therapy for management of fluid overload needs to be considered in the management of these critically ill patients.
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Affiliation(s)
- Santhosh G John
- Department of Medicine, University of Arizona Medical Center , Tucson, AZ, USA
| | - Preethi William
- Department of Medicine, University of Arizona Medical Center , Tucson, AZ, USA
| | | | - Bijin Thajudeen
- Department of Medicine, University of Arizona Medical Center , Tucson, AZ, USA
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Honoré PM, Jacobs R, Joannes-Boyau O, De Waele E, Van Gorp V, Boer W, Spapen HD. Con: Dialy- and continuous renal replacement (CRRT) trauma during renal replacement therapy: still under-recognized but on the way to better diagnostic understanding and prevention. Nephrol Dial Transplant 2014; 28:2723-7; discussion 2727-8. [PMID: 24169609 DOI: 10.1093/ndt/gft086] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Dialy- and continuous renal replacement (CRRT) trauma are still un(der)recognized conditions that may be encountered during blood purification therapy. This particular form of trauma requires timely identification, a better understanding of pathophysiology and a definition of at-risk groups to prevent or correct any associated unwarranted effects. Among others, progress in the knowledge of antimicrobial pharmacokinetic/pharmacodynamic (PK/PD) behaviour during CRRT to obtain more efficient antimicrobial therapy with less side-effects is one key example of limiting CRRT trauma. Optimal anticipation and prevention of CRRT trauma will preserve the safe use of CRRT in haemodynamically unstable critically ill patients with acute kidney injury (AKI), especially in septic patients who are at the greatest risk.
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Affiliation(s)
- Patrick M Honoré
- Internist-Nephrologist-Intensivist Universitair Ziekenhuis Brussel, Vrije Universitieit Brussel, Brussels, Belgium
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da Costa MR, Pizzatti L, Lindoso RS, Sant'Anna JF, DuRocher B, Abdelhay E, Vieyra A. Mechanisms of kidney repair by human mesenchymal stromal cells after ischemia: a comprehensive view using label-free MS(E). Proteomics 2014; 14:1480-93. [PMID: 24723500 DOI: 10.1002/pmic.201300084] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 02/24/2014] [Accepted: 03/27/2014] [Indexed: 01/08/2023]
Abstract
Acute kidney injury (AKI) is one of the more frequent and lethal pathological conditions seen in intensive care units. Currently available treatments are not totally effective but stem cell-based therapies are emerging as promising alternatives, especially the use of mesenchymal stromal cells (MSC), although the signaling pathways involved in their beneficial actions are not fully understood. The objective of this study was to identify signaling networks and key proteins involved in the repair of ischemia by MSC. Using an in vitro model of AKI to investigate paracrine interactions and label-free high definition 2D-NanoESI-MS(E) , differentially expressed proteins were identified in a human renal proximal tubule cell lineage (HK-2) exposed to human MSC (hMSC) after an ischemic insult. In silico analysis showed that hMSC stimulated antiapoptotic activity, normal ROS handling, energy production, cytoskeleton organization, protein synthesis, and cell proliferation. The proteomic data were validated by parallel experiments demonstrating reduced apoptosis in HK-2 cells and recovery of intracellular ATP levels. qRT-PCR for proteins implicated in the above processes revealed that hMSC exerted their effects by stimulating translation, not transcription. Western blotting of proteins associated with ROS and energy metabolism confirmed their higher abundance in HK-2 cells exposed to hMSC.
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Affiliation(s)
- Milene R da Costa
- Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; National Institute of Science and Technology for Structural Biology and Bioimaging, Rio de Janeiro, Brazil
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De Corte W, Vuylsteke S, De Waele JJ, Dhondt AW, Decruyenaere J, Vanholder R, Hoste EAJ. Severe lactic acidosis in critically ill patients with acute kidney injury treated with renal replacement therapy. J Crit Care 2014; 29:650-5. [PMID: 24636927 DOI: 10.1016/j.jcrc.2014.02.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 02/19/2014] [Accepted: 02/24/2014] [Indexed: 12/23/2022]
Abstract
PURPOSE Severe lactic acidosis (SLA) is frequent in intensive care unit (ICU) patients with acute kidney injury (AKI) treated with renal replacement therapy (RRT). The aim of the study is to describe the epidemiology of SLA in this setting. MATERIALS AND METHODS An observational single-center cohort analysis was performed on AKI patients treated with RRT. At initiation of RRT, SLA patients (serum lactate concentration>5 mmol/L and pH<7.35) were compared with non-SLA patients. RESULTS Of the 454 patients dialyzed during the study period, 342 patients matched inclusion criteria (116 with and 226 patients without SLA). In SLA patients, lactate stabilized/decreased in 69.7% at 4 hours (P=.001) and in 81.8% during the period of 4 to 24 hours (P<.001) after initiation of RRT. Mortality during this 24-hour period was 31.0%. Intensive care unit mortality was 83.6% compared with 47.3% in non-SLA patients. Initial lactate concentration was not related to ICU mortality in SLA patients. CONCLUSIONS Severe lactic acidosis was frequent in AKI patients treated with RRT. Severe lactic acidosis patients were more severely ill and had higher mortality compared with patients without. During the first 24 hours of RRT, a correction of lactate concentration and acidosis was observed. In SLA patients, lactate concentration at initiation of RRT was not able to discriminate between survivors and nonsurvivors.
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Affiliation(s)
- Wouter De Corte
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium; Department of Anaesthesia and Intensive Care Medicine, AZ Groeninge Hospital, Kortrijk, Belgium.
| | - S Vuylsteke
- Department of Paediatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jan J De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Johan Decruyenaere
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Eric A J Hoste
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium; Research Foundation Flanders, Belgium
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Sutherland SM, Alexander SR. Continuous renal replacement therapy in children. Pediatr Nephrol 2012; 27:2007-2016. [PMID: 22366896 DOI: 10.1007/s00467-011-2080-x] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 11/28/2011] [Accepted: 11/30/2011] [Indexed: 11/28/2022]
Abstract
Over the past several decades, the epidemiology of acute kidney injury (AKI) in children has changed significantly. Pediatric patients with AKI frequently have co-morbid conditions, substantial fluid overload, and marked disease severity. At the same time, continuous renal replacement therapy (CRRT) has become the preferred modality for the management of these patients. This manuscript provides a state-of-the-art review of the technical aspects of pediatric CRRT and examines the most recent data regarding CRRT indications, timing of initiation, dosing, and outcomes in critically ill children.
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Affiliation(s)
- Scott M Sutherland
- Department of Pediatrics, Division of Nephrology, Stanford University Medical Center, 300 Pasteur Drive, Room G-306, Stanford, CA, 94035, USA.
| | - Steven R Alexander
- Department of Pediatrics, Division of Nephrology, Stanford University Medical Center, 300 Pasteur Drive, Room G-306, Stanford, CA, 94035, USA
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