Dose of Continuous Renal Replacement Therapy in Critically Ill Patients: A Bona Fide Quality Indicator

A New Dosing Frontier: Retrospective Assessment of Effluent Flow Rates and Residual Renal Function Among Critically Ill Patients Receiving Continuous Renal Replacement Therapy

OBJECTIVES

In 2020, cefiderocol became the first Food and Drug Administration-approved medication with continuous renal replacement therapy (CRRT) dosing recommendations based on effluent flow rates (QE). We aimed to evaluate the magnitude and frequency of factors that may influence these recommendations, that is, QE intrapatient variability and residual renal function.

DESIGN

Retrospective observational cohort study.

SETTING

ICUs within Hartford Hospital (890-bed, acute-care hospital) in Connecticut from 2017 to 2023.

PATIENTS

Adult ICU patients receiving CRRT for greater than 72 hours.

MEASUREMENTS AND MAIN RESULTS

CRRT settings including QE and urine output (UOP) were extracted from the time of CRRT initiation (0 hr) and trends were assessed. To assess the impact on antibiotic dosing, cefiderocol doses were assigned to 0 hour, 24 hours, 48 hours, and 72 hours QE values per product label, and the proportion of antibiotic dose changes required as a result of changes in inpatient's QE was evaluated. Among the 380 ICU patients receiving CRRT for greater than 72 hours, the median (interquartile range) 0 hour QE was 2.96 (2.35-3.29) L/hr. Approximately 9 QE values were documented per patient per 24-hour window. QE changes of greater than 0.75 L/hr were observed in 21.6% of patients over the first 24 hours and in 7.9% (24-48 hr) and 5.8% (48-72 hr) of patients. Approximately 40% of patients had UOP greater than 500 mL at 24 hours post-CRRT initiation. Due to QE changes within 24 hours of CRRT initiation, a potential cefiderocol dose adjustment would have been warranted in 38% of patients (increase of 21.3%; decrease of 16.6%). QE changes were less common after 24 hours, warranting cefiderocol dose adjustments in less than 15% of patients.

CONCLUSIONS

Results highlight the temporal and variable dynamics of QE and prevalence of residual renal function. Data also demonstrate a risk of antibiotic under-dosing in the first 24 hours of CRRT initiation due to increases in QE. For antibiotics with QE-based dosing recommendations, empiric dose escalation may be warranted in the first 24 hours of CRRT initiation.

Vancomycin removal and pharmacokinetics during accelerated venovenous hemofiltration

INTRODUCTION

Vancomycin pharmacokinetics are affected by renal replacement therapy and physiologic changes in critically ill patients. Literature regarding vancomycin removal and pharmacokinetics during accelerated venovenous hemofiltration (AVVH), a form of prolonged intermittent renal replacement therapy, is limited.

OBJECTIVE

To describe the removal and pharmacokinetics of vancomycin during AVVH.

METHODS

Eighteen critically ill adults receiving vancomycin and AVVH were included. Vancomycin serum concentrations were obtained within 4 h before and 2-6 h after the AVVH session. Patients' serum concentrations were plotted against time, and individual pharmacokinetic parameters were determined by a one-compartmental analysis. Continuous data are reported as a median (interquartile range [IQR]) and categorical data as a percentage.

RESULTS

The median AVVH effluent rate was 39.3 mL/kg/h (IQR 35.5-48 mL/kg/h) for a duration of 9 h (IQR 8-9.75 h). AVVH decreased vancomycin concentrations by 29.8% (IQR 24.9%-35.9%), at a rate of 3.4% per hour (IQR 3.1%-4.3% per hour) of AVVH. The vancomycin elimination rate constant and half-life were 0.039 h-1 (IQR 0.036-0.053 h-1 ) and 17.6 h (IQR 13.1-18.8 h), respectively. The area under the curve during AVVH was 171.7 mg*h/L (IQR 149.1-190 mg*h/L). The volume of distribution in 10 patients was 1 L/kg (IQR 0.73-1.1 L/kg). After AVVH, vancomycin 1000 mg (IQR 750-1000 mg) was needed to maintain a serum trough concentration ≥15 mg/L.

CONCLUSION

Vancomycin is significantly removed by AVVH, which requires supplemental dosing after completion of the AVVH session to maintain desired serum concentrations. Therapeutic drug monitoring of vancomycin serum concentrations is recommended for patients undergoing AVVH.

Lacosamide dosing in patients receiving continuous renal replacement therapy

BACKGROUND

Lacosamide is one of the anticonvulsants used in critically ill patients. This study aimed to suggest appropriate lacosamide dosing regimens in critically ill patients receiving continuous renal replacement therapy (CRRT) via Monte Carlo simulations.

METHODS

Mathematical models were created using published demographic and pharmacokinetics in adult critically ill patients. CRRT modalities with different effluent rates were added into the models. Lacosamide regimens were evaluated on the probability of target attainment (PTA) using pharmacodynamic targets of trough concentrations and area under the curve within a range of 5-10 mg/L and 80.25-143 and 143-231 mg*h/L for the initial 72 h-therapy, respectively. Optimal regimens were defined from regimens that yielded the highest PTA. Each dosing regimen was tested in a group of different 10,000 virtual patients.

RESULTS

Our results revealed the optimal lacosamide dosing regimen of 300-450 mg/day is recommended for adult patients receiving both CRRT modalities with 20-25 effluent rates. The dose of 600 mg/day was suggested in higher effluent rate of 35 mL/kg/h. Moreover, a patient with body weight > 100 kg was less likely to attain the targets.

CONCLUSIONS

Volume of distribution, total clearance, CRRT clearance and body weight were significantly contributed to lacosamide dosing. Clinical validation of the finding is strongly indicated.

Fluid Management during Continuous Renal Replacement Therapy: A Case-Based Approach

Continuous renal replacement therapy (CRRT) is frequently used for fluid management of critically ill patients with acute or chronic kidney failure. There is significant practice variation worldwide in fluid management during CRRT. Multiple clinical studies have suggested that both the magnitude and duration of fluid overload are associated with morbidity and mortality in critically ill patients. Therefore, timely and effective fluid management with CRRT is paramount in managing critically ill patients with fluid overload. While the optimal method of fluid management during CRRT is still unclear and warrants further investigation, observational data have suggested a U-shape relationship between net ultrafiltration rate and mortality. Furthermore, recent clinical data have underpinned a significant gap in prescribed versus achieved fluid balance during CRRT, which is also associated with mortality. This review uses a case-based approach to discuss two fluid management strategies based on net ultrafiltration rate and fluid balance goals during CRRT and harmonizes operational definitions.

Extracorporeal blood purification therapies for sepsis-associated acute kidney injury in critically ill patients: expert opinion from the SIAARTI-SIN joint commission

Sepsis-Associated Acute Kidney Injury is a life-threatening condition leading to high morbidity and mortality in critically ill patients admitted to the intensive care unit. Over the past decades, several extracorporeal blood purification therapies have been developed for both sepsis and sepsis-associated acute kidney injury management. Despite the widespread use of extracorporeal blood purification therapies in clinical practice, it is still unclear when to start this kind of treatment and how to define its efficacy. Indeed, several questions on sepsis-associated acute kidney injury and extracorporeal blood purification therapy still remain unresolved, including the indications and timing of renal replacement therapy in patients with septic vs. non-septic acute kidney injury, the optimal dialysis dose for renal replacement therapy modalities in sepsis-associated acute kidney injury patients, and the rationale for using extracorporeal blood purification therapies in septic patients without acute kidney injury. Moreover, the development of novel extracorporeal blood purification therapies, including those based on the use of adsorption devices, raised the attention of the scientific community both on the clearance of specific mediators released by microorganisms and by injured cells and potentially involved in the pathogenic mechanisms of organ dysfunction including sepsis-associated acute kidney injury, and on antibiotic removal. Based on these considerations, the joint commission of the Italian Society of Anesthesiology and Critical Care (SIAARTI) and the Italian Society of Nephrology (SIN) herein addressed some of these issues, proposed some recommendations for clinical practice and developed a common framework for future clinical research in this field.

An Innovative Approach to Minimizing Downtime in Continuous Kidney Replacement Therapy

Continuous kidney replacement therapy (CKRT) is often utilized to stabilize patients with severe acute kidney injury associated with significant electrolyte abnormalities and/or oliguria and concomitant fluid accumulation. Circuit downtime may reduce daily treatment time and affect delivered doses of CKRT. Studies have found clotting to be the leading cause of downtime and underdosing, which are associated with negative treatment outcomes. The NxStage Cartridge Express with Speedswap (NxStage Medical, Inc.) was designed to minimize downtime by allowing filter priming to occur in parallel with ongoing CKRT and by permitting filter exchanges without the need to replace the entire cartridge. Data from pilot studies suggest that filter exchanges using this system interrupt treatment by an average of 4 minutes per exchange-a considerable reduction from traditional systems that require treatment to be discontinued while the filter is primed, which can take 30 minutes or more. In addition to increasing patient time on therapy, this system has the potential to reduce costs for patients who require a high number of filter changes, and reduce nursing labor and environmental impact (reduced plastic waste). Future studies should confirm whether patients at higher risk of clotted/clogged filters benefit from CKRT with a system designed for rapid filter changes.

Can Artificial Intelligence Assist in Delivering Continuous Renal Replacement Therapy?

Continuous renal replacement therapy (CRRT) is widely utilized to support critically ill patients with acute kidney injury. Artificial intelligence (AI) has the potential to enhance CRRT delivery, but evidence is limited. We reviewed existing literature on the utilization of AI in CRRT with the objective of identifying current gaps in evidence and research considerations. We conducted a scoping review focusing on the development or use of AI-based tools in patients receiving CRRT. Ten papers were identified; 6 of 10 (60%) published in 2021, and 6 of 10 (60%) focused on machine learning models to augment CRRT delivery. All innovations were in the design/early validation phase of development. Primary research interests focused on early indicators of CRRT need, prognostication of mortality and kidney recovery, and identification of risk factors for mortality. Secondary research priorities included dynamic CRRT monitoring, predicting CRRT-related complications, and automated data pooling for point-of-care analysis. Literature gaps included prospective validation and implementation, biases ascertainment, and evaluation of AI-generated health care disparities. Research on AI applications to enhance CRRT delivery has grown exponentially in the last years, but the field remains premature. There is a need to evaluate how these applications could enhance bedside decision-making capacity and assist structure and processes of CRRT delivery.

Research on the Application Effect of Strengthening Risk Management in Continuous Renal Replacement Therapy Nursing of Critically Ill Patients

Objective

To evaluate the efficacy of risk management in the nursing of critically ill patients on continuous renal replacement therapy (CRRT).

Methods

In this retrospective study, 80 critically ill patients on continuous renal replacement therapy in our hospital from February 2020 to February 2021 were recruited. They were randomly assigned to receive either the risk management treatment (risk management group) or the conventional management treatment (conventional management group) via the random number table method. Outcome measurements included the occurrence of adverse events, complications, psychological status, quality of life, treatment compliance, duration of CRRT, and nursing satisfaction.

Results

Risk management treatment was associated with lower incidence of adverse events compared to conventional management treatment (P value < 0.05). The risk management group also resulted in a lower incidence of complications compared to the conventional management group (P value < 0.05). Patients who received risk management treatments demonstrated a significantly lower anxiety/depression level and a higher World Health Organization Quality of Life Brief Version (WHOQOL-BREF) (P value < 0.05). The risk management group resulted in more cases with high compliance and fewer cases with moderate and poor compliance (P < 0.05). Risk management was associated with more cases with a CRRT duration less than 36 hours and 36–48 hours and fewer cases with a duration longer than 48 h (X² = 2.999, P value < 0.05). Patients who were given a risk management treatment had a higher nursing satisfaction compared to conventional management treatment (X² = 4.501, P value < 0.05).

Conclusion

Risk management treatment in caring of critically ill patients on CRRT shows better efficacy than conventional management treatments.

Lessons Learned from a Small Pediatric Continuous Renal Replacement Therapy Program

Continuous renal replacement therapy (CRRT) has become a pillar of care in pediatric intensive care units (PICUs) over the past few decades. Quality indicators (QIs) have been evaluated that reflect safe and accountable CRRT. However, there is a paucity of data on outcomes and QIs in smaller-volume CRRT programming. The purpose of this retrospective study was to evaluate the efficiencies, effectiveness, and outcomes of a small-volume CRRT program. Eighty-two patients received CRRT over a 13-year period, and 79% survived to discharge. Sepsis or nonseptic shock (n = 11 (22%) versus n = 6 (50%); p value = 0.004) and time to CRRT initiation after PICU admission (1.1 versus 5.0 days; p value = 0.005) were independent predictors for mortality. The program also had positive outcomes for QIs related to CRRT efficiency and time of initiation, dosing delivery, and rate of adverse events. This study is important as it illustrates the opportunity that smaller centers have to initiate CRRT programming and provide safe and effective care.

Pain in Hemodialysis Patients: Prevalence, Intensity, Location, and Functional Interference in Daily Activities

Although pain is a frequent complaint of patients with chronic kidney disease who undergo hemodialysis, few studies have assessed the functional interference of pain in activities of daily living (ADLs). Hence, the aim of this study was to evaluate the prevalence, location, intensity, and functional interference of pain in ADLs of chronic kidney disease patients undergoing hemodialysis and to estimate the association of specific pain sites with severe functional interference by pain in ADLs. This cross-sectional study included patients with chronic kidney disease undergoing hemodialysis. The prevalence, intensity, and functional interference of pain in ADLs were assessed using the brief pain inventory. Poisson regression was used to calculate the prevalence ratio. A total of 65 patients participated in the study. The overall prevalence of pain was 89.23%; the prevalence of headache was 18.46% and that of pain in the trunk was 55.38%, upper limbs was 35.38%, and lower limbs was 60.00%. The prevalence of moderate and severe pain at the time of hemodialysis was 13.85% and 21.54%, respectively. A high prevalence of severe functional interference of pain in general activity (61.54%), mobility (56.92%), and disposition (55.38%) was observed. Pain is a frequent complaint in patients undergoing hemodialysis, mainly musculoskeletal and intradialytic, and it interferes with ADLs and incapacitates the patient. Pain was highly prevalent in the upper and lower limbs and the trunk. Furthermore, a higher prevalence of severe pain at the time of hemodialysis and functional interference of pain, mainly in general activity, mobility, and disposition, were observed.