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Ferrari F, Milla P, Sartori M, Zanza C, Tesauro M, Longhitano Y, De Silvestri A, Abbruzzese C, De Rosa S, Lassola S, Samoni S, Brendolan A, Zanella M, Scaravilli V, Grasselli G, Arpicco S, Ronco C. Antibiotics Removal during Continuous Renal Replacement Therapy in Septic Shock Patients: Mixed Modality Versus "Expanded Haemodialysis". Clin Pharmacokinet 2024; 63:1167-1176. [PMID: 39102092 DOI: 10.1007/s40262-024-01397-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND AND OBJECTIVE Renal replacement therapy (RRT) plays a critical role in antimicrobial removal, particularly for low-molecular-weight drugs with low plasma protein binding, low distribution volume and hydrophilicity. Medium cut-off (MCO) membranes represent a new generation in dialysis technology, enhancing diffusive modality efficacy and increasing the cut-off from 30 to 45 kDa, crucial for middle molecule removal. This monocentric randomized crossover pilot study aimed to evaluate the impact of continuous haemodialysis with MCO membrane (MCO-CVVHD) on the removal of piperacillin, tazobactam and meropenem compared with continuous veno-venous hemodiafiltration with standard high-flux membrane (HFM-CVVHDF). METHODS Twenty patients were randomized to undergo MCO-CVVHD followed by HFM-CVVHDF or vice versa. Extraction ratio (ER), effluent clearance (Cleff) and treatment efficiency were assessed at various intervals. Antibiotic nadir plasma levels were measured for both treatment days. RESULTS HFM-CVVHDF showed greater ER compared with MCO-CVVHD for meropenem (β = - 8.90 (95% CI - 12.9 to - 4.87), p < 0.001) and tazobactam (β = - 8.29 (95% CI - 13.5 to - 3.08), p = 0.002) and Cleff for each antibiotic (meropenem β = - 10,206 (95% CI - 14,787 to - 5787), p = 0.001); tazobactam (β = - 4551 (95% CI - 7781 to - 1322), p = 0.012); piperacillin (β = - 3913 (95% CI - 6388 to - 1437), p = 0.002), even if the carryover effect influenced the Cleff for meropenem and tazobactam. No difference was observed in nadir plasma concentrations or efficiency for any antibiotic. Piperacillin (β = - 38.1 (95% CI - 47.9 to - 28.3), p < 0.001) and tazobactam (β = - 4.45 (95% CI - 6.17 to - 2.72), p < 0.001) showed lower nadir plasma concentrations the second day compared with the first day, regardless the filter type. CONCLUSION MCO demonstrated comparable in vivo removal of piperacillin, tazobactam and meropenem to HFM.
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Affiliation(s)
- Fiorenza Ferrari
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Milla
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Marco Sartori
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Christian Zanza
- Geriatric Medicine Residency Program, University of Rome "Tor Vergata", 00133, Rome, Italy.
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA.
| | - Manfredi Tesauro
- Geriatric Medicine Residency Program, University of Rome "Tor Vergata", 00133, Rome, Italy
- Department of Systems Medicine, University of Rome "Tor Vergata", 00133, Rome, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Department of Emergency Medicine-Emergency Medicine Residency Program, Humanitas University-Research Hospital, 20089, Rozzano, Italy
| | - Annalisa De Silvestri
- SSD Biostatistica e Clinical Trial Center, Direzione Scientifica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chiara Abbruzzese
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia De Rosa
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy
- Centre for Medical Sciences-CISMed, University of Trento, Trento, Italy
| | - Sergio Lassola
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy
| | - Sara Samoni
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
- Departement of Nephrology, Dialysis and Renal Transplantation, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Brendolan
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Monica Zanella
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Vittorio Scaravilli
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Giacomo Grasselli
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Silvia Arpicco
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
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Cabanilla MG, Briski MJ, Bruss Z, Saa L, Vasquez PC, Rodriguez CN, Mitchell JA, Bernauer ML, Argyropoulos CP, Crandall CS, Teixeira JP. The influence of continuous renal replacement therapy on 1,3-β-d-glucan levels in critically ill patients: a single-center retrospective propensity score study. Ren Fail 2023; 45:2255680. [PMID: 37781748 PMCID: PMC10547441 DOI: 10.1080/0886022x.2023.2255680] [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: 05/23/2023] [Accepted: 08/31/2023] [Indexed: 10/03/2023] Open
Abstract
1,3-β-d-Glucan (BDG) is commonly used for diagnosing invasive fungal infections (IFIs). While exposure to cellulose-based hemodialyzers is known to cause false-positive BDG results, the impact of modern hemofilters used in continuous renal replacement therapy (CRRT) remains unclear. This retrospective, single-center cohort study aimed to evaluate the effect of CRRT on BDG levels in critically ill patients. We included adult intensive care unit (ICU) patients with ≥1 BDG measurement between December 2019 and December 2020. The primary outcome was the rate of false-positive BDG results in patients exposed to CRRT compared to unexposed patients. Propensity score analysis was performed to control for confounding factors. A total of 103 ICU patients with ≥1 BDG level were identified. Most (72.8%) were medical ICU patients. Forty patients underwent CRRT using hemofilter membranes composed of sodium methallyl sulfonate copolymer (AN 69 HF) (82.5%) and of polyarylethersulfone (PAES) (17.5%). Among the 91 patients without proven IFI, 31 (34.1%) had false-positive BDG results. Univariable analysis showed an association between CRRT exposure and false-positive BDG results. However, the association between CRRT exposure and false-positive BDG results was no longer significant across three propensity score models employed: 1:1 match (n = 32) (odds ratio (OR) 1.65, p = .48), model-adjusted (n = 91) (OR 1.75, p = .38), quintile-adjusted (n = 91) (OR 1.78, p = .36). In this single-center retrospective analysis, exposure to synthetic CRRT membranes did not independently increase the risk of false-positive BDG results. Larger prospective studies are needed to further evaluate the association between CRRT exposure and false-positive BDG results in critically ill patients with suspected IFI.
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Affiliation(s)
- M. Gabriela Cabanilla
- Department of Internal Medicine and Department of Pharmacy, Division of Infectious Diseases, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Matthew J. Briski
- Department of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Zachary Bruss
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Lisa Saa
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Pamela C. Vasquez
- Department of Internal Medicine, Division of Nephrology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Chelsea N. Rodriguez
- Department of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Jessica A. Mitchell
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | | | - Christos P. Argyropoulos
- Department of Internal Medicine, Division of Nephrology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Cameron S. Crandall
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - J. Pedro Teixeira
- Department of Internal Medicine, Division of Nephrology, Division of Pulmonary, Critical Care and Sleep Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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Thanapongsatorn P, Sinjira T, Kaewdoungtien P, Kusirisin P, Kulvichit W, Sirivongrangson P, Peerapornratana S, Lumlertgul N, Srisawat N. Standard versus no post-filter ionized calcium monitoring in regional citrate anticoagulation for continuous renal replacement therapy (NPC trial). Clin Kidney J 2023; 16:1469-1479. [PMID: 37664560 PMCID: PMC10468745 DOI: 10.1093/ckj/sfad069] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Indexed: 09/05/2023] Open
Abstract
Background Current guidelines recommend monitoring of post-filter ionized calcium (pfCa) when using regional citrate anticoagulation during continuous renal replacement therapy (RCA-CRRT) to determine citrate efficiency for the prevention of filter clotting. However, the reliability of pfCa raises the question of whether routine monitoring is required. Reducing the frequency of pfCa monitoring could potentially reduce costs and workload. Our objective was to test the efficacy and safety of no pfCa monitoring among critically ill patients receiving RCA-CRRT. Methods This study was a non-inferiority randomized controlled trial conducted between January 2021 and October 2021 at King Chulalongkorn Memorial Hospital, Thailand. Critically ill patients who were treated with RCA-CRRT were randomized to receive either standard pfCa monitoring (aiming pfCa level of 0.25-0.35 mmol/L), or no pfCa monitoring, in which a constant rate of citrate infusion was maintained at pre-determined citrate concentrations of 4 mmol/L with blinding of pfCa levels to treating clinicians. The primary outcome was the filter lifespan. Non-inferiority would be demonstrated if the upper limit of the 95% confidence interval (CI) for the difference in filter lifespan between the groups was less than 20 h. Results Fifty patients were randomized to the standard pfCa monitoring group (n = 25) or no pfCa monitoring group (n = 25). The mean filter lifespan was 54 ± 20 h in the standard pfCa monitoring group and 47 ± 23 h in the no pfCa monitoring group (absolute difference 7.1 h; 95% CI -5.3, 19.5, P = .25). When restricting the analysis to circuits reaching the maximum duration of circuit lifespan at 72 h and clotted filters, the filter lifespan was 61 ± 17 h in the standard pfCa group vs 60 ± 19 h in the no pfCa monitoring group (absolute difference 0.9 h; 95% CI -11.5, 13.4, P = .88). Compared with the no pfCa monitoring group, the standard pfCa monitoring group had a significantly higher mean citrate concentrations (4.43 ± 0.32 vs 4 mmol/L, P < .001) and a higher rate of severe hypocalcemia (44% vs 20%, P = .13). No statistical differences were found in filter clotting, citrate accumulation, citrate overload and mortality between the two groups. Conclusions Among critically ill patients receiving RCA-CRRT, no pfCa monitoring by maintaining the citrate concentrations of 4 mmol/L is feasible. Larger randomized controlled trials should be conducted to ensure the efficacy, safety and cost-effectiveness of this strategy. Trial registration ClinicalTrials.gov: NCT04792424 (registered 11 March 2021).
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Affiliation(s)
- Peerapat Thanapongsatorn
- Department of Medicine, Central Chest Institute of Thailand, Nonthaburi, Thailand
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Tanyapim Sinjira
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Piyanut Kaewdoungtien
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Prit Kusirisin
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Win Kulvichit
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Sadudee Peerapornratana
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Laboratory Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nuttha Lumlertgul
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nattachai Srisawat
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Academy of Science, Royal Society of Thailand, Bangkok, Thailand
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Whiting L, Bianchi N, Faouzi M, Schneider A. Kinetics of small and middle molecule clearance during continuous hemodialysis. Sci Rep 2023; 13:12905. [PMID: 37558740 PMCID: PMC10412530 DOI: 10.1038/s41598-023-40075-y] [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: 10/10/2022] [Accepted: 08/04/2023] [Indexed: 08/11/2023] Open
Abstract
Regional citrate anticoagulation (RCA) enables prolonged continuous kidney replacement therapy (CKRT) filter lifespan. However, membrane diffusive performance might progressively decrease and remain unnoticed. We prospectively evaluated the kinetics of solute clearance and factors associated with decreased membrane performance in 135 consecutive CKRT-RCA circuits (35 patients). We recorded baseline patients' characteristics and clinical signs of decreased membrane performance. We calculated effluent/serum ratios (ESR) as well as respective clearances for urea, creatinine and β2-microglobuline at 12, 24, 48 and 72 h after circuit initiation. Using mixed-effects logistic regression model analyses, we assessed the effect of time on those values and determined independent predictors of decreased membrane performance as defined by an ESR for urea < 0.81. We observed a minor but statistically significant decrease in both ESR and solute clearance across the duration of therapy for all three solutes. We observed decreased membrane performance in 31 (23%) circuits while clinical signs were present in 19 (14.1%). The risk of decreased membrane performance significantly increased over time: 1.8% at T1 (p = 0.16); 7.3% at T2 (p = 0.01); 15.7% at T3 (p = 0.001) and 16.4% at T4 (p < 0.003). Four factors present within 24 h of circuit initiation were independently associated with decreased membrane performance: arterial blood bicarbonate level (OR 1.50; p < 0.001), activated partial thromboplastin time (aPTT; OR = 0.93; p = 0.02), fibrinogen level (OR 6.40; p = 0.03) and Charlson score (OR 0.10; p < 0.01). COVID-19 infection was not associated with increased risk of decreased membrane performance. Regular monitoring of ESR might be appropriate in selected patients undergoing CKRT.
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Affiliation(s)
- Livia Whiting
- Service de Médecine Intensive Adulte (SMIA), Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nathan Bianchi
- Service de Médecine Intensive Adulte (SMIA), Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Mohamed Faouzi
- Division of Biostatistics, Center for Primary Care and Public Health (UNISANTE), University of Lausanne, Lausanne, Switzerland
| | - Antoine Schneider
- Service de Médecine Intensive Adulte (SMIA), Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
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Fayad AI, Buamscha DG, Ciapponi A. Timing of kidney replacement therapy initiation for acute kidney injury. Cochrane Database Syst Rev 2022; 11:CD010612. [PMID: 36416787 PMCID: PMC9683115 DOI: 10.1002/14651858.cd010612.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common condition among patients in intensive care units (ICUs) and is associated with high numbers of deaths. Kidney replacement therapy (KRT) is a blood purification technique used to treat the most severe forms of AKI. The optimal time to initiate KRT so as to improve clinical outcomes remains uncertain. This is an update of a review first published in 2018. This review complements another Cochrane review by the same authors: Intensity of continuous renal replacement therapy for acute kidney injury. OBJECTIVES To assess the effects of different timing (early and standard) of KRT initiation on death and recovery of kidney function in critically ill patients with AKI. SEARCH METHODS We searched the Cochrane Kidney and Transplant's Specialised Register to 4 August 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register, ClinicalTrials and LILACS to 1 August 2022. SELECTION CRITERIA We included all randomised controlled trials (RCTs). We included all patients with AKI in the ICU regardless of age, comparing early versus standard KRT initiation. For safety and cost outcomes, we planned to include cohort studies and non-RCTs. DATA COLLECTION AND ANALYSIS Data were extracted independently by two authors. The random-effects model was used, and results were reported as risk ratios(RR) for dichotomous outcomes and mean difference(MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS We included 12 studies enrolling 4880 participants. Overall, most domains were assessed as being at low or unclear risk of bias. Compared to standard treatment, early KRT initiation may have little to no difference on the risk of death at day 30 (12 studies, 4826 participants: RR 0.97,95% CI 0.87 to 1.09; I²= 29%; low certainty evidence), and death after 30 days (7 studies, 4534 participants: RR 0.99, 95% CI 0.92 to 1.07; I² = 6%; moderate certainty evidence). Early KRT initiation may make little or no difference to the risk of death or non-recovery of kidney function at 90 days (6 studies, 4011 participants: RR 0.91, 95% CI 0.74 to 1.11; I² = 66%; low certainty evidence); CIs included both benefits and harms. Low certainty evidence showed early KRT initiation may make little or no difference to the number of patients who were free from KRT (10 studies, 4717 participants: RR 1.07, 95% CI 0.94 to1.22; I² = 55%) and recovery of kidney function among survivors who were free from KRT after day 30 (10 studies, 2510 participants: RR 1.02, 95% CI 0.97 to 1.07; I² = 69%) compared to standard treatment. High certainty evidence showed early KRT initiation increased the risk of hypophosphataemia (1 study, 2927 participants: RR 1.80, 95% CI 1.33 to 2.44), hypotension (5 studies, 3864 participants: RR 1.54, 95% CI 1.29 to 1.85; I² = 0%), cardiac-rhythm disorder (6 studies, 4483 participants: RR 1.35, 95% CI 1.04 to 1.75; I² = 16%), and infection (5 studies, 4252 participants: RR 1.33, 95% CI 1.00 to 1.77; I² = 0%); however, it is uncertain whether early KRT initiation increases or reduces the number of patients who experienced any adverse events (5 studies, 3983 participants: RR 1.23, 95% CI 0.90 to 1.68; I² = 91%; very low certainty evidence). Moderate certainty evidence showed early KRT initiation probably reduces the number of days in hospital (7 studies, 4589 participants: MD-2.45 days, 95% CI -4.75 to -0.14; I² = 10%) and length of stay in ICU (5 studies, 4240 participants: MD -1.01 days, 95% CI -1.60 to -0.42; I² = 0%). AUTHORS' CONCLUSIONS Based on mainly low to moderate certainty of the evidence, early KRT has no beneficial effect on death and may increase the recovery of kidney function. Earlier KRT probably reduces the length of ICU and hospital stay but increases the risk of adverse events. Further adequate-powered RCTs using robust and validated tools that complement clinical judgement are needed to define the optimal time of KRT in critical patients with AKI in order to improve their outcomes. The surgical AKI population should be considered in future research.
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Affiliation(s)
- Alicia Isabel Fayad
- Pediatric Nephrology, Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina
| | - Daniel G Buamscha
- Pediatric Critical Care Unit, Juan Garrahan Children's Hospital, Buenos Aires, Argentina
| | - Agustín Ciapponi
- Argentine Cochrane Centre, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Buenos Aires, Argentina
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Chen H, Klainbart S, Kelmer E, Segev G. Continuous renal replacement therapy is a safe and effective modality for the initial management of dogs with acute kidney injury. J Am Vet Med Assoc 2022; 261:87-96. [PMID: 36288204 DOI: 10.2460/javma.22.07.0294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe the management of dogs with acute kidney injury (AKI) by continuous renal replacement therapy (CRRT), and to investigate the relationship between a prescribed CRRT dose, the hourly urea reduction ratio (URR), and the overall efficacy. ANIMALS 45 client-owned dogs diagnosed with severe AKI, receiving 48 CRRT treatments at a veterinary teaching hospital. PROCEDURES Retrospective study. Search of medical records of dogs with AKI managed by CRRT. RESULTS Median serum urea and creatinine at CRRT initiation were 252 mg/dL [Inter quartile range (IQR), 148 mg/dL; range, 64 to 603 mg/dL] and 9.0 mg/dL (IQR, 7 mg/dL; range, 4.3 to 42.2 mg/dL), respectively. Median treatment duration was 21 hours (IQR, 8.8 hours; range, 3 to 32 hours). Systemic heparinization and regional citrate anticoagulation were used in 24 treatments each (50%). The prescribed median CRRT dose for the entire treatment was 1 mL/kg/min (IQR, 0.4 mL/kg/min; range, 0.3 to 2.5 mL/kg/min). The median hourly URR was 4% (IQR, 1%; range, 2% to 12%), overall URR was 76% (IQR, 30%; range, 11% to 92%) and median Kt/V was 2.34 (IQR, 1.9; range, 0.24 to 7.02). The CRRT dose was increased gradually from 0.9 mL/kg/min to 1.4 mL/kg/min (P < .001) and the hourly URR decreased from 6.5% to 5.5% (P = .05). The main complication was clotting of the extra-corporeal circuit, occurring in 6/48 treatments (13%). Twenty-four dogs (53%) survived to discharge. CLINICAL RELEVANCE CRRT is safe when the prescription is based on the current veterinary guidelines for gradual urea reduction. Treatment efficacy can be maximized by gradually increasing the dose according to the actual URR.
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Affiliation(s)
- Hilla Chen
- Veterinary Teaching Hospital, Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Sigal Klainbart
- Veterinary Teaching Hospital, Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Efrat Kelmer
- Veterinary Teaching Hospital, Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Gilad Segev
- Veterinary Teaching Hospital, Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
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Chiao C, Faust H, Singh T. Regional citrate and systemic heparin are adequate to maintain filter half-life for COVID-19 patients on continuous renal replacement therapy. Semin Dial 2022; 35:325-329. [PMID: 35141966 PMCID: PMC9115506 DOI: 10.1111/sdi.13061] [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: 05/13/2021] [Revised: 08/23/2021] [Accepted: 01/23/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The aim of our study is to compare clotting of CRRT filters in patients with COVID-19-associated AKI versus septic shock-associated AKI. METHODS Retrospective study of adult ICU patients with COVID-19 compared to those with septic shock admitted to a tertiary hospital April-October 2020. Independent t test and chi-square test used to determine statistical significance of CRRT filter clotting between the two groups. Time-to-event data analyzed with Kaplan-Meier curves. Analyses performed on Microsoft Excel and MedCalc. RESULTS Twenty-seven ICU patients with AKI requiring CRRT were included, 13 with COVID-19 and 14 non-COVID-19 patients with septic shock. The mean half-life of CRRT hemofilter was similar in COVID-19 patients compared to non-COVID-19 patients (27.4 vs. 27.5 h, p = 0.79). The number of CRRT hemofilter changes per day was similar in both groups (0.6 filter changes per day, p = 0.84). However, significantly more patients with COVID-19 were on systemic heparin (69% vs. 13%, p = 0.02). CONCLUSION We found that COVID-19 patients with AKI requiring CRRT had similar CRRT hemofilter half-life compared with sepsis-associated AKI patients with use of regional citrate and systemic heparin. Further studies are needed to find which methods of anticoagulation are optimal in patients with COVID-19 infection with AKI requiring CRRT.
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Affiliation(s)
- Cassandra Chiao
- Department of MedicineUniversity of Wisconsin‐Madison School of Medicine and Public HealthMadisonWisconsinUSA
| | - Hilary Faust
- Department of MedicineUniversity of Wisconsin‐Madison School of Medicine and Public HealthMadisonWisconsinUSA
| | - Tripti Singh
- Department of MedicineUniversity of Wisconsin‐Madison School of Medicine and Public HealthMadisonWisconsinUSA
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Whiting L, Bianchi NA, Alouazen K, Joannes-Boyau O, Chiche JD, Schneider A. Validation of a Protocol for Continuous Hemodiafiltration with Regional Citrate Anticoagulation with Omni®. Blood Purif 2022; 51:1039-1047. [PMID: 35636389 PMCID: PMC9808739 DOI: 10.1159/000524329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/22/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Omni® (B Braun, Melsungen, Germany) is able to run continuous renal replacement therapy (CRRT) in continuous veno-venous hemofiltration (CVVH), hemodialysis (CVVHD), and hemodiafiltration (CVVHDF) modes. However, to date, there is no validated protocol to guide the use of Omni® in CVVHDF mode with regional citrate anticoagulation (RCA). METHODS We designed a protocol for CVVHDF-RCA tailored for Omni®. This protocol was tested in patients included in an observational study conducted in our center between January and March 2021. For all study patients, we collected baseline characteristics, laboratory results, CRRT circuit lifespan as well as plasma and effluent samples at 12, 24, 48, and 72 h of CRRT circuit initiation. At each study time point, we computed urea, creatinine, and β2-microglobulin clearance as well as effluent/blood ratios. Data from circuits in CVVHDF-RCA mode are compared with those in standard therapy (CVVHD-RCA) with the same device. RESULTS We analyzed ten circuits (5 patients) in CVVHDF-RCA mode and 32 (13 patients) in CVVHD-RCA mode. No adverse events related to the therapy were observed. In CVVHDF-RCA mode, median circuit running time was 68 (IQR 8.1) hours versus 46 (IQR 9.0) in CVVHD mode, p = 0.053. Therapy adaptations (dialysate rate and/or blood flow) were required in one (10%) circuit (15.6% in CVVHD mode, p = 0.56). Compared to CVVHD, CVVHDF was able to achieve similar clearance and effluent/blood ratio for urea, creatinine, and β2-microglobulin across the entire duration of circuit lifetime. CONCLUSION The proposed protocol for CVVHDF-RCA for Omni® was associated with similar circuit lifetime, number of required adaptations and clearances to standard CVVHD-RCA. It appears to be safe and feasible.
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Affiliation(s)
- Livia Whiting
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland,
| | - Nathan Axel Bianchi
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Karima Alouazen
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Olivier Joannes-Boyau
- Service d'Anesthésie-Réanimation Sud, Centre Médico-Chirurgical Magellan, Centre Hospitalier Universitaire (CHU) de Bordeaux, Bordeaux, France
| | - Jean-Daniel Chiche
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Antoine Schneider
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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9
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Ferrari F, Husain-Syed F, Milla P, Lorenzin A, Scudeller L, Sartori M, Gramaticopolo S, D'Auria L, Guglielmi A, Cornara P, De Rosa S, Zanella M, Corradi V, De Cal M, Danzi V, Giavarina D, Brendolan A, Mojoli F, Arpicco S, Ronco C. Clinical Assessment of Continuous Hemodialysis with the Medium Cutoff EMiC®2 Membrane in Patients with Septic Shock. Blood Purif 2022; 51:912-922. [PMID: 35263746 DOI: 10.1159/000522321] [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: 10/05/2021] [Accepted: 01/28/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION At the time of renal replacement therapy, approximately 20% of critically ill patients have septic shock. In this study, medium cutoff (MCO) continuous venovenous hemodialysis (CVVHD) was compared to high-flux membrane continuous venovenous hemodiafiltration (CVVHDF) in terms of hemodynamic improvement, efficiency, middle molecule removal, and inflammatory system activation. METHODS This is a monocenter crossover randomized study. Between December 31, 2017, and December 31, 2019, 20 patients with septic shock and stage 3 acute kidney injury (AKI) admitted to 2 Italian ICUs were enrolled. All patients underwent CVVHD with Ultraflux® EMiC®2 and CVVHDF with AV1000S® without washout. Each treatment lasted 24 h. RESULTS Compared to AV1000S®-CVVHDF, EMIC®2-CVVHD normalized cardiac index (β = -0.64; p = 0.02) and heart rate (β = 5.72; p = 0.01). Interleukin-8 and myeloperoxidase removal were greater with AV1000S®-CVVHDF than with EMiC®2-CVVHD (β = 0.35; p < 0.001; β = 0.43; p = 0.03, respectively). Leukocytosis improved over 24 h in EMiC®2-CVVHD-treated patients (β = 4.13; p = 0.03), whereas procalcitonin levels decreased regardless of the modality (β = 0.89; p = 0.01) over a 48-h treatment period. Reduction rates, instantaneous plasmatic clearance of urea, creatinine, and β2-microglobulin were similar across modalities. β2-Microglobulin removal efficacy was greater in the EMiC®2 group (β = 0-2.88; p = 0.002), while albumin levels did not differ. Albumin was undetectable in the effluent in both treatments. DISCUSSION In patients with septic shock and severe AKI, the efficacy of uremic toxin removal was comparable between MCO-CVVHD and CVVHDF. Further, MCO-CVVHD was associated with improved hemodynamics. Fraction of filtration and transmembrane pressure reduction and the maintenance of equal efficacy might be the key features of CVVHD with MCO membranes in critically ill patients.
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Affiliation(s)
- Fiorenza Ferrari
- Department of Anesthesia and Intensive Care Unit, I.R.C.C.S., San Matteo Hospital and University of Pavia, Pavia, Italy.,International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Faeq Husain-Syed
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy.,Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Giessen, Germany
| | - Paola Milla
- Dipartimento di Scienza e Tecnologia del Farmaco, Università degli Studi di Torino, Turin, Italy
| | - Anna Lorenzin
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Luigia Scudeller
- Research and Innovation Unit, I. R.C.C.S., Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Sartori
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Silvia Gramaticopolo
- Department of Anesthesia and Intensive Care, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Luigi D'Auria
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Angelo Guglielmi
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Pietro Cornara
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Silvia De Rosa
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy.,Department of Anesthesia and Intensive Care, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Monica Zanella
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Valentina Corradi
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Massimo De Cal
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Vinicio Danzi
- Department of Anesthesia and Intensive Care, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Davide Giavarina
- Department of Clinical Chemistry and Hematology Laboratory, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Alessandra Brendolan
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Francesco Mojoli
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Silvia Arpicco
- Dipartimento di Scienza e Tecnologia del Farmaco, Università degli Studi di Torino, Turin, Italy
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy.,Department of Medicine (DIMED), Università di Padova, Padua, Italy
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10
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Hang C, Liu LJ, Huang ZY, Zhu JL, Zhou BC, Li XZ. Optimal indicator for changing the filter during the continuous renal replacement therapy in intensive care unit patients with acute kidney injury: A crossover randomized trial. World J Emerg Med 2022; 13:196-201. [PMID: 35646215 PMCID: PMC9108922 DOI: 10.5847/wjem.j.1920-8642.2022.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 01/12/2022] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND The study aims to investigate an optimal indicator for changing the filter during the continuous renal replacement therapy (CRRT) in intensive care unit (ICU) patients with acute kidney injury (AKI). METHODS Patients with AKI requiring CRRT in an ICU were randomly divided into two groups for crossover trial, i.e., groups A and B. Patients in the group A were firstly treated with continuous veno-venous hemofiltration (CVVH), followed by continuous veno-venous hemodiafiltration (CVVHDF). Patients in the group B were firstly treated with CVVHDF followed by CVVH. Delivered doses of solutes with different molecular weights at the indicated time points between groups were compared. A correlation analysis between the delivered dose and pre-filter pressure (PPRE) and transmembrane pressure (PTM) was performed. Receiver operating characteristic (ROC) curves were constructed to evaluate the accuracy of PTM as an indicator for filter replacement. RESULTS A total of 50 cases were analyzed, 27 in the group A and 23 in the group B. Delivered doses of different molecular-weight solutes significantly decreased before changing the filter in both modalities, compared with those at the initiation of treatment (all P<0.05). In the late stage of CRRT, the possible rebound of serum medium-molecular-weight solute concentration was observed. PTM was negatively correlated with the delivered dose of medium-molecular-weight solute in both modalities. The threshold for predicting the rebound of serum concentration of medium-molecular-weight solute by PTM was 146.5 mmHg (1 mmHg=0.133 kPa). CONCLUSIONS The filter can be used as long as possible within the manufacturer's safe use time limits to remove small-molecular-weight solutes. PTM of 146.5 mmHg may be an optimal indicator for changing the filter in CRRT therapies to remove medium-molecular-weight solutes.
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Affiliation(s)
- Cheng Hang
- Intensive Care Unit, Kunshan Hospital of TCM, Suzhou 215300, China
| | - Li-jun Liu
- Intensive Care Unit, the Second Affiliated Hospital of Soochow University, Suzhou 215004, China
| | - Zhao-yun Huang
- Intensive Care Unit, Kunshan Hospital of TCM, Suzhou 215300, China
| | - Jian-liang Zhu
- Intensive Care Unit, the Second Affiliated Hospital of Soochow University, Suzhou 215004, China
| | - Bao-chun Zhou
- Intensive Care Unit, the Second Affiliated Hospital of Soochow University, Suzhou 215004, China
| | - Xiao-zhen Li
- Intensive Care Unit, the Second Affiliated Hospital of Soochow University, Suzhou 215004, China
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11
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Xu Q, Jiang B, Li J, Lu W, Li J. Comparison of CVVH and CVVHDF on filter lifespan and solute removal - a randomized controlled trial. Ther Apher Dial 2021; 26:1030-1039. [PMID: 34967496 DOI: 10.1111/1744-9987.13787] [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: 07/07/2021] [Revised: 12/19/2021] [Accepted: 12/24/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION This study aimed to investigate whether Continuous Veno-Venous Hemodiafiltration (CVVHDF) has a different filter lifespan and molecular solutes clearance when compared to Continuous Veno-Venous Hemofiltration (CVVH). METHODS Sixty patients were enrolled in this study and randomly assigned to the CVVHDF (n=30) or CVVH (n=30) groups. Demographics, laboratory tests, urea, creatinine, IL-6, β2-microglobulin, and myoglobulin clearance were recorded. RESULTS Patients in the CVVH group had a shorter median time of filter lifespan compared with those in the CVVHDF group (20 vs 37.5 hours, p = 0.002). Urea and creatinine clearance were not significantly different between groups over time (p >0.05). IL-6, β2-microglobulin, and myoglobulin clearance were higher in the CVVH group. The transmembrane pressure (TMP) was significantly higher in the CVVH group. CONCLUSION The use of CVVHDF may lead to a longer filter lifespan and lower clearance of medium and large molecules without affecting the small molecular solute clearance.
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Affiliation(s)
- Qiancheng Xu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China.,Department of Critical Care Medicine, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, Anhui, China
| | - Bo Jiang
- Department of Critical Care Medicine, The Second People's Hospital of Wuhu, Wuhu, Anhui, China
| | - Juan Li
- Department of Nephrology, The Second People's Hospital of Wuhu, Wuhu, Anhui, China
| | - Weihua Lu
- Department of Critical Care Medicine, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, Anhui, China
| | - Jianguo Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
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12
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Verma S, Palevsky PM. Prescribing Continuous Kidney Replacement Therapy in Acute Kidney Injury: A Narrative Review. Kidney Med 2021; 3:827-836. [PMID: 34693262 PMCID: PMC8515066 DOI: 10.1016/j.xkme.2021.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Severe acute kidney injury is a common complication in critically ill patients, often necessitating support with a modality of kidney replacement therapy. Continuous kidney replacement therapies (CKRTs) have become a mainstay in the management of patients with acute kidney injury in the intensive care unit. Understanding the fundamentals of CKRT is necessary to safely and effectively prescribe treatment. In this narrative review, we summarize critical aspects of CKRT management, including selection of the mode of therapy; choice of hemofilter/hemodialyzer used; determination of the blood flow rate, composition and flow rates of dialysate and/or replacement fluids, and the ultrafiltration rate; and use and methods of anticoagulation. Requirements for vascular access and appropriate monitoring and dose adjustment of medications and a plan for monitoring the delivery of therapy and ensuring appropriate nutritional management are also discussed.
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Affiliation(s)
- Siddharth Verma
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Paul M Palevsky
- Kidney Medicine Section, Medical Service, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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13
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Li P, Zhang L, Lin L, Tang X, Guan M, Wei T, Chen L. Effect of Dynamic Circuit Pressures Monitoring on the Lifespan of Extracorporeal Circuit and the Efficiency of Solute Removal During Continuous Renal Replacement Therapy. Front Med (Lausanne) 2021; 8:621921. [PMID: 34631725 PMCID: PMC8494973 DOI: 10.3389/fmed.2021.621921] [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: 10/27/2020] [Accepted: 08/24/2021] [Indexed: 02/05/2023] Open
Abstract
Objective: To observe the effects of dynamic pressure monitoring on the lifespan of the extracorporeal circuit and the efficiency of solute removal during continuous renal replacement therapy (CRRT). Materials and Methods: A prospective observational study was performed at the West China Hospital of Sichuan University in the ICU. Analyses of the downloaded pressure data recorded by CRRT machines and the solute removal efficiencies, calculated by 2*Ce/(Cpre+Cpost), where Ce, Cpre, and Cpost are the concentrations of the effluent, pre-filter blood, and post-filter blood, respectively, were performed. Samples were collected at 0, 2, 6, 12, and 24 h when continuous veno-venous hemodiafiltration (CVVHDF) was used after the initiation of CRRT. Measurements in concentrations of creatinine, blood urea nitrogen, and β2-microglobulin in the plasma and effluent were recorded. Results: Extracorporeal circuits characterized by moderate-to-severe (M–S) access outflow dysfunction (AOD) events, defined as access outflow pressure less than or equal to −200 mmHg for more than 5 min, had shorter median lifespans with no anticoagulation (32.3 vs. 10.90 h, P = 0.001) compared with the no M–S AOD events group. The significant outcome also existed in regional citrate anticoagulation (RCA) (72 vs. 42.47 h, P = 0.02). Moreover, Cox regression analysis revealed that the lack of M–S AOD events, RCA, or CVVHDF independently prolonged the circuit lifespan. All tested solutes removal efficiencies started to decline at 12 h. Furthermore, efficiencies of all solutes removal dropped obviously at 24 h when TMP ≥ 150 mmHg. Conclusion: RCA and CVVHDF predicted a longer circuit lifespan. M–S AOD events were associated with a shorter circuit lifespan when RCA or no anticoagulant was used. Replacement of extracorporeal circuit could be considered when running time of filter lasted up to 24 h with TMP ≥ 150 mmHg.
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Affiliation(s)
- Peiyun Li
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Ling Zhang
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Li Lin
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Xin Tang
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Mingjing Guan
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Tiantian Wei
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Lixin Chen
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
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14
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Tsujimoto Y, Miki S, Shimada H, Tsujimoto H, Yasuda H, Kataoka Y, Fujii T. Non-pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy. Cochrane Database Syst Rev 2021; 9:CD013330. [PMID: 34519356 PMCID: PMC8438600 DOI: 10.1002/14651858.cd013330.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication amongst people who are critically ill, and it is associated with an increased risk of death. For people with severe AKI, continuous kidney replacement therapy (CKRT), which is delivered over 24 hours, is needed when they become haemodynamically unstable. When CKRT is interrupted due to clotting of the extracorporeal circuit, the delivered dose is decreased and thus leading to undertreatment. OBJECTIVES This review assessed the efficacy of non-pharmacological measures to maintain circuit patency in CKRT. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 25 January 2021 which includes records identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included all randomised controlled trials (RCTs) (parallel-group and cross-over studies), cluster RCTs and quasi-RCTs that examined non-pharmacological interventions to prevent clotting of extracorporeal circuits during CKRT. DATA COLLECTION AND ANALYSIS: Three pairs of review authors independently extracted information including participants, interventions/comparators, outcomes, study methods, and risk of bias. The primary outcomes were circuit lifespan and death due to any cause at day 28. We used a random-effects model to perform quantitative synthesis (meta-analysis). We assessed risk of bias in included studies using the Cochrane Collaboration's tool for assessing risk of bias. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS A total of 20 studies involving 1143 randomised participants were included in the review. The methodological quality of the included studies was low, mainly due to the unclear randomisation process and blinding of the intervention. We found evidence on the following 11 comparisons: (i) continuous venovenous haemodialysis (CVVHD) versus continuous venovenous haemofiltration (CVVH) or continuous venovenous haemodiafiltration (CVVHDF); (ii) CVVHDF versus CVVH; (iii) higher blood flow (≥ 250 mL/minute) versus standard blood flow (< 250 mL/minute); (iv) AN69 membrane (AN69ST) versus other membranes; (v) pre-dilution versus post-dilution; (vi) a longer catheter (> 20 cm) placing the tip targeting the right atrium versus a shorter catheter (≤ 20 cm) placing the tip in the superior vena cava; (vii) surface-modified double-lumen catheter versus standard double-lumen catheter with identical geometry and flow design; (viii) single-site infusion anticoagulation versus double-site infusion anticoagulation; (ix) flat plate filter versus hollow fibre filter of the same membrane type; (x) a filter with a larger membrane surface area versus a smaller one; and (xi) a filter with more and shorter hollow fibre versus a standard filter of the same membrane type. Circuit lifespan was reported in 9 comparisons. Low certainty evidence indicated that CVVHDF (versus CVVH: MD 10.15 hours, 95% CI 5.15 to 15.15; 1 study, 62 circuits), pre-dilution haemofiltration (versus post-dilution haemofiltration: MD 9.34 hours, 95% CI -2.60 to 21.29; 2 studies, 47 circuits; I² = 13%), placing the tip of a longer catheter targeting the right atrium (versus placing a shorter catheter targeting the tip in the superior vena cava: MD 6.50 hours, 95% CI 1.48 to 11.52; 1 study, 420 circuits), and surface-modified double-lumen catheter (versus standard double-lumen catheter: MD 16.00 hours, 95% CI 13.49 to 18.51; 1 study, 262 circuits) may prolong circuit lifespan. However, higher blood flow may not increase circuit lifespan (versus standard blood flow: MD 0.64, 95% CI -3.37 to 4.64; 2 studies, 499 circuits; I² = 70%). More and shorter hollow fibre filters (versus standard filters: MD -5.87 hours, 95% CI -10.18 to -1.56; 1 study, 6 circuits) may reduce circuit lifespan. Death from any cause was reported in four comparisons We are uncertain whether CVVHDF versus CVVH, CVVHD versus CVVH or CVVHDF, longer versus a shorter catheter, or surface-modified double-lumen catheters versus standard double-lumen catheters reduced death due to any cause, in very low certainty evidence. Recovery of kidney function was reported in three comparisons. We are uncertain whether CVVHDF versus CVVH, CVVHDF versus CVVH, or surface-modified double-lumen catheters versus standard double-lumen catheters increased recovery of kidney function. Vascular access complications were reported in two comparisons. Low certainty evidence indicated using a longer catheter (versus a shorter catheter: RR 0.40, 95% CI 0.22 to 0.74) may reduce vascular access complications, however the use of surface-modified double lumen catheters versus standard double-lumen catheters may make little or no difference to vascular access complications. AUTHORS' CONCLUSIONS The use of CVVHDF as compared with CVVH, pre-dilution haemofiltration, a longer catheter, and surface-modified double-lumen catheter may be useful in prolonging the circuit lifespan, while higher blood flow and more and shorter hollow fibre filter may reduce circuit life. The Overall, the certainty of evidence was assessed to be low to very low due to the small sample size of the included studies. Data from future rigorous and transparent research are much needed in order to fully understand the effects of non-pharmacological interventions in preventing circuit coagulation amongst people with AKI receiving CKRT.
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Affiliation(s)
- Yasushi Tsujimoto
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
- Department of Nephrology and Dialysis, Kyoritsu Hospital, Kawanishi, Japan
- Systematic Review Workshop Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Sho Miki
- Department of Nephrology, Sumitomo Hospital, Osaka, Japan
| | - Hiroki Shimada
- Department of Nephrology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Hiraku Tsujimoto
- Hospital Care Research Unit, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama-shi, Japan
| | - Yuki Kataoka
- Systematic Review Workshop Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoko Fujii
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
- ANZIC-RC, Monash University School of Public Health and Preventive Medicine, Melbourne, Australia
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15
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Bouajram RH, Awdishu L. A Clinician's Guide to Dosing Analgesics, Anticonvulsants, and Psychotropic Medications in Continuous Renal Replacement Therapy. Kidney Int Rep 2021; 6:2033-2048. [PMID: 34386653 PMCID: PMC8343808 DOI: 10.1016/j.ekir.2021.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/29/2021] [Accepted: 05/03/2021] [Indexed: 11/30/2022] Open
Abstract
Acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) is a common complication in critical illness and has a significant impact on pharmacokinetic factors determining drug exposure, including absorption, distribution, transport, metabolism, and clearance. In this review, we provide a practical guide to drug dosing considerations in critically ill patients undergoing CRRT, focusing on the most commonly used analgesic, anticonvulsant, and psychotropic medications in the clinical care of critically ill patients. A literature search was conducted to identify articles in which drug dosing was evaluated in adult patients receiving CRRT between the years 1980 and 2020. We included articles with pharmacokinetic/pharmacodynamic analyses and those that described medication clearance via CRRT. A summary of the data focused on practical pharmacokinetic and pharmacodynamic principles is presented, with recommendations for drug dosing of analgesics, anticonvulsants, and psychotropic medications. Pharmacokinetic and pharmacodynamic studies to guide drug dosing of analgesics, anticonvulsants, and psychotropic medications in critically ill patients receiving CRRT are sparse. Considering the widespread use of these medications, narrow therapeutic index of these drug classes, and risks of over- and underdosing, additional studies in patients receiving CRRT are needed to inform drug dosing.
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Affiliation(s)
- Rima H. Bouajram
- Department of Pharmaceutical Services, University of California, San Francisco Medical Center, San Francisco, California, USA
| | - Linda Awdishu
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, California, USA
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Jang SM, Awdishu L. Drug dosing considerations in continuous renal replacement therapy. Semin Dial 2021; 34:480-488. [PMID: 33939855 DOI: 10.1111/sdi.12972] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/23/2021] [Accepted: 03/19/2021] [Indexed: 12/24/2022]
Abstract
Acute kidney injury (AKI) is a common complication in critically ill patients, which is associated with increased in-hospital mortality. Delivering effective antibiotics to treat patients with sepsis receiving continuous renal replacement therapy (RRT) is complicated by variability in pharmacokinetics, dialysis delivery, lack of primary literature, and therapeutic drug monitoring. Pharmacokinetic alterations include changes in absorption, distribution, protein binding (PB), metabolism, and renal elimination. Drug absorption may be significantly changed due to alterations in gastric pH, perfusion, gastrointestinal motility, and intestinal atrophy. Volume of distribution for hydrophilic drugs may be increased due to volume overload. Estimation of renal clearance is challenged by the effective delivery of RRT. Drug characteristics such as PB, volume of distribution, and molecular weight impact removal of the drug by RRT. The totality of these alterations leads to reduced exposure. Despite our best knowledge, therapeutic drug monitoring of patients receiving continuous RRT demonstrates wide variability in antimicrobial concentrations, highlighting the need for expanded monitoring of all drugs. This review article will focus on changes in drug pharmacokinetics in AKI and dosing considerations to attain antibiotic pharmacodynamic targets in critically ill patients receiving continuous RRT.
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Affiliation(s)
- Soo Min Jang
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | - Linda Awdishu
- Clinical Pharmacy, UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, USA
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Neyra JA, Tolwani A. CRRT prescription and delivery of dose. Semin Dial 2021; 34:432-439. [PMID: 33909931 DOI: 10.1111/sdi.12974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/22/2021] [Accepted: 03/30/2021] [Indexed: 12/31/2022]
Abstract
Continuous renal replacement therapy (CRRT) is the preferred modality of extracorporeal renal support for critically ill patients with acute kidney injury (AKI). The dose of CRRT is reported as effluent flow in ml/kg body weight per hour (ml/kg/h). Solid evidence supports that the delivered CRRT effluent dose for critically ill patients with AKI should be 20-25 ml/kg/h on average. To account for treatment interruptions and the natural decline in filter efficiency over time, it is recommended to prescribe 25-30 ml/kg/h of effluent dose. However, transient higher doses of CRRT in specific clinical scenarios may be needed to accommodate specific solute control needs of a particular patient at a given time. Consequently, there should be consideration of the potential adverse consequences of non-selective clearance such as undesired antimicrobials and nutrients removal. In this manuscript, we provide a summary of evidence related to CRRT dose, practical aspects for its calculation at the time of prescribing CRRT, and considerations for addressing the expected gap between prescribed and delivered CRRT dose. We also provide a framework for monitoring and implementation of CRRT dose as a quality indicator of CRRT delivery.
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Affiliation(s)
- Javier A Neyra
- Department of Internal Medicine, Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - Ashita Tolwani
- Department of Internal Medicine, Division of Nephrology, University of Alabama, Birmingham, AL, USA
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Regional citrate anti-coagulation dose titration: impact on dose of continuous renal replacement therapy. Clin Exp Nephrol 2021; 25:963-969. [PMID: 33885995 DOI: 10.1007/s10157-021-02064-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Regional citrate anti-coagulation (RCA) is the recommended anti-coagulation for continuous renal replacement therapy (CRRT). Citrated replacement fluids provide convenience but may compromise effluent delivery when adjusted to maintain circuit ionised calcium levels (circuit-iCa). This study aims to evaluate the effect of RCA titration on the delivered CRRT effluent dose. METHODS This prospective observational study evaluated patients on RCA-CRRT in continuous veno-venous hemodiafiltration mode. Citrated replacement fluid was titrated to target circuit-iCa 0.26-0.40 mmol/L. Patients were then stratified into 'reduced-dose' who required citrate down-titration and 'stable-dose' who did not. RESULTS Data from 200 RCA-CRRT sessions were collected. The reduced-dose RCA group (n = 114) had higher median initial citrate dose (3.00 vs 2.50; P < 0.001) but lower time-averaged dose (2.49 vs 2.60; P < 0.001). In addition, median prescribed effluent dose was 33.3 mL/kg/h (28.6-39.2) but median delivered effluent dose was significantly lower at 29.9 mL/kg/h (25.4-36.9; P < 0.001). Mortality was higher in the reduced-dose RCA group (39.5% vs 25.6%; P = 0.022) and in patients with delivered-to-prescribed effluent dose ratio of < 0.9 vs ≥ 0.9 (51.3% vs 29.2%; P = 0.014). CONCLUSION RCA titration can significantly impact delivered CRRT effluent dose. Measures should be taken to address the CRRT dose deficit and prevent poor outcomes due to inadequate dialysis.
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Kalaria SN, Armahizer M, McCarthy P, Badjatia N, Gobburu JV, Gopalakrishnan M. A prospective, real-world, clinical pharmacokinetic study to inform lacosamide dosing in critically ill patients undergoing continuous venovenous haemofiltration (PADRE-02). Br J Clin Pharmacol 2021; 87:4375-4385. [PMID: 33855736 DOI: 10.1111/bcp.14858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/28/2021] [Accepted: 03/31/2021] [Indexed: 01/19/2023] Open
Abstract
AIMS Although the use of continuous renal replacement therapy (CRRT) has increased, limited dosing information exists on the effect of CRRT on antiepileptic drug pharmacokinetics. The objectives of this practice-based study are to evaluate the pharmacokinetics of lacosamide and recommend individualized dosing recommendations in critically ill patients receiving continuous venovenous haemofiltration (CVVH). METHODS Seven patients receiving lacosamide and CVVH in a neurocritical care unit were enrolled. Pre-filter, post-filter and ultrafiltrate samples were obtained at baseline, right after the completion of the infusion, and up to six additional sampling time points post-administration. Patient-specific flow rates and clinical measures were also collected simultaneously at the time of sampling. Plasma concentrations were measured using a validated high-performance liquid chromatography with ultraviolet radiation detection (HPLC-UV) bioanalytical method. Non-compartmental analysis was utilized to characterize the pharmacokinetics of lacosamide. RESULTS The observed mean sieving coefficient for lacosamide was 0.80 ± 0.10, suggesting high removal of lacosamide. Concentrations measured in six out of seven patients were observed to be outside the therapeutic range (5-12 mg/L). The estimated average volume of distribution was found to be similar to healthy patients (0.58 L/kg). The mean bias and precision of the estimated total clearance was -2.53% and 14.9%, respectively. Simulations of various doses suggest that effluent flow rate-based dosing regimens could be used to individualize lacosamide therapeutics. CONCLUSIONS CVVH clearance contributed a major fraction of the total lacosamide clearance in neurocritically ill patients. Given that drug clearance increases with higher effluent flow rates, lacosamide dosing regimens should be increased to match exposures observed in patients with normal renal function.
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Affiliation(s)
- Shamir N Kalaria
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, Maryland, United States.,Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland, United States
| | - Michael Armahizer
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland, United States
| | - Paul McCarthy
- Department of Cardiovascular and Thoracic Surgery, Division of Critical Care, West Virginia University School of Medicine, Morgantown, West Virginia, United States
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Jogarao V Gobburu
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, Maryland, United States
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, Maryland, United States
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Kalaria S, Williford S, Guo D, Shu Y, Medlin C, Li M, Yeung SYA, Ali F, Jean W, Gopalakrishnan M, Heavner M. Optimizing ceftaroline dosing in critically ill patients undergoing continuous renal replacement therapy. Pharmacotherapy 2021; 41:205-211. [PMID: 33438291 DOI: 10.1002/phar.2502] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/16/2020] [Accepted: 12/21/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Currently, no dosing information exists for ceftaroline fosamil in patients undergoing continuous renal replacement therapy (CRRT). The objectives of this study are to characterize the pharmacokinetics of ceftaroline in critically ill patients undergoing CRRT modalities and to derive individualized dosing recommendations. METHODS This pharmacokinetic study aimed to enroll critically ill patients receiving ceftaroline fosamil and any CRRT modality from adult intensive care units. Selection of the specific CRRT modality and dosing regimen was based on clinical discretion. Pre-filter, post-filter, and ultrafiltrate samples were obtained before the administration of the fourth dose, after the completion of the infusion, and up to five additional time points post-infusion. Plasma concentrations were measured using a validated ultra-high performance liquid chromatography assay. Individual pharmacokinetic parameters were calculated using non-compartmental analysis. RESULTS Four patients were enrolled to investigate the need for dosing adjustments. The average sieving coefficient for ceftaroline was 0.81 ± 0.1, indicating high filter efficiency. The average volume of distribution was 41.8 L (0.48 L/kg) and is within the previously reported range in patients with normal renal function. Non-renal clearance accounted for more than 50% of the total clearance observed in patients. The observed pharmacokinetic profiles suggest that the pharmacodynamic target for 2-log10 CFU reduction from baseline (%fT >1 mg/L of 50%) was met for each patient. Due to the impact of CRRT and non-renal clearance, dosing recommendations were derived for different ranges of effluent flow rates and adjusted body weights. For a patient with an adjusted body weight of 70 kg and receiving CRRT at an effluent flow rate of 3 L/h, a ceftaroline fosamil dosing regimen of 400 mg every 12 h is proposed. CONCLUSION Ceftaroline is cleared extensively in critically ill patients receiving CRRT and may impact pharmacodynamic target achievement. Dose adjustments should be based on the intensity of the CRRT regimen, patient weight, and the clinical status of the patient.
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Affiliation(s)
- Shamir Kalaria
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Sarah Williford
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Dong Guo
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Yan Shu
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Christopher Medlin
- Department of Pharmacy Practice and Science, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Matthew Li
- Department of Pharmacy Practice and Science, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Siu Yan Amy Yeung
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Farhan Ali
- Department of Medicine, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Wisna Jean
- Department of Medicine, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Mojdeh Heavner
- Department of Pharmacy Practice and Science, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
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Kalaria SN, Armahizer M, McCarthy P, Badjatia N, Gobburu JV, Gopalakrishnan M. A Practice-Based, Clinical Pharmacokinetic Study to Inform Levetiracetam Dosing in Critically Ill Patients Undergoing Continuous Venovenous Hemofiltration (PADRE-01). Clin Transl Sci 2020; 13:950-959. [PMID: 32223067 PMCID: PMC7485952 DOI: 10.1111/cts.12782] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/22/2020] [Indexed: 12/11/2022] Open
Abstract
Limited data exist on the effect of continuous renal replacement therapy (CRRT) methods on anti-epileptic drug pharmacokinetics (PK). This prospective practice-based PK study aims to assess the impact of continuous venovenous hemofiltration (CVVH), a modality of CRRT, on levetiracetam PK in critically ill patients and to derive individualized dosing recommendations. Eleven patients receiving oral or intravenous levetiracetam and CVVH in various intensive care units at a large academic medical center were enrolled to investigate the need for dosing adjustments. Prefilter, postfilter, and ultrafiltrate samples were obtained before dosing, after the completion of the infusion or 1-hour postoral dose, and up to 6 additional time points postinfusion or postoral administration. Patient-specific blood and ultrafiltrate flow rates and laboratory values were also collected at the time of sampling. The average sieving coefficient (SC) for levetiracetam was 0.89 ± 0.1, indicating high filter efficiency. Six of the 11 patients experienced concentrations outside the reported therapeutic range (12-46 mg/L). The average volume of distribution was 0.73 L/kg. CVVH clearance contributes a major fraction of the total levetiracetam clearance (36-73%) in neurocritically ill patients. The average bias and precision of the estimated vs. observed total clearance value was ~ 10.6% and 21.5%. Major dose determinants were identified to be SC and effluent flow rate. Patients with higher ultrafiltrate rates will have increased drug clearance and, therefore, will require higher doses in order to match exposures seen in patients with normal renal function.
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Affiliation(s)
- Shamir N. Kalaria
- Center for Translational MedicineUniversity of Maryland School of PharmacyBaltimoreMarylandUSA
- Department of Pharmacy ServicesUniversity of Maryland Medical CenterBaltimoreMarylandUSA
| | - Michael Armahizer
- Department of Pharmacy ServicesUniversity of Maryland Medical CenterBaltimoreMarylandUSA
| | - Paul McCarthy
- Department of Cardiovascular and Thoracic SurgeryDivision of Critical CareWest Virginia University School of MedicineMorgantownWest VirginiaUSA
| | - Neeraj Badjatia
- Department of NeurologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Jogarao V. Gobburu
- Center for Translational MedicineUniversity of Maryland School of PharmacyBaltimoreMarylandUSA
| | - Mathangi Gopalakrishnan
- Center for Translational MedicineUniversity of Maryland School of PharmacyBaltimoreMarylandUSA
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Ostermann M, Bellomo R, Burdmann EA, Doi K, Endre ZH, Goldstein SL, Kane-Gill SL, Liu KD, Prowle JR, Shaw AD, Srisawat N, Cheung M, Jadoul M, Winkelmayer WC, Kellum JA. Controversies in acute kidney injury: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Conference. Kidney Int 2020; 98:294-309. [PMID: 32709292 PMCID: PMC8481001 DOI: 10.1016/j.kint.2020.04.020] [Citation(s) in RCA: 239] [Impact Index Per Article: 59.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/31/2020] [Accepted: 04/09/2020] [Indexed: 12/19/2022]
Abstract
In 2012, Kidney Disease: Improving Global Outcomes (KDIGO) published a guideline on the classification and management of acute kidney injury (AKI). The guideline was derived from evidence available through February 2011. Since then, new evidence has emerged that has important implications for clinical practice in diagnosing and managing AKI. In April of 2019, KDIGO held a controversies conference entitled Acute Kidney Injury with the following goals: determine best practices and areas of uncertainty in treating AKI; review key relevant literature published since the 2012 KDIGO AKI guideline; address ongoing controversial issues; identify new topics or issues to be revisited for the next iteration of the KDIGO AKI guideline; and outline research needed to improve AKI management. Here, we present the findings of this conference and describe key areas that future guidelines may address.
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St. Thomas' Hospital, King's College London, London, UK.
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Emmanuel A Burdmann
- Laboratório de Investigação Médica 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo, Japan
| | - Zoltan H Endre
- Prince of Wales Hospital and Clinical School, University of New South Wales, Randwick, NSW, Australia
| | - Stuart L Goldstein
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Kathleen D Liu
- Department of Medicine, Division of Nephrology, University of California, San Francisco, San Francisco, California, USA; Department of Anesthesia, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, California, USA
| | - John R Prowle
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Andrew D Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand; Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Academy of Science, Royal Society of Thailand, Bangkok, Thailand
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Impact of the intensity of intermittent renal replacement therapy in critically ill patients. J Nephrol 2020; 34:105-112. [PMID: 32495232 DOI: 10.1007/s40620-020-00760-x] [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: 03/06/2020] [Accepted: 05/23/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Intermittent renal replacement therapy (IRRT) is prescribed across intensive care units (ICU) worldwide. While research regarding the prescribed dialysis dose has not yielded results concerning mortality, it is still unknown whether the same applies to the actual delivered dose. METHODS We retrospectively analyzed two different cohorts of patients (562 IRRT sessions) who were admitted to the intensive care units at Hospital Clínic of Barcelona and required renal replacement therapy with IRRT. The first cohort included patients with acute kidney injury (AKI) (n = 42) and the second included patients already on chronic hemodialysis (CKD 5D) (n = 47). Only patients who had at least 3 recorded hemodialysis sessions in the ICU and with no previous continuous renal replacement therapy (CRRT) were included. The achieved dose was measured as Kt (L) by ionic dialysance and the primary endpoint was 90-day mortality. RESULTS Ninety-day mortality was 40.5% (n = 17) in the AKI cohort and 23.9% (n = 11) in the CKD 5D cohort with mean Kt of 43 ± 8.27 L and 47 ± 9.65 L respectively. Kt dose of IRRT was associated with 90-day mortality in the AKI cohort in a multivariate surveillance analysis adjusted for confounding factors (HR 0.935 [0.88-0.99], p = 0.02). Only the Kt dose and age remained statistically associated with the outcome in the AKI cohort. CONCLUSIONS Delivered dialysis dose as measured by ionic-dialysance Kt may be associated with survival in critically-ill patients with AKI, while it does not seem to affect outcomes in critically-ill CKD 5D patients. This exploratory analysis will need confirmation in larger prospective studies.
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Abstract
PURPOSE OF REVIEW Continuous renal replacement therapy (CRRT) is now the mainstay of renal organ support in the critically ill. As our understanding of CRRT delivery and its impact on patient outcomes improves there is a focus on researching the potential benefits of tailored, patient-specific treatments to meet dynamic needs. RECENT FINDINGS The most up-to-date studies investigating aspects of CRRT prescription that can be individualized: CRRT dose, timing, fluid management, membrane selection, anticoagulation and vascular access are reviewed. The use of different doses of CRRT lack conventional high-quality evidence and importantly studies reveal variation in assessment of dose delivery. Research reveals conflicting evidence for clinicians in distinguishing which patients will benefit from 'watchful waiting' vs. early initiation of CRRT. Both dynamic CRRT dosing and precision fluid management using CRRT are difficult to investigate and currently only observational data supports individualization of prescriptions. Similarly, individualization of membrane choice is largely experimental. SUMMARY Clinicians have limited evidence to individualize the prescription of CRRT. To develop this, we need to understand the requirements for renal support for individual patients, such as electrolyte imbalance, fluid overload or clearance of systemic inflammatory mediators to allow us to target these abnormalities in appropriately designed randomized trials.
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Fayad AII, Buamscha DG, Ciapponi A. Timing of renal replacement therapy initiation for acute kidney injury. Cochrane Database Syst Rev 2018; 12:CD010612. [PMID: 30560582 PMCID: PMC6517263 DOI: 10.1002/14651858.cd010612.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common condition among patients in intensive care units (ICUs), and is associated with high death. Renal replacement therapy (RRT) is a blood purification technique used to treat the most severe forms of AKI. The optimal time to initiate RRT so as to improve clinical outcomes remains uncertain.This review complements another Cochrane review by the same authors: Intensity of continuous renal replacement therapy for acute kidney injury. OBJECTIVES To assess the effects of different timing (early and standard) of RRT initiation on death and recovery of kidney function in critically ill patients with AKI. SEARCH METHODS We searched the Cochrane Kidney and Transplant's Specialised Register to 23 August 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched LILACS to 11 September 2017. SELECTION CRITERIA We included all randomised controlled trials (RCTs). We included all patients with AKI in ICU regardless of age, comparing early versus standard RRT initiation. For safety and cost outcomes we planned to include cohort studies and non-RCTs. DATA COLLECTION AND ANALYSIS Data were extracted independently by two authors. The random-effects model was used and results were reported as risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS We included five studies enrolling 1084 participants. Overall, most domains were assessed as being at low or unclear risk of bias. Compared to standard treatment, early initiation may reduce the risk of death at day 30, although the 95% CI does not rule out an increased risk (5 studies, 1084 participants: RR 0.83, 95% CI 0.61 to 1.13; I2 = 52%; low certainty evidence); and probably reduces the death after 30 days post randomisation (4 studies, 1056 participants: RR 0.92, 95% CI 0.76 to 1.10; I2= 29%; moderate certainty evidence); however in both results the CIs included a reduction and an increase of death. Earlier start may reduce the risk of death or non-recovery kidney function (5 studies, 1076 participants: RR 0.83, 95% CI 0.66 to 1.05; I2= 54%; low certainty evidence). Early strategy may increase the number of patients who were free of RRT after RRT discontinuation (5 studies, 1084 participants: RR 1.13, 95% CI 0.91 to 1.40; I2= 58%; low certainty evidence) and probably slightly increases the recovery of kidney function among survivors who discontinued RRT after day 30 (5 studies, 572 participants: RR 1.03, 95% CI 1.00 to 1.06; I2= 0%; moderate certainty evidence) compared to standard; however the lower limit of CI includes the null effect. Early RRT initiation increased the number of patients who experienced adverse events (4 studies, 899 participants: RR 1.10, 95% CI 1.03 to 1.16; I2 = 0%; high certainty evidence). Compared to standard, earlier RRT start may reduce the number of days in ICU (4 studies, 1056 participants: MD -1.78 days, 95% CI -3.70 to 0.13; I2 = 90%; low certainty evidence), but the CI included benefit and harm. AUTHORS' CONCLUSIONS Based mainly on low quality of evidence identified, early RRT may reduce the risk of death and may improve the recovery of kidney function in critically patients with AKI, however the 95% CI indicates that early RRT might worsen these outcomes. There was an increased risk of adverse events with early RRT. Further adequate-powered RCTs using appropriate criteria to define the optimal time of RRT are needed to reduce the imprecision of the results.
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Affiliation(s)
- Alicia Isabel I Fayad
- Ricardo Gutierrez Children's HospitalPediatric NephrologyInstitute for Clinical Effectiveness and Health PolicyLos Incas Av 4174Buenos AiresArgentina1427
| | - Daniel G Buamscha
- Juan Garrahan Children's HospitalPediatric Critical Care UnitCombate de Los Pozoz Y PichinchaBuenos AiresArgentina
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresArgentinaC1414CPV
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Use of Estimating Equations for Dosing Antimicrobials in Patients with Acute Kidney Injury Not Receiving Renal Replacement Therapy. J Clin Med 2018; 7:jcm7080211. [PMID: 30103503 PMCID: PMC6111623 DOI: 10.3390/jcm7080211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/02/2018] [Accepted: 08/07/2018] [Indexed: 01/09/2023] Open
Abstract
Acute kidney injury (AKI) can potentially lead to the accumulation of antimicrobial drugs with significant renal clearance. Drug dosing adjustments are commonly made using the Cockcroft-Gault estimate of creatinine clearance (CLcr). The Modified Jelliffe equation is significantly better at estimating kidney function than the Cockcroft-Gault equation in the setting of AKI. The objective of this study is to assess the degree of antimicrobial dosing discordance using different glomerular filtration rate (GFR) estimating equations. This is a retrospective evaluation of antimicrobial dosing using different estimating equations for kidney function in AKI and comparison to Cockcroft-Gault estimation as a reference. Considering the Cockcroft-Gault estimate as the criterion standard, antimicrobials were appropriately adjusted at most 80.7% of the time. On average, kidney function changed by 30 mL/min over the course of an AKI episode. The median clearance at the peak serum creatinine was 27.4 (9.3–66.3) mL/min for Cockcroft Gault, 19.8 (9.8–47.0) mL/min/1.73 m2 for MDRD and 20.5 (4.9–49.6) mL/min for the Modified Jelliffe equations. The discordance rate for antimicrobial dosing ranged from a minimum of 8.6% to a maximum of 16.4%. In the event of discordance, the dose administered was supra-therapeutic 100% of the time using the Modified Jelliffe equation. Use of estimating equations other than the Cockcroft Gault equation may significantly alter dosing of antimicrobials in AKI.
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Schell-Chaple H. Continuous Renal Replacement Therapy Update: An Emphasis on Safe and High-Quality Care. AACN Adv Crit Care 2017; 28:31-40. [PMID: 28254854 DOI: 10.4037/aacnacc2017816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Continuous renal replacement therapy (CRRT) was introduced more than 40 years ago as a renal support option for critically ill patients who had contraindications to intermittent hemodialysis and peritoneal dialysis. Despite being the most common renal support therapy used in intensive care units today, the tremendous variability in CRRT management challenges the interpretation of findings from CRRT outcome studies. The lack of standardization in practice and training of clinicians along with the high risk of CRRT-related adverse events has been the impetus for the recent expert consensus work on identifying quality indicators for CRRT programs. This article summarizes the potential complications that establish CRRT as a high-risk therapy and also the recently published best-practice recommendations for providing high-quality CRRT.
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Affiliation(s)
- Hildy Schell-Chaple
- Hildy Schell-Chaple is Clinical Nurse Specialist, University of California, San Francisco Medical Center, 505 Parnassus Ave, San Francisco, CA 94143
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Brandenburger T, Dimski T, Slowinski T, Kindgen-Milles D. Renal replacement therapy and anticoagulation. Best Pract Res Clin Anaesthesiol 2017; 31:387-401. [PMID: 29248145 DOI: 10.1016/j.bpa.2017.08.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 08/17/2017] [Indexed: 12/21/2022]
Abstract
Today, up to 20% of all intensive care unit patients require renal replacement therapy (RRT), and continuous renal replacement therapies (CRRT) are the preferred technique. In CRRT, effective anticoagulation of the extracorporeal circuit is mandatory to prevent clotting of the circuit or filter and to maintain filter performance. At present, a variety of systemic and regional anticoagulation modes for CRRT are available. Worldwide, unfractionated heparin is the most widely used anticoagulant. All systemic techniques are associated with significant adverse effects. Most important are bleeding complications and heparin-induced thrombocytopenia (HIT-II). Regional citrate anticoagulation (RCA) is a safe and effective technique. Compared to systemic anticoagulation, RCA prolongs filter running times, reduces bleeding complications, allows effective control of acid-base status, and reduces adverse events like HIT-II. In this review, we will discuss systemic and regional anticoagulation techniques for CRRT including anticoagulation for patients with HIT-II. Today, RCA can be recommended as the therapy of choice for the majority of critically ill patients requiring CRRT.
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Affiliation(s)
- Timo Brandenburger
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, D-40225 Düsseldorf, Germany
| | - Thomas Dimski
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, D-40225 Düsseldorf, Germany
| | - Torsten Slowinski
- Department of Nephrology, University Hospital Charite, Campus Mitte, Chariteplatz 2, Berlin D-10117, Germany
| | - Detlef Kindgen-Milles
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, D-40225 Düsseldorf, Germany.
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Connor MJ, Karakala N. Continuous Renal Replacement Therapy: Reviewing Current Best Practice to Provide High-Quality Extracorporeal Therapy to Critically Ill Patients. Adv Chronic Kidney Dis 2017; 24:213-218. [PMID: 28778360 DOI: 10.1053/j.ackd.2017.05.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Continuous renal replacement therapy (CRRT) use continues to expand globally. Despite improving technology, CRRT remains a complex intervention. Delivery of high-quality CRRT requires close collaboration of a multidisciplinary team including members of the critical care medicine, nephrology, nursing, pharmacy, and nutrition support teams. While significant gaps in medical evidence regarding CRRT persist, the growing evidence base supports evolving best practice and consensus to define high-quality CRRT. Unfortunately, there is wide variability in CRRT operating characteristics and limited uptake of these best practices. This article will briefly review the current best practice on important aspects of CRRT delivery including CRRT dose, anticoagulation, dialysis vascular access, fluid management, and drug dosing in CRRT.
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Finazzi S, Garbero E, Trussardi G, Bertolini G. The Hematocrit Affects the Volume of Plasma Treated With Coupled Plasma Filtration and Adsorption With Predilution. Artif Organs 2017; 41:E26-E29. [PMID: 28543387 DOI: 10.1111/aor.12944] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/24/2017] [Accepted: 02/21/2017] [Indexed: 01/04/2023]
Abstract
Coupled plasma filtration and adsorption (CPFA) is an extracorporeal blood purification technique proposed for the treatment of septic-shock. By removing pro- and anti-inflammatory mediators from plasma, CPFA is supposed to have a therapeutic effect on the abnormal inflammatory response seen in this condition. Recently, blood predilution with citrate solution has been adopted to prevent clotting in the CPFA circuit-one of the main problems of the technique. Taking into account the patient's hematocrit, we worked out a formula for the volume of plasma effectively treated by CPFA after predilution. Neglecting this effect, as is commonly done, introduces significant distortions in the estimation of the volume, possibly causing under-treatment. The distortion is stronger when the hematocrit and the predilution fraction are large and weaker when both values shrink. By correctly indicating the daily dose of plasma adsorption received by patients, this formula is essential for assessing the therapeutic efficacy of CPFA and, subsequently, establishing its optimal doses.
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Affiliation(s)
- Stefano Finazzi
- IRCCS-Mario Negri Institute for Pharmacological Research, Ranica, Italy
| | - Elena Garbero
- IRCCS-Mario Negri Institute for Pharmacological Research, Ranica, Italy
| | | | - Guido Bertolini
- IRCCS-Mario Negri Institute for Pharmacological Research, Ranica, Italy
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Rewa OG, Villeneuve PM, Lachance P, Eurich DT, Stelfox HT, Gibney RTN, Hartling L, Featherstone R, Bagshaw SM. Quality indicators of continuous renal replacement therapy (CRRT) care in critically ill patients: a systematic review. Intensive Care Med 2016; 43:750-763. [DOI: 10.1007/s00134-016-4579-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 09/26/2016] [Indexed: 11/30/2022]
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Neri M, Villa G, Garzotto F, Bagshaw S, Bellomo R, Cerda J, Ferrari F, Guggia S, Joannidis M, Kellum J, Kim JC, Mehta RL, Ricci Z, Trevisani A, Marafon S, Clark WR, Vincent JL, Ronco C. Nomenclature for renal replacement therapy in acute kidney injury: basic principles. Crit Care 2016; 20:318. [PMID: 27719682 PMCID: PMC5056503 DOI: 10.1186/s13054-016-1489-9] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/14/2016] [Indexed: 11/10/2022] Open
Abstract
This article reports the conclusions of a consensus expert conference on the basic principles and nomenclature of renal replacement therapy (RRT) currently utilized to manage acute kidney injury (AKI). This multidisciplinary consensus conference discusses common definitions, components, techniques, and operations of the machines and platforms used to deliver extracorporeal therapies, utilizing a "machine-centric" rather than a "patient-centric" approach. We provide a detailed description of the performance characteristics of membranes, filters, transmembrane transport of solutes and fluid, flows, and methods of measurement of delivered treatment, focusing on continuous renal replacement therapies (CRRT) which are utilized in the management of critically ill patients with AKI. This is a consensus report on nomenclature harmonization for principles of extracorporeal renal replacement therapies. Devices and operations are classified and defined in detail to serve as guidelines for future use of terminology in papers and research.
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Affiliation(s)
- Mauro Neri
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Viale Rodolfi 37, Vicenza, 36100, Italy.,Department of Management and Engineering, University of Padova, Vicenza, Italy
| | - Gianluca Villa
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Viale Rodolfi 37, Vicenza, 36100, Italy.,Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain, University of Florence, Florence, Italy
| | - Francesco Garzotto
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Viale Rodolfi 37, Vicenza, 36100, Italy
| | - Sean Bagshaw
- Division of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Jorge Cerda
- Department of Medicine, Albany Medical College, Albany, NY, 12209, USA
| | - Fiorenza Ferrari
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Viale Rodolfi 37, Vicenza, 36100, Italy
| | - Silvia Guggia
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Viale Rodolfi 37, Vicenza, 36100, Italy
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - John Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeong Chul Kim
- Department of Radiology and Biomedical Research Imaging Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ravindra L Mehta
- Division of Nephrology, University of California, San Diego, CA, USA
| | - Zaccaria Ricci
- Department of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Alberto Trevisani
- Department of Management and Engineering, University of Padova, Vicenza, Italy
| | - Silvio Marafon
- Department of Intensive Care, San Bortolo Hospital, Vicenza, Italy
| | - William R Clark
- Purdue University College of Engineering, West Lafayette, IN, USA
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Viale Rodolfi 37, Vicenza, 36100, Italy.
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Fayad AI, Buamscha DG, Ciapponi A. Intensity of continuous renal replacement therapy for acute kidney injury. Cochrane Database Syst Rev 2016; 10:CD010613. [PMID: 27699760 PMCID: PMC6457961 DOI: 10.1002/14651858.cd010613.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common condition among patients in intensive care units (ICU), and is associated with substantial morbidity and mortality. Continuous renal replacement therapy (CRRT) is a blood purification technique used to treat the most severe forms of AKI but its effectiveness remains unclear. OBJECTIVES To assess the effects of different intensities (intensive and less intensive) of CRRT on mortality and recovery of kidney function in critically ill AKI patients. SEARCH METHODS We searched Cochrane Kidney and Transplant's Specialised Register to 9 February 2016 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched LILACS to 9 February 2016. SELECTION CRITERIA We included all randomised controlled trials (RCTs). We included all patients with AKI in ICU regardless of age, comparing intensive (usually a prescribed dose ≥35 mL/kg/h) versus less intensive CRRT (usually a prescribed dose < 35 mL/kg/h). For safety and cost outcomes we planned to include cohort studies and non-RCTs. DATA COLLECTION AND ANALYSIS Data were extracted independently by two authors. The random-effects model was used and results were reported as risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS We included six studies enrolling 3185 participants. Studies were assessed as being at low or unclear risk of bias. There was no significant difference between intensive versus less intensive CRRT on mortality risk at day 30 (5 studies, 2402 participants: RR 0.88, 95% CI 0.71 to 1.08; I2 = 75%; low quality of evidence) or after 30 days post randomisation (5 studies, 2759 participants: RR 0.92, 95% CI 0.80 to 1.06; I2 = 65%; low quality of evidence). There were no significant differences between intensive versus less intensive CRRT in the numbers of patients who were free of RRT after CRRT discontinuation (5 studies, 2402 participants: RR 1.12, 95% CI 0.91 to 1.37; I2 = 71%; low quality of evidence) or among survivors at day 30 (5 studies, 1415 participants: RR 1.03, 95% CI 0.96 to 1.11; I2 = 69%; low quality of evidence) and day 90 (3 studies, 988 participants: RR 0.98, IC 95% 0.94 to 1.01, I2 = 0%; moderatequality of evidence). There were no significant differences between intensive and less intensive CRRT on the number of days in hospital (2 studies, 1665 participants): MD -0.23 days, 95% CI -3.35 to 2.89; I2 = 8%; low quality of evidence) and the number of days in ICU (2 studies, 1665 participants: MD -0.58 days, 95% CI -3.73 to 2.56, I2 = 19%; low quality of evidence). Intensive CRRT increased the risk of hypophosphataemia (1 study, 1441 participants: RR 1.21, 95% CI 1.11 to 1.31; high quality evidence) compared to less intensive CRRT. There was no significant differences between intensive and less intensive CRRT on numbers of patients who experienced adverse events (3 studies, 1753 participants: RR 1.08, 95% CI 0.73 to 1.61; I2 = 16%; moderate quality of evidence). In the subgroups analysis by severity of illness and by aetiology of AKI, intensive CRRT would seem to reduce the risk mortality (2 studies, 531 participants: RR 0.73, 95% CI 0.61 to 0.88; I2 = 0%; high quality of evidence) only in the subgroup of patients with post-surgical AKI. AUTHORS' CONCLUSIONS Based on the current low quality of evidence identified, more intensive CRRT did not demonstrate beneficial effects on mortality or recovery of kidney function in critically ill patients with AKI. There was an increased risk of hypophosphataemia with more intense CRRT. Intensive CRRT reduced the risk of mortality in patients with post-surgical AKI.
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Affiliation(s)
- Alicia I Fayad
- Ricardo Gutierrez Children's HospitalPediatric NephrologyInstitute for Clinical Effectiveness and Health PolicyLos Incas Av 4174Buenos AiresArgentina1427
| | - Daniel G Buamscha
- Juan Garrahan Children's HospitalPediatric Critical Care UnitCombate de Los Pozoz Y PichinchaBuenos AiresArgentina
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
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Abstract
PURPOSE OF REVIEW Quality and safety are important priorities in the care of critically ill patients. For patients with acute kidney injury (AKI) or for those receiving continuous renal replacement therapy (CRRT), measures and outcomes associated with quality of care have been suboptimally developed and evaluated. The review is timely as it summarizes current quality practices in AKI and CRRT, and presents ongoing and future developments. RECENT FINDINGS The review begins with the history of quality and safety in healthcare. We then discuss the current quality of care offered in AKI and CRRT. Quality measure development methodology, such as plan-do-study-act and the focus-analyze-describe-execute models and lean thinking are then presented and discussed. Finally, recent evidence for quality in AKI and CRRT care, including proposed quality measures, are discussed. SUMMARY Few studies have examined the quality of care provided to patients with AKI and CRRT. Evidence suggests opportunities to improve the quality of care received by patients at risk of or who have developed AKI. Priorities for improving quality of care exist across several important themes including risk identification, diagnosis, monitoring, investigation, and strategies for management. Similarly, evidence-informed quality measures of CRRT care have not been rigorously evaluated. These are important knowledge-to-care gaps that require further investigation.
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Truche AS, Darmon M, Bailly S, Clec'h C, Dupuis C, Misset B, Azoulay E, Schwebel C, Bouadma L, Kallel H, Adrie C, Dumenil AS, Argaud L, Marcotte G, Jamali S, Zaoui P, Laurent V, Goldgran-Toledano D, Sonneville R, Souweine B, Timsit JF. Continuous renal replacement therapy versus intermittent hemodialysis in intensive care patients: impact on mortality and renal recovery. Intensive Care Med 2016; 42:1408-17. [PMID: 27260258 DOI: 10.1007/s00134-016-4404-6] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 05/23/2016] [Indexed: 01/20/2023]
Abstract
PURPOSE The best renal replacement therapy (RRT) modality remains controversial. We compared mortality and short- and long-term renal recovery between patients treated with continuous RRT and intermittent hemodialysis. METHODS Patients of the prospective observational multicenter cohort database OUTCOMEREA™ were included if they underwent at least one RRT session between 2004 and 2014. Differences in patients' baseline and daily characteristics between treatment groups were taken into account by using a marginal structural Cox model, allowing one to substantially reduce the bias resulting from confounding factors in observational longitudinal data analysis. The composite primary endpoint was 30-day mortality and dialysis dependency. RESULTS Among 1360 included patients with RRT, 544 (40.0 %) and 816 (60.0 %) were initially treated by continuous RRT and intermittent hemodialysis, respectively. At day 30, 39.6 % patients were dead. Among survivors, 23.8 % still required RRT. There was no difference between groups for the primary endpoint in global population (HR 1.00, 95 % CI 0.77-1.29; p = 0.97). In patients with higher weight gain at RRT initiation, mortality and dialysis dependency were significantly lower with continuous RRT (HR 0.54, 95 % CI 0.29-0.99; p = 0.05). Conversely, this technique appeared to be deleterious in patients without shock (HR 2.24, 95 % CI 1.24-4.04; p = 0.01). Six-month mortality and persistent renal dysfunction were not influenced by the RRT modality in patients with dialysis dependence at ICU discharge. CONCLUSION Continuous RRT did not appear to improve 30-day and 6-month patient outcomes. It seems beneficial for patients with fluid overload, but might be deleterious in the absence of hemodynamic failure.
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Affiliation(s)
- Anne-Sophie Truche
- UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, 75018, Paris, France.,Medical Intensive Care Unit, Grenoble University Hospital, Grenoble 1 University, U823, La Tronche, France.,Nephrology, Grenoble University Hospital, La Tronche, France
| | - Michael Darmon
- Medical Intensive Care Unit, Saint Etienne University Hospital, Saint-Etienne, France.,Jacques Lisfranc Medicine University, Jean Monnet University, Saint-Etienne, France
| | - Sébastien Bailly
- UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, 75018, Paris, France.,Grenoble Alpes University, U823, Rond-point de La Chantourne, 38700, La Tronche, France
| | - Christophe Clec'h
- UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, 75018, Paris, France.,Intensive Care Unit, AP-HP, Avicenne Hospital, Paris, France.,Medicine University, Paris 13 University, Bobigny, France
| | - Claire Dupuis
- UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, 75018, Paris, France.,AP-HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, 75018, Paris, France
| | - Benoit Misset
- Intensive Care Unit, Saint Joseph Hospital Network, Paris, France.,Sorbonne Cite, Medicine University, Paris Descartes University, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, AP-HP, Saint Louis Hospital, Paris, France.,Medicine University, Paris 5 University, Paris, France
| | - Carole Schwebel
- Medical Intensive Care Unit, Grenoble University Hospital, Grenoble 1 University, U823, La Tronche, France
| | - Lila Bouadma
- AP-HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, 75018, Paris, France
| | - Hatem Kallel
- Medical Surgical ICU, Centre Hospitalier de Cayenne, Guyane, France
| | - Christophe Adrie
- Physiology Department, Cochin University Hospital, Assistance Publique Des Hôpitaux de Paris (AP-HP), Paris Descartes University, Sorbonne Cite, Paris, France
| | - Anne-Sylvie Dumenil
- AP-HP, Antoine Béclère University Hospital, Medical-surgical Intensive Care Unit, Clamart, France
| | - Laurent Argaud
- Medical Intensive Care Unit, Lyon University Hospital, Lyon, France
| | | | - Samir Jamali
- Critical Care Medicine Unit Dourdan Hospital, Dourdan, France
| | - Philippe Zaoui
- Nephrology, Grenoble University Hospital, La Tronche, France
| | - Virginie Laurent
- Medical Intensive Care Unit, André Mignot Hospital, Versailles, France
| | | | - Romain Sonneville
- AP-HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, 75018, Paris, France
| | - Bertrand Souweine
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Jean-Francois Timsit
- UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, 75018, Paris, France. .,AP-HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, 75018, Paris, France. .,Université Paris Diderot/Hôpital Bichat, Réanimation Medicale et des maladies infectieuses, 46 rue Henri Huchard, Paris, 75018, France.
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Hirsch JS, Mohan S. Integrating Real Time Data to Improve Outcomes in Acute Kidney Injury. Nephron Clin Pract 2015; 131:242-6. [PMID: 26575177 DOI: 10.1159/000441981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 10/26/2015] [Indexed: 11/19/2022] Open
Abstract
Critically ill patients with acute kidney injury requiring renal replacement therapy have a poor prognosis. Despite well-known factors, which contribute to outcomes, including dose delivery, patients frequently miss the target dose and volume removal. One major barrier to effective care of these patients is the traditional dissociation of dialysis device data from other clinical information systems, notably the electronic health record (EHR). This lack of integration and the resulting manual documentation leads to errors and biases in documentation and missed opportunities to intervene in a timely fashion. This review summarizes the technological advancements facilitating direct connection of dialysis devices to EHRs. This connection facilitates automated data capture of many variables - including delivered dose, ultrafiltration rate and pressure measurements - which in turn can be leveraged for data mining, quality improvement and real-time targeted therapy adjustments. These interventions hold the promise to significantly improve outcomes for this patient population.
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Affiliation(s)
- Jamie S Hirsch
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, USA
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Hanafusa N. Application of Continuous Renal Replacement Therapy: What Should We Consider Based on Existing Evidence? Blood Purif 2015; 40:312-9. [PMID: 26657106 DOI: 10.1159/000441579] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) is performed mainly in patients with acute kidney injury, severe sepsis, or septic shock. Evidence has emerged about the indications for and therapeutic conditions of CRRT. In this review, we focus on the evidence for CRRT to date. SUMMARY CRRT employs diffusion, convection and adsorption to remove solutes from plasma. Indications can be divided into renal and non-renal indications. Concrete renal indications have not yet been determined, except for life-threatening absolute indications. Modality selection is a point of debate. Intermittent renal replacement therapy is reportedly equivalent to CRRT in terms of overall survival. However, the selection of modality must consider individual circumstances. The optimal dosage of CRRT has proven to be lower than that previously recommended, and the dosage is almost the same as the one employed in the 'real-world' setting. Patients treated by CRRT often have bleeding complications. In this situation, regional citrate anticoagulation can be used, but nafamostat is widely used in Japan. The right jugular vein is the most preferred vascular access site because it has the lowest likelihood of catheter malfunction. As for the complications of CRRT, hypophosphatemia and nutrient loss should be managed properly. When CRRT is no longer necessary, we should consider the appropriate timing of discontinuation. KEY MESSAGES Even though CRRT is an established technique, several points remain under debate. Individualization of therapy should be considered in light of the changes in patient characteristics.
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Affiliation(s)
- Norio Hanafusa
- Division of Total Renal Care Medicine, University of Tokyo Hospital, Tokyo, Japan
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Rewa O, Villeneuve PM, Eurich DT, Stelfox HT, Gibney RTN, Hartling L, Featherstone R, Bagshaw SM. Quality indicators in continuous renal replacement therapy (CRRT) care in critically ill patients: protocol for a systematic review. Syst Rev 2015; 4:102. [PMID: 26224139 PMCID: PMC4520065 DOI: 10.1186/s13643-015-0088-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Renal replacement therapy is increasingly utilized in the intensive care unit (ICU), of which continuous renal replacement therapy (CRRT) is most common. Despite CRRT being a relatively resource-intensive and expensive technology, there remains wide practice variation in its application. This systematic review will appraise the evidence for quality indicators (QIs) of CRRT care in critically ill patients. METHODS Ovid MEDLINE, Ovid EMBASE, CINAHL, and the Cochrane Library including the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials (CENTRAL), and databases from the National Information Center of Health Services Research and Health Care Technology will be searched for original studies involving QIs in CRRT. Gray literature sources will be searched for technical reports, practice guidelines, and conference proceedings. Websites of relevant organizations will be identified, and industry leaders in the development and marketing of CRRT technology and non-profit organizations that represent key opinion leads in the use of CRRT will be contacted. We will search the Agency of Healthcare Research and Quality National Quality Measures Clearinghouse for CRRT-related QIs. Studies will be included if they contain quality measures, occur in critically ill patients, and are associated with CRRT. Analysis will be primarily descriptive. Each QI will be evaluated for importance, scientific acceptability, usability, and feasibility using the four criteria proposed by the United States Strategic Framework Board for a National Quality Measurement and Reporting System. Finally, QIs will be appraised for their potential operational characteristics, for their potential to be integrated into electronic medical records, and on their affordability, if applicable. DISCUSSION This systematic review will comprehensively identify and synthesize QIs in CRRT. The results of this study will fuel the development of an inventory of essential QIs to support the appropriate, safe, and efficient delivery of CRRT in critically ill patients. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015015530.
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Affiliation(s)
- Oleksa Rewa
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 8440 112 St. NW, Critical Care Medicine 2-124E Clinical Sciences Building, Edmonton, Alberta, T6G 2B7, Canada.
| | - Pierre-Marc Villeneuve
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 8440 112 St. NW, Critical Care Medicine 2-124E Clinical Sciences Building, Edmonton, Alberta, T6G 2B7, Canada.
| | - Dean T Eurich
- 2-040 Li Ka Shing Center for Health Research Innovation, School of Public Health, University of Alberta, Edmonton, Alberta, Canada.
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - R T Noel Gibney
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 8440 112 St. NW, Critical Care Medicine 2-124E Clinical Sciences Building, Edmonton, Alberta, T6G 2B7, Canada.
| | - Lisa Hartling
- Department of Pediatrics, Faculty of Medicine and Dentistry, Aberhart Centre, Room 8417, Edmonton, Alberta, T6G 1Z1, Canada.
| | - Robin Featherstone
- Alberta Research Center for Health Evidence (ARCHE), University of Alberta, 4-486D Edmonton Clinic Health Academy, 11405 - 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada.
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 8440 112 St. NW, Critical Care Medicine 2-124E Clinical Sciences Building, Edmonton, Alberta, T6G 2B7, Canada.
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Dosing of continuous renal replacement therapy in critically ill patients with acute kidney injury: how low should we go?*. Crit Care Med 2013; 41:2655-7. [PMID: 24162682 DOI: 10.1097/ccm.0b013e31829cb20a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Zhang Z, Ni H, Fan H, Li D, Xu X. Actually delivered dose of continuous renal replacement therapy is underestimated in hemofiltration. ASAIO J 2013; 59:622-6. [PMID: 24172268 DOI: 10.1097/mat.0000436713.34635.a8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Dose determination in continuous renal replacement therapy (CRRT) is controversial. Most clinical trials use effluent flow rate as a surrogate of the dose. However, such definition may overestimate actually delivered dose due to declining filter function. The current study aimed to determine the difference between prescribed and delivered clearance and its association with transmembrane pressure. Hemofiltration was done in a mixed pre- and postdilution mode. Creatinine concentrations in serum and effluent fluid were measured simultaneously at 4, 10, 16, 28, 40, 52, and 64 hours for an individual hemofilter. Prescribed clearance (K) was estimated as the effluent flow rate corrected for predilution, and delivered clearance (Kx) was estimated using the ratio of serum and effluent creatinine. A total of 60 patients involving 248 filters were included in our analysis. The mean filter life span was 37.7 hours (standard deviation: 17.6). K overestimated Kx by 9.3% (95% confidence interval: -4.4% to 32.3%). The differences between K and Kx increased progressively over time. Transmembrane pressure was significantly correlated to the reduction with a Spearman's rho of 0.44 (p < 0.001). K significantly overestimates Kx during CRRT, and the difference increases progressively over time. Filters are recommended to be changed at 48-72 hours on a routine basis.
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Affiliation(s)
- Zhongheng Zhang
- From the Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Zhejiang, P.R. China
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Affiliation(s)
- Ashita Tolwani
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL 35294-0007, USA.
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Wald R, Friedrich JO, Bagshaw SM, Burns KEA, Garg AX, Hladunewich MA, House AA, Lapinsky S, Klein D, Pannu NI, Pope K, Richardson RM, Thorpe K, Adhikari NKJ. Optimal Mode of clearance in critically ill patients with Acute Kidney Injury (OMAKI)--a pilot randomized controlled trial of hemofiltration versus hemodialysis: a Canadian Critical Care Trials Group project. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R205. [PMID: 23095370 PMCID: PMC3682309 DOI: 10.1186/cc11835] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 10/03/2012] [Indexed: 11/10/2022]
Abstract
Introduction Among critically ill patients with acute kidney injury (AKI) needing continuous renal replacement therapy (CRRT), the effect of convective (via continuous venovenous hemofiltration [CVVH]) versus diffusive (via continuous venovenous hemodialysis [CVVHD]) solute clearance on clinical outcomes is unclear. Our objective was to evaluate the feasibility of comparing these two modes in a randomized trial. Methods This was a multicenter open-label parallel-group pilot randomized trial of CVVH versus CVVHD. Using concealed allocation, we randomized critically ill adults with AKI and hemodynamic instability to CVVH or CVVHD, with a prescribed small solute clearance of 35 mL/kg/hour in both arms. The primary outcome was trial feasibility, defined by randomization of >25% of eligible patients, delivery of >75% of the prescribed CRRT dose, and follow-up of >95% of patients to 60 days. A secondary analysis using a mixed-effects model examined the impact of therapy on illness severity, defined by sequential organ failure assessment (SOFA) score, over the first week. Results We randomized 78 patients (mean age 61.5 years; 39% women; 23% with chronic kidney disease; 82% with sepsis). Baseline SOFA scores (mean 15.9, SD 3.2) were similar between groups. We recruited 55% of eligible patients, delivered >80% of the prescribed dose in each arm, and achieved 100% follow-up. SOFA tended to decline more over the first week in CVVH recipients (-0.8, 95% CI -2.1, +0.5) driven by a reduction in vasopressor requirements. Mortality (54% CVVH; 55% CVVHD) and dialysis dependence in survivors (24% CVVH; 19% CVVHD) at 60 days were similar. Conclusions Our results suggest that a large trial comparing CVVH to CVVHD would be feasible. There is a trend toward improved vasopressor requirements among CVVH-treated patients over the first week of treatment. Trial Registration ClinicalTrials.gov: NCT00675818
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