1
|
Pasero D, Pistidda L, Piredda D, Liperi C, Cossu A, Esposito R, Muroni A, Mereu C, Rum C, Branca GP, Mulas F, Puci M, Sotgiu G, Terragni P. Lung (extracorporeal CO 2 removal) and renal (continuous renal replacement therapy) support: the role of ultraprotective strategy in Covid 19 and non-Covid 19 ARDS. A case-control study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:27. [PMID: 38671540 PMCID: PMC11055375 DOI: 10.1186/s44158-024-00164-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Preliminary studies suggest that moderate ARDS and acute renal failure might benefit from extracorporeal CO2 removal (ECCO2R) coupled with CRRT. However, evidence is limited and potential for this coupled treatment may need to be explored. The aim of the present study was to evaluate whether a protective driving pressure was obtained applying low-flow ECCO2-R plus CRRT in patients affected by moderate ARDS with COVID-19 compared to an historical group without COVID-19. METHODS A case-control study has been conducted comparing a group of consecutive moderate ARDS patients presenting AKI and affected by COVID-19, who needed low-flow ECCO2-R plus CRRT to achieve an ultra-protective ventilatory strategy, with historical group without COVID-19 that matched for clinical presentation and underwent the same ultra-protective treatment. VT was set at 6 mL/kg predicted body weight then ECCO2R was assessed to facilitate ultra-protective low VT ventilation to preserve safe Pplat and low driving pressure. RESULTS ECCO2R+CRRT reduced the driving pressure from 17 (14-18) to 11.5 (10-15) cmH2O (p<0.0004) in the fourteen ARDS patients by decreasing VT from 6.7 ml/kg PBW (6.1-6.9) to 5.1 (4.2-5.6) after 1 hour (p <0.0001). In the ARDS patients with COVID-19, the driving pressure reduction was more effective from baseline 18 (14-24) cmH2O to 11 (10-15) cmH2O (p<0.004), compared to the control group from 15 (13-17) to 12(10-16) cmH2O (p< 0.03), after one hour. ECCO2R+CRRT did not affected 28 days mortality in the two groups, while we observed a shorter duration of mechanical ventilation (19 {7-29} vs 24 {22-38} days; p=0.24) and ICU length of stay (19 {7-29} vs 24 {22-78} days; p=0.25) in moderate ARDS patients with COVID-19 compared to control group. CONCLUSIONS In moderate ARDS patients with or without COVID-19 disease, ECCO2R+CRRT may be and effective supportive treatment to reach protective values of driving pressure unless severe oxygenation defects arise requiring ECMO therapy initiation.
Collapse
Affiliation(s)
- Daniela Pasero
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy.
- Department of Medicine, Surgery and Pharmacy, University of Sassari, A.O.U Sassari, Viale San Pietro 43, 07100, Sassari, Italy.
| | - Laura Pistidda
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
- Department of Medicine, Surgery and Pharmacy, University of Sassari, A.O.U Sassari, Viale San Pietro 43, 07100, Sassari, Italy
| | - Davide Piredda
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | - Corrado Liperi
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | - Andrea Cossu
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | | | - Angela Muroni
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | - Cristiano Mereu
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | - Carlino Rum
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | | | - Franco Mulas
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | - Mariangela Puci
- Department of Medicine, Surgery and Pharmacy, University of Sassari, A.O.U Sassari, Viale San Pietro 43, 07100, Sassari, Italy
- Clinical Epidemiology and Medical Statistics Unit, University of Sassari, Sassari, Italy
| | - Giovanni Sotgiu
- Department of Medicine, Surgery and Pharmacy, University of Sassari, A.O.U Sassari, Viale San Pietro 43, 07100, Sassari, Italy
- Clinical Epidemiology and Medical Statistics Unit, University of Sassari, Sassari, Italy
| | - Pierpaolo Terragni
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
- Department of Medicine, Surgery and Pharmacy, University of Sassari, A.O.U Sassari, Viale San Pietro 43, 07100, Sassari, Italy
| |
Collapse
|
2
|
Cavaliere F, Biancofiore G, Bignami E, DE Robertis E, Giannini A, Grasso S, McCREDIE VA, Scolletta S, Taccone FS, Terragni P. A year in review in Minerva Anestesiologica 2023: critical care. Minerva Anestesiol 2024; 90:110-118. [PMID: 38415512 DOI: 10.23736/s0375-9393.24.18017-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Franco Cavaliere
- IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Gianni Biancofiore
- Department of Transplant Anesthesia and Critical Care, University School of Medicine, Pisa, Italy
| | - Elena Bignami
- Division of Anesthesiology, Critical Care and Pain Medicine, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Edoardo DE Robertis
- Section of Anesthesia, Analgesia and Intensive Care, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Alberto Giannini
- Unit of Pediatric Anesthesia and Intensive Care, Children's Hospital - ASST Spedali Civili di Brescia, Brescia, Italy
| | - Salvatore Grasso
- Section of Anesthesiology and Intensive Care, Department of Emergency and Organ Transplantation, Polyclinic Hospital, Aldo Moro University, Bari, Italy
| | - Victoria A McCREDIE
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - Sabino Scolletta
- Department of Emergency-Urgency and Organ Transplantation, Anesthesia and Intensive Care, University Hospital of Siena, Siena, Italy
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Pierpaolo Terragni
- Division of Anesthesia and General Intensive Care, Department of Medical, Surgical and Experimental Sciences, University Hospital of Sassari, University of Sassari, Sassari, Italy
| |
Collapse
|
3
|
Tonetti T, Zanella A, Pérez-Torres D, Grasselli G, Ranieri VM. Current knowledge gaps in extracorporeal respiratory support. Intensive Care Med Exp 2023; 11:77. [PMID: 37962702 PMCID: PMC10645840 DOI: 10.1186/s40635-023-00563-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 11/08/2023] [Indexed: 11/15/2023] Open
Abstract
Extracorporeal life support (ECLS) for acute respiratory failure encompasses veno-venous extracorporeal membrane oxygenation (V-V ECMO) and extracorporeal carbon dioxide removal (ECCO2R). V-V ECMO is primarily used to treat severe acute respiratory distress syndrome (ARDS), characterized by life-threatening hypoxemia or ventilatory insufficiency with conventional protective settings. It employs an artificial lung with high blood flows, and allows improvement in gas exchange, correction of hypoxemia, and reduction of the workload on the native lung. On the other hand, ECCO2R focuses on carbon dioxide removal and ventilatory load reduction ("ultra-protective ventilation") in moderate ARDS, or in avoiding pump failure in acute exacerbated chronic obstructive pulmonary disease. Clinical indications for V-V ECLS are tailored to individual patients, as there are no absolute contraindications. However, determining the ideal timing for initiating extracorporeal respiratory support remains uncertain. Current ECLS equipment faces issues like size and durability. Innovations include intravascular lung assist devices (ILADs) and pumpless devices, though they come with their own challenges. Efficient gas exchange relies on modern oxygenators using hollow fiber designs, but research is exploring microfluidic technology to improve oxygenator size, thrombogenicity, and blood flow capacity. Coagulation management during V-V ECLS is crucial due to common bleeding and thrombosis complications; indeed, anticoagulation strategies and monitoring systems require improvement, while surface coatings and new materials show promise. Moreover, pharmacokinetics during ECLS significantly impact antibiotic therapy, necessitating therapeutic drug monitoring for precise dosing. Managing native lung ventilation during V-V ECMO remains complex, requiring a careful balance between benefits and potential risks for spontaneously breathing patients. Moreover, weaning from V-V ECMO is recognized as an area of relevant uncertainty, requiring further research. In the last decade, the concept of Extracorporeal Organ Support (ECOS) for patients with multiple organ dysfunction has emerged, combining ECLS with other organ support therapies to provide a more holistic approach for critically ill patients. In this review, we aim at providing an in-depth overview of V-V ECMO and ECCO2R, addressing various aspects of their use, challenges, and potential future directions in research and development.
Collapse
Affiliation(s)
- Tommaso Tonetti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Anesthesiology and General Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - David Pérez-Torres
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - V Marco Ranieri
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Anesthesiology and General Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy
| |
Collapse
|
4
|
Extracorporeal Carbon Dioxide Removal: From Pathophysiology to Clinical Applications; Focus on Combined Continuous Renal Replacement Therapy. Biomedicines 2023; 11:biomedicines11010142. [PMID: 36672649 PMCID: PMC9855411 DOI: 10.3390/biomedicines11010142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/29/2022] [Accepted: 12/31/2022] [Indexed: 01/08/2023] Open
Abstract
Lung-protective ventilation (LPV) with low tidal volumes can significantly increase the survival of patients with acute respiratory distress syndrome (ARDS) by limiting ventilator-induced lung injuries. However, one of the main concerns regarding the use of LPV is the risk of developing hypercapnia and respiratory acidosis, which may limit the clinical application of this strategy. This is the reason why different extracorporeal CO2 removal (ECCO2R) techniques and devices have been developed. They include low-flow or high-flow systems that may be performed with dedicated platforms or, alternatively, combined with continuous renal replacement therapy (CRRT). ECCO2R has demonstrated effectiveness in controlling PaCO2 levels, thus allowing LPV in patients with ARDS from different causes, including those affected by Coronavirus disease 2019 (COVID-19). Similarly, the suitability and safety of combined ECCO2R and CRRT (ECCO2R-CRRT), which provides CO2 removal and kidney support simultaneously, have been reported in both retrospective and prospective studies. However, due to the complexity of ARDS patients and the limitations of current evidence, the actual impact of ECCO2R on patient outcome still remains to be defined. In this review, we discuss the main principles of ECCO2R and its clinical application in ARDS patients, in particular looking at clinical experiences of combined ECCO2R-CRRT treatments.
Collapse
|
5
|
Extracorporeal CO 2 Removal During Renal Replacement Therapy to Allow Lung-Protective Ventilation in Patients With COVID-19-Associated Acute Respiratory Distress Syndrome. ASAIO J 2023; 69:36-42. [PMID: 35998214 PMCID: PMC9797119 DOI: 10.1097/mat.0000000000001803] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The aim of this retrospective multicenter observational study is to test the feasibility and safety of a combined extracorporeal CO 2 removal (ECCO 2 R) plus renal replacement therapy (RRT) system to use an ultraprotective ventilator setting while maintaining (1) an effective support of renal function and (2) values of pH within the physiologic limits in a cohort of coronavirus infectious disease 2019 (COVID-19) patients. Among COVID-19 patients admitted to the intensive care unit of 9 participating hospitals, 27 patients with acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI) requiring invasive mechanical ventilation undergoing ECCO 2 R-plus-RRT treatment were included in the analysis. The treatment allowed to reduce V T from 6.0 ± 0.6 mL/kg at baseline to 4.8 ± 0.8, 4.6 ± 1.0, and 4.3 ± 0.3 mL/kg, driving pressure (ΔP) from 19.8 ± 2.5 cm H 2 O to 14.8 ± 3.6, 14.38 ± 4.1 and 10.2 ± 1.6 cm H 2 O after 24 hours, 48 hours, and at discontinuation of ECCO 2 R-plus-RRT (T3), respectively ( p < 0.001). PaCO 2 and pH remained stable. Plasma creatinine decreased over the study period from 3.30 ± 1.27 to 1.90 ± 1.30 and 1.27 ± 0.90 mg/dL after 24 and 48 hours of treatment, respectively ( p < 0.01). No patient-related events associated with the extracorporeal system were reported. These data show that in patients with COVID-19-induced ARDS and AKI, ECCO 2 R-plus-RRT is effective in allowing ultraprotective ventilator settings while maintaining an effective support of renal function and values of pH within physiologic limits.
Collapse
|
6
|
Millar JE, Boyle AJ, Drake TM, Adams CE, Glass AW, Blackwood B, McNamee JJ, McAuley DF. Extracorporeal carbon dioxide removal in acute hypoxaemic respiratory failure: a systematic review, Bayesian meta-analysis and trial sequential analysis. Eur Respir Rev 2022; 31:31/166/220030. [DOI: 10.1183/16000617.0030-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 08/26/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose:To assess the safety and efficacy of extracorporeal carbon dioxide removal (ECCO2R)versusstandard care in patients with acute hypoxaemic respiratory failure (AHRF).Methods:MEDLINE, Embase and clinical trial registries were searched from 1994 to 31 December 2021. We included randomised controlled trials (RCTs) and observational studies. Pairs of reviewers independently extracted data and assessed the risk of bias. The primary outcome was mortality. Secondary outcomes included ventilator-free days, length of stay, safety and adverse events and physiological changes. As a primary analysis, we performed a meta-analysis of mortality until day 30 using a Bayesian random effects model. We then performed a trial sequential analysis of RCTs.Results:21 studies met inclusion criteria: three RCTs, enrolling 531 patients, and 18 observational studies. In a pooled analysis of RCTs, the posterior probability of increased mortality with the use of ECCO2R was 73% (relative risk 1.19, 95% credible interval 0.70–2.29). There was substantial heterogeneity in the reporting of safety and adverse events. However, the incidence of extra and intracranial haemorrhage was higher (relative risk 3.00, 95% credible interval 0.41–20.51) among those randomised to ECCO2R. Current trials have accumulated 80.8% of the diversity-adjusted required information size and the lack of effect reaches futility for a 10% absolute risk reduction in mortality.Conclusions:The use of ECCO2R in patients with AHRF is not associated with improvements in clinical outcomes. Furthermore, it is likely that further trials of ECCO2R aiming to achieve an absolute risk reduction in mortality of ≥10% are futile.
Collapse
|
7
|
Vemuri SV, Rolfsen ML, Sykes AV, Takiar PG, Leonard AJ, Malhotra A, Spragg RG, Macedo E, Hepokoski ML. Association Between Acute Kidney Injury During Invasive Mechanical Ventilation and ICU Outcomes and Respiratory System Mechanics. Crit Care Explor 2022; 4:e0720. [PMID: 35782295 PMCID: PMC9246080 DOI: 10.1097/cce.0000000000000720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Compare ICU outcomes and respiratory system mechanics in patients with and without acute kidney injury during invasive mechanical ventilation.
Collapse
|
8
|
Wishahi M, Kamal NM. Multidisciplinary basic and clinical research of acute kidney injury with COVID-19: Pathophysiology, mechanisms, incidence, management and kidney transplantation. World J Nephrol 2022; 11:105-114. [PMID: 35733654 PMCID: PMC9160708 DOI: 10.5527/wjn.v11.i3.105] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 03/04/2022] [Accepted: 04/30/2022] [Indexed: 02/06/2023] Open
Abstract
Acute kidney injury (AKI) linked to coronavirus disease 2019 (COVID-19) has been identified in the course of the disease. AKI can be mild or severe and that is dependent on the presence of comorbidities and the severity of COVID-19. Among patients who had been hospitalized with COVID-19, some were admitted to intensive care unit. The etiology of AKI associated with COVID-19 is multifactorial. Prevention of severe AKI is the prime task in patients with COVID-19 that necessitates a battery of measurements and precautions in management. Patients with AKI who have needed dialysis are in an increased risk to develop chronic kidney disease (CKD) or a progression of their existing CKD. Kidney transplantation patients with COVID-19 are in need of special management to adjust the doses of immunosuppression drugs and corticosteroids to guard against graft rejection but not to suppress the immune system to place the patient at risk of developing a COVID-19 infection. Immunosuppression drugs and corticosteroids for patients who have had a kidney transplant has to be adjusted based on laboratory results and is individualized aiming at the protection of the transplanted from rejection.
Collapse
Affiliation(s)
- Mohamed Wishahi
- Department of Urology, Theodor Bilharz Research Institute, Cairo 12411, Egypt
| | - Nabawya M Kamal
- Department of Anaesthesia and Surgical Intensive Care, Theodor Bilharz Research Institute, Cairo 12411, Egypt
| |
Collapse
|
9
|
Somaili M. Early versus Delayed Strategies for Renal Replacement Therapy Initiation in Adult Patients with Severe Acute Kidney Injury Complicating Septic Shock: A Systematic Review and Meta-analysis. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:449-486. [PMID: 37843147 DOI: 10.4103/1319-2442.385969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
Sepsis-associated acute kidney injury (AKI) is a frequent complication in hospitalized patients and is associated with significant morbidity and mortality. Renal replacement therapy (RRT) is used to manage AKI. The optimal timing of starting RRT in patients with AKI is still uncertain. This study is aimed to assess the effect of different timing strategies of RRT (early vs. standard) on mortality and dependence on dialysis in severe AKI complicating septic shock. A systematic review was conducted using the Ovid Medline database, trial registries, and manual searches of key journals from January 2000 to October 2020. Appropriate outcomes were pooled and analyzed via a meta-analysis. Only randomized controlled trials (RCTs) were included to compare between the early vs. delayed strategies of RRT. The inverse generic method was used, and the data were pooled using random effects. Five studies were included in this review, with 4329 participants. Overall, most domains were assessed as low-risk or with some concerns about the risk of bias. Compared with standard therapy, early initiation probably results in little or no difference regarding death, and may also result in no or little difference in independence on dialysis. The early strategy may result in a slight increase in adverse events. Compared with the standard strategy, earlier RRT initiation may slightly reduce the length of hospital stay. Further RCTs are needed to define the optimal timing of RRT initiation in this population.
Collapse
Affiliation(s)
- Mohammed Somaili
- Department of Medicine, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
| |
Collapse
|
10
|
Chopra S, Syal A, Arya Y. Acute kidney injury in COVID-19: Considerations in pregnancy. Tzu Chi Med J 2022; 34:29-34. [PMID: 35233353 PMCID: PMC8830551 DOI: 10.4103/tcmj.tcmj_290_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/19/2021] [Accepted: 03/26/2021] [Indexed: 01/08/2023] Open
Abstract
The clinical manifestations of COVID-19 are diverse with the involvement of different organ systems. Renal involvement is particularly noteworthy with acute kidney injury (AKI) being an important disease manifestation, particularly in pregnancy. Pregnancy itself serves as a high-risk condition for COVID-19 disease and a risk factor for deterioration, developing a more severe illness than nonpregnant women, and subsequent higher intensive care unit admission, oxygen therapy, and ventilatory support. There are reports in the literature highlighting the involvement of vital organs in pregnancy; however, data pertaining to AKI in pregnancy during COVID-19 are lacking in terms of risk factors, disease management, and outcomes. The entire spectrum of hormonal changes and adaptive mechanisms in pregnancy can be adversely affected by this viral infection. A literature search regarding AKI in COVID-19 in pregnancy was performed on PubMed, Scopus, Google Scholar, and ScienceDirect, and the relevant articles were selected. Our review highlights key issues pertaining to AKI in COVID-19 in pregnancy in an attempt to overcome, albeit partly, the scarcity of corroborative literature regarding the same.
Collapse
|
11
|
Husain-Syed F, Birk HW, Wilhelm J, Ronco C, Ranieri VM, Karle B, Kuhnert S, Tello K, Hecker M, Morty RE, Herold S, Kehl O, Walmrath HD, Seeger W, Vadász I. Extracorporeal Carbon Dioxide Removal Using a Renal Replacement Therapy Platform to Enhance Lung-Protective Ventilation in Hypercapnic Patients With Coronavirus Disease 2019-Associated Acute Respiratory Distress Syndrome. Front Med (Lausanne) 2020; 7:598379. [PMID: 33304914 PMCID: PMC7693445 DOI: 10.3389/fmed.2020.598379] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/07/2020] [Indexed: 01/20/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome (ARDS) is associated with high mortality. Lung-protective ventilation is the current standard of care in patients with ARDS, but it might lead to hypercapnia, which is independently associated with worse outcomes. Extracorporeal carbon dioxide removal (ECCO2R) has been proposed as an adjuvant therapy to avoid progression of clinical severity and limit further ventilator-induced lung injury, but its use in COVID-19 has not been described yet. Acute kidney injury requiring renal replacement therapy (RRT) is common among critically ill COVID-19 patients. In centers with available dialysis, low-flow ECCO2R (<500 mL/min) using RRT platforms could be carried out by dialysis specialists and might be an option to efficiently allocate resources during the COVID-19 pandemic for patients with hypercapnia as the main indication. Here, we report the feasibility, safety, and efficacy of ECCO2R using an RRT platform to provide either standalone ECCO2R or ECCO2R combined with RRT in four hypercapnic patients with moderate ARDS. A randomized clinical trial is required to assess the overall benefit and harm. Clinical Trial Registration:ClinicalTrials.gov. Unique identifier: NCT04351906.
Collapse
Affiliation(s)
- Faeq Husain-Syed
- Divison of Nephrology, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Horst-Walter Birk
- Divison of Nephrology, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany
| | - Jochen Wilhelm
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Universities of Giessen and Marburg Lung Center, Justus Liebig University Giessen, Giessen, Germany.,The Cardio-Pulmonary Institute, Giessen, Germany.,Institute for Lung Health, Justus Liebig University Giessen, Giessen, Germany
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy.,Department of Medicine (DIMED), Università di Padova, Padua, Italy
| | - V Marco Ranieri
- Department of Medical and Surgical Sciences (DIMEC), Anaesthesia and Intensive Care Medicine, Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Bianka Karle
- Divison of Nephrology, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany
| | - Stefan Kuhnert
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany
| | - Khodr Tello
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Universities of Giessen and Marburg Lung Center, Justus Liebig University Giessen, Giessen, Germany.,The Cardio-Pulmonary Institute, Giessen, Germany
| | - Matthias Hecker
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Universities of Giessen and Marburg Lung Center, Justus Liebig University Giessen, Giessen, Germany
| | - Rory E Morty
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Universities of Giessen and Marburg Lung Center, Justus Liebig University Giessen, Giessen, Germany.,The Cardio-Pulmonary Institute, Giessen, Germany.,Department of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany
| | - Susanne Herold
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Universities of Giessen and Marburg Lung Center, Justus Liebig University Giessen, Giessen, Germany.,The Cardio-Pulmonary Institute, Giessen, Germany
| | - Oliver Kehl
- Divison of Nephrology, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany
| | - Hans-Dieter Walmrath
- Divison of Nephrology, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany
| | - Werner Seeger
- Divison of Nephrology, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Universities of Giessen and Marburg Lung Center, Justus Liebig University Giessen, Giessen, Germany.,The Cardio-Pulmonary Institute, Giessen, Germany.,Institute for Lung Health, Justus Liebig University Giessen, Giessen, Germany.,Department of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany
| | - István Vadász
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Universities of Giessen and Marburg Lung Center, Justus Liebig University Giessen, Giessen, Germany.,The Cardio-Pulmonary Institute, Giessen, Germany
| |
Collapse
|
12
|
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: 232] [Impact Index Per Article: 58.0] [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.
Collapse
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.
| |
Collapse
|
13
|
Zheng KI, Feng G, Liu WY, Targher G, Byrne CD, Zheng MH. Extrapulmonary complications of COVID-19: A multisystem disease? J Med Virol 2020; 93:323-335. [PMID: 32648973 PMCID: PMC7405144 DOI: 10.1002/jmv.26294] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/07/2020] [Indexed: 12/15/2022]
Abstract
The outbreak of coronavirus disease 2019 (COVID‐19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), has been recently declared a pandemic by the World Health Organization. In addition to its acute respiratory manifestations, SARS‐CoV‐2 may also adversely affect other organ systems. To date, however, there is a very limited understanding of the extent and management of COVID‐19‐related conditions outside of the pulmonary system. This narrative review provides an overview of the current literature about the extrapulmonary manifestations of COVID‐19 that may affect the urinary, cardiovascular, gastrointestinal, hematological, hematopoietic, neurological, or reproductive systems. This review also describes the current understanding of the extrapulmonary complications caused by COVID‐19 to improve the management and prognosis of patients with COVID‐19. SARS‐CoV‐2 appears to adversely affect not only the respiratory system but also several other organ systems, including the urinary, cardiovascular, GI, and neurological systems. To date, however, there is very limited understanding of the extent and management of COVID‐19‐related conditions outside of the pulmonary system. Further research is needed to better understand the underlying mechanisms linking SARS‐CoV‐2 with the occurrence of multiple extra‐pulmonary complications.
Collapse
Affiliation(s)
- Kenneth I Zheng
- MAFLD Research Center, Department of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Gong Feng
- Xi'an Medical University, Xi'an, China
| | - Wen-Yue Liu
- Department of Endocrinology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Giovanni Targher
- Section of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Christopher D Byrne
- Southampton National Institute for Health Research Biomedical Research Center, Southampton General Hospital, University Hospital Southampton, Southampton, UK
| | - Ming-Hua Zheng
- MAFLD Research Center, Department of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| |
Collapse
|
14
|
Management of acute kidney injury in patients with COVID-19. THE LANCET. RESPIRATORY MEDICINE 2020; 8:738-742. [PMID: 32416769 PMCID: PMC7255232 DOI: 10.1016/s2213-2600(20)30229-0] [Citation(s) in RCA: 421] [Impact Index Per Article: 105.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 12/16/2022]
Abstract
The outbreak of coronavirus disease 2019 (COVID-19) has rapidly evolved into a global pandemic. Most patients with COVID-19 have mild symptoms, but about 5% develop severe symptoms, which can include acute respiratory distress syndrome, septic shock, and multiple organ failure. Kidney involvement is frequent, with clinical presentation ranging from mild proteinuria to progressive acute kidney injury (AKI) necessitating renal replacement therapy (RRT). An understanding of the pathophysiology and mechanisms of kidney damage and AKI in the setting of critical illness and COVID-19 is emerging, although further research is needed to identify patients at risk of AKI and to guide management strategies. As no specific treatment options exist for AKI secondary to COVID-19, intensive care is largely supportive. Current approaches to prevention and management of AKI, and identification of potential indications for use of RRT and sequential extracorporeal therapies, are based mainly on clinical experience, and AKI strategies are adapted empirically to patients with COVID-19. International collaborative and cross-disciplinary research is needed to obtain adequate evidence to support current clinical approaches and to develop new approaches to management.
Collapse
|
15
|
Ronco C, Bagshaw SM, Bellomo R, Clark WR, Husain-Syed F, Kellum JA, Ricci Z, Rimmelé T, Reis T, Ostermann M. Extracorporeal Blood Purification and Organ Support in the Critically Ill Patient during COVID-19 Pandemic: Expert Review and Recommendation. Blood Purif 2020; 50:17-27. [PMID: 32454500 PMCID: PMC7270067 DOI: 10.1159/000508125] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/23/2020] [Indexed: 01/27/2023]
Abstract
Critically ill COVID-19 patients are generally admitted to the ICU for respiratory insufficiency which can evolve into a multiple-organ dysfunction syndrome requiring extracorporeal organ support. Ongoing advances in technology and science and progress in information technology support the development of integrated multi-organ support platforms for personalized treatment according to the changing needs of the patient. Based on pathophysiological derangements observed in COVID-19 patients, a rationale emerges for sequential extracorporeal therapies designed to remove inflammatory mediators and support different organ systems. In the absence of vaccines or direct therapy for COVID-19, extracorporeal therapies could represent an option to prevent organ failure and improve survival. The enormous demand in care for COVID-19 patients requires an immediate response from the scientific community. Thus, a detailed review of the available technology is provided by experts followed by a series of recommendation based on current experience and opinions, while waiting for generation of robust evidence from trials.
Collapse
Affiliation(s)
- Claudio Ronco
- Department of Nephrology, University of Padova, Padova, Italy
- International Renal Research Institute (IRRIV), San Bortolo Hospital, Vicenza, Italy
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - William R Clark
- Davidson School of Chemical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Faeq Husain-Syed
- Department of Internal Medicine II, Division of Nephrology, Pulmonology and Critical Care Medicine, University Hospital Giessen and Marburg, Giessen, Germany
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Thomas Rimmelé
- Anesthesiology and Critical Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- EA 7426 "Pathophysiology of Injury-induced Immunosuppression", Pi3, Hospices Civils de Lyon - BioMérieux - Claude Bernard University Lyon, Lyon, France
| | - Thiago Reis
- Department of Nephrology, Clinica de Doenças Renais de Brasilia, Brasilia, Brazil
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom,
| |
Collapse
|
16
|
Hospach I, Goldstein J, Harenski K, Laffey JG, Pouchoulin D, Raible M, Votteler S, Storr M. In vitro characterization of PrismaLung+: a novel ECCO 2R device. Intensive Care Med Exp 2020; 8:14. [PMID: 32405714 PMCID: PMC7221037 DOI: 10.1186/s40635-020-00301-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 04/01/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Invasive mechanical ventilation is lifesaving in the setting of severe acute respiratory failure but can cause ventilation-induced lung injury. Advances in extracorporeal CO2 removal (ECCO2R) technologies may facilitate more protective lung ventilation in acute respiratory distress syndrome, and enable earlier weaning and/or avoid invasive mechanical ventilation entirely in chronic obstructive pulmonary disease exacerbations. We evaluated the in vitro CO2 removal capacity of the novel PrismaLung+ ECCO2R device compared with two existing gas exchangers. METHODS The in vitro CO2 removal capacity of the PrismaLung+ (surface area 0.8 m2, Baxter) was compared with the PrismaLung (surface area 0.35 m2, Baxter) and A.L.ONE (surface area 1.35 m2, Eurosets) devices, using a closed-loop bovine blood-perfused extracorporeal circuit. The efficacy of each device was measured at varying pCO2 inlet (pinCO2) levels (45, 60, and 80 mmHg) and blood flow rates (QB) of 200-450 mL/min; the PrismaLung+ and A.L.ONE devices were also tested at a QB of 600 mL/min. The amount of CO2 removed by each device was assessed by measurement of the CO2 infused to maintain circuit equilibrium (CO2 infusion method) and compared with measured CO2 concentrations in the inlet and outlet of the CO2 removal device (blood gas analysis method). RESULTS The PrismaLung+ device performed similarly to the A.L.ONE device, with both devices demonstrating CO2 removal rates ~ 50% greater than the PrismaLung device. CO2 removal rates were 73 ± 4.0, 44 ± 2.5, and 72 ± 1.9 mL/min, for PrismaLung+, PrismaLung, and A.L.ONE, respectively, at QB 300 mL/min and pinCO2 45 mmHg. A Bland-Altman plot demonstrated that the CO2 infusion method was comparable to the blood gas analysis method for calculating CO2 removal. The resistance to blood flow across the test device, as measured by pressure drop, varied as a function of blood flow rate, and was greatest for PrismaLung and lowest for the A.L.ONE device. CONCLUSIONS The newly developed PrismaLung+ performed more effectively than PrismaLung, with performance of CO2 removal comparable to A.L.ONE at the flow rates tested, despite the smaller membrane surface area of PrismaLung+ versus A.L.ONE. Clinical testing of PrismaLung+ is warranted to further characterize its performance.
Collapse
Affiliation(s)
- Ingeborg Hospach
- Baxter International, Research and Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany
| | - Jacques Goldstein
- Baxter World Trade SPRL, Acute Therapies Global, Braine-l'Alleud, Belgium
| | - Kai Harenski
- Baxter, Baxter Deutschland GmbH, Unterschleissheim, Germany
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, NUI Galway, Galway, Ireland
| | | | - Manuela Raible
- Baxter International, Research and Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany
| | - Stefanie Votteler
- Baxter International, Research and Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany
| | - Markus Storr
- Baxter International, Research and Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany.
| |
Collapse
|
17
|
Satici C, López-Padilla D, Schreiber A, Kharat A, Swingwood E, Pisani L, Patout M, Bos LD, Scala R, Schultz MJ, Heunks L. ERS International Congress, Madrid, 2019: highlights from the Respiratory Intensive Care Assembly. ERJ Open Res 2020; 6:00331-2019. [PMID: 32166088 PMCID: PMC7061203 DOI: 10.1183/23120541.00331-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/23/2020] [Indexed: 12/19/2022] Open
Abstract
The Respiratory Intensive Care Assembly of the European Respiratory Society is delighted to present the highlights from the 2019 International Congress in Madrid, Spain. We have selected four sessions that discussed recent advances in a wide range of topics: from acute respiratory failure to cough augmentation in neuromuscular disorders and from extra-corporeal life support to difficult ventilator weaning. The subjects are summarised by early career members in close collaboration with the Assembly leadership. We aim to give the reader an update on the most important developments discussed at the conference. Each session is further summarised into a short list of take-home messages.
Collapse
Affiliation(s)
- Celal Satici
- Respiratory Medicine, Istanbul Gaziosmanpasa Training and Research Hospital, Health Science University, Istanbul, Turkey
| | - Daniel López-Padilla
- Respiratory Dept, Gregorio Marañón University Hospital, Spanish Sleep Network, Madrid, Spain
| | - Annia Schreiber
- Interdepartmental Division of Critical Care, University of Toronto, Unity Health Toronto (St Michael's Hospital) and the Li Ka Shing Knowledge Institute, Toronto, Canada
| | - Aileen Kharat
- Pulmonology Dept, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Ema Swingwood
- University Hospitals Bristol NHS Foundation Trust, Adult Therapy Services, Bristol Royal Infirmary, Bristol, UK
| | - Luigi Pisani
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Lieuwe D. Bos
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
- Respiratory Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Raffaele Scala
- Pulmonology and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy
| | - Marcus J. Schultz
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Leo Heunks
- Intensive Care, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| |
Collapse
|
18
|
Joannidis M, Forni LG, Klein SJ, Honore PM, Kashani K, Ostermann M, Prowle J, Bagshaw SM, Cantaluppi V, Darmon M, Ding X, Fuhrmann V, Hoste E, Husain-Syed F, Lubnow M, Maggiorini M, Meersch M, Murray PT, Ricci Z, Singbartl K, Staudinger T, Welte T, Ronco C, Kellum JA. Lung-kidney interactions in critically ill patients: consensus report of the Acute Disease Quality Initiative (ADQI) 21 Workgroup. Intensive Care Med 2019; 46:654-672. [PMID: 31820034 PMCID: PMC7103017 DOI: 10.1007/s00134-019-05869-7] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/13/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Multi-organ dysfunction in critical illness is common and frequently involves the lungs and kidneys, often requiring organ support such as invasive mechanical ventilation (IMV), renal replacement therapy (RRT) and/or extracorporeal membrane oxygenation (ECMO). METHODS A consensus conference on the spectrum of lung-kidney interactions in critical illness was held under the auspices of the Acute Disease Quality Initiative (ADQI) in Innsbruck, Austria, in June 2018. Through review and critical appraisal of the available evidence, the current state of research, and both clinical and research recommendations were described on the following topics: epidemiology, pathophysiology and strategies to mitigate pulmonary dysfunction among patients with acute kidney injury and/or kidney dysfunction among patients with acute respiratory failure/acute respiratory distress syndrome. Furthermore, emphasis was put on patients receiving organ support (RRT, IMV and/or ECMO) and its impact on lung and kidney function. CONCLUSION The ADQI 21 conference found significant knowledge gaps about organ crosstalk between lung and kidney and its relevance for critically ill patients. Lung protective ventilation, conservative fluid management and early recognition and treatment of pulmonary infections were the only clinical recommendations with higher quality of evidence. Recommendations for research were formulated, targeting lung-kidney interactions to improve care processes and outcomes in critical illness.
Collapse
Affiliation(s)
- Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Lui G Forni
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, Guildford, UK.,Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Sebastian J Klein
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.,Doctoral College Medical Law and Healthcare, Faculty of Law, University Innsbruck, Innsbruck, Austria
| | - Patrick M Honore
- Department of Intensive Care Medicine, CHU Brugmann University Hospital, Brussels, Belgium
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, London, UK
| | - John Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK.,William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Vincenzo Cantaluppi
- Nephrology, Dialysis and Kidney Transplantation Unit, Department of Translational Medicine, University of Eastern Piedmont "A. Avogadro", Maggiore della Carità University Hospital, Novara, Italy
| | - Michael Darmon
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France.,Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris, France
| | - Xiaoqiang Ding
- Department of Nephrology, Shanghai Institute of Kidney and Dialysis, Shanghai Key Laboratory of Kidney and Blood Purification, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Medicine B, University Muenster, Muenster, Germany
| | - Eric Hoste
- ICU, Ghent University Hospital, Ghent, Belgium.,Research Fund-Flanders (FWO), Brussels, Belgium
| | - Faeq Husain-Syed
- Division of Nephrology, Pulmonology and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Giessen, Germany
| | - Matthias Lubnow
- Department of Cardiology, Pulmonary and Critical Care Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Marco Maggiorini
- Medical Intensive Care Unit, Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Patrick T Murray
- School of Medicine, University College Dublin, Dublin, Ireland.,UCD Catherine McAuley Education and Research Centre, Dublin, Ireland
| | - Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Paediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Thomas Staudinger
- Department of Medicine I, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Tobias Welte
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padua, Italy.,International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
19
|
Wang JQ, Liu YR, Xia Q, Chen RN, Liang J, Xia QR, Li J. Emerging Roles for NLRC5 in Immune Diseases. Front Pharmacol 2019; 10:1352. [PMID: 31824312 PMCID: PMC6880621 DOI: 10.3389/fphar.2019.01352] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/25/2019] [Indexed: 12/15/2022] Open
Abstract
Innate immunity activates the corresponding immune response relying on multiple pattern recognition receptors (PRRs) that includes pattern recognition receptors (PRRs), like NOD-like receptors (NLRs), RIG-I-like receptors (RLRs), and C-type lectin receptors (CLRs), which could accurately recognize invasive pathogens. In particular, NLRs belong to a large protein family of pattern recognition receptors in the cytoplasm, where they are highly correlated with activation of inflammatory response system followed by rapid clearance of invasive pathogens. Among the NLRs family, NLRC5, also known as NOD4 or NOD27, accounts for a large proportion and involves in immune responses far and wide. Notably, in the above response case of inflammation, the expression of NLRC5 remarkably increased in immune cells and immune-related tissues. However, the evidence for higher expression of NLRC5 in immune disease still remains controversial. It is noted that the growing evidence further accounts for the participation of NLRC5 in the innate immune response and inflammatory diseases. Moreover, NLRC5 has also been confirmed to exert a critical role in the control of regulatory diverse signaling pathways. Together with its broad participation in the occurrence and development of immune diseases, NLRC5 can be consequently treated as a potential therapeutic target. Nevertheless, the paucity of absolute understanding of intrinsic characteristics and underlying mechanisms of NLRC5 still make it hard to develop targeting drugs. Therefore, current summary about NLRC5 information is indispensable. Herein, current knowledge of NLRC5 is summarized, and research advances in terms of NLRC5 in characteristics, biological function, and regulatory mechanisms are reviewed.
Collapse
Affiliation(s)
- Jie-Quan Wang
- Department of Pharmacy, Hefei Fourth People's Hospital, Hefei, China.,Department of Pharmacy, Anhui Mental Health Center, Hefei, China.,Department of Pharmacy, Affiliated Psychological Hospital of Anhui Medical University, Hefei, China.,School of Pharmacy, Anhui Medical University, Ministry of Education, Hefei, China
| | - Ya-Ru Liu
- Department of Pharmacy, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Quan Xia
- Department of Pharmacy, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ruo-Nan Chen
- School of Pharmacy, Anhui Medical University, Ministry of Education, Hefei, China.,Department of Pharmacy, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jun Liang
- Department of Pharmacy, Hefei Fourth People's Hospital, Hefei, China.,Department of Pharmacy, Anhui Mental Health Center, Hefei, China.,Department of Pharmacy, Affiliated Psychological Hospital of Anhui Medical University, Hefei, China
| | - Qing-Rong Xia
- Department of Pharmacy, Hefei Fourth People's Hospital, Hefei, China.,Department of Pharmacy, Anhui Mental Health Center, Hefei, China.,Department of Pharmacy, Affiliated Psychological Hospital of Anhui Medical University, Hefei, China
| | - Jun Li
- School of Pharmacy, Anhui Medical University, Ministry of Education, Hefei, China
| |
Collapse
|
20
|
[Current techniques for extracorporeal decarboxylation]. Med Klin Intensivmed Notfmed 2019; 114:733-740. [PMID: 31020339 DOI: 10.1007/s00063-019-0567-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 02/13/2019] [Indexed: 02/06/2023]
Abstract
The widespread use of extracorporeal lung assist (ECLA) in recent years has led to the introduction of different decarboxylation systems into clinical practice. Due to the large CO2 transport capacity of the blood such systems require considerably lower extracorporeal blood flows and therefore allow for effective decarboxylation with reduced invasiveness and complexity. While systems derived from classical lung assist are mainly used to control severe acute hypercapnic respiratory failure, recently a growing number of therapies based on renal replacement platforms have become available ("respiratory dialysis"). Such low-flow systems still allow for effective partial CO2 elimination and can control respiratory acidosis as well as facilitate or even enable protective and ultraprotective ventilation strategies in acute lung failure (ARDS). While the use of extracorporeal CO2 elimination (ECCO2R) has been shown to decrease ventilator-induced lung injury (VILI), positive effects on hard clinical endpoints such as mortality or duration of mechanical ventilation are still unproven. In light of limited evidence, ECCO2R must be regarded as an experimental procedure. Its use should therefore at present be restricted to centers with appropriate experience.
Collapse
|
21
|
Extracorporeal organ support (ECOS) in critical illness and acute kidney injury: from native to artificial organ crosstalk. Intensive Care Med 2018; 44:1447-1459. [DOI: 10.1007/s00134-018-5329-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 07/18/2018] [Indexed: 12/11/2022]
|