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Setty AA, Chiang TY, Santos JA, Isenberg BC, Vedula EM, Keating RA, Sutherland DW, Borenstein JT. Toward microfluidic integration of respiratory and renal organ support in a single cartridge. Artif Organs 2023; 47:1442-1451. [PMID: 37376726 DOI: 10.1111/aor.14603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/15/2023] [Accepted: 06/22/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Extracorporeal organ assist devices provide lifesaving functions for acutely and chronically ill patients suffering from respiratory and renal failure, but their availability and use is severely limited by an extremely high level of operational complexity. While current hollow fiber-based devices provide high-efficiency blood gas transfer and waste removal in extracorporeal membrane oxygenation (ECMO) and hemodialysis, respectively, their impact on blood health is often highly deleterious and difficult to control. Further challenges are encountered when integrating multiple organ support functions, as is often required when ECMO and ultrafiltration (UF) are combined to deal with fluid overload in critically ill patients, necessitating an unwieldy circuit containing two separate cartridges. METHODS We report the first laboratory demonstration of simultaneous blood gas oxygenation and fluid removal in single microfluidic circuit, an achievement enabled by the microchannel-based blood flow configuration of the device. Porcine blood is flowed through a stack of two microfluidic layers, one with a non-porous, gas-permeable silicone membrane separating blood and oxygen chambers, and the other containing a porous dialysis membrane separating blood and filtrate compartments. RESULTS High levels of oxygen transfer are measured across the oxygenator, while tunable rates of fluid removal, governed by the transmembrane pressure (TMP), are achieved across the UF layer. Key parameters including the blood flow rate, TMP and hematocrit are monitored and compared with computationally predicted performance metrics. CONCLUSIONS These results represent a model demonstration of a potential future clinical therapy where respiratory support and fluid removal are both realized through a single monolithic cartridge.
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Affiliation(s)
- Aakash A Setty
- Bioengineering Division, Draper, Cambridge, Massachusetts, USA
| | - Tzu Y Chiang
- Bioengineering Division, Draper, Cambridge, Massachusetts, USA
| | - Jose A Santos
- Bioengineering Division, Draper, Cambridge, Massachusetts, USA
| | | | - Else M Vedula
- Bioengineering Division, Draper, Cambridge, Massachusetts, USA
| | - Rose A Keating
- Bioengineering Division, Draper, Cambridge, Massachusetts, USA
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Li Y, Liu W, Yu K, Wang H, Wang C. What metabolites are removed by CRRT except creatinine? Crit Care 2022; 26:351. [DOI: 10.1186/s13054-022-04221-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 10/28/2022] [Indexed: 11/16/2022] Open
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Romagnoli S, Clark WR, Ricci Z, Ronco C. Renal replacement therapy for AKI: When? How much? When to stop? Best Pract Res Clin Anaesthesiol 2017; 31:371-385. [PMID: 29248144 DOI: 10.1016/j.bpa.2017.10.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 10/25/2017] [Indexed: 11/29/2022]
Abstract
Severe acute kidney injury (AKI) requiring renal replacement therapy (RRT) is a serious clinical disorder in the intensive care unit (ICU), occurring in a significant proportion of critically ill patients. However, many questions remain about the optimal administration of RRT with regard to several important considerations, including treatment dose, timing of treatment initiation and cessation, therapy mode, type of anticoagulation, and management of fluid overload. While Level 1 evidence exists for RRT dosing in AKI, all the studies contributing to this evidence base employed fixed-dose regimens throughout a patient's continuous RRT (CRRT) course, without regard for the possibility of individualizing treatment dose according to the clinical status of a given patient at a specific time. As opposed to CRRT dose, no consensus about the timing of RRT in critically ill AKI patients exists currently. While numerous clinical trials over the past 40 years have attempted to assess "early" versus "late" initiation of RRT, they have been plagued by a myriad of methodological problems, including their largely observational nature and the widely varying definitions of early and late initiation. Although questions about the appropriate timing of CRRT discontinuation arise very frequently in clinical practice, even less information is available in the literature to guide this important decision. The aim of this review is to provide a comprehensive update on RRT delivery to critically ill AKI patients, with specific attention paid to treatment dose and timing and emphasis on addressing the practical questions that arise in daily clinical practice.
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Affiliation(s)
- Stefano Romagnoli
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - William R Clark
- Davidson School of Chemical Engineering, Purdue University, West Lafayette, IN, USA.
| | - Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy; Department of Nephrology, San Bortolo Hospital, Vicenza, Italy
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Clark WR, Neri M, Garzotto F, Ricci Z, Goldstein SL, Ding X, Xu J, Ronco C. The future of critical care: renal support in 2027. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:92. [PMID: 28395664 PMCID: PMC5387317 DOI: 10.1186/s13054-017-1665-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Since its inception four decades ago, both the clinical and technologic aspects of continuous renal replacement therapy (CRRT) have evolved substantially. Devices now specifically designed for critically ill patients with acute kidney injury are widely available and the clinical challenges associated with treating this complex patient population continue to be addressed. However, several important questions remain unanswered, leaving doubts in the minds of many clinicians about therapy prescription/delivery and patient management. Specifically, questions surrounding therapy dosing, timing of initiation and termination, fluid management, anticoagulation, drug dosing, and data analytics may lead to inconsistent delivery of CRRT and even reluctance to prescribe it. In this review, we discuss current limitations of CRRT and potential solutions over the next decade from both a patient management and a technology perspective. We also address the issue of sustainability for CRRT and related therapies beyond 2027 and raise several points for consideration.
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Affiliation(s)
- William R Clark
- School of Chemical Engineering, Purdue University, 480 Stadium Mall Drive; FRNY 1051, West Lafayette, IN, 47907, USA.
| | - Mauro Neri
- International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy
| | - Francesco Garzotto
- International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy
| | - Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Xiaoqiang Ding
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai Quality Control Center for Dialysis, Shanghai, China
| | - Jiarui Xu
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai Quality Control Center for Dialysis, Shanghai, China
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy.,Department of Nephrology, San Bortolo Hospital, Vicenza, Italy
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Passos RDH, Ramos JGR, Gobatto A, Mendonça EJB, Miranda EA, Dutra FRD, Coelho MFR, Pedroza AC, Batista PBP, Dutra MMD. Lactate clearance is associated with mortality in septic patients with acute kidney injury requiring continuous renal replacement therapy: A cohort study. Medicine (Baltimore) 2016; 95:e5112. [PMID: 27749594 PMCID: PMC5059097 DOI: 10.1097/md.0000000000005112] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
The aim of the study was to assess the clinical utility of lactate measured at different time points to predict mortality at 48 hours and 28 days in septic patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT).Consecutive critically ill patients with septic AKI requiring CRRT were prospectively studied. Variables were collected at initiation of CRRT and 24 hours later.In total, 186 patients were analyzed. Overall mortality at 48 hours was 28% and at 28 days was 69%. Initial lactate, lactate at 24 hours and the proportion of patients with a lactate clearance superior to 10% were different between survivors at 28 days [2.0 mmol/L, 1.95 mmol/L and 18/45 (40%)] and nonsurvivors [3.46 mmol, 4.66 mmol, and 18/94 (19%)]. Multivariate analysis demonstrated that lactate at 24 hours and lactate clearance, but not initial lactate, were independently associated to mortality. Area under the ROC curves for 28-day mortality was 0.635 for initial lactate; 0.828 for lactate at 24 hours and 0.701 for lactate clearance.Lactate clearance and lactate after 24 hours of CRRT, but not initial lactate, were independently associated with mortality in septic AKI patients undergoing CRRT. Serial lactate measurements may be useful prognostic markers than initial lactate in these patients.
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Affiliation(s)
- Rogério da Hora Passos
- Critical Care Unit Hospital Sao Rafael, Salvador, Brazil /Nephrology Division Hospital Portugues, Salvador
- Correspondence: Rogério da Hora Passos, Critical Care Unit Hospital Sao Rafael, Salvador, Brazil/Nephrology Division Hospital Portugues, Salvador, Brazil (e-mail: )
| | - Joao Gabriel Rosa Ramos
- Critical Care Unit Hospital São Rafael, Salvador, Brazil/UNIME Medical School, Lauro de Freitas
| | | | | | | | | | | | | | - Paulo Benigno Pena Batista
- Hospital São Rafael Critical Care Unit Hospital São Rafael, Salvador, Brazil/UNIME Medical School, Lauro de Freitas, Brazil
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Udani S, Chen LX, Daley M, Lat I, Koyner JL. Compliance with Antibiotic Dosing Guidelines in Critically Ill Patients Receiving Renal Replacement Therapy. J Pharm Technol 2013. [DOI: 10.1177/875512251302900403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Compliance with antibiotic dosing guidelines and achievement of target serum concentrations in patients with infection who are on renal replacement therapy (RRT) is complex, essential for supportive care, and not well studied. Objective: To determine adherence rates to antibiotic dosing guidelines in the setting of RRT in the intensive care unit (ICU). Methods: We conducted a retrospective, single-center, cohort study evaluating antibiotic dosing in all patients in the ICU receiving RRT between July 2007 and June 2009. Appropriate dosing was determined by comparing dose administered with established guidelines. Dosing was denoted as accurate if adjustment occurred prior to the third administered dose or, if appropriate dosing is every 12 hours or more, within 24 hours. We compared rates according to modality of RRT (intermittent hemodialysis [IHD] vs continuous veno-venous hemodialysis [CVVHD]), indication for RRT (acute kidney injury [AKI] vs end-stage renal disease [ESRD]), and presence of a clinical pharmacist on rounds. Results: Adherence rates of 546 patients receiving RRT, with 1761 individual antibiotic prescriptions, were analyzed. Dosing errors were more common in the group receiving CVVHD than in the IHD group (58.1% vs 49.5%; p < 0.001). Frequency of dosing errors did not differ significantly between patients receiving RRT for AKI versus those with ESRD (55.4% vs 51.3%; p = 0.24) or in ICUs with or without a pharmacist on rounds (53.0% vs 54.6%; p = 0.67). Underdosing occurred less frequently with a clinical pharmacist on rounds (18.7% vs 31.3%; p < 0.001). However, in-hospital mortality was not significantly different in underdosed individuals compared with the rest of the cohort (52.3% vs 51.6%; p = 0.92). Conclusions: Antibiotic underdosing is common. Increased awareness of dose adjustment guidelines for CVVHD and having a clinical pharmacist on rounds may improve rates of underdosing.
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Affiliation(s)
- Suneel Udani
- SUNEEL UDANI MD MPH, Fellow, Nephrology, Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL
| | - Ling-Xin Chen
- LING-XIN CHEN MD, Resident, Internal Medicine, Department of Medicine, University of Chicago
| | - Mitchell Daley
- MITCHELL DALEY PharmD, Clinical Pharmacy Specialist, Critical Care, Department of Pharmacy, University Medical Center Brackenridge, Austin, TX
| | - Ishaq Lat
- ISHAQ LAT PharmD FCCM FCCP BCPS, Clinical Coordinator, Critical Care, Clinical Specialist, Medical Intensive Care Unit, Department of Pharmacy Services, University of Chicago
| | - Jay L Koyner
- JAY L KOYNER MD, Assistant Professor of Medicine, Section of Nephrology, Department of Medicine, University of Chicago
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Drug dosing consideration in patients with acute and chronic kidney disease-a clinical update from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2011; 80:1122-37. [PMID: 21918498 DOI: 10.1038/ki.2011.322] [Citation(s) in RCA: 291] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Drug dosage adjustment for patients with acute or chronic kidney disease is an accepted standard of practice. The challenge is how to accurately estimate a patient's kidney function in both acute and chronic kidney disease and determine the influence of renal replacement therapies on drug disposition. Kidney Disease: Improving Global Outcomes (KDIGO) held a conference to investigate these issues and propose recommendations for practitioners, researchers, and those involved in the drug development and regulatory arenas. The conference attendees discussed the major challenges facing drug dosage adjustment for patients with kidney disease. In particular, although glomerular filtration rate is the metric used to guide dose adjustment, kidney disease does affect nonrenal clearances, and this is not adequately considered in most pharmacokinetic studies. There are also inadequate studies in patients receiving all forms of renal replacement therapy and in the pediatric population. The conference generated 37 recommendations for clinical practice, 32 recommendations for future research directions, and 24 recommendations for regulatory agencies (US Food and Drug Administration and European Medicines Agency) to enhance the quality of pharmacokinetic and pharmacodynamic information available to clinicians. The KDIGO Conference highlighted the gaps and focused on crafting paths to the future that will stimulate research and improve the global outcomes of patients with acute and chronic kidney disease.
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Levine M, Brooks DE, Truitt CA, Wolk BJ, Boyer EW, Ruha AM. Toxicology in the ICU. Chest 2011; 140:795-806. [DOI: 10.1378/chest.10-2548] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Bogard KN, Peterson NT, Plumb TJ, Erwin MW, Fuller PD, Olsen KM. Antibiotic dosing during sustained low-efficiency dialysis: Special considerations in adult critically ill patients*. Crit Care Med 2011; 39:560-70. [DOI: 10.1097/ccm.0b013e318206c3b2] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Eyler RF, Mueller BA. Antibiotic dosing in critically ill patients with acute kidney injury. Nat Rev Nephrol 2011; 7:226-35. [PMID: 21343897 DOI: 10.1038/nrneph.2011.12] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
A common cause of acute kidney injury (AKI) is sepsis, which makes appropriate dosing of antibiotics in these patients essential. Drug dosing in critically ill patients with AKI, however, can be complicated. Critical illness and AKI can both substantially alter pharmacokinetic parameters as compared with healthy individuals or patients with end-stage renal disease. Furthermore, drug pharmacokinetic parameters are highly variable within the critically ill population. The volume of distribution of hydrophilic agents can increase as a result of fluid overload and decreased binding of the drug to serum proteins, and antibiotic loading doses must be adjusted upwards to account for these changes. Although renal elimination of drugs is decreased in patients with AKI, residual renal function in conjunction with renal replacement therapies (RRTs) result in enhanced drug clearance, and maintenance doses must reflect this situation. Antibiotic dosing decisions should be individualized to take into account patient-related, RRT-related, and drug-related factors. Efforts must also be made to optimize the attainment of antibiotic pharmacodynamic goals in this population.
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Affiliation(s)
- Rachel F Eyler
- Department of Clinical, Social, and Administrative Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, MI 48109-1065, USA
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First experience with the Prismaflex HF 20 set in four infants. Int J Artif Organs 2011; 34:10-5. [PMID: 21298618 DOI: 10.5301/ijao.2011.6315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2010] [Indexed: 11/20/2022]
Abstract
PURPOSE Renal replacement therapy (RRT) in infants is challenging due to a lack of widely available technology that is specific to this patient population. We present our initial experience with the newly developed Prismaflex HF20 disposable set used on the Prismaflex device in infants with renal failure. PATIENTS Four infants, age 5 to 24 months, were enrolled. Overall 120 treatment sessions were performed over 300 patient-days. Treatment monitoring included patient weight change and fluid balance, treatment efficacy, number of interventions, and alarms. RESULTS Desired fluid balance according to the prescribed weight loss was achieved in all patients (R²=0.86, p<0.0001). Treatment efficacy was monitored by blood urea nitrogen (BUN) and serum creatinine values at the start of RRT (59 ± 17 mg/dL and 5.1 ± 1.1 mg/dL) and their decrease after 4 hours of RRT (23 ± 7 mg/dL and 2.2 ± 0.6 mg/dL). Measured urea and creatinine clearances for the HF20 filter were 23 ± 7 ml/min and 19 ± 4 ml/min, respectively. No complications occurred. CONCLUSION This is the first report on the use of the Prismaflex HF20 set in infants. No adverse events were observed, treatments were well tolerated in all patients, and flow rate adaptability to infants' needs was good.
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Yang ZH, Zhang CM, Liu T, Lou XF, Chen ZJ, Ye S. Continuous renal replacement therapy for patients with acute kidney injury caused by melamine-related urolithiasis. World J Pediatr 2010; 6:158-62. [PMID: 20490771 DOI: 10.1007/s12519-010-0031-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Accepted: 09/16/2009] [Indexed: 10/19/2022]
Abstract
BACKGROUND In 2008 there was an epidemic of renal disease affecting infants after consumption of melamine-tainted milk products. Most of the infected children were asymptomatic or with mild symptoms, and a few suffered from acute obstructive kidney injury secondary to melamine-contained renal stones (8 of 15,577 children screened at our hospital for urolithiasis). This study was intended to retrospectively review the management of acute kidney injury using continuous renal replacement therapy (CRRT) in the 8 children with acute kidney injury. METHODS The 8 infants with acute kidney injury caused by melamine-related urolithiasis were referred to the pediatric intensive care unit at the hospital in late 2008. CRRT was given to treat their kidney injuries. Medical records of the infants were reviewed for demographic features, diagnosis, CRRT treatment, and outcomes. RESULTS Before CRRT, hypertension was found in 6 of the 8 children. Varying degrees of oliguria, anuria, elevated levels of blood urea nitrogen (BUN) (13.11-35.6 mmol/L) and creatinine (Cr) (238.8-773.7 mumol/L) were observed in these patients. After CRRT, the levels of BUN, Cr and electrolytes decreased. Urine output and edema were improved clinically. CONCLUSION CRRT can rapidly improve renal function, avoiding such surgical interventions as lithotripsy, percutaneous nephrolithotomy, and ureteroscopy. It is an efficient modality to treat acute kidney injury caused by melamine-related urolithiasis.
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Affiliation(s)
- Zi-Hao Yang
- Department of Pediatric ICU, Children's Hospital of Zhejiang University School of Medicine and Zhejiang Key Laboratory for Diagnosis and Therapy of Neonatal Diseases, Hangzhou, 310003, China
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Heintz BH, Matzke GR, Dager WE. Antimicrobial Dosing Concepts and Recommendations for Critically Ill Adult Patients Receiving Continuous Renal Replacement Therapy or Intermittent Hemodialysis. Pharmacotherapy 2009; 29:562-77. [DOI: 10.1592/phco.29.5.562] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Ronco C, Cruz D, Oudemans van Straaten H, Honore P, House A, Bin D, Gibney N. Dialysis dose in acute kidney injury: no time for therapeutic nihilism--a critical appraisal of the Acute Renal Failure Trial Network study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:308. [PMID: 18983695 PMCID: PMC2592750 DOI: 10.1186/cc7016] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The optimal dialysis dose for acute kidney injury is a matter of great controversy. Clinical trials, predominantly single-center studies, have shown conflicting results. The Acute Renal Failure Trial Network (ATN) Study was designed to compare clinical outcomes between patients allocated to an intensive dose versus a less-intensive dose of renal replacement therapy. Recently, the results of this large randomized controlled multicenter study were published. The present article will discuss certain aspects of this trial: the overall design, the baseline patient characteristics, and comparison of the results with earlier studies. Finally, the article will address the implications of the ATN Study results for clinical practice.
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Affiliation(s)
- Claudio Ronco
- Nephrology Department, St Bortolo Hospital, Viale Rodolfi 37, 36100 Vicenza, Italy.
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