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Lu X, Chen Y, Zhang G, Zeng X, Lai L, Qu C. Application of interpretable machine learning algorithms to predict acute kidney injury in patients with cerebral infarction in ICU. J Stroke Cerebrovasc Dis 2024; 33:107729. [PMID: 38657830 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/14/2024] [Accepted: 04/20/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is not only a complication but also a serious threat to patients with cerebral infarction (CI). This study aimed to explore the application of interpretable machine learning algorithms in predicting AKI in patients with cerebral infarction. METHODS The study included 3920 patients with CI admitted to the Intensive Care Unit and Emergency Medicine of the Central Hospital of Lishui City, Zhejiang Province. Nine machine learning techniques, including XGBoost, logistics, LightGBM, random forest (RF), AdaBoost, GaussianNB (GNB), Multi-Layer Perceptron (MLP), support vector machine (SVM), and k-nearest neighbors (KNN) classification, were used to develop a predictive model for AKI in these patients. SHapley Additive exPlanations (SHAP) analysis provided visual explanations for each patient. Finally, model effectiveness was assessed using metrics such as average precision (AP), sensitivity, specificity, accuracy, F1 score, precision-recall (PR) curve, calibration plot, and decision curve analysis (DCA). RESULTS The XGBoost model performed better in the internal validation set and the external validation set, with an AUC of 0.940 and 0.887, respectively. The five most important variables in the model were, in order, glomerular filtration rate, low-density lipoprotein, total cholesterol, hemiplegia and serum kalium. CONCLUSION This study demonstrates the potential of interpretable machine learning algorithms in predicting CI patients with AKI.
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Affiliation(s)
- Xiaochi Lu
- Department of Emergency medicine, Lishui Municipal Central Hospital, Lishui, 323000, PR China
| | - Yi Chen
- Department of Emergency medicine, Lishui Municipal Central Hospital, Lishui, 323000, PR China
| | - Gongping Zhang
- Department of Emergency medicine, Lishui Municipal Central Hospital, Lishui, 323000, PR China
| | - Xu Zeng
- Department of Emergency medicine, Lishui Municipal Central Hospital, Lishui, 323000, PR China
| | - Linjie Lai
- Department of Emergency medicine, Lishui Municipal Central Hospital, Lishui, 323000, PR China
| | - Chaojun Qu
- Department of Intensive care unit, Lishui Municipal Central Hospital, Lishui, 323000, PR China.
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Trebuian CI, Marza AM, Chioibaş R, Şutoi D, Petrica A, Crintea-Najette I, Popa D, Borcan F, Flondor D, Mederle OA. Lactate Profile Assessment-A Good Predictor of Prognosis in Patients with COVID-19 and Septic Shock Requiring Continuous Renal Therapy. Clin Pract 2024; 14:980-994. [PMID: 38921256 PMCID: PMC11202829 DOI: 10.3390/clinpract14030078] [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: 04/17/2024] [Revised: 05/14/2024] [Accepted: 05/24/2024] [Indexed: 06/27/2024] Open
Abstract
INTRODUCTION Lactate is a useful prognostic marker, as its level increases in hypoxic tissue and/or during accelerated aerobic glycolysis due to excessive beta-adrenergic stimulation and decreased lactate clearance. The Surviving Sepsis Campaign Bundle 2018 Update suggests premeasurement of lactate within 2-4 h so that physicians perform, assist, administer, and introduce lactate-guided resuscitation to reduce mortality due to sepsis. METHODS A total of 108 patients with septic shock who underwent continuous renal replacement therapy (CRRT) for acute kidney injury were enrolled in this observational study. Demographic, clinical, and laboratory data were collected, and patients were divided into two groups: survivors and non-survivors. RESULTS Multivariate analysis demonstrated that lactate levels at 24 h after initiation of CRRT treatment, but not lactate levels at intensive care unit (ICU) admission, were associated with mortality. Lactate clearance was associated with lower mortality among the survivors (OR = 0.140) at 6 h after ICU admission and late mortality (OR = 0.260) after 24 h. The area under the ROC curves for mortality was 0.682 for initial lactate; 0.797 for lactate at 24 h; and 0.816 for lactate clearance at 24 h. CONCLUSIONS Our result reinforces that the determination of lactate dynamics represents a good predictor for mortality, and serial lactate measurements may be more useful prognostic markers than initial lactate in patients with septic shock.
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Affiliation(s)
- Cosmin Iosif Trebuian
- Department of Surgery I, Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, 2nd Eftimie Murgu Square, 300041 Timisoara, Romania; (C.I.T.); (A.M.M.); (D.Ş.); (A.P.); (I.C.-N.); (D.P.); (O.A.M.)
- Department of Anesthesia and Intensive Care, Emergency County Hospital Resita, 320210 Resita, Romania
| | - Adina Maria Marza
- Department of Surgery I, Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, 2nd Eftimie Murgu Square, 300041 Timisoara, Romania; (C.I.T.); (A.M.M.); (D.Ş.); (A.P.); (I.C.-N.); (D.P.); (O.A.M.)
- Emergency Department, Emergency Clinical Municipal Hospital Timisoara, 300079 Timisoara, Romania
| | - Raul Chioibaş
- Department of Surgery I, Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, 2nd Eftimie Murgu Square, 300041 Timisoara, Romania; (C.I.T.); (A.M.M.); (D.Ş.); (A.P.); (I.C.-N.); (D.P.); (O.A.M.)
| | - Dumitru Şutoi
- Department of Surgery I, Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, 2nd Eftimie Murgu Square, 300041 Timisoara, Romania; (C.I.T.); (A.M.M.); (D.Ş.); (A.P.); (I.C.-N.); (D.P.); (O.A.M.)
| | - Alina Petrica
- Department of Surgery I, Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, 2nd Eftimie Murgu Square, 300041 Timisoara, Romania; (C.I.T.); (A.M.M.); (D.Ş.); (A.P.); (I.C.-N.); (D.P.); (O.A.M.)
- Emergency Department of “Pius Brinzeu”, Emergency Clinical County Hospital Timisoara, 300736 Timisoara, Romania
| | - Iulia Crintea-Najette
- Department of Surgery I, Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, 2nd Eftimie Murgu Square, 300041 Timisoara, Romania; (C.I.T.); (A.M.M.); (D.Ş.); (A.P.); (I.C.-N.); (D.P.); (O.A.M.)
- Emergency Department, Emergency Clinical Municipal Hospital Timisoara, 300079 Timisoara, Romania
| | - Daian Popa
- Department of Surgery I, Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, 2nd Eftimie Murgu Square, 300041 Timisoara, Romania; (C.I.T.); (A.M.M.); (D.Ş.); (A.P.); (I.C.-N.); (D.P.); (O.A.M.)
- Emergency Department, Emergency Clinical Municipal Hospital Timisoara, 300079 Timisoara, Romania
| | - Florin Borcan
- Faculty of Pharmacy, Victor Babes University of Medicine and Pharmacy, 2nd Eftimie Murgu Square, 300041 Timisoara, Romania; (F.B.); (D.F.)
| | - Daniela Flondor
- Faculty of Pharmacy, Victor Babes University of Medicine and Pharmacy, 2nd Eftimie Murgu Square, 300041 Timisoara, Romania; (F.B.); (D.F.)
- Research Center for Pharmaco-Toxicological Evaluation, Victor Babes University of Medicine and Pharmacy Timisoara, 2nd Eftimie Murgu Square, 300041 Timisoara, Romania
| | - Ovidiu Alexandru Mederle
- Department of Surgery I, Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, 2nd Eftimie Murgu Square, 300041 Timisoara, Romania; (C.I.T.); (A.M.M.); (D.Ş.); (A.P.); (I.C.-N.); (D.P.); (O.A.M.)
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Ran KR, Ejimogu NE, Yang W, Kilgore CB, Nair SK, Monroy Trujillo JM, Jackson CM, Mukherjee D, Anderson WS, Gallia GL, Weingart JD, Robinson S, Cohen AR, Bettegowda C, Huang J, Tamargo RJ, Xu R. Risk of Subdural Hematoma Expansion in Patients With End-Stage Renal Disease: Continuous Venovenous Hemodialysis Versus Intermittent Hemodialysis. Neurosurgery 2024; 94:567-574. [PMID: 37800923 DOI: 10.1227/neu.0000000000002708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/10/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Subdural hematoma (SDH) patients with end-stage renal disease (ESRD) require renal replacement therapy in addition to neurological management. We sought to determine whether continuous venovenous hemodialysis (CVVHD) or intermittent hemodialysis (iHD) is associated with higher rates of SDH re-expansion as well as morbidity and mortality. METHODS Hemodialysis-dependent patients with ESRD who were discovered to have an SDH were retrospectively identified from 2016 to 2022. Rates of SDH expansion during CVVHD vs iHD were compared. Hemodialysis mode was included in a multivariate logistic regression model to test for independent association with SDH expansion and mortality. RESULTS A total of 123 hemodialysis-dependent patients with ESRD were discovered to have a concomitant SDH during the period of study. Patients who received CVVHD were on average 10.2 years younger ( P < .001), more likely to have traumatic SDH (47.7% vs 19.0%, P < .001), and more likely to have cirrhosis (25.0% vs 10.1%, P = .029). SDH expansion affecting neurological function occurred more frequently during iHD compared with CVVHD (29.7% vs 12.0%, P = .013). Multivariate logistic regression analysis found that CVVHD was independently associated with decreased risk of SDH affecting neurological function (odds ratio 0.25, 95% CI 0.08-0.65). Among patients who experienced in-hospital mortality or were discharged to hospice, 5% suffered a neurologically devastating SDH expansion while on CVVHD compared with 35% on iHD. CONCLUSION CVVHD was independently associated with decreased risk of neurologically significant SDH expansion. Therefore, receiving renal replacement therapy through a course of CVVHD may increase SDH stability in patients with ESRD.
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Affiliation(s)
- Kathleen R Ran
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Nna-Emeka Ejimogu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Collin B Kilgore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Sumil K Nair
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jose M Monroy Trujillo
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - William S Anderson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jon D Weingart
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Shenandoah Robinson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Alan R Cohen
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
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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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Bohorquez H, Koyner JL, Jones CR. Intraoperative Renal Replacement Therapy in Orthotopic Liver Transplantation. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:378-386. [PMID: 37657884 DOI: 10.1053/j.akdh.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 03/09/2023] [Accepted: 03/09/2023] [Indexed: 09/03/2023]
Abstract
Acute kidney injury in patients admitted to the hospital for liver transplantation is common, with up to 80% of pretransplant patients having some form of acute kidney injury. Many of these patients start on dialysis prior to their transplant and have it continued intraoperatively during their surgery. This review discusses the limited existing literature and expert opinion around the indications and outcomes around intraoperative dialysis (intraoperative renal replacement therapy) during liver transplantation. More specifically, we discuss which patients may benefit from intraoperative renal replacement therapy and the impact of hyponatremia and hyperammonemia on the dialysis prescription. Additionally, we discuss the complex interplay between anesthesia and intraoperative renal replacement therapy and how the need for clearance and ultrafiltration changes throughout the different phases of the transplant (preanhepatic, anhepatic, and postanhepatic). Lastly, this review will cover the limited data around patient outcomes following intraoperative renal replacement therapy during liver transplantation as well as the best evidence for when to stop dialysis.
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Affiliation(s)
- Humberto Bohorquez
- Surgical director, Pancreas Transplantation, Section of Abdominal Organ Transplantation, Department of Surgery, Ochsner Health, New Orleans, LA
| | - Jay L Koyner
- Medical Director Acute Dialysis Services, Section of Nephrology, Department of Medicine, University of Chicago, Chicago IL.
| | - Courtney R Jones
- Associate Professor of Anesthesiology and Critical Care, Director of Transplant Anesthesia, Division of Transplantation, Department of Anesthesia, University of Cincinnati College of Medicine, Cincinnati, OH
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Chen S, Yee J, Chiaramonte R. Safely correct hyponatremia with continuous renal replacement therapy: A flexible, all-purpose method based on the mixing paradigm. PHYSICS REPORTS-REVIEW SECTION OF PHYSICS LETTERS 2023; 11:e15496. [PMID: 36602098 DOI: 10.14814/phy2.15496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 09/28/2022] [Accepted: 10/04/2022] [Indexed: 01/06/2023]
Abstract
Treating chronic hyponatremia by continuous renal replacement therapy (CRRT) is challenging because the gradient between a replacement fluid's [sodium] and a patient's serum sodium can be steep, risking too rapid of a correction rate with possible consequences. Besides CRRT, other gains and losses of sodium- and potassium-containing solutions, like intravenous fluid and urine output, affect the correction of serum sodium over time, known as osmotherapy. The way these fluids interact and contribute to the sodium/potassium/water balance can be parsed as a mixing problem. As Na/K/H2 O are added, mixed in the body, and drained via CRRT, the net balance of solutes must be related to the change in serum sodium, expressible as a differential equation. Its solution has many variables, one of which is the sodium correction rate, but all variables can be evaluated by a root-finding technique. The mixing paradigm is proved to replicate the established equations of osmotherapy, as in the special case of a steady volume. The flexibility to solve for any variable broadens our treatment options. If the pre-filter replacement fluid cannot be diluted, then we can compensate by calculating the CRRT blood flow rate needed. Or we can deduce the infusion rate of dextrose 5% water, post-filter, to appropriately slow the rise in serum sodium. In conclusion, the mixing model is a generalizable and practical tool to analyze patient scenarios of greater complexity than before, to help doctors customize a CRRT prescription to safely and effectively reach the serum sodium target.
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Affiliation(s)
- Sheldon Chen
- Section of Nephrology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Jerry Yee
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, Michigan, USA
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Baeg SI, Lee K, Jeon J, Jang HR. Management for Electrolytes Disturbances during Continuous Renal Replacement Therapy. Electrolyte Blood Press 2022; 20:64-75. [PMID: 36688209 PMCID: PMC9827043 DOI: 10.5049/ebp.2022.20.2.64] [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: 10/31/2022] [Revised: 12/18/2022] [Accepted: 12/19/2022] [Indexed: 01/05/2023] Open
Abstract
Despite the lack of proven superiority in mortality compared to intermittent hemodialysis, continuous renal replacement therapy (CRRT) is the preferred renal replacement therapy modality for critically ill patients with acute kidney injury (AKI) due to better hemodynamic stability and steady correction of electrolytes disturbances and volume overload. Multiple and complex electrolyte disorders in patients with AKI can be managed effectively with CRRT because controlled and predictable correction is feasible. Thus, CRRT has an advantage with safety over conventional hemodialysis, especially in patients with both renal dysfunction and electrolyte disorder that require a sophisticated treatment with avoidance of rapid correction. On the contrary, CRRT can potentially lead to paradoxical disturbance of electrolytes such as hypokalemia or hypophosphatemia, especially in patients under high dose or prolonged duration of CRRT treatment. These electrolytes related complications can be prevented with close monitoring followed by the appropriate use of CRRT fluids. Although there is a lack of solid evidence and standardized guideline for CRRT prescriptions, optimal management of various electrolyte disturbances can be achieved with individualized and tailored dialysate and replacement fluid prescriptions. Several commercially available CRRT solutions with varying compositions provide flexibility to manage electrolyte disorders and maintain the stability of electrolyte. In this review, we discuss various prescription methods to manage common electrolyte imbalances as well as preventative strategies to maintain electrolyte homeostasis during CRRT providing detailed protocols used in our center. This review may contribute to future research that can lead to the development of clinical practice guidelines.
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Affiliation(s)
- Song In Baeg
- Division of Nephrology, Department of Internal Medicine, Myongji Hospital, Hanyang University Medical Center, Goyang, Republic of Korea
| | - Kyungho Lee
- Division of Nephrology, Department of Medicine, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Junseok Jeon
- Division of Nephrology, Department of Medicine, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Hye Ryoun Jang
- Division of Nephrology, Department of Medicine, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
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Mishra RC, Sodhi K, Prakash KC, Tyagi N, Chanchalani G, Annigeri RA, Govil D, Savio RD, Subbarayan B, Arora N, Chatterjee R, Chacko J, Khasne RW, Chakravarthi RM, George N, Ahmed A, Javeri Y, Chhallani AK, Khanikar RG, Margabandhu S, Lopa AJ, Chaudhry D, Samavedam S, Kar A, Dixit SB, Gopal P. ISCCM Guidelines on Acute Kidney Injury and Renal Replacement Therapy. Indian J Crit Care Med 2022; 26:S13-S42. [PMID: 36896356 PMCID: PMC9989875 DOI: 10.5005/jp-journals-10071-24109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 01/31/2022] [Indexed: 11/09/2022] Open
Abstract
Acute kidney injury (AKI) is a complex syndrome with a high incidence and considerable morbidity in critically ill patients. Renal replacement therapy (RRT) remains the mainstay of treatment for AKI. There are at present multiple disparities in uniform definition, diagnosis, and prevention of AKI and timing of initiation, mode, optimal dose, and discontinuation of RRT that need to be addressed. The Indian Society of Critical Care Medicine (ISCCM) AKI and RRT guidelines aim to address the clinical issues pertaining to AKI and practices to be followed for RRT, which will aid the clinicians in their day-to-day management of ICU patients with AKI. How to cite this article Mishra RC, Sodhi K, Prakash KC, Tyagi N, Chanchalani G, Annigeri RA, et al. ISCCM Guidelines on Acute Kidney Injury and Renal Replacement Therapy. Indian J Crit Care Med 2022;26(S2):S13-S42.
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Affiliation(s)
- Rajesh C Mishra
- EPIC Hospital, Sanjivani Super Speciality Hospital, Ahmedabad, Gujarat, India
| | | | | | - Niraj Tyagi
- Institute of Critical Care Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Rajeev A Annigeri
- Department of Nephrology, Apollo Hospital, Chennai, Tamil Nadu, India
| | - Deepak Govil
- Institute of Critical Care and Anaesthesiology, Medanta, Gurugram, Haryana, India
| | - Raymond D Savio
- Department of Critical Care Medicine, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | | | - Nitin Arora
- Department of Intensive Care, University Hospitals Birmingham, Birmingham, West Midlands, United Kingdom
| | - Ranajit Chatterjee
- Department of Anaesthesiology and Critical Care, Swami Dayanand Hospital, New Delhi, India
| | - Jose Chacko
- Narayana Health City, Bengaluru, Karnataka, India
| | - Ruchira W Khasne
- Department of Critical Care Medicine, SMBT Institute of Medical Sciences and Research Centre, Nashik, Maharashtra, India
| | | | - Nita George
- VPS Lakeshore Hospital, Kochi, Kerala, India
| | - Ahsan Ahmed
- KPC Medical College and Hospital, Kolkata, West Bengal, India
| | - Yash Javeri
- Department of Critical Care, Anesthesia and Emergency Medicine, Regency Super Speciality Hospital, Lucknow, Uttar Pradesh, India
| | | | - Reshu G Khanikar
- Department of Critical Care Medicine, Health City Hospital, Guwahati, Assam, India
| | | | - Ahsina J Lopa
- Intensive Care Unit, MH Samorita Hospital and Medical College, Tejgaon, Dhaka, Bangladesh
| | | | - Srinivas Samavedam
- Department of Critical Care, Vrinchi Hospital, Hyderabad, Telangana, India
| | - Arindam Kar
- Reliance Hospital, Mumbai, Maharashtra, India
| | - Subhal B Dixit
- Department of Critical Care, Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Palepu Gopal
- Department of Critical Care Medicine, Continental Hospitals, Hyderabad, Telangana, India
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Troché G, Laurent V, Ferré A, Jacq G, Paul M, Merceron S, Legriel S. Natraemia variations induced by acute dialysis in critically ill patients: a database study. Sci Rep 2022; 12:14930. [PMID: 36056117 PMCID: PMC9440038 DOI: 10.1038/s41598-022-18897-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 08/22/2022] [Indexed: 11/08/2022] Open
Abstract
Natraemia is often abnormal in critically ill patients and may change rapidly during renal replacement therapy (RRT). This database study in a single intensive care unit (ICU) evaluated natraemia before and after the first RRT session for acute kidney injury. Of 252 patients who required RRT in 2018-2020, 215 were included. Prevalences were 53.9% for hyponatraemia (≤ 135 mmol/L) and 3.7% for hypernatraemia (> 145 mmol/L). Dialysate sodium was ≥ 145 mmol/L in 83% of patients. Median dialysis sodium gradient was 12 mmol/L, with a value above 16 mmol/L in 25% of patients. Median natraemia increased from 135 before to 140 mmol/L after RRT, the median hourly increase being faster than recommended, at 1.0 mmol/L [0.2-1.7]. By multivariate analysis, the only variable significantly associated with the RRT-induced natraemia change was the dialysis sodium gradient [odds ratio, 1.66; 95% confidence interval 1.39-2.10]. Pearson's correlation coefficient between the gradient and the natraemia change was 0.57. When performing RRT in ICU patients, in addition to the haemodynamic considerations put forward in recommendations, the dialysis sodium gradient deserves careful attention in order to control natraemia variations. Studies to devise a formula for predicting natraemia variations might prove helpful to confirm our results.
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Affiliation(s)
- Gilles Troché
- Service de Réanimation Médico-Chirurgicale, Hôpital André Mignot, Centre Hospitalier de Versailles, 177 rue de Versailles, 78150, Le Chesnay, France.
| | - Virginie Laurent
- Service de Réanimation Médico-Chirurgicale, Hôpital André Mignot, Centre Hospitalier de Versailles, 177 rue de Versailles, 78150, Le Chesnay, France
| | - Alexis Ferré
- Service de Réanimation Médico-Chirurgicale, Hôpital André Mignot, Centre Hospitalier de Versailles, 177 rue de Versailles, 78150, Le Chesnay, France
| | - Gwenaelle Jacq
- Service de Réanimation Médico-Chirurgicale, Hôpital André Mignot, Centre Hospitalier de Versailles, 177 rue de Versailles, 78150, Le Chesnay, France
| | - Marine Paul
- Service de Réanimation Médico-Chirurgicale, Hôpital André Mignot, Centre Hospitalier de Versailles, 177 rue de Versailles, 78150, Le Chesnay, France
| | - Sybille Merceron
- Service de Réanimation Médico-Chirurgicale, Hôpital André Mignot, Centre Hospitalier de Versailles, 177 rue de Versailles, 78150, Le Chesnay, France
| | - Stephane Legriel
- Service de Réanimation Médico-Chirurgicale, Hôpital André Mignot, Centre Hospitalier de Versailles, 177 rue de Versailles, 78150, Le Chesnay, France
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Baeg SI, Jeon J, Kang D, Na SJ, Cho J, Kim K, Yang JH, Chung CR, Lee JE, Huh W, Suh GY, Kim YG, Kim DJ, Jang HR. Impact of protocolized fluid management on electrolyte stability in patients undergoing continuous renal replacement therapy. Front Med (Lausanne) 2022; 9:915072. [PMID: 36117982 PMCID: PMC9471083 DOI: 10.3389/fmed.2022.915072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveContinuous renal replacement therapy (CRRT) is the standard treatment for critically ill patients with acute kidney injury (AKI). Electrolyte disturbance such as hypokalemia or hypophosphatemia occurs paradoxically in patients undergoing CRRT due to high clearance. We developed a fluid management protocol for dialysate and replacement fluid that depends on serum electrolytes and focuses on potassium and phosphate levels to prevent electrolyte disturbance during CRRT. The impact of our new fluid protocol on electrolyte stability was evaluated.MethodsAdult patients who received CRRT between 2013 and 2017 were included. Patients treated 2 years before (2013–2014; pre-protocol group) and 2 years following development of the fluid protocol (2016–2017; protocol group) were compared. The primary outcomes were individual coefficient of variation (CV) and abnormal event rates of serum phosphate and potassium. Secondary outcomes were frequency of electrolyte replacement and incidence of cardiac arrhythmias. Individual CV and abnormal event rates for each electrolyte were analyzed using the Wilcoxon rank-sum test and Chi-square test with Yates’ continuity correction.ResultsA total of 1,448 patients was included. Both serum phosphate and potassium were higher in the protocol group. The CVs of serum phosphate (pre-protocol vs. protocol, 0.275 [0.207–0.358] vs. 0.229 [0.169–0.304], p < 0.01) and potassium (0.104 [0.081–0.135] vs. 0.085 [0.064–0.110], p < 0.01) were significantly lower in the protocol group. The abnormal event rates of serum phosphate (rate [95% CI], 0.410 [0.400–0.415] vs. 0.280 [0.273–0.286], p < 0.01) and potassium (0.205 [0.199–0.211] vs. 0.083 [0.079–0.087], p < 0.01) were also significantly lower in the protocol group.ConclusionThe protocolized management of fluid in CRRT effectively prevented hypophosphatemia and hypokalemia by inducing excellent stability of serum phosphate and potassium levels.
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Affiliation(s)
- Song In Baeg
- Division of Nephrology, Department of Internal Medicine, Myongji Hospital, Hanyang University Medical Center, Goyang, South Korea
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Junseok Jeon
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Danbee Kang
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
- Center of Clinical Epidemiology, Samsung Medical Center, Seoul, South Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Juhee Cho
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
- Center of Clinical Epidemiology, Samsung Medical Center, Seoul, South Korea
| | - Kyunga Kim
- Statistics and Data Center, Samsung Medical Center, Seoul, South Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung Eun Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Wooseong Huh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yoon-Goo Kim
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dae Joong Kim
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hye Ryoun Jang
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
- *Correspondence: Hye Ryoun Jang,
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11
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Wang F, Dai M, Zhao Y, Yang Y, Chen Z, Lin L, Tang X, Zhang L. Reliability of monitoring acid-base and electrolyte parameters through circuit lines during regional citrate anticoagulation-continuous renal replacement therapy. Nurs Crit Care 2021; 27:646-651. [PMID: 34382281 PMCID: PMC9540182 DOI: 10.1111/nicc.12696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 02/05/2023]
Abstract
Background The current practice involves blood sampling from the circuit line to measure acid‐base and electrolyte parameters during continuous renal replacement therapy (CRRT). However, there is limited evidence supporting its reliability due to the effects of anticoagulant mechanism and access recirculation associated with regional citrate anticoagulation (RCA). Aim To evaluate the reliability of monitoring acid‐base and electrolyte parameters through circuit lines in regular and reversed connections during RCA‐CRRT. Study design In this prospective cohort study, we included critically ill patients receiving RCA‐CRRT via a double‐lumen catheter. During the second hour after CRRT initiation, we collected blood samples to monitor acid‐base and electrolyte parameters and their levels were compared between samples from the circuit lines (at 0, 3, and 5 minutes) and those from the central venous catheter (CVC) line (at 0 minute). During this time, CRRT switched to the replacement state as controls. Results We observed 128 CRRT circuits in 60 adult patients receiving RCA‐CRRT. Ninety‐eight (76.6%) circuits had regular connections, while 30 (23.4%) had reversed connections. Among regular connections, no differences were observed in any acid‐base or electrolyte parameters between samples from the CVC line and those from the circuit line at all time points (P > .05). Among reversed connections, ionized calcium levels were dramatically decreased at all three time points in samples from the circuit line compared with those from the CVC line (0.65 ± 0.12, 0.72 ± 0.11, and 0.78 ± 0.99 vs 0.98 ± 0.07 mmol/L, P < .001), with comparable levels of other acid‐base or electrolyte parameters between the sampling patterns (P > .05). Conclusions Acid‐base and electrolyte parameters could be reliably monitored through the circuit line during RCA‐CRRT in regular connections. However, in reversed connections, pre‐filter ionized calcium concentrations determined through the circuit line were lower than those determined through the CVC line. Relevance to clinical practice We suggest sampling from arterial or CVC lines rather than from the circuit line in a reversed connection during RCA‐CRRT.
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Affiliation(s)
- Fang Wang
- Department of Nephrology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
| | - Mingjin Dai
- Department of Nephrology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
| | - Yuliang Zhao
- Deparment of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yingying Yang
- Deparment of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhiwen Chen
- Department of Nephrology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
| | - Li Lin
- Department of Nephrology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
| | - Xue Tang
- Department of Nephrology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
| | - Ling Zhang
- Deparment of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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12
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Paramitha MP, Suyanto JC, Puspitasari S. The role of continuous renal replacement therapy (Crrt) in Coronavirus disease 2019 (Covid-19) patients. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021; 39:12-18. [PMID: 38620898 PMCID: PMC8179726 DOI: 10.1016/j.tacc.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 06/01/2021] [Accepted: 06/03/2021] [Indexed: 01/08/2023]
Abstract
Even without the presence of the novel Coronavirus disease 2019 (COVID-19), acute kidney injury has been a serious problem in medicine for decades, with mortality rate up to 70% among those who eventually required renal replacement therapy, and the number has not changed significantly for the last 30 years despite major advances in technology and experience. On the other hand, even without acute kidney injury, COVID-19 was a major cause of death globally in the year 2020, but the occurrence of acute kidney injury among COVID-19 patients is an independent risk factor of increased mortality. Continuous renal replacement therapy has been recommended to treat acute kidney injury in COVID-19 patients instead of conventional intermittent hemodialysis. Moreover, its use might have another beneficial role in stopping the progression of severe COVID-19 by removing pro-inflammatory cytokines during cytokine storm syndrome, which is postulated as the pathophysiology behind severe and critically severe cases of COVID-19. This review will cover a brief history of continuous renal replacement therapy and its modalities, before digging up more into its use in COVID-19 patients, including the optimum filtration dose and timing, membrane filtration used, vascular access, anticoagulation therapy, and drug dosing adjustment during continuous renal replacement therapy.
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Affiliation(s)
- Maharani Pradnya Paramitha
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Joshua Christian Suyanto
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Sri Puspitasari
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Hospital, Surabaya, Indonesia
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13
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Yessayan LT, Szamosfalvi B, Rosner MH. Management of dysnatremias with continuous renal replacement therapy. Semin Dial 2021; 34:472-479. [PMID: 34218456 DOI: 10.1111/sdi.12983] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/17/2021] [Accepted: 04/05/2021] [Indexed: 11/28/2022]
Abstract
Disorders of serum sodium concentration are common in critically ill patients who may have concomitant acute kidney injury, chronic kidney disease, or end-stage kidney disease. Many of these patients may require customized serum sodium level management with dialysis which, if not strictly controlled, can lead to significant complications. Thus, controlled correction of the serum sodium level is necessary to avoid the development of osmotic demyelination syndrome in hyponatremic patients and dialysis disequilibrium syndrome in hypernatremic patients. Continuous renal replacement therapy offers unique benefits through the ability to slowly and safely correct dysnatremias that can be tailored to specific patient needs and should be considered in select patients.
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Affiliation(s)
- Lenar T Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Balazs Szamosfalvi
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mitchell H Rosner
- Division of Nephrology, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
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14
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Basalely AM, Duong MD, Liu D, Zolotnitskaya A. Management of severe hyponatremia with low-dose continuous kidney replacement therapy and peripheral D5W in an infant with acute kidney injury. BMJ Case Rep 2021; 14:14/7/e240308. [PMID: 34215634 DOI: 10.1136/bcr-2020-240308] [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: 11/04/2022] Open
Abstract
We report a 7-month-old female infant who presented with anuric acute kidney injury and severe hyponatremia (serum sodium 110 mEq/L). The patient was treated with low-dose continuous kidney replacement therapy (CKRT), that is, 85% of total clearance dose divided equally between normonatric (Na 140 mEq/L) replacement and dialysate fluids. The remaining 15% of the clearance was provided by peripheral infusion of dextrose 5% (D5W). The patient's sodium was maintained between 119 mEq/L and 121 mEq/L for the first 24 hours of CKRT. Over the next 2 days, the rate of D5W infusion was slowly decreased while replacement and dialysis flow rates were proportionately increased. Serum sodium was normalised by day 2 of the therapy. The patient had no neurologic sequelae associated with this therapy.
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Affiliation(s)
- Abby Miriam Basalely
- Pediatric Nephrology, Cohen Children's Medical Center, New Hyde Park, New York, USA .,Pediatric Nephrology, Children's Hospital at Montefiore, Bronx, New York, USA
| | - Minh Dien Duong
- Pediatric Nephrology, Children's Hospital at Montefiore, Bronx, New York, USA
| | - Diane Liu
- Pediatric Nephrology, Children's Hospital at Montefiore, Bronx, New York, USA
| | - Anna Zolotnitskaya
- Pediatric Nephrology, Children's Hospital at Montefiore, Bronx, New York, USA
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15
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Valdenebro M, Martín-Rodríguez L, Tarragón B, Sánchez-Briales P, Portolés J. Renal replacement therapy in critically ill patients with acute kidney injury: 2020 nephrologist's perspective. Nefrologia 2021; 41:102-114. [PMID: 36166210 DOI: 10.1016/j.nefroe.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 07/28/2020] [Indexed: 06/16/2023] Open
Abstract
Renal replacement therapies (RRT) as support for acute kidney injury in critically ill patients have become a routine and essential practice in their management, resulting in the widespread use of various techniques among these patients, such as intermittent hemodialysis (IHD), extended hemodialysis and continuous RRT (CRRT). In this review we aim to summarize current evidence of indication, choice of modality, timing of initiation, dosing and technical aspects of RRT. We carried out a narrative review based on guidelines, consensus documents by main working groups and the latest relevant clinical trials on RRT in the critically ill. We did not find enough evidence of any RRT modality having superior benefits in terms of patient survival, length of intensive care unit/hospital stay or renal outcomes among critically ill patients, in spite of optimization of clinical indication, modality, timing of initiation and intensity of initial therapy. This is still a controverted matter, since only early start of high-flux CRRT has been proven beneficial over IHD among hemodynamically unstable postoperative patients. Our objective is to portrait current RRT practices in multidisciplinary management of critically ill patients by intensive care and nephrology professionals. Implication of a nephrologist in the assessment of hemodynamic status, coexisting medical conditions, renal outcome expectations and management of resources could potentially have benefits at the time of RRT selection and troubleshooting.
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Affiliation(s)
- María Valdenebro
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; RedinRen RETIC ISCIII 16/009/009
| | - Leyre Martín-Rodríguez
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; RedinRen RETIC ISCIII 16/009/009
| | - Blanca Tarragón
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Paula Sánchez-Briales
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Jose Portolés
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; RedinRen RETIC ISCIII 16/009/009.
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16
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Neyra JA, Yessayan L, Thompson Bastin ML, Wille KM, Tolwani AJ. How To Prescribe And Troubleshoot Continuous Renal Replacement Therapy: A Case-Based Review. KIDNEY360 2020; 2:371-384. [PMID: 35373031 PMCID: PMC8741005 DOI: 10.34067/kid.0004912020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 12/14/2020] [Indexed: 02/07/2023]
Abstract
Continuous RRT (CRRT) is the preferred dialysis modality for solute management, acid-base stability, and volume control in patients who are critically ill with AKI in the intensive care unit (ICU). CRRT offers multiple advantages over conventional hemodialysis in the critically ill population, such as greater hemodynamic stability, better fluid management, greater solute control, lower bleeding risk, and a more continuous (physiologic) approach of kidney support. Despite its frequent use, several aspects of CRRT delivery are still not fully standardized, or do not have solid evidence-based foundations. In this study, we provide a case-based review and recommendations of common scenarios and interventions encountered during the provision of CRRT to patients who are critically ill. Specific focus is on initial prescription, CRRT dosing, and adjustments related to severe hyponatremia management, concomitant extracorporeal membrane oxygenation support, dialysis catheter placement, use of regional citrate anticoagulation, and antibiotic dosing. This case-driven simulation is made as the clinical status of the patient evolves, and is on the basis of step-wise decisions made during the care of this patient, according to the specific patient's needs and the logistics available at the corresponding institution.
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Affiliation(s)
- Javier A. Neyra
- Division of Nephrology, Bone and Mineral Metabolism, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Melissa L. Thompson Bastin
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - Keith M Wille
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashita J Tolwani
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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17
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Tinawi M, Bastani B. A mathematical approach to severe hyponatremia and hypernatremia in renal replacement therapies. Semin Dial 2020; 34:42-50. [PMID: 33063373 DOI: 10.1111/sdi.12918] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Severe dysnatremias are perplexing problems in patients undergoing renal replacement therapy on a chronic or acute basis. The ability to manipulate sodium concentration in the dialysate or replacement solutions is limited. Compounding dialysate or replacement fluids to alter sodium concentration could result in errors. Rapid correction of hyponatremia or hypernatremia due to equilibrium with dialysate or replacement solutions could lead to osmotic demyelination syndrome or cerebral edema respectively. Continuous renal replacement therapy is the preferred dialysis modality in patients with severe dysnatremias. In this article, we present simple formulas to determine the rate of hypotonic or hypertonic solutions needed to mitigate rapid correction of dysnatremias. These formulas can be used readily by the clinician at bedside.
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Affiliation(s)
| | - Bahar Bastani
- Division of Nephrology, Saint Louis University Health Sciences Center, St. Louis, MO, USA
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18
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Tandukar S, Kim C, Kalra K, Verma S, Palevsky PM, Puttarajappa C. Severe Hyponatremia and Continuous Renal Replacement Therapy: Safety and Effectiveness of Low-Sodium Dialysate. Kidney Med 2020; 2:437-449. [PMID: 32775984 PMCID: PMC7406832 DOI: 10.1016/j.xkme.2020.05.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
RATIONALE & OBJECTIVE In patients with severe hyponatremia in the setting of acute kidney injury or end-stage kidney disease, continuous renal replacement therapy (CRRT) using standard-sodium (140 mEq/L) fluids may lead to excessively rapid correction of plasma sodium concentration. Use of dialysate and replacement fluids with reduced sodium concentrations can provide a controlled rate of correction of plasma sodium concentration. STUDY DESIGN We performed a single-center retrospective analysis of the safety and effectiveness of this approach in patients with plasma sodium concentrations ≤ 126 mEq/L who underwent CRRT for 24 or more hours using low-sodium (119 or 126 mEq/L) dialysate and replacement fluids. Change in plasma sodium level was assessed at 24 and 48 hours after initiation of low-sodium CRRT and at the end of treatment. SETTING & PARTICIPANTS Between January 2016 and June 2018, a total of 23 hyponatremic patients underwent continuous venovenous hemodiafiltration using low-sodium dialysate and replacement fluids; 4 patients were excluded from analysis because of CRRT duration less than <24 hours. RESULTS The 19 patients included in the study had a mean age of 56 years, 11 (58%) were men, and 15 (79%) were white. The initial mean plasma sodium level was 121 mEq/L and the initial CRRT effluent dose was 27 mL/kg/h. Only 2 (11%) patients had an increase in plasma sodium concentration > 6 mEq/L at 24 hours. Mean changes in plasma sodium levels at 24 and 48 hours and at the time of CRRT discontinuation were 3, 3, and 6 mEq/L, respectively. None of the patients developed osmotic demyelination syndrome. LIMITATIONS Key limitations were small sample size and lack of a control group. CONCLUSIONS Use of low-sodium dialysate and replacement fluids is a safe strategy for the prevention of overly rapid correction of plasma sodium levels in hyponatremic patients undergoing CRRT.
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Affiliation(s)
| | - Catherine Kim
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kartik Kalra
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Siddharth Verma
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Paul M. Palevsky
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA
- Renal Section, Medical Service, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Chethan Puttarajappa
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA
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19
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Griffin BR, Ambruso S, Jovanovich A, Bansal A, Linas S, Dylewski J. Continuous Renal Replacement Therapy Dosing in the Severely Underweight: A Case Report. Kidney Med 2019; 1:217-220. [PMID: 32734202 PMCID: PMC7380368 DOI: 10.1016/j.xkme.2019.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Guidelines recommend that patients treated with continuous renal replacement therapy be delivered an effluent dose of 20 to 25 mL/kg/h. There is debate, especially at the extremes of body mass index, as to whether actual or ideal body weight (IBW) should be used in these dose calculations. A middle-aged woman with severe anorexia presented with 48 hours of altered mental status. Laboratory tests showed severe metabolic acidosis necessitating intubation, which was ultimately found to be due to nonprescribed use of metformin for weight loss. The patient became anuric and was initiated on continuous venovenous hemodialysis. Due to refractory acidosis, the modality was converted to continuous venovenous hemodiafiltration by adding postfilter hypertonic bicarbonate solution. Based on changes in sodium and bicarbonate levels over 4 hours with hypertonic bicarbonate solution, we were able to calculate an “effective” volume of distribution for this severely underweight patient. Our calculations suggest that IBW gives a better approximation of effective volume of distribution than actual body weight in a severely underweight woman. Inadequate effluent flow rate calculated based on actual rather than IBW may lead to insufficient correction of metabolic derangements in extremely underweight patients.
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Affiliation(s)
- Benjamin R Griffin
- Division of Renal Diseases and Hypertension, University of Colorado Denver Anschutz Medical Campus, Aurora, CO
| | - Sophia Ambruso
- Division of Renal Diseases and Hypertension, University of Colorado Denver Anschutz Medical Campus, Aurora, CO.,Renal Section, VA Eastern Colorado Health Care System, Denver, CO
| | - Anna Jovanovich
- Division of Renal Diseases and Hypertension, University of Colorado Denver Anschutz Medical Campus, Aurora, CO.,Renal Section, VA Eastern Colorado Health Care System, Denver, CO
| | - Anip Bansal
- Division of Renal Diseases and Hypertension, University of Colorado Denver Anschutz Medical Campus, Aurora, CO
| | - Stu Linas
- Division of Renal Diseases and Hypertension, University of Colorado Denver Anschutz Medical Campus, Aurora, CO.,Division of Nephrology, Denver Health Medical Center, Denver, CO
| | - James Dylewski
- Division of Renal Diseases and Hypertension, University of Colorado Denver Anschutz Medical Campus, Aurora, CO.,Division of Nephrology, Denver Health Medical Center, Denver, CO
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20
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Practical document on the management of hyponatremia in critically ill patients. Med Intensiva 2019; 43:302-316. [PMID: 30678998 DOI: 10.1016/j.medin.2018.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 11/29/2018] [Accepted: 12/09/2018] [Indexed: 02/06/2023]
Abstract
Hyponatremia is the most prevalent electrolyte disorder in Intensive Care Units. It is associated with an increase in morbidity, mortality and hospital stay. The majority of the published studies are observational, retrospective and do not include critical patients; hence it is difficult to draw definitive conclusions. Moreover, the lack of clinical evidence has led to important dissimilarities in the recommendations coming from different scientific societies. Finally, etiopathogenic mechanisms leading to hyponatremia in the critical care patient are complex and often combined, and an intensive analysis is clearly needed. A study was therefore made to review all clinical aspects about hyponatremia management in the critical care setting. The aim was to develop a Spanish nationwide algorithm to standardize hyponatremia diagnosis and treatment in the critical care patient.
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21
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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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22
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Passos RDH, Caldas JR, Ramos JGR, Batista PBP, Noritomi DT, Akamine N, Junior MDSD, dos Santos BFC, Junior VGP, Monte JCM, Batista MC, dos Santos OFP. Acid base variables predict survival early in the course of treatment with continuous venovenous hemodiafiltration. Medicine (Baltimore) 2018; 97:e12221. [PMID: 30200141 PMCID: PMC6133476 DOI: 10.1097/md.0000000000012221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Metabolic acid-base disorders, especially metabolic acidosis, are common in critically ill patients who require renal replacement therapy. Continuous veno-venous hemodiafiltration (CVVHDF) achieves profound changes in acid-base status, but metabolic acidosis can remain unchanged or even deteriorate in some patients. The objective of this study is to understand the changes of acid-base variables in critically ill patients with septic associated acute kidney injury (SA-AKI) during CVVHDF and to determine how they relate to clinical outcome.Observational study of 200 subjects with SA-AKI treated with CVVHDF for at least 72 hours. Arterial blood gases and electrolytes and other relevant acid-base variables were analyzed using quantitative acid-base chemistry.Survivors and nonsurvivors had similar demographic characteristics and acid-base variables on day one of CVVHDF. However, during the next 48 hours, the resolution of acidosis was significantly different between the 2 groups, with an area under the ROC curve for standard base excess (SBE) and mortality of 0.62 (0.54-0.70), this was better than APACHE II score prediction power. Quantitative physicochemical analysis revealed that the majority of the change in SBE was due to changes in Cl and Na concentrations.Survivors of SA-AKI treated with CVVHDF recover hyperchloremic metabolic acidosis more rapidly than nonsurvivors. Further study is needed to determine if survival can be improved by measures to correct acidosis more rapidly.
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Affiliation(s)
| | | | | | | | | | - Nelson Akamine
- Departamento de Doentes Graves—Hospital Israelita Albert Einstein—São Paulo
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Wu B, Wang J, Yang G, Xing C, Mao H. Rapid calcium loss may cause arrhythmia in hemofiltration with regional citrate anticoagulation: a case report. BMC Nephrol 2018; 19:136. [PMID: 29898699 PMCID: PMC6000971 DOI: 10.1186/s12882-018-0936-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 05/30/2018] [Indexed: 11/24/2022] Open
Abstract
Background Renal replacement therapy (RRT) with regional citrate anticoagulation (RCA) is an important therapeutic approach for refractory hypercalcemia complicated with renal failure. However, RCA has the potential to induce arrhythmia caused by rapid calcium loss. We report a case of arrhythmia associated with rapid calcium loss during RCA-RRT. Case presentation A 51-year-old man with hypercalcemia, primary hyperparathyroidism, and acute kidney injury was treated by predilutional-RCA-hemofiltration at a rate of 4.3 L/h. The effect of lowering serum calcium was unsatisfactory despite reducing calcium substitution gradually from 5.3 to 2.2 mmol/h in the first 8-h session of RCA-hemofiltration. New-onset sinus tachycardia with a prolonged QT interval occurred when calcium substitution was infused at rate of 1.1 mmol/h after 15 min of starting the second RCA-hemofiltration session (estimated net calcium loss was 7.54 mmol/h). When the calcium substitution was increased to usual rate of 5.6 mmol/h, the arrhythmia disappeared after 2 min. Arrhythmia did not recur when the calcium substitution rate was 2.2 mmol/h during the third session (estimated net calcium loss was 6.44 mmol/L). After the third RCA-hemofiltration session, the patient underwent parathyroidectomy and serum calcium returned to normal. Conclusions This case indicated that rapid calcium loss may cause arrhythmia in RCA-hemofiltration, and the rate of net calcium loss should be limited below a threshold value to prevent similar adverse effect during RCA-RRT.
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Affiliation(s)
- Buyun Wu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Jing Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Huijuan Mao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
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Rosner MH, Connor MJ. Management of Severe Hyponatremia with Continuous Renal Replacement Therapies. Clin J Am Soc Nephrol 2018; 13:787-789. [PMID: 29463598 PMCID: PMC5969490 DOI: 10.2215/cjn.13281117] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Mitchell H. Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia; and
| | - Michael J. Connor
- Divisions of Pulmonary, Allergy, Critical Care, and Sleep Medicine and
- Renal Medicine, Emory University School of Medicine, Atlanta, Georgia
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Zheng S, Weng Q, Wu W, Ding G. Blood purification treatment initiated at the time of sepsis diagnosis effectively attenuates serum HMGB1 upregulation and improves patient prognosis. Exp Ther Med 2017; 14:3029-3035. [PMID: 28912856 PMCID: PMC5585716 DOI: 10.3892/etm.2017.4854] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 05/05/2017] [Indexed: 01/21/2023] Open
Abstract
The aim of the present study was to investigate the increase in serum and urine levels of high mobility group box protein 1 (HMGB1) during sepsis and the effect of blood purification treatments on HMGB1 levels and patient prognosis. A total of 40 intensive care patients with sepsis were randomly assigned to different groups (n=10 per group): A control group (sepsis group), a continuous renal replacement treatment (CRRT) group, a hemoperfusion (HP) group and an HP+CRRT group. The blood purification treatments using HP and/or CRRT were performed immediately after the diagnosis of sepsis. HMGB1 levels were measured using ELISA, and Acute Physiology and Chronic Health Evaluation (APACHE) II scores and 30-day survival rates were evaluated. Relative to a healthy control group (n=10), HMGB1 levels were observed to be significantly upregulated during sepsis (P<0.05). Following the initiation of sepsis, serum HMGB1 continued to increase in the sepsis group and was significantly elevated at 24 h (P<0.05), whereas urine HMGB1 levels decreased significantly at 12 and 24 h (P<0.05). Serum HMGB1 levels were significantly positively correlated with APACHE II scores (r=0.7284, P<0.01) and significantly negatively correlated with urine HMGB1 levels (r=−0.5103, P=0.026). Serum HMGB1 levels were significantly reduced in the HP and HP+CRRT groups by 12 and 24 h following the initiation of treatment (both P<0.05). Changes in the urine HMGB1 level differed in each group. Relative to the sepsis group, the APACHE II scores of all blood purification groups were significantly reduced (P<0.05) and the 30-day survival rate of the HP+CRRT group was significantly increased (P=0.0107). The results of the present study indicate that blood purification initiated at the point of diagnosis in patients with sepsis may attenuate serum HMGB1 upregulation, promote urinary excretion of HMGB1 and improve the prognosis of sepsis.
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Affiliation(s)
- Shixiang Zheng
- Division of Critical Care Medicine, Union Hospital of Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
| | - Qinyong Weng
- Division of Critical Care Medicine, Union Hospital of Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
| | - Wenwei Wu
- Division of Critical Care Medicine, Union Hospital of Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
| | - Guohua Ding
- Division of Nephrology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430000, P.R. China
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Hamdi T, Yessayan L, Yee J, Szamosfalvi B. High sodium continuous veno-venous hemodialysis with regional citrate anticoagulation and online dialysate generation in patients with acute liver failure and cerebral edema. Hemodial Int 2017; 22:184-191. [DOI: 10.1111/hdi.12572] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Tamim Hamdi
- Department of Internal Medicine, Division of Nephrology; UT Southwestern; Dallas TX USA
| | - Lenar Yessayan
- Department of Internal Medicine, Division of Nephrology; University of Michigan; Ann Arbor MI USA
| | - Jerry Yee
- Department of Internal Medicine, Division of Nephrology; Henry Ford Hospital; Detroit MI USA
| | - Balazs Szamosfalvi
- Department of Internal Medicine, Division of Nephrology; University of Michigan; Ann Arbor MI USA
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Heung M, Yessayan L. Renal Replacement Therapy in Acute Kidney Injury: Controversies and Consensus. Crit Care Clin 2017; 33:365-378. [PMID: 28284300 DOI: 10.1016/j.ccc.2016.12.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute kidney injury (AKI) is a common complication among critically ill patents, and 5% of intensive care unit (ICU) patients require initiation of renal replacement therapy (RRT). In recent years, clinical trials have provided evidence-based guidance for some important aspects of RRT management in patients with AKI, such as dialysis dosing and approaches to anticoagulation in patients undergoing continuous RRT. However, there remain many areas of uncertainty, and delivery of RRT in the ICU requires clinical judgment, flexibility, and an understanding of dialysis principles. This article reviews the components of RRT prescription and provides an update on best practices.
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Affiliation(s)
- Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, 1500 East Medical Center Drive, SPC 5364, Ann Arbor, MI 48109-5364, USA.
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, 1500 East Medical Center Drive, SPC 5364, Ann Arbor, MI 48109-5364, USA
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