1
|
Zeng Z, Shen Y, Wan L, Yang X, Liang Z, He M. Risk factors for unplanned weaning of continuous renal replacement therapy in ICU patients: a meta-analysis. Ren Fail 2024; 46:2387431. [PMID: 39135545 PMCID: PMC11328600 DOI: 10.1080/0886022x.2024.2387431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 07/21/2024] [Accepted: 07/29/2024] [Indexed: 08/18/2024] Open
Abstract
OBJECTIVE To systematically review the risk factors for unplanned weaning during continuous renal replacement therapy in ICU patients. METHODS A combination of subject words + free words was used to search the relevant literature published in CNKI, Wanfang, VIP, CBM, PubMed, EMbase, Web of Science, Cochrane Library, Mediline and other databases. The search period was from the establishment of the databases to June 25, 2024. Revman 5.4 software and Stata15.0 software was used to meta-analyze the risk factors for unplanned weaning during continuous renal replacement therapy in ICU patients. RESULTS A total of 23 studies were included in this meta-analysis, describing 15 variables, 3793 patients, and using 7197 filters. Meta-analysis results showed that risk factors for unplanned weaning during continuous renal replacement therapy in ICU patients were as follows: Low mean arterial pressure [OR = 1.02, 95%CI (1.00, 1.03), p < 0.05], hypothermia [OR = 3.40, 95%CI (1.78, 6.47), p < 0.05], age (≥60 years) [OR = 4.45, 95%CI (3.18, 6.22), p < 0.05], comorbid underlying disease [OR = 3.63, 95%CI (2.70, 4.88), p < 0.05], agitation [OR = 4.97, 95%CI (3.20, 7.74), p < 0.05], no anticoagulant use [OR = 1.65, 95%CI (1.25, 2.17), p < 0.05], short activated partial prothrombin time [OR = 1.23, 95%CI (1.13, 1.34), p < 0.05], hyper-hematocrit [OR = 1.73, 95%CI (1.13, 2.66), p = 0.01], low ionized calcium concentration [OR = 1.48, 95% CI (1.08, 2.02), p = 0.01], CRRT that was treated at a high dose [OR = 1.42, 95%CI (1.14, 1.76), p < 0.05], mechanical ventilation [OR = 4.25, 95%CI (2.67, 6.77), p < 0.05], and lack of dedicated care [OR = 5.08, 95%CI (2.51, 10.28), p < 0.05]. However, it is unclear whether platelet count, prothrombin activity, and blood flow velocity are risk factors for unplanned weaning during CRRT in ICU patients, and more studies are needed for further validation. CONCLUSION Available evidence suggests that a variety of factors contribute to unplanned weaning of CRRT in ICU patients. Early detection of these risk factors is essential for healthcare professionals to develop preventive and curative strategies. REGISTRATION This study is registered on the PROSERO website under registration number CRD42024543554.
Collapse
Affiliation(s)
- Zhi Zeng
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Yuqi Shen
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Li Wan
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Xiuru Yang
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Zhenghua Liang
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Mei He
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| |
Collapse
|
2
|
Kinjoh K, Nagamura R, Sakuda Y. A Retrospective Study on the Start and End of Continuous Hemodialysis Using a Polymethylmethacrylate Hemofilter for Severe Acute Pancreatitis. Intern Med 2024; 63:2241-2249. [PMID: 38220199 DOI: 10.2169/internalmedicine.2708-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2024] Open
Abstract
Objective We previously reported the successful outcomes in severe acute pancreatitis (SAP) after continuous hemodialysis using a polymethylmethacrylate hemofilter (PMMA-CHD). The present study makes informative suggestions regarding the initiation and termination of PMMA-CHD. Methods We retrospectively studied 63 patients with SAP admitted to the intensive care unit between January 1, 2011, and December 31, 2022, including 30 who received PMMA-CHD therapy for renal dysfunction. Statistical significance was evaluated using a multiple logistic regression analysis for severity scores, prognostic factor scores in the Japanese severity criteria, the Kidney Disease: Improving Global Outcomes (KDIGO) stage, and the lung injury score (LIS). Results At the onset of blood purification therapy using PMMA-CHD, a significant increase in the KDIGO stage was shown, with a cutoff value of 2.0. The prognostic factor score and LIS at the start of blood purification therapy were significantly high, with a cutoff value of 3.0. Analyses of severity scores, the KDIGO stage, and the LIS before the start of PMMA-CHD were also increased significantly, with cutoff values of +2.0, +1.0, and +3.0, respectively. Furthermore, on analyses of improvements in values after starting PMMA-CHD, the value of KDIGO staging significantly decreased, and the cutoff value was -2.0. The prognostic factor score was also significantly decreased, with a cutoff value of -2.0. Conclusion Prognostic factor scores of the Japanese severity criteria and LIS, as well as the KDIGO stage, are valuable indicators for determining the start and end of PMMA-CHD therapy.
Collapse
Affiliation(s)
- Kiyohiko Kinjoh
- Division of Blood Purification Therapy, Okinawa Kyodo Hospital, Japan
| | - Ryoji Nagamura
- Department of Gastroentrology, Okinawa Kyodo Hospital, Japan
| | | |
Collapse
|
3
|
Deja A, Guzzo I, Cappoli A, Labbadia R, Bayazit AK, Yildizdas D, Schmitt CP, Tkaczyk M, Cvetkovic M, Kostic M, Hayes W, Shroff R, Jankauskiene A, Virsilas E, Longo G, Vidal E, Mir S, Bulut IK, Pasini A, Paglialonga F, Montini G, Yilmaz E, Costa LC, Teixeira A, Schaefer F. Factors influencing circuit lifetime in paediatric continuous kidney replacement therapies - results from the EurAKId registry. Pediatr Nephrol 2024:10.1007/s00467-024-06459-6. [PMID: 39023538 DOI: 10.1007/s00467-024-06459-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 06/22/2024] [Accepted: 06/24/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Continuous kidney replacement therapy (CKRT) has recently become the preferred kidney replacement modality for children with acute kidney injury (AKI). We hypothesise that CKRT technical parameters and treatment settings in addition to the clinical characteristics of patients may influence the circuit lifetime in children. METHODS The study involved children included in the EurAKId registry (NCT02960867), who underwent CKRT treatment. We analysed patient characteristics and CKRT parameters. The primary end point was mean circuit lifetime (MCL). Secondary end points were number of elective circuit changes and occurrence of dialysis-related complications. RESULTS The analysis was composed of 247 children who underwent 37,562 h of CKRT (median 78, IQR 37-165 h per patient). A total of 1357 circuits were utilised (3, IQR 2-6 per patient). MCL was longer in regional citrate anticoagulation (RCA), compared to heparin (HA) and no anticoagulation (NA) (42, IQR 32-58 h; 24, IQR 14-34 h; 18, IQR 12-24 h, respectively, p < 0.001). RCA was associated with longer MCL regardless of the patient's age or dialyser surface. In multivariate analysis, MCL correlated with dialyser surface area (beta = 0.14, p = 0.016), left internal jugular vein vascular access site (beta = -0.37, p = 0.027), and the use of HA (beta = -0.14, p = 0.038) or NA (beta = -0.37, p < 0.001) vs. RCA. RCA was associated with the highest ratio of elective circuit changes and the lowest incidence of complications. CONCLUSION Anticoagulation modality, dialyser surface, and vascular access site influence MCL. RCA should be considered when choosing first-line anticoagulation for CKRT in children. Further efforts should focus on developing guidelines and clinical practice recommendations for paediatric CKRT.
Collapse
Affiliation(s)
- Anna Deja
- Department of Paediatrics and Nephrology, Medical University of Warsaw, Warsaw, Poland.
| | - Isabella Guzzo
- Division of Nephrology, Dialysis and Transplant Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Andrea Cappoli
- Division of Nephrology, Dialysis and Transplant Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Raffaella Labbadia
- Division of Nephrology, Dialysis and Transplant Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Aysun Karabay Bayazit
- Department of Pediatric Nephrology, Cukurova University, Faculty of Medicine, Adana, Turkey
| | - Dincer Yildizdas
- Department of Pediatric Nephrology, Cukurova University, Faculty of Medicine, Adana, Turkey
| | - Claus Peter Schmitt
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Marcin Tkaczyk
- Department of Pediatrics and Immunology, Nephrology Division, Polish Mothers Memorial Hospital Research Institute, Lodz, Poland
| | - Mirjana Cvetkovic
- Department of Nephrology, University Children Hospital, Belgrade, Serbia
| | - Mirjana Kostic
- Department of Nephrology, University Children Hospital, Belgrade, Serbia
| | - Wesley Hayes
- Department of Pediatric Nephrology, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Rukshana Shroff
- Department of Pediatric Nephrology, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Augustina Jankauskiene
- Clinic of Pediatrics, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Ernestas Virsilas
- Clinic of Pediatrics, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Germana Longo
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Woman's and Children's Health, University of Padua, Padua, Italy
| | - Enrico Vidal
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Woman's and Children's Health, University of Padua, Padua, Italy
| | - Sevgi Mir
- Department of Pediatric Nephrology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Ipek Kaplan Bulut
- Department of Pediatric Nephrology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Andrea Pasini
- Pediatric Nephrology and Dialysis, Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Fabio Paglialonga
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Grande IRRCS, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Grande IRRCS, Ospedale Maggiore Policlinico, Milan, Italy
| | - Ebru Yilmaz
- Department of Pediatric Nephrology, Dr Behcet Children Research and Education Hospital, Izmir, Turkey
| | - Liane Correia Costa
- Department of Pediatric Nephrology, Centro Materno-Infantil Do Norte, Porto, Portugal
| | - Ana Teixeira
- Department of Pediatric Nephrology, Centro Materno-Infantil Do Norte, Porto, Portugal
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
4
|
Khater NA, Sadeq AA, Al Absi DT, Simsekler MCE, Khattab IM, Shalaby EA, AbuKhater R, Kashiwagi DT, Andras C, Molesi A, Omar F, Abbas M, Pirayil MS, Anwar S. Impact of specialized renal technologists on optimizing delivery of continuous kidney replacement therapy in critical care areas a retrospective study. Hemodial Int 2024; 28:304-312. [PMID: 38937144 DOI: 10.1111/hdi.13167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 05/15/2024] [Accepted: 06/09/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Continuous renal replacement therapy (CKRT) is delivered to some of the most critically ill patients in hospitals. This therapy is expensive and requires coordination of multidisciplinary teams to ensure the prescribed dose is delivered. With increased demands on the critical care nursing staff and increased complexities of patients admitted to critical care units, we evaluated the role of specialized renal technologists in ensuring the prescribed dose is delivered. Therefore, the aim of this study is to investigate the impact of supporting intensive care unit nurses with specialized renal technologists on optimizing efficiency of CKRT sessions in the United Arab Emirates. METHODS This is a retrospective study that compared critically ill patients on CKRT overseen by specialized renal technologists versus who are non-covered in the year 2021. RESULTS A total of 331 sessions on 158 patients were included in the study. The mean filter life was longer in specialized renal technologists-covered patients compared to the non-covered group (66 vs. 59 h, p = 0.019). After adjustment by multiple regression analysis for risk factors (i.e., age, gender, mechanical ventilation, sepsis, mean arterial pressure, vasopressors, and SOFA) that may affect CKRT machines' filter life, presence of a specialized renal technologists resulted in significantly longer filter life (co-efficient 0.129; CI 95% 1.080, 11.970; p-value: 0.019). CONCLUSION Our study suggests that specialized renal technologists play a vital role in prolonging CKRT machine's filter life span and optimizing CKRT machine's efficiency. Further research should focus on other potential benefits of having specialized renal technologists performing CKRT sessions, and to confirm the finding of this study. Additionally, a cost-benefit analysis could be conducted to determine the economic impact of having specialized teams performing CKRT.
Collapse
Affiliation(s)
- Noha Abou Khater
- Department of Medicine, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | - Ahmed Adel Sadeq
- Department of Pharmacy, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | - Dima Tareq Al Absi
- Department of Management Science and Engineering, Khalifa University of science and technology, Abu Dhabi, UAE
| | - Mecit Can Emre Simsekler
- Department of Management Science and Engineering, Khalifa University of science and technology, Abu Dhabi, UAE
| | | | | | - Rawan AbuKhater
- Department of Medicine, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | | | - Christian Andras
- Department of Critical Care Medicine, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | - Andrea Molesi
- Department of Critical Care Medicine, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | - Fahad Omar
- Department of Critical Care Medicine, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | - Mezher Abbas
- Department of Critical Care Medicine, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | | | - Siddiq Anwar
- Department of Medicine, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
- School of Medicine, Khalifa University, Abu Dhabi, UAE
| |
Collapse
|
5
|
Zhu D, He J, Xiao Z, Zhou X, Zhang X. Citrate and low-dose heparin combined anticoagulation in pediatric continuous renal replacement therapy. Sci Rep 2024; 14:13504. [PMID: 38866989 PMCID: PMC11169537 DOI: 10.1038/s41598-024-64433-6] [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: 02/01/2024] [Accepted: 06/10/2024] [Indexed: 06/14/2024] Open
Abstract
There remains no optimal anticoagulation protocol for continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) in pediatric patients with elevated D-dimer levels. We aimed to assess the effects of different anticoagulation strategies on the risk of CRRT filter clotting in these patients. Pediatric patients undergoing CRRT were retrospectively grouped based on pre-CRRT D-dimer levels and anticoagulant: D-RCA group (normal D-dimer, RCA only, n = 22), D+ RCA group (elevated D-dimer, RCA only, n = 50), and D+ RCA+ systemic heparin anticoagulation (SHA) group (elevated D-dimer, RCA combined with SHA, n = 55). The risk of filter clotting and incidence of bleeding were compared among the groups. Among the groups, the D+ RCA+ SHA group had the longest filter lifespan; further, the incidence of bleeding was not increased by concurrent use of low-dose heparin for anticoagulation. Moreover, concurrent heparin anticoagulation was associated with a decreased risk of filter clotting. Contrastingly, high pre-CRRT hemoglobin and D-dimer levels and post-filter ionized calcium level > 0.4 mmol/L were associated with an increased risk of filter clotting. RCA combined with low-dose heparin anticoagulation could reduce the risk of filter clotting and prolong filter lifespan without increasing the risk of bleeding in patients with elevated D-dimer levels undergoing CRRT.
Collapse
Affiliation(s)
- Desheng Zhu
- Pediatric Intensive Care Unit, The Affiliated Children's Hospital of Xiangya School of Medicine, Central South University (Hunan Children's Hospital), No. 86 Ziyuan Rd, Yuhua District, Changsha, 410007, Hunan, China
| | - Jie He
- Pediatric Intensive Care Unit, The Affiliated Children's Hospital of Xiangya School of Medicine, Central South University (Hunan Children's Hospital), No. 86 Ziyuan Rd, Yuhua District, Changsha, 410007, Hunan, China
| | - Zhenghui Xiao
- Pediatric Intensive Care Unit, The Affiliated Children's Hospital of Xiangya School of Medicine, Central South University (Hunan Children's Hospital), No. 86 Ziyuan Rd, Yuhua District, Changsha, 410007, Hunan, China
| | - Xiong Zhou
- Pediatric Intensive Care Unit, The Affiliated Children's Hospital of Xiangya School of Medicine, Central South University (Hunan Children's Hospital), No. 86 Ziyuan Rd, Yuhua District, Changsha, 410007, Hunan, China
| | - Xinping Zhang
- Pediatric Intensive Care Unit, The Affiliated Children's Hospital of Xiangya School of Medicine, Central South University (Hunan Children's Hospital), No. 86 Ziyuan Rd, Yuhua District, Changsha, 410007, Hunan, China.
| |
Collapse
|
6
|
Yue Q, Wu H, Xi M, Li F, Li T, Li Y. Filter Lifespan, Treatment Effect, and Influencing Factors of Continuous Renal Replacement Therapy for Severe Burn Patients. J Burn Care Res 2024; 45:764-770. [PMID: 38113522 PMCID: PMC11073580 DOI: 10.1093/jbcr/irad196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Indexed: 12/21/2023]
Abstract
Continuous renal replacement therapy (CRRT) is often disrupted due to various factors, such as patient-related issues, vascular access complications, treatment plans, and medical staff factors. This unexpected interruption is referred to as non-selective filter stoppage and can result in additional treatment expenses. This study conducted a retrospectively analyzed 501 CRRT filters used in 62 patients with severe burns, lifespan and therapeutic effect of all filters were mainly analyzed, used logistic regression analysis was performed to identify risk factors associated with non-selective cessation filters. Out of 493 filters, 279 cases received heparin (56.60%), the median lifespan of the filter was 14.08 h (25th, 75th quantile: 7.30, 21.50); 128 cases were treated with nafamostat mesylate (26.00%), and the median lifespan of the filter was 16.42 h (10.49, 22.76); 86 cases were treated with sodium citrate (17.40%), and the median lifespan of the filter was 31.06 h (19.25, 48.75). In addition, significant differences were observed in the electrolyte index, renal function index, and procalcitonin levels before and after treatment with a single filter (P < .001). Multivariate logistic regression showed that the risk of non-selective cessation of sodium citrate anticoagulants was lower than that of heparin anticoagulation. Overall, CRRT is progressively becoming more prevalent in the treatment of patients with severe burns. The lifespan of individual filters and total patient treatment duration showed a consistent upward trend. The filter's lifespan was notably greater during sodium citrate anticoagulation when compared to nafamostat mesylate and heparin, meanwhile notably reducing the risk of non-selective cessation. Therefore, we recommend sodium citrate for anticoagulation in patients without any contraindications.
Collapse
Affiliation(s)
- Qian Yue
- Medical College of Wuhan University of Science and Technology, Wuhan, China
| | - Hong Wu
- Wuhan Institute of Burns, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan, China
| | - Maomao Xi
- Wuhan Institute of Burns, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan, China
| | - Feng Li
- Wuhan Institute of Burns, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan, China
| | - Tiantian Li
- Wuhan Institute of Burns, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan, China
| | - Yinyin Li
- Wuhan Institute of Burns, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan, China
| |
Collapse
|
7
|
Yu X, Ouyang L, Li J, Peng Y, Zhong D, Yang H, Zhou Y. Knowledge, attitude, practice, needs, and implementation status of intensive care unit staff toward continuous renal replacement therapy: a survey of 66 hospitals in central and South China. BMC Nurs 2024; 23:281. [PMID: 38671501 PMCID: PMC11055233 DOI: 10.1186/s12912-024-01953-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/19/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) is a commonly utilized form of renal replacement therapy (RRT) in the intensive care unit (ICU). A specialized CRRT team (SCT, composed of physicians and nurses) engage playing pivotal roles in administering CRRT, but there is paucity of evidence-based research on joint training and management strategies. This study armed to evaluate the knowledge, attitude, and practice (KAP) of ICU staff toward CRRT, and to identify education pathways, needs, and the current status of CRRT implementation. METHODS This study was performed from February 6 to March 20, 2023. A self-made structured questionnaire was used for data collection. Descriptive statistics, T-tests, Analysis of variance (ANOVA), multiple linear regression, and Pearson correlation coefficient tests (α = 0.05) were employed. RESULTS A total of 405 ICU staff from 66 hospitals in Central and South China participated in this study, yielding 395 valid questionnaires. The mean knowledge score was 51.46 ± 5.96 (61.8% scored highly). The mean attitude score was 58.71 ± 2.19 (73.9% scored highly). The mean practice score was 18.15 ± 0.98 (85.1% scored highly). Multiple linear regression analysis indicated that gender, age, years of CRRT practice, ICU category, and CRRT specialist panel membership independently affected the knowledge score; Educational level, years of CRRT practice, and CRRT specialist panel membership independently affected the attitude score; Education level and teaching hospital employment independently affected the practice score. The most effective method for ICU staff to undergo training and daily work experience is within the department. CONCLUSION ICU staff exhibit good knowledge, a positive attitude and appropriately practiced CRRT. Extended CRRT practice time in CRRT, further training in a general ICU or teaching hospital, joining a CRRT specialist panel, and upgraded education can improve CRRT professional level. Considering the convenience of training programs will enhance ICU staff participation. Training should focus on basic CRRT principles, liquid management, and alarm handling.
Collapse
Affiliation(s)
- Xiaoyan Yu
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China
| | - Lin Ouyang
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China
| | - Jinxiu Li
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China
| | - Ying Peng
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China
| | - Dingming Zhong
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China
| | - Huan Yang
- Blood Purification Center, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China
| | - Yanyan Zhou
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China.
| |
Collapse
|
8
|
Musalem P, Pedreros-Rosales C, Müller-Ortiz H. Anticoagulation in renal replacement therapies: Why heparin should be abandoned in critical ill patients? Int Urol Nephrol 2024; 56:1383-1393. [PMID: 37755609 DOI: 10.1007/s11255-023-03805-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/13/2023] [Indexed: 09/28/2023]
Abstract
Extracorporeal circuits used in renal replacement therapy (RRT) can develop thrombosis, leading to downtimes and reduced therapy efficiency. To prevent this, anticoagulation is used, but the optimal anticoagulant has not yet been identified. Heparin is the most widely used anticoagulant in RRT, but it has limitations, such as unpredictable pharmacokinetics, nonspecific binding to plasma proteins and cells, and the possibility of suboptimal anticoagulation or bleeding complications, specifically in critically ill patients with acute renal failure who are already at high risk of bleeding. Citrate anticoagulation is a better alternative, being considered a standard for continuous renal replacement therapy, since it is associated with a lower risk of bleeding complications and better efficacy, even in patients with acute renal failure or liver disease. The aim of this article is to provide an updated review of the different strategies of anticoagulation in renal replacement therapies that can be implemented in critical scenarios, focusing on the advantages and disadvantages of each one and the beneficial aspects of using citrate over heparin in critical ill patients.
Collapse
Affiliation(s)
- Pilar Musalem
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile
- Nephrology, Dialysis and Transplantation Service, Hospital Las Higueras, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile
| | - Cristian Pedreros-Rosales
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile.
- Nephrology, Dialysis and Transplantation Service, Hospital Las Higueras, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile.
| | - Hans Müller-Ortiz
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile
- Nephrology, Dialysis and Transplantation Service, Hospital Las Higueras, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile
| |
Collapse
|
9
|
Kashima Y, Koami H, Sakamoto Y. The Relationship Between Acute-Phase Circuit Occlusion and Blood Calcium Concentration in an Ex Vivo Continuous Renal Replacement Therapy Model. Cureus 2024; 16:e59330. [PMID: 38817525 PMCID: PMC11139355 DOI: 10.7759/cureus.59330] [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] [Accepted: 04/29/2024] [Indexed: 06/01/2024] Open
Abstract
Background and objective Continuous renal replacement therapy (CRRT) is a blood purification therapy modality for the treatment of renal failure in critically ill hospitalized patients with multiorgan dysfunction, effectively preventing uremia and multiple organ failure while improving renal function. However, the perfusion of patient blood through extracorporeal circulation often results in unexpected early occlusion of the CRRT circuit or hemofilter, leading to frequent interruptions in CRRT and wastage of medical resources. Moreover, clinical research on such circuit occlusions is limited. In Japan, CRRT circuits require long-term perfusion, often lasting 24 hours or more, indicating the need for a model capable of inducing occlusion at any arbitrary time; this model can evaluate various aspects, including causes and underlying mechanisms, and contribute to the development of an occlusion prediction method. Hence, we hypothesized the need for a model for inducing occlusion at arbitrary time points. Consequently, we strove to develop an ex vivo circuit occlusion model involving the injection of calcium into circulating citrated animal blood to evaluate the relationship between the amount of calcium chloride injected, circuit occlusion time, and changes in circuit pressure over time. Methods We developed a circuit occlusion model using a commercially available CRRT circuit, polysulfone membrane hemofilter, heating extension tube, and thermostatic water bath, along with commercially available citrated bovine whole blood. The circuit was filled with blood over a 10-min duration using a roller pump and was occluded after a specific period by varying the flow rate of calcium injected into bovine whole blood. Additionally, continuous injection of 1 mEq/mL calcium chloride into the circuit was maintained while bovine whole blood circulated. Measurements were performed at each calcium injection flow rate (2, 3, and 4 mL/h), with each measurement performed five times. The group that did not receive calcium injection was used as the control (0 mL/h: Con), and the experiment was performed three times. Groups were defined as "0, 2, 3, and 4" for each calcium injection flow rate. The relationship among the amount of calcium chloride injected, circuit occlusion time, and changes in circuit pressure over time was evaluated. Furthermore, blood tests and blood viscoelastic tests were performed at arbitrary times. Results The circuit occlusion time varied with each calcium injection flow rate, and a significant difference was observed between each group (p<0.05). Circuit pressure gradually changed at four min before occlusion when calcium was injected at 2, 3, and 4 mL/h, with a more rapid change at one min before occlusion. We measured circuit pressure at four and one min before occlusion (-4 min, and -1 min, respectively), and at the time of circuit occlusion (0 min) in the Con and 4 mL/h groups. Significant differences were observed in AP between -4 min and 0 min and -1 min and 0 min at a calcium flow rate of 4 mL/h. Additionally, significant differences were seen in prefilter and return pressures between -4 min and 0 min, -4 min and -1 min, and -1 min and 0 min at a calcium flow rate of 4 mL/h (p<0.05). Conclusions Our proposed model accurately estimated the occlusion time based on changes in circuit pressure. This model can be used to create various experimental systems depending on the desired occlusion time.
Collapse
Affiliation(s)
- Yu Kashima
- Medical Engineering, Junshin Gakuen University, Fukuoka, JPN
- Department of Emergency and Critical Care Medicine, Saga University, Saga, JPN
| | - Hiroyuki Koami
- Department of Emergency and Critical Care Medicine, Saga University, Saga, JPN
| | - Yuichiro Sakamoto
- Department of Emergency and Critical Care Medicine, Saga University, Saga, JPN
| |
Collapse
|
10
|
de Fallois J, Scharm R, Lindner TH, Scharf C, Petros S, Weidhase L. Kidney replacement and conservative therapies in rhabdomyolysis: a retrospective analysis. BMC Nephrol 2024; 25:96. [PMID: 38486159 PMCID: PMC10938657 DOI: 10.1186/s12882-024-03536-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/06/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Toxic renal effects of myoglobin following rhabdomyolysis can cause acute kidney injury (AKI) with the necessity of kidney replacement therapy (KRT). Fast elimination of myoglobin seems notable to save kidney function and intensify kidney repair. Clinical data regarding efficacy of KRT in critical care patients with rhabdomyolysis and AKI are limited. This retrospective analysis aimed to identify differences between conservative therapy and different modalities of KRT regarding myoglobin elimination and clinical outcome. METHODS This systematic, retrospective, single-center study analyzed 328 critical care patients with rhabdomyolysis (myoglobin > 1000 µg/l). Median reduction rate of myoglobin after starting KRT was calculated and compared for different modalities. Multivariate logistic regression models were established to identify potential confounder on hospital mortality. Filter lifetime of the various extracorporeal circuits was analyzed by Kaplan-Meier curves. RESULTS From 328 included patients 171 required KRT. Health condition at admission of this group was more critical compared to patient with conservative therapy. Myoglobin reduction rate did not differ between the groups (KRT 49% [30.8%; 72.2%] vs. conservative treatment (CT) 61% [38.5%; 73.5%]; p = 0.082). Comparison between various extracorporeal procedures concerning mortality showed no significant differences. Hospital mortality was 55.6% among patients with KRT and 18.5% with CT (p < 0.001). Multivariate logistic regression model identified requirement for KRT (OR: 2.163; CI: 1.061-4.407); p = 0.034) and the SOFA Score (OR: 1.111; CI: 1.004-1.228; p = 0.041) as independent predictive factors for hospital mortality. When comparing specific KRT using multivariate regression, no benefit was demonstrated for any treatment modality. Life span of the extracorporeal circuit was shorter with CVVH compared to that of others (log-Rank p = 0.017). CONCLUSIONS This study emphasizes that AKI requiring KRT following rhabdomyolysis is accompanied by high mortality rate. Differences in myoglobin reduction rate between various KRTs could not be confirmed, but CVVH was associated with reduced filter lifetime compared to other KRTs, which enable myoglobin elimination, too.
Collapse
Affiliation(s)
- Jonathan de Fallois
- Medical Department III, Division of Nephrology, University of Leipzig Medical Center, Leipzig, Germany
| | - Robert Scharm
- Medical Intensive Care Unit, Medical ICU, University of Leipzig Medical Center, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Tom H Lindner
- Medical Department III, Division of Nephrology, University of Leipzig Medical Center, Leipzig, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Sirak Petros
- Medical Intensive Care Unit, Medical ICU, University of Leipzig Medical Center, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Lorenz Weidhase
- Medical Intensive Care Unit, Medical ICU, University of Leipzig Medical Center, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
| |
Collapse
|
11
|
Xinping Z, Jie H, Zhenya Y, Desheng Z, Xiong Z. Citrate anticoagulation in plasma exchange followed by continuous renal replacement therapy in critically ill children. Int J Artif Organs 2024; 47:85-95. [PMID: 38229209 DOI: 10.1177/03913988231223375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
OBJECTIVE To investigate the effectiveness and safety of regional citrate-anticoagulated (RCA) plasma exchange (PE) and whether citrate-related metabolic disorders can be improved by sequential RCA continuous renal replacement therapy (CRRT). METHODS This retrospective, single-center observational study included 79 critically ill children requiring PE followed by CRRT (June 2018 to June 2021) at the Pediatric Intensive Care Unit of Hunan Children's Hospital, China. Patients were divided into the RCA-PE (n = 30) and systemic heparin anticoagulation (SHA-PE) (n = 49) groups. Filter level comparison post-PE assessed RCA-PE efficacy, and metabolic changes occurring pre- and post-PE and CRRT were used to evaluate the effect of CRRT on RCA-based anticoagulation safety. RESULTS The RCA-PE group had a better overall filter performance than the SHA-PE group. Two hours after PE, pH and HCO₃- levels increased more significantly for the RCA-PE than the SHA-PE group. The RCA-PE incidence of metabolic alkalosis was 48.3%, higher by 4.2% (p < 0.001) compared to the SHA-PE group. In the RCA-PE group, pH and HCO₃- decreased significantly 4 h after CRRT; the metabolic alkalosis caused by RCA-PE decreased to 13.8% (p = 0.005). No significant difference in pH, HCO₃-, and metabolic alkalosis incidence was observed between the two groups 4 h after CRRT. CONCLUSIONS The overall filtration performance of RCA-PE is superior to that of SHA-PE followed by CRRT. The metabolic complications associated with RCA-PE are mainly metabolic alkalosis that can be improved by using CRRT after RCA-PE and this is a better alternative for anticoagulation during PE in critically ill children.
Collapse
Affiliation(s)
- Zhang Xinping
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
| | - He Jie
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
| | - Yao Zhenya
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
| | - Zhu Desheng
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
| | - Zhou Xiong
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
| |
Collapse
|
12
|
Yoshimoto K, Matsuura R, Komaru Y, Yoshida T, Miyamoto Y, Hamasaki Y, Inokuchi R, Nangaku M, Doi K. Solute Clearance Evaluation and Filter Clotting Prediction in Continuous Renal Replacement Therapy. J Clin Med 2023; 12:7703. [PMID: 38137772 PMCID: PMC10743554 DOI: 10.3390/jcm12247703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/06/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
Unexpected filter clotting is a major problem in continuous renal replacement therapy (CRRT). Reduced solute clearance is observed prior to filter clotting. This single-center, retrospective, observational study aimed to determine whether reduced solute clearance of low- and medium-molecular-weight molecules in CRRT can predict filter clotting. Solute clearances of urea and myoglobin (Mb) were measured at 24 h after initiation of continuous hemodiafiltration (CHDF). Clearance per flow (CL/F) was calculated. The primary outcome was clotting of the filter in the subsequent 24 h, and 775 CHDF treatments conducted on 230 patients for at least 24 consecutive hours in our ICU were analyzed. Filter clotting was observed in 127 treatments involving 39 patients. Urea and Mb CL/F at 24 h were significantly lower in the patients who experienced clotting. Further analysis was limited to the first CHDF treatment of each patient to adjust for confounding factors. Multivariate logistic regression analysis revealed that both urea CL/F < 94% and Mb CL/F < 64% were significant predictors of clotting within the next 24 h. Lower urea and Mb CL/F measured at 24 h after CRRT initiation were associated with filter clotting in the next 24 h. Further study is necessary to ascertain whether measurement of urea and MB CL/F will help with avoiding unexpected filter clotting.
Collapse
Affiliation(s)
- Kohei Yoshimoto
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.Y.)
| | - Ryo Matsuura
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo 113-8655, Japan (T.Y.)
| | - Yohei Komaru
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.Y.)
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo 113-8655, Japan (T.Y.)
| | - Teruhiko Yoshida
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo 113-8655, Japan (T.Y.)
| | - Yoshihisa Miyamoto
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo 113-8655, Japan (T.Y.)
| | - Yoshifumi Hamasaki
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo 113-8655, Japan (T.Y.)
| | - Ryota Inokuchi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.Y.)
| | - Masaomi Nangaku
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo 113-8655, Japan (T.Y.)
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.Y.)
| |
Collapse
|
13
|
Lim L, Park JY, Lee H, Oh SY, Kang C, Ryu HG. Risk factors of hemodialysis catheter dysfunction in patients undergoing continuous renal replacement therapy: a retrospective study. BMC Nephrol 2023; 24:334. [PMID: 37950190 PMCID: PMC10636869 DOI: 10.1186/s12882-023-03383-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Continuous renal replacement therapy is a relatively common modality applied to critically ill patients with renal impairment. To maintain stable continuous renal replacement therapy, sufficient blood flow through the circuit is crucial, but catheter dysfunction reduces the blood flow by inadequate pressures within the circuit. Therefore, exploring and modifying the possible risk factors related to catheter dysfunction can help to provide continuous renal replacement therapy with minimal interruption. METHODS Adult patients who received continuous renal replacement therapy at Seoul National University Hospital between January 2019 and December 2021 were retrospectively analyzed. Patients who received continuous renal replacement therapy via a temporary hemodialysis catheter, inserted at the bedside under ultrasound guidance within 12 h of continuous renal replacement therapy initiation were included. RESULTS A total of 507 continuous renal replacement therapy sessions in 457 patients were analyzed. Dialysis catheter dysfunction occurred in 119 sessions (23.5%). Multivariate analysis showed that less prolonged prothrombin time (adjusted OR 0.49, 95% CI, 0.30-0.82, p = 0.007) and activated partial thromboplastin time (adjusted OR 1.01, 95% CI, 1.00-1.01, p = 0.049) were associated with increased risk of catheter dysfunction. Risk factors of re-catheterization included vascular access to the left jugular and femoral vein. CONCLUSIONS In critically ill patients undergoing continuous renal replacement therapy, less prolonged prothrombin time was associated with earlier catheter dysfunction. Use of left internal jugular veins and femoral vein were associated with increased risk of re-catheterization compared to the right internal jugular vein.
Collapse
Affiliation(s)
- Leerang Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Daehak-Ro 101, Jongno-Gu, Seoul, 03080, Korea
| | - Jung Yeon Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Daehak-Ro 101, Jongno-Gu, Seoul, 03080, Korea
| | - Hannah Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Daehak-Ro 101, Jongno-Gu, Seoul, 03080, Korea
| | - Seung-Young Oh
- Department of Critical Care Medicine, Seoul National University Hospital, Daehak-Ro 101, Jongno-Gu, Seoul, 03080, Korea
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Daehak-Ro 101, Jongno-Gu, Seoul, 03080, Korea
| | - Christine Kang
- Department of Critical Care Medicine, Seoul National University Hospital, Daehak-Ro 101, Jongno-Gu, Seoul, 03080, Korea
| | - Ho Geol Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Daehak-Ro 101, Jongno-Gu, Seoul, 03080, Korea.
- Department of Critical Care Medicine, Seoul National University Hospital, Daehak-Ro 101, Jongno-Gu, Seoul, 03080, Korea.
| |
Collapse
|
14
|
Kanji S, Roger C, Taccone FS, Muller L. Practical considerations for individualizing drug dosing in critically ill adults receiving renal replacement therapy. Pharmacotherapy 2023; 43:1194-1205. [PMID: 37491976 DOI: 10.1002/phar.2858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 07/27/2023]
Abstract
Critically ill patients with sepsis admitted to the intensive care unit (ICU) often present with or develop renal dysfunction requiring renal replacement therapy (RRT) in addition to antimicrobial therapy. While early and appropriate antimicrobials for sepsis have been associated with an increased probability of survival, adequate dosing is also required in these patients. Adequate dosing of antimicrobials refers to dosing strategies that achieve serum drug levels at the site of infection that are able to provide a microbiological and/or clinical response while avoiding toxicity from excessive antibiotic exposure. Therapeutic drug monitoring (TDM) is the recommended strategy to achieve this goal, however, TDM is not routinely available in all ICUs and for all antimicrobials. In the absence of TDM, clinicians are therefore required to make dosing decisions based on the clinical condition of the patient, the causative organism, the characteristics of RRT, and an understanding of the physicochemical properties of the antimicrobial. Pharmacokinetics (PK) of antimicrobials can be highly variable between critically ill patients and also within the same patient over the course of their ICU stay. The initiation of RRT, which can be in the form of intermittent hemodialysis, continuous, or prolonged intermittent therapy, further complicates the predictability of drug disposition. This variability highlights the need for individualized dosing. This review highlights the practical considerations for the clinician for antimicrobial dosing in critically ill patients receiving RRT.
Collapse
Affiliation(s)
- Salmaan Kanji
- The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Claire Roger
- Department of Anaesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
- UR UM 103 IMAGINE, Faculty of Medicine, University of Montpellier, Nîmes, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Laurent Muller
- Department of Anaesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
- UR UM 103 IMAGINE, Faculty of Medicine, University of Montpellier, Nîmes, France
| |
Collapse
|
15
|
Guo L, Hu Y, Zeng Q, Yang X. Factors affecting continuous renal replacement therapy duration in critically ill patients: A retrospective study. Ther Apher Dial 2023; 27:898-908. [PMID: 37308250 DOI: 10.1111/1744-9987.14024] [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: 03/22/2023] [Revised: 05/05/2023] [Accepted: 06/01/2023] [Indexed: 06/14/2023]
Abstract
INTRODUCTION This study aimed to analyze the factors affecting continuous renal replacement therapy (CRRT) duration in critically ill patients and provide a reference for clinical treatment. MATERIAL AND METHODS We divided patients into regional citrate anti-coagulation (RCA) and low-molecular-weight-heparin (LMWH) groups according to the anti-coagulation method and collected the relevant data, to analyze the factors associated with CRRT time. RESULTS Compared with the LMWH group, the RCA group had a longer mean treatment time (55.36 ± 22.57 vs. 37.65 ± 27.09 h, p < 0.001), lower transmembrane pressure, and lower filter pressure, regardless of vascular access site. Multivariable linear regression analysis showed a significant correlation between anti-coagulation patterns, filter pressure at CRRT discontinuation, nurses' level of intensive care unit experience, pre-machine fibrinogen level, and CRRT time. CONCLUSION Anti-coagulation is the most important factor affecting CRRT duration. Filter pressure, nurses' level of intensive care unit experience, and fibrinogen level also affecting CRRT duration.
Collapse
Affiliation(s)
- Litao Guo
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yandong Hu
- Department of Critical Care Medicine, Sanmenxia Central Hospital, Henan, China
| | - Qinjing Zeng
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xinjuan Yang
- Department of Critical Care Medicine, Sanmenxia Central Hospital, Henan, China
| |
Collapse
|
16
|
Mariano F, Mella A, Randone P, Agostini F, Bergamo D, Berardino M, Biancone L. Safety and Metabolic Tolerance of Citrate Anticoagulation in Critically Ill Polytrauma Patients with Acute Kidney Injury Requiring an Early Continuous Kidney Replacement Therapy. Biomedicines 2023; 11:2570. [PMID: 37761011 PMCID: PMC10526994 DOI: 10.3390/biomedicines11092570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 09/15/2023] [Accepted: 09/17/2023] [Indexed: 09/29/2023] Open
Abstract
For severe polytrauma patients with an early AKI requiring renal replacement therapy, anticoagulation remains a great challenge. Due to a high bleeding risk, hemodynamic instability, and increased lactate levels, continuous modality (CKRT) and citrate anticoagulation seem to be the most appropriate. However, their safety with regard to the potential risk of impaired citrate metabolism is not documented. A retrospective study of 60 severe polytrauma patients admitted to the emergency department between January 2000 and December 2021 was conducted; the patients requiring CKRT during the first 72 h were treated with citrate (n. 46, group Citrate) or with heparin (n. 14, group Heparin). Out of 60 patients, 31 survived (51.7%). According to logistic regression analysis, age and SOFA score were significant predictors of mortality. The incidence of rhabdomyolysis was more common in the survivors (77.4 vs. 51.7%), and Kaplan-Meyer analysis showed a better trend towards survival at 90 days for the group Citrate than the group Heparin (p 0.0956). In the group Citrate, hemorrhagic episodes were significantly less common (0.045 vs. 0.273 episodes/day, p < 0.001); the effective duration (h/day) of CKRT was longer; and the effective net ultrafiltration rate (mL/kg/h) and blood flow rate were lower. For severe polytrauma patients, early, soft CKRT with citrate anticoagulation at a low blood flow rate and circuit citratemia showed a better safety and hemodynamic stability, suggesting that citrate should be the first choice anticoagulant in this subset of patients.
Collapse
Affiliation(s)
- Filippo Mariano
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (A.M.); (D.B.); (L.B.)
- Nephrology, Dialysis and Transplantation U, University Hospital City of Science and Health, CTO Hospital, 10126 Turin, Italy;
| | - Alberto Mella
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (A.M.); (D.B.); (L.B.)
- Nephrology, Dialysis and Transplantation U, University Hospital City of Science and Health, CTO Hospital, 10126 Turin, Italy;
| | - Paolo Randone
- Nephrology, Dialysis and Transplantation U, University Hospital City of Science and Health, CTO Hospital, 10126 Turin, Italy;
| | - Fulvio Agostini
- Anesthesia and Intensive Care 3, University Hospital City of Science and Health, CTO Hospital, 10126 Turin, Italy; (F.A.); (M.B.)
| | - Daniela Bergamo
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (A.M.); (D.B.); (L.B.)
| | - Maurizio Berardino
- Anesthesia and Intensive Care 3, University Hospital City of Science and Health, CTO Hospital, 10126 Turin, Italy; (F.A.); (M.B.)
| | - Luigi Biancone
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (A.M.); (D.B.); (L.B.)
- Nephrology, Dialysis and Transplantation U, University Hospital City of Science and Health, CTO Hospital, 10126 Turin, Italy;
| |
Collapse
|
17
|
Zhang K, Liu C, Zhao H. Meta-analysis of haematocrit and activated partial thromboplastin time as risk factors for unplanned interruptions in patients undergoing continuous renal replacement therapy. Int J Artif Organs 2023; 46:498-506. [PMID: 37376844 DOI: 10.1177/03913988231180639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
OBJECTIVE Although continuous renal replacement therapy (CRRT) is common, unplanned interruptions often limit its usefulness. Unplanned interruption refers to the forced interruption of blood purification treatment, the failure to complete blood purification treatment goals or the failure to meet blood purification schedule times. This study aimed to evaluate the effect of haematocrit and activated partial thromboplastin time (APTT) on the incidence of unplanned interruptions in critical patients with CRRT. METHODS A systematic review and a meta-analysis were performed by searching the databases of China National Knowledge Infrastructure, Wanfang, VIP, China Biomedical Literature, Cochrane Library, PubMed, Web of Science and Embase from their inception to 31st March 2022 for all studies with a comparator or independent variable relating to the unplanned interruption of CRRT. RESULTS Nine studies involving 1165 participants were included. Haematocrit and APTT were independent risk factors for the unplanned interruption of CRRT. The higher the haematocrit level, the greater the risk of unplanned CRRT interruptions (relative risk ratio [RR] = 1.04, 95% confidence interval [CI]: 1.02, 1.07, Z = 4.27, p < 0.001). The prolongation of APPT reduced the risk of unplanned CRRT interruptions (RR = 0.94, 95% CI: 0.92, 0.96, Z = 6.10, p < 0.001). CONCLUSION Haematocrit and APTT are the influencing factors on the incidence of unplanned interruptions in critical patients undergoing CRRT.
Collapse
Affiliation(s)
- Kun Zhang
- Department of Critical Care Medicine, Hebei General Hospital, Shijiazhuang, China
| | - Chunxia Liu
- Department of Critical Care Medicine, Hebei General Hospital, Shijiazhuang, China
| | - Heling Zhao
- Department of Critical Care Medicine, Hebei General Hospital, Shijiazhuang, China
| |
Collapse
|
18
|
Lau YH, Li AY, Lim SL, Woo KL, Ramanathan K, Chua HR, Akalya K, Tan AY, Phua J, Tan JJ, Puah SH, Chia YW, Loh SC, Ahmed Khan F, Chatterjee S, Kaushik M, See KC. Association of anticoagulation use during continuous kidney replacement therapy and 90-day outcomes: A multicentre study. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:390-397. [PMID: 38920170 DOI: 10.47102/annals-acadmedsg.202337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction Anticoagulation is recommended during continuous kidney replacement therapy (CKRT) to prolong the filter lifespan for optimal filter performance. We aimed to evaluate the effect of anticoagulation during CKRT on dialysis dependence and mortality within 90 days of intensive care unit (ICU) admission. Method Our retrospective observational study evaluated the first CKRT session in critically ill adults with acute kidney injury (AKI) in Singapore from April to September 2017. The primary outcome was a composite of dialysis dependence or death within 90 days of ICU admission; the main exposure variable was anticoagulation use (regional citrate anticoagulation [RCA] or systemic heparin). Multivariable logistic regression was performed to adjust for possible confounders: age, female sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, liver dysfunction, coagulopathy (international normalised ratio[INR] >1.5) and platelet counts of less than 100,000/uL). Results The study cohort included 276 patients from 14 participating adult ICUs, of whom 176 (63.8%) experienced dialysis dependence or death within 90 days of ICU admission (19 dialysis dependence, 157 death). Anticoagulation significantly reduced the odds of the primary outcome (adjusted odds ratio [AOR] 0.47, 95% confidence interval [CI] 0.27-0.83, P=0.009). Logistic regression analysis using anticoagulation as a 3-level indicator variable demonstrated that RCA was associated with mortality reduction (AOR 0.46, 95% CI 0.25-0.83, P=0.011), with heparin having a consistent trend (AOR 0.51, 95% CI 0.23-1.14, P=0.102). Conclusion Among critically ill patients with AKI, anticoagulation use during CKRT was associated with reduced dialysis or death at 90 days post-ICU admission, which was statistically significant for regional citrate anticoagulation and trended in the same direction of benefit for systemic heparin anticoagulation. Anticoagulation during CKRT should be considered whenever possible.
Collapse
Affiliation(s)
- Yie Hui Lau
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | - Andrew Y Li
- Department of Respiratory Service, Department of Medicine, Woodlands Health Campus, Singapore
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Kai Lee Woo
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | | | - Horng-Ruey Chua
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore
| | - K Akalya
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore
| | - Addy Yh Tan
- Department of Anaesthesia, National University Hospital Singapore
| | - Jason Phua
- Fast and Chronic programmes, Alexandra Hospital, National University Health System; Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Jonathan Je Tan
- Anaesthesia, Intensive Care, Mount Elizabeth Novena Hospital, Singapore
| | - Ser Hon Puah
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Yew Woon Chia
- Department of Cardiology, Tan Tock Seng Hospital, Singapore
| | - Sean Ch Loh
- Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | | | | | | | - Kay Choong See
- Division of Respiratory and Critical Care Medicine, National University Hospital Singapore
| |
Collapse
|
19
|
Treu D, Ashenuga M, Massingham K, Brugger J, Medina L, Ficociello LH, Thompson D. An Innovative Approach to Minimizing Downtime in Continuous Kidney Replacement Therapy. ASAIO J 2023; 69:e250-e255. [PMID: 36976305 PMCID: PMC10226470 DOI: 10.1097/mat.0000000000001928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
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.
Collapse
Affiliation(s)
| | - Michael Ashenuga
- NxStage, Product Marketing, Fresenius Medical Care, Lawrence, Massachusetts
| | - Kara Massingham
- NxStage, Product Marketing, Fresenius Medical Care, Lawrence, Massachusetts
| | | | | | | | - David Thompson
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts
| |
Collapse
|
20
|
Raja M, Leal R, Doyle J. Continuous renal replacement therapy in patients receiving extracorporeal membrane oxygenation therapy. J Intensive Care Soc 2023; 24:227-229. [PMID: 37260434 PMCID: PMC10227899 DOI: 10.1177/17511437211067088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023] Open
Abstract
Methods of continuous renal replacement therapy (CRRT) in extracorporeal membrane oxygenation (ECMO) patients include dedicated central venous cannula (CVC) (vCRRT), in-series with filter connected to ECMO circuit (eCRRT) or in-line with haemodiafilter incorporated within ECMO circuit. We assessed the efficacy and safety of eCRRT versus vCRRT in 20 ECMO-CRRT patients. Average filter lifespan was 42 vs 28 hours and filter runs completing 72hours were 40% vs 13.8% (eCRRT vs vCRRT, respectively). One incidence of ECMO circuit air embolus occurred (vCRRT). eCRRT achieved adequate filtration and increased filter lifespan, and has become our default for ECMO-CRRT if a pre-existing dialysis CVC is not present.
Collapse
Affiliation(s)
- Meera Raja
- Department of Adult Intensive Care Unit, Brompton Hospital, London, UK
| | - Ricardo Leal
- Department of Adult Intensive Care Unit, Brompton Hospital, London, UK
| | - James Doyle
- Department of Adult Intensive Care Unit, Brompton Hospital, London, UK
| |
Collapse
|
21
|
Teixeira JP, Neyra JA, Tolwani A. Continuous KRT: A Contemporary Review. Clin J Am Soc Nephrol 2023; 18:256-269. [PMID: 35981873 PMCID: PMC10103212 DOI: 10.2215/cjn.04350422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AKI is a common complication of critical illness and is associated with substantial morbidity and risk of death. Continuous KRT comprises a spectrum of dialysis modalities preferably used to provide kidney support to patients with AKI who are hemodynamically unstable and critically ill. The various continuous KRT modalities are distinguished by different mechanisms of solute transport and use of dialysate and/or replacement solutions. Considerable variation exists in the application of continuous KRT due to a lack of standardization in how the treatments are prescribed, delivered, and optimized to improve patient outcomes. In this manuscript, we present an overview of the therapy, recent clinical trials, and outcome studies. We review the indications for continuous KRT and the technical aspects of the treatment, including continuous KRT modality, vascular access, dosing of continuous KRT, anticoagulation, volume management, nutrition, and continuous KRT complications. Finally, we highlight the need for close collaboration of a multidisciplinary team and development of quality assurance programs for the provision of high-quality and effective continuous KRT.
Collapse
Affiliation(s)
- J. Pedro Teixeira
- Divisions of Nephrology and Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Javier A. Neyra
- Division of Nephrology, Bone, and Mineral Metabolism, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashita Tolwani
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| |
Collapse
|
22
|
Mann L, Ten Eyck P, Wu C, Story M, Jenigiri S, Patel J, Honkanen I, O’Connor K, Tener J, Sambharia M, Fraer M, Nourredine L, Somers D, Nizar J, Antes L, Kuppachi S, Swee M, Kuo E, Huang CL, Jalal DI, Griffin BR. CVVHD results in longer filter life than pre-filter CVVH: Results of a quasi-randomized clinical trial. PLoS One 2023; 18:e0278550. [PMID: 36630406 PMCID: PMC9833553 DOI: 10.1371/journal.pone.0278550] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 11/11/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Filter clotting is a major issue in continuous kidney replacement therapy (CKRT) that interrupts treatment, reduces delivered effluent dose, and increases cost of care. While a number of variables are involved in filter life, treatment modality is an understudied factor. We hypothesized that filters in pre-filter continuous venovenous hemofiltration (CVVH) would have shorter lifespans than in continuous venovenous hemodialysis (CVVHD). METHODS This was a single center, pragmatic, unblinded, quasi-randomized cluster trial conducted in critically ill adult patients with severe acute kidney injury (AKI) at the University of Iowa Hospitals and Clinics (UIHC) between March 2020 and December 2020. Patients were quasi-randomized by time block to receive pre-filter CVVH (convection) or CVVHD (diffusion). The primary outcome was filter life, and secondary outcomes were number of filters used, number of filters reaching 72 hours, and in-hospital mortality. RESULTS In the intention-to-treat analysis, filter life in pre-filter CVVH was 79% of that observed in CVVHD (mean ratio 0.79, 95% CI 0.65-0.97, p = 0.02). Median filter life (with interquartile range) in pre-filter CVVH was 21.8 (11.4-45.3) and was 26.6 (13.0-63.5) for CVVHD. In addition, 11.8% of filters in pre-filter CVVH were active for >72 hours, versus 21.2% in the CVVHD group. Finally, filter clotting accounted for the loss of 26.7% of filters in the CVVH group compared to 17.5% in the CVVHD group. There were no differences in overall numbers of filters used or mortality between groups. CONCLUSIONS Among critically patients with severe AKI requiring CKRT, use of pre-filter CVVH resulted in significantly shorter filter life compared to CVVHD. TRIAL REGISTRATION ClinicalTrials.gov, NCT04762524. Registered 02/21/21-Retroactively registered, https://clinicaltrials.gov/ct2/show/NCT04762524?cond=The+Impact+of+CRRT+Modality+on+Filter+Life&draw=2&rank=1.
Collapse
Affiliation(s)
- Lewis Mann
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Patrick Ten Eyck
- University of Iowa Institute for Clinical and Translational Science, Iowa City, Iowa, United States of America
| | - Chaorong Wu
- University of Iowa Institute for Clinical and Translational Science, Iowa City, Iowa, United States of America
| | - Maria Story
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Sree Jenigiri
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Jayesh Patel
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Iiro Honkanen
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Kandi O’Connor
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Janis Tener
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Meenakshi Sambharia
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Mony Fraer
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Lama Nourredine
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Douglas Somers
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Jonathan Nizar
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Lisa Antes
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Sarat Kuppachi
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Melissa Swee
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Elizabeth Kuo
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Chou-Long Huang
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Diana I. Jalal
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, United States of America
| | - Benjamin R. Griffin
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, United States of America
| |
Collapse
|
23
|
Miyaji MJ, Ide K, Takashima K, Maeno M, Krallman KA, Lazear D, Goldstein SL. Comparison of nafamostat mesilate to citrate anticoagulation in pediatric continuous kidney replacement therapy. Pediatr Nephrol 2022; 37:2733-2742. [PMID: 35348901 DOI: 10.1007/s00467-022-05502-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/05/2022] [Accepted: 02/07/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) is the preferred continuous kidney replacement therapy (CKRT) anticoagulation strategy for children in the USA. Nafamostat mesilate (NM), a synthetic serine protease, is used widely for CKRT anticoagulation in Japan and Korea. We compared the safety and efficacy of NM to RCA for pediatric CKRT. METHODS Starting June 2019, the most recent 100 medical records of children receiving CKRT with either RCA or NM were reviewed retrospectively, at one children's hospital in Japan (NM) and one in the USA (RCA). The number of hours a single CKRT filter was in use, was the primary outcome. Safety was assessed by bleeding complications for the NM group and citrate toxicity leading to RCA discontinuation or electrolyte imbalance in the RCA group. RESULTS Eighty patients received NM and 78 patients received RCA. Median filter life was longer for the NM group (NM: 38 [22, 74] vs. RCA: 36 [17, 66] h, p = 0.02). When filter life was censored for discontinuation other than clotting, the 60-h survival rate was higher for RCA (71% vs. 54%). The hazard ratio comparing NM over RCA varied over time (HR 0.7; 0.2-1.5, p = 0.33 at 0 h to HR 5.5; 1.3-23.7, p = 0.334 at 72 h). The lack of difference in filter survival persisted controlling for filter surface area, catheter diameter, and pre-CKRT platelet count. Major bleeding rates did not differ between groups (NM: 5% vs. RCA: 9%). CONCLUSIONS RCA and NM provide satisfactory anticoagulation for CKRT in children with no difference in major bleeding rates. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Mai J Miyaji
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7022, Cincinnati, OH, 45229, USA
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
- Master of Science Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Kentaro Ide
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kohei Takashima
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Mikiko Maeno
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kelli A Krallman
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7022, Cincinnati, OH, 45229, USA
| | - Danielle Lazear
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7022, Cincinnati, OH, 45229, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7022, Cincinnati, OH, 45229, USA.
- University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| |
Collapse
|
24
|
Sudusinghe D, Riddell A, Gandhi T, Chowdary P, Davenport A. Increased risk of dialysis circuit clotting in hemodialysis patients with COVID-19 is associated with elevated FVIII, fibrinogen and D-dimers. Hemodial Int 2022; 27:38-44. [PMID: 36081392 PMCID: PMC9537782 DOI: 10.1111/hdi.13046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/09/2022] [Accepted: 08/23/2022] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Severe COVID-19 infections increase the risk of thrombotic events and Intensive Care Units reported increased extracorporeal circuit clotting (ECC) in COVID-19 patients with acute kidney injury. We wished to determine whether hemodialysis (HD) patients with COVID-19 also have increased risk of circuit clotting. METHODS We reviewed coagulation studies and HD records, 4 weeks before and after COVID-19 polymerase chain reaction detection in HD patients between April 2020 and June 2021. FINDINGS Sixty-eight (33.5%) of 203 HD patients with COVID-19, 65% male, mean age 64.9 ± 15.3 years, experienced some circuit clotting, and no clotting recorded prior to positive test results. In those who experienced ECC, prothrombin, activated partial thromboplastin or thrombin times were not different, whereas median factor VIII (273 [168-419] vs. 166 [139-225] IU/dl, p < 0.001), D-dimers (2654 [1381-6019] vs. 1351 [786-2334] ng/ml, p < 0.05), and fibrinogen (5.6 ± 1.4 vs. 4.9 ± 1.4 g/L, p < 0.05) were greater. Antithrombin (94 [83-112] vs. 89 [84-103] IU/dl), protein C (102 [80-130] vs. 86 [76-106] IU/dl), protein S (65 [61-75] vs. 65 [52-79] IU/dl) and platelet counts (193 [138-243] vs. 174 [138-229] × 109 /L) did not differ. On multivariable logistic analysis, circuit clotting was associated with log factor VIII (odds ratio [OR] 14.8 (95% confidence limits [95% CL] 1.12-19.6), p = 0.041), fibrinogen (OR 1.57 [95% CL 1.14-21.7], p = 0.006) and log D dimer (OR 4.8 [95% CL 1.16-12.5], p = 0.028). DISCUSSION Extracorporeal circuit clotting was increased within 4 weeks of testing positive for COVID-19. Clotting was associated with increased factor VIII, fibrinogen and D-dimer, suggesting that the risk of circuit clotting was related to the inflammatory response to COVID-19.
Collapse
Affiliation(s)
- Dinesha Sudusinghe
- Department of Physiology, Faculty of Medical SciencesUniversity of Sri JayewardenepuraNugegodaSri Lanka
| | - Anne Riddell
- Haemophilia and Thrombosis Laboratory (Health Services Laboratories)Royal Free HospitalLondonUK,Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK
| | - Tejas Gandhi
- Haemophilia and Thrombosis Laboratory (Health Services Laboratories)Royal Free HospitalLondonUK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK,Research Department of HaematologyCancer Institute UCLLondonUK
| | - Andrew Davenport
- Department of Renal Medicine, Royal Free Hospital, Faculty of Medical SciencesUniversity College LondonLondonUK
| |
Collapse
|
25
|
Sansom B, Udy A, Sriram S, Presneill J, Bellomo R. Circuit haemodynamics during non-citrate and regional citrate continuous renal replacement, and impact of blood flow on filter life. Int J Artif Organs 2022; 45:988-996. [PMID: 36036083 DOI: 10.1177/03913988221118585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND During continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA), blood flow (Qb) might affect vascular access dysfunction (AD) and, thereby, circuit life. METHODS Circuit life and circuit haemodynamics were studied in three intensive care units (ICUs) by analysing hemofilter device data (Prismaflex®, Baxter, Chicago, IL). The three sites shared similar RCA protocols but differed in Qb (120-130 vs 150-200 mL/h). Non-RCA circuits were compared with RCA circuits in which the impact of Qb was also assessed. RESULTS About 3,981,906 min of circuit pressures were analysed in 2568 circuits in 567 patients. High-Qb RCA was associated with more extreme pressures, and greater AD (IRR 3.7 (1.93-7.08) as well as reduced filter life 21.1 (10.2-42.6) vs 27.0 (14.8-41.6) h). AD in high-Qb RCA circuits was associated with a 49% reduction in filter life, versus 24% reduction in low-Qb RCA, associated with a rise in the rate of increase in transfilter pressure. CONCLUSIONS High-Qb RCA-CRRT was associated with greater access dysfunction, earlier filter loss and increased haemodynamic impacts of access dysfunction, suggesting low-Qb RCA-CRRT may improve circuit mechanics, function and longevity.
Collapse
Affiliation(s)
- Benjamin Sansom
- Department of Intensive Care, The Royal Melbourne Hospital, Parkville, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Andrew Udy
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Shyamala Sriram
- Department of Intensive Care, The Royal Melbourne Hospital, Parkville, Melbourne, VIC, Australia
| | - Jeffrey Presneill
- Department of Intensive Care, The Royal Melbourne Hospital, Parkville, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, The Royal Melbourne Hospital, Parkville, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Intensive Care, The Austin, Melbourne, VIC, Australia
| |
Collapse
|
26
|
He J, Xiao Z, Zhou X, Cao J, Kang X, Zhang X. Comparison of different modalities of continuous renal replacement therapy with regional sodium citrate anticoagulation in paediatric patients. Int J Artif Organs 2022; 45:997-1005. [PMID: 35903018 DOI: 10.1177/03913988221115447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To evaluate the efficacy and safety of continuous renal replacement therapy (CRRT) modalities with regional sodium citrate anticoagulation (RCA) in children. METHODS This retrospective study was conducted at the paediatric intensive care unit of Hunan Children's Hospital in China. Medical records of paediatric patients hospitalised for RCA-CRRT between April 2017 and March 2021 were reviewed. Patients received continuous venovenous haemodialysis, continuous venovenous haemofiltration (CVVH), or continuous venovenous haemodiafiltration (CVVHDF). RESULTS Patients on continuous venovenous haemodialysis (n = 2) were excluded because of their small sample size. The remaining participants were divided into CVVH and CVVHDF groups; 80 patients received CRRT, with 40 and 62 sessions in the CVVH and CVVHDF groups, respectively. The filtre lifespan was longer in the CVVHDF group than in the CVVH group (median value [interquartile range]; 47 [15] hours vs. 35 [17.5] hours; p = 0.029). Compared with the CVVHDF group, the hazard ratio for filtre lifespan in the CVVH group was 3.023 (95% confidence interval 1.820-5.023, p < 0.001). There were no significant differences in ionised calcium levels of the circuits between the two groups at different time points (p < 0.05). Metabolic alkalosis, hyperlactataemia, hypocalcaemia, and hypercalcaemia occurred in both groups, with metabolic alkalosis being the most common complication. No patients in either group experienced sodium citrate accumulation or hypernatraemia. Inter-group differences in the incidence of these complications were not statistically significant (p > 0.05). CONCLUSIONS Our results suggest that CVVHDF is a better option for RCA-CRRT than CVVH.
Collapse
Affiliation(s)
- Jie He
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
| | - Zhenghui Xiao
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
| | - Xiong Zhou
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
| | - Jianshe Cao
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
| | - Xiayan Kang
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
| | - Xinping Zhang
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
| |
Collapse
|
27
|
Villa G, Fioccola A, Mari G, Cecchi M, Pomarè Montin D, Scirè-Calabrisotto C, De Rosa S, Ricci Z, Rosalia RA, Resta MV, Ferrari F, Patera F, Greco M, Ronco C, Romagnoli S. A Role of Circuit Clotting and Strategies to Prevent It during Blood Purification Therapy with oXiris Membrane: An Observational Multicenter Study. Blood Purif 2022; 51:1-10. [PMID: 35472697 DOI: 10.1159/000524230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 03/08/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Membrane fouling is a significant complication potentially reducing clinical effects of extracorporeal blood purification (EBP) in critically ill septic patients with acute kidney injury. Although fascinating, the effect of heparin coating in preventing membrane fouling is currently unknown. This multicenter prospective study aims to preliminary describe the incidence, associated factors, and clinical consequences of premature circuit clotting in a cohort of adult critically ill septic patients treated with EBP using a high biocompatible heparin-coated hemodiafilter characterized by advanced adsorption properties. METHODS This study was a retrospective analysis of prospectively entered data in the oXirisNet Registry; overall, 97 septic patients undergoing EBP with oXiris between May 2019 and March 2020 were enrolled in this study. Patients were divided into two groups according to the occurrence of filter clotting (premature vs. nonpremature). Logistic regression analysis was used to identify factors associated with premature circuit clotting. RESULTS Premature clotting occurred in 18 (18.6%) patients. Results of the multivariate logistic regression analysis demonstrated that hematocrit (p = 0.02, odds ratio [OR] 1.15 [1.05; 1.30]), serum procalcitonin (PCT) (p = 0.03, OR 1.1 [1.05; 1.2]), and anticoagulation strategy (p = 0.05 at Wald's test) were independent predictors of circuit clotting. Systemic anticoagulation (p = 0.02, OR 0.03 [0.01; 0.52]) and regional citrate anticoagulation (p = 0.10, OR 0.23 [0.04; 1.50]) were both protective factors if compared to no-anticoagulation strategy. Patients with nonpremature circuit clotting showed more rapid recovery from hemodynamic instability, pulmonary hypo-oxygenation, and electrolyte disorders and greater improvement of inflammatory markers and SOFA scores. CONCLUSION Although in this study the incidence of premature circuit clotting was relatively low (18.6%) compared to previously reported values (54%), membrane clotting in adult critically ill septic patients could cause clinically relevant interferences with treatment performances. Prevention of clotting should be based on avoiding higher patients' hematocrit, high serum PCT, and no-anticoagulation strategy which resulted as independent predictors of circuit clotting.
Collapse
Affiliation(s)
- Gianluca Villa
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Careggi Hospital, Florence, Italy
| | - Antonio Fioccola
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
| | - Gaia Mari
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
| | - Matteo Cecchi
- Department of Experimental and Clinical Medicine, Section of Internal Medicine, University of Florence, Florence, Italy
| | - Diego Pomarè Montin
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
| | - Caterina Scirè-Calabrisotto
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
| | - Silvia De Rosa
- Department of Anesthesia and Intensive Care, San Bortolo Hospital, Vicenza, Italy
| | - Zaccaria Ricci
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Meyer Children's Hospital, Florence, Italy
| | | | - Marco Vittorio Resta
- Department of General Anesthesia and Intensive Care, San Donato IRCCS Polyclinic, Milan, Italy
| | - Fiorenza Ferrari
- Anesthesia and Intensive Care, Emergency Department, IRCCS San Matteo Polyclinic, University of Pavia, Pavia, Italy
- International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy
| | - Francesco Patera
- Department of Internal Medicine, Division of Nephrology, Dialysis and Transplantation, Santa Maria Della Misericordia Hospital, Perugia, Italy
| | - Massimiliano Greco
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy
- Department of Medicine, University of Padua, Padua, Italy
- Department of Nephrology, San Bortolo Hospital, Vicenza, Italy
| | - Stefano Romagnoli
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Careggi Hospital, Florence, Italy
| |
Collapse
|
28
|
Abstract
Continuous renal replacement therapy is an important, yet challenging, treatment of critically ill patients with kidney dysfunction. Clotting within the dialysis filter or circuit leads to time off therapy and impaired delivery of prescribed treatment. Anticoagulation can be used to prevent this complication; however, doing so introduces risk for unintended complications such as bleeding or metabolic derangements in patients who are already critically ill. A thorough understanding of indications, therapeutic options, and monitoring principles is necessary for safe and effective use of this strategy. This review provides clinicians important information regarding when to anticoagulate, differences in pharmacologic agents, recommended doses, routes of drug delivery, and appropriate laboratory monitoring for patients receiving anticoagulation to support continuous renal replacement therapy.
Collapse
|
29
|
Raina R, Sethi S, Khooblall A, Kher V, Deshpande S, Yerigeri K, Pandya A, Nair N, Datla N, McCulloch M, Bunchman T, Davenport A. Non-anticoagulation pediatric continuous renal replacement therapy methods to increase circuit life. Hemodial Int 2022; 26:147-159. [PMID: 34989465 DOI: 10.1111/hdi.13003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Acute kidney injury (AKI) is a clinical condition characterized by an abrupt increase in serum creatinine levels due to functional changes in the kidneys from a newfound insult or injury. For supportive treatment, continuous renal replacement therapy (CRRT) is one of the most widely used modalities due to its precise control of fluid balance over extended periods of time. However, its complications include circuit clotting, the most frequent cause for CRRT interruption. Vascular access and circuit management were found to be major determinants of performance efficiency. Anticoagulation required to prevent clotting has the downside of increasing the risk of bleeding, especially in the setting of overdosage. Hence, a delicate balance needs to be maintained consistently. METHODS This study explores the adequacy of non-anticoagulation measures in the prevention of circuit clotting. A comprehensive literature search was conducted using PubMed/Medline and Embase databases to include all relevant studies. FINDINGS The most-effective CRRT catheter would be made of nonthrombogenic material, noncuffed and nontunneled with separate lumens for arterial and venous blood. Further, studies show that blood flow during the process is optimized at 200 ml/min, which can be lowered in the pediatric population due to more narrow catheters. Platelet count and hematocrit need to be closely monitored as levels above 450,000 × 106 /L and 0.40, respectively, increase risk of clotting. Predilution is a non-anticoagulation technique to reduce the risk of clotting by returning replacement solution to the blood before it reaches the filter. Also, biocompatible membranes such as polyacrylonitrile or polysulfone activate the coagulation cascade significantly less than the conventional cellulose-based membranes, thereby reducing clotting chances. DISCUSSIONS With the advent of such techniques and maneuvers, anticoagulation can be efficiently maintained in patients undergoing CRRT without increasing the risk of bleeding.
Collapse
Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Sidharth Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Amrit Khooblall
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Vijay Kher
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Shweta Deshpande
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Keval Yerigeri
- Department of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Aadi Pandya
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Nikhil Nair
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Nithin Datla
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Mignon McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Timothy Bunchman
- Pediatric Nephrology & Transplantation, Children's Hospital of Richmond at VCU, Richmond, Virginia, USA
| | - Andrew Davenport
- University College London Centre for Nephrology, Division of Medicine, University College London Medical School, Royal Free Hospital, London, UK
| |
Collapse
|
30
|
Berrocal Tomé FJ, Maqueda Palau M, Moreno Jiménez C, De-Dios Guerra A. Factores asociados a la duración del hemofiltro en técnicas continuas de depuración extracorpórea en el paciente ingresado en cuidados intensivos. ENFERMERÍA NEFROLÓGICA 2021. [DOI: 10.37551/s2254-28842021033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objetivos: Determinar la vida media de los hemofiltros en el paciente crítico ingresado en la UCI y los principales factores asociados a su duración. Metodología: Estudio descriptivo observacional transversal, realizado en una Unidad de Cuidados Intensivos de adultos polivalente. Se estudiaron los hemofiltros colocados en 67 pacientes mayores de 18 años, entre enero y noviembre de 2019. Variables: edad, sexo, peso, unidad de ingreso, velocidad de flujo sanguíneo, fracción de filtrado, débito horario, anticoagulación del sistema, tiempo de tromboplastina activada (TTPA), indicación médica de la terapia, causa de la retirada, localización del catéter, hora de inicio y finalización de la terapia. Resultados: La edad media de los pacientes fue de 62,66 años (±9,95), 81 (71,64%) hombres. Se analizaron un total de 238 hemofiltros con una vida media de 26,28 horas (±22,8). El 80,1 % de los catéteres fueron femorales, el 19% yugulares y el 0,8% subclavios. Se empleó como terapia de anticoagulación, heparina sódica en un 45,8%, citratos en el 20,2% y en un 34% no se utilizó anticoagulación. La velocidad media de flujo sanguíneo fue de 190,08 ml/min (±53,48). Se encontró relación estadística entre las variables flujo sanguíneo (rs=0,208; p=0,001), localización del catéter y duración del hemofiltro (p=0,03). Conclusiones: La vida media del hemofiltro fue de 26 horas. La velocidad del flujo sanguíneo y localización del catéter son factores que repercuten en la duración del hemofiltro.
Collapse
Affiliation(s)
- Francisco Javier Berrocal Tomé
- Unidad de Cuidados Intensivos. Hospital Universitari Son Espases. Palma. España. Grupo de trabajo en Técnicas Extracorpóreas de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC)
| | - Mónica Maqueda Palau
- Unidad de Cuidados Intensivos. Hospital Universitari Son Espases. Palma. España. Grup d´Investigació en Cures. cronicitat i evidències en salut (CurES-IdISBa). España
| | | | | |
Collapse
|
31
|
Xu Q, Jiang B, Li J, Lu W, Li J. Comparison of CVVH and CVVHDF on filter lifespan and solute removal - a randomized controlled trial. Ther Apher Dial 2021; 26:1030-1039. [PMID: 34967496 DOI: 10.1111/1744-9987.13787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 12/19/2021] [Accepted: 12/24/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION This study aimed to investigate whether Continuous Veno-Venous Hemodiafiltration (CVVHDF) has a different filter lifespan and molecular solutes clearance when compared to Continuous Veno-Venous Hemofiltration (CVVH). METHODS Sixty patients were enrolled in this study and randomly assigned to the CVVHDF (n=30) or CVVH (n=30) groups. Demographics, laboratory tests, urea, creatinine, IL-6, β2-microglobulin, and myoglobulin clearance were recorded. RESULTS Patients in the CVVH group had a shorter median time of filter lifespan compared with those in the CVVHDF group (20 vs 37.5 hours, p = 0.002). Urea and creatinine clearance were not significantly different between groups over time (p >0.05). IL-6, β2-microglobulin, and myoglobulin clearance were higher in the CVVH group. The transmembrane pressure (TMP) was significantly higher in the CVVH group. CONCLUSION The use of CVVHDF may lead to a longer filter lifespan and lower clearance of medium and large molecules without affecting the small molecular solute clearance.
Collapse
Affiliation(s)
- Qiancheng Xu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China.,Department of Critical Care Medicine, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, Anhui, China
| | - Bo Jiang
- Department of Critical Care Medicine, The Second People's Hospital of Wuhu, Wuhu, Anhui, China
| | - Juan Li
- Department of Nephrology, The Second People's Hospital of Wuhu, Wuhu, Anhui, China
| | - Weihua Lu
- Department of Critical Care Medicine, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, Anhui, China
| | - Jianguo Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| |
Collapse
|
32
|
Langer T, Giani M. Acid-base effects of regional citrate anticoagulation for continuous renal replacement therapy: don't judge the technique only by its name, every bag is not the same! Minerva Anestesiol 2021; 87:1281-1283. [PMID: 34874133 DOI: 10.23736/s0375-9393.21.16207-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Monza-Brianza, Italy - .,Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda Hospital, Milan, Italy -
| | - Marco Giani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Monza-Brianza, Italy.,ASST Monza, San Gerardo Hospital, Monza, Monza-Brianza, Italy
| |
Collapse
|
33
|
Yuzawa H, Hirose Y, Kimura T, Shinozaki K, Oguchi M, Morito T, Sadahiro T. Filter lifetimes of different hemodiafiltration membrane materials in dogs: reevaluation of the optimal anticoagulant dosage. RENAL REPLACEMENT THERAPY 2021. [DOI: 10.1186/s41100-021-00323-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
In continuous renal replacement therapy (CRRT), administration of anticoagulants is necessary for achieving a certain level of filter lifetime. Generally, anticoagulant doses are controlled to keep activated partial thromboplastin time and other indicators within a certain target range, regardless of the membrane materials used for the filter. However, in actual clinical practice, the filter lifetime varies significantly depending on the membrane material used. The objective of this study was to demonstrate that the minimum anticoagulant dose necessary for prolonging the filter lifetime while reducing the risk of hemorrhagic complications varies depending on the type of membrane.
Methods
In three beagles, hemodiafiltration was performed with hemofilters using polysulfone (PS), polymethylmethacrylate (PMMA), and AN69ST membranes separately. The minimum dose of nafamostat mesylate (NM) that would allow for 6 h of hemodiafiltration (required dose) was investigated for each membrane material.
Results
The NM doses required for 6 h of hemodiafiltration were 2 mg/kg/h for the PS membrane, 6 mg/kg/h for the PMMA membrane, and 6 mg/kg/h for the AN69ST membrane.
Conclusion
For hemodiafiltration performed in beagles, the required NM dose varied for each filter membrane material. Using the optimal anticoagulant dose for each membrane material would allow for safer CRRT performance.
Collapse
|
34
|
Shaikhouni S, Yessayan L. Management of Acute Kidney Injury/Renal Replacement Therapy in the Intensive Care Unit. Surg Clin North Am 2021; 102:181-198. [PMID: 34800386 DOI: 10.1016/j.suc.2021.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Common causes of acute kidney injury (AKI) in the ICU setting include acute tubular necrosis (due to shock, hemolysis, rhabdomyolysis, or procedures that compromise renal perfusion), abdominal compartment syndrome, urinary retention, and interstitial nephritis. Treatment is geared toward addressing the underlying cause. Dialysis may be required if renal injury does not resolve. Early initiation of dialysis based on the stage of AKI alone has not been shown to provide a mortality benefit. Dialysis modalities are based on the dialysis indication and the patient's clinical status. Providers should pay close attention to nutritional requirements and medication dosing according to renal function and dialysis modality.
Collapse
Affiliation(s)
- Salma Shaikhouni
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA.
| |
Collapse
|
35
|
Zhang W, Bai M, Zhang L, Yu Y, Li Y, Zhao L, Yue Y, Li Y, Zhang M, Fu P, Sun S, Chen X. Development and External Validation of a Model for Predicting Sufficient Filter Lifespan in Anticoagulation-Free Continuous Renal Replacement Therapy Patients. Blood Purif 2021; 51:668-678. [PMID: 34673634 PMCID: PMC9501746 DOI: 10.1159/000519409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/18/2021] [Indexed: 02/05/2023]
Abstract
Background Anticoagulation-free continuous renal replacement therapy (CRRT) was recommended by the current clinical guideline for patients with increased bleeding risk and contraindications of citrate. Nevertheless, anticoagulation-free CRRT yielded heterogeneous filter lifespan. Furthermore, the specific cutoff values for traditional coagulation parameters to predict sufficient filter lifespan of anticoagulation-free CRRT have not yet been determined. The purpose of our present study was to develop and validate a model for predicting sufficient filter lifespan in anticoagulation-free CRRT patients. Methods Patients who underwent anticoagulation-free CRRT in our center between June 2013 and June 2019 were retrospectively included. The primary outcome was sufficient filter lifespan (≥24 h). Thirty-seven predictors were included for modeling based on their clinical significance and previous reports. The final model was developed by using multivariable logistic regression analysis and was validated in a separate external cohort. Results The development cohort included 170 patients. Sufficient filter lifespan was observed in 80 patients. Thirteen variables were independent predictors for sufficient filter lifespan by logistic regression: body temperature, mean arterial pressure, activated partial thromboplastin time, direct bilirubin, alkaline phosphatase, blood urea nitrogen, vasopressor use, body mass index, white blood cell, platelet count, D-dimer, uric acid, and pH. The area under the curve (AUC) of the stepwise model and internal validation model was 0.82 (95% confidence interval [CI] [0.76–0.88]) and 0.8 (95% CI [0.74–0.87]), respectively. The positive predictive value and the negative predictive value of the stepwise model were 0.77 and 0.79, respectively. The validation cohort included 44 eligible patients and the AUC of the external validation model was 0.82 (95% CI [0.69–0.96]). Conclusions The use of a prediction model instead of an assessment based only on coagulation parameters could facilitate the identification of the patients with filter lifespan of ≥24 h when they accepted anticoagulation-free CRRT.
Collapse
Affiliation(s)
- Wei Zhang
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China.,Nephrology Institute of the Chinese People's Liberation Army, Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Ling Zhang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Yu
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Yangping Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Lijuan Zhao
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Yuan Yue
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Yajuan Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Min Zhang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Ping Fu
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Xiangmei Chen
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China.,Nephrology Institute of the Chinese People's Liberation Army, Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
| |
Collapse
|
36
|
Li P, Zhang L, Lin L, Tang X, Guan M, Wei T, Chen L. Effect of Dynamic Circuit Pressures Monitoring on the Lifespan of Extracorporeal Circuit and the Efficiency of Solute Removal During Continuous Renal Replacement Therapy. Front Med (Lausanne) 2021; 8:621921. [PMID: 34631725 PMCID: PMC8494973 DOI: 10.3389/fmed.2021.621921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 08/24/2021] [Indexed: 02/05/2023] Open
Abstract
Objective: To observe the effects of dynamic pressure monitoring on the lifespan of the extracorporeal circuit and the efficiency of solute removal during continuous renal replacement therapy (CRRT). Materials and Methods: A prospective observational study was performed at the West China Hospital of Sichuan University in the ICU. Analyses of the downloaded pressure data recorded by CRRT machines and the solute removal efficiencies, calculated by 2*Ce/(Cpre+Cpost), where Ce, Cpre, and Cpost are the concentrations of the effluent, pre-filter blood, and post-filter blood, respectively, were performed. Samples were collected at 0, 2, 6, 12, and 24 h when continuous veno-venous hemodiafiltration (CVVHDF) was used after the initiation of CRRT. Measurements in concentrations of creatinine, blood urea nitrogen, and β2-microglobulin in the plasma and effluent were recorded. Results: Extracorporeal circuits characterized by moderate-to-severe (M–S) access outflow dysfunction (AOD) events, defined as access outflow pressure less than or equal to −200 mmHg for more than 5 min, had shorter median lifespans with no anticoagulation (32.3 vs. 10.90 h, P = 0.001) compared with the no M–S AOD events group. The significant outcome also existed in regional citrate anticoagulation (RCA) (72 vs. 42.47 h, P = 0.02). Moreover, Cox regression analysis revealed that the lack of M–S AOD events, RCA, or CVVHDF independently prolonged the circuit lifespan. All tested solutes removal efficiencies started to decline at 12 h. Furthermore, efficiencies of all solutes removal dropped obviously at 24 h when TMP ≥ 150 mmHg. Conclusion: RCA and CVVHDF predicted a longer circuit lifespan. M–S AOD events were associated with a shorter circuit lifespan when RCA or no anticoagulant was used. Replacement of extracorporeal circuit could be considered when running time of filter lasted up to 24 h with TMP ≥ 150 mmHg.
Collapse
Affiliation(s)
- Peiyun Li
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Ling Zhang
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Li Lin
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Xin Tang
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Mingjing Guan
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Tiantian Wei
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Lixin Chen
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| |
Collapse
|
37
|
Cassina T, Villa M, Soldani-Agnello A, Zini P. Comparison of two regional citrate anticoagulation modalities for continuous renal replacement therapy by a prospective analysis of safety, workload, effectiveness, and cost. Minerva Anestesiol 2021; 87:1309-1319. [PMID: 34527405 DOI: 10.23736/s0375-9393.21.15559-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Currently, regional citrate anticoagulation (RCA) is the preferred approach for continuous renal replacement therapy (CRRT), and several RCA protocols are commercially available. This study was aimed at comparing two RCA modalities for CRRT in terms of safety, workload, effectiveness, and costs. METHODS We prospectively evaluated two different RCA approaches in patients admitted to our intensive care unit (ICU) who needed CRRT. Patients with acute liver failure were excluded. We compared a hypertonic sodium-citrate solution 136 mmol/L added before the filter as anticoagulant during bicarbonate continuous hemodialysis (RCA-CVVHD) versus citrate-buffered replacement fluid 13.3 mmol/L infused by predilution setting in continuous venovenous hemofiltration (RCA-CVVH). Alkalosis, calcium homeostasis, nursing workload, filter lifespan, urea-creatinine metabolic control, and costs were recorded. RESULTS Forty-five and 31 patients who underwent RCA-CVVH and RCA-CVVHD, respectively, were included. Alkalosis-free time distributions were significantly different in favor of a higher alkalosis incidence in the RCA-CVVHD group (log-rank test χ2(1)=8.18, P=0.004). Multivariable analysis showed that RCA-CVVHD was associated with a longer filter lifespan (HR=0.47; 95% CI: 0.28-0.78), higher total cost (1362 CHF [782-1901] vs. 976 CHF [671-1353], P<0.001), and higher number of anticoagulation adjustments (9 [IQR, 4-14] vs. 2 [IQR, 1-4]). The mean urea and creatinine reduction ratios at the first 24 hours were significantly higher in the RCA-CVVHD group. Calcium homeostasis and filter downtime were similar in the two groups. CONCLUSIONS Pre-filter hypertonic sodium-citrate solution (136 mmol/L) results in longer filter patency and improves depuration effectiveness. However, compared to RCA-CVVHF, it causes metabolic alkalosis and increases nursing interventions and cost.
Collapse
Affiliation(s)
- Tiziano Cassina
- Department of Cardiac Anesthesiology and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland
| | - Michele Villa
- Department of Cardiac Anesthesiology and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland -
| | - Annalisa Soldani-Agnello
- Department of Cardiac Anesthesiology and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland
| | - Piergiorgio Zini
- Department of Cardiac Anesthesiology and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland
| |
Collapse
|
38
|
Tsujimoto Y, Miki S, Shimada H, Tsujimoto H, Yasuda H, Kataoka Y, Fujii T. Non-pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy. Cochrane Database Syst Rev 2021; 9:CD013330. [PMID: 34519356 PMCID: PMC8438600 DOI: 10.1002/14651858.cd013330.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication amongst people who are critically ill, and it is associated with an increased risk of death. For people with severe AKI, continuous kidney replacement therapy (CKRT), which is delivered over 24 hours, is needed when they become haemodynamically unstable. When CKRT is interrupted due to clotting of the extracorporeal circuit, the delivered dose is decreased and thus leading to undertreatment. OBJECTIVES This review assessed the efficacy of non-pharmacological measures to maintain circuit patency in CKRT. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 25 January 2021 which includes records identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included all randomised controlled trials (RCTs) (parallel-group and cross-over studies), cluster RCTs and quasi-RCTs that examined non-pharmacological interventions to prevent clotting of extracorporeal circuits during CKRT. DATA COLLECTION AND ANALYSIS: Three pairs of review authors independently extracted information including participants, interventions/comparators, outcomes, study methods, and risk of bias. The primary outcomes were circuit lifespan and death due to any cause at day 28. We used a random-effects model to perform quantitative synthesis (meta-analysis). We assessed risk of bias in included studies using the Cochrane Collaboration's tool for assessing risk of bias. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS A total of 20 studies involving 1143 randomised participants were included in the review. The methodological quality of the included studies was low, mainly due to the unclear randomisation process and blinding of the intervention. We found evidence on the following 11 comparisons: (i) continuous venovenous haemodialysis (CVVHD) versus continuous venovenous haemofiltration (CVVH) or continuous venovenous haemodiafiltration (CVVHDF); (ii) CVVHDF versus CVVH; (iii) higher blood flow (≥ 250 mL/minute) versus standard blood flow (< 250 mL/minute); (iv) AN69 membrane (AN69ST) versus other membranes; (v) pre-dilution versus post-dilution; (vi) a longer catheter (> 20 cm) placing the tip targeting the right atrium versus a shorter catheter (≤ 20 cm) placing the tip in the superior vena cava; (vii) surface-modified double-lumen catheter versus standard double-lumen catheter with identical geometry and flow design; (viii) single-site infusion anticoagulation versus double-site infusion anticoagulation; (ix) flat plate filter versus hollow fibre filter of the same membrane type; (x) a filter with a larger membrane surface area versus a smaller one; and (xi) a filter with more and shorter hollow fibre versus a standard filter of the same membrane type. Circuit lifespan was reported in 9 comparisons. Low certainty evidence indicated that CVVHDF (versus CVVH: MD 10.15 hours, 95% CI 5.15 to 15.15; 1 study, 62 circuits), pre-dilution haemofiltration (versus post-dilution haemofiltration: MD 9.34 hours, 95% CI -2.60 to 21.29; 2 studies, 47 circuits; I² = 13%), placing the tip of a longer catheter targeting the right atrium (versus placing a shorter catheter targeting the tip in the superior vena cava: MD 6.50 hours, 95% CI 1.48 to 11.52; 1 study, 420 circuits), and surface-modified double-lumen catheter (versus standard double-lumen catheter: MD 16.00 hours, 95% CI 13.49 to 18.51; 1 study, 262 circuits) may prolong circuit lifespan. However, higher blood flow may not increase circuit lifespan (versus standard blood flow: MD 0.64, 95% CI -3.37 to 4.64; 2 studies, 499 circuits; I² = 70%). More and shorter hollow fibre filters (versus standard filters: MD -5.87 hours, 95% CI -10.18 to -1.56; 1 study, 6 circuits) may reduce circuit lifespan. Death from any cause was reported in four comparisons We are uncertain whether CVVHDF versus CVVH, CVVHD versus CVVH or CVVHDF, longer versus a shorter catheter, or surface-modified double-lumen catheters versus standard double-lumen catheters reduced death due to any cause, in very low certainty evidence. Recovery of kidney function was reported in three comparisons. We are uncertain whether CVVHDF versus CVVH, CVVHDF versus CVVH, or surface-modified double-lumen catheters versus standard double-lumen catheters increased recovery of kidney function. Vascular access complications were reported in two comparisons. Low certainty evidence indicated using a longer catheter (versus a shorter catheter: RR 0.40, 95% CI 0.22 to 0.74) may reduce vascular access complications, however the use of surface-modified double lumen catheters versus standard double-lumen catheters may make little or no difference to vascular access complications. AUTHORS' CONCLUSIONS The use of CVVHDF as compared with CVVH, pre-dilution haemofiltration, a longer catheter, and surface-modified double-lumen catheter may be useful in prolonging the circuit lifespan, while higher blood flow and more and shorter hollow fibre filter may reduce circuit life. The Overall, the certainty of evidence was assessed to be low to very low due to the small sample size of the included studies. Data from future rigorous and transparent research are much needed in order to fully understand the effects of non-pharmacological interventions in preventing circuit coagulation amongst people with AKI receiving CKRT.
Collapse
Affiliation(s)
- Yasushi Tsujimoto
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
- Department of Nephrology and Dialysis, Kyoritsu Hospital, Kawanishi, Japan
- Systematic Review Workshop Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Sho Miki
- Department of Nephrology, Sumitomo Hospital, Osaka, Japan
| | - Hiroki Shimada
- Department of Nephrology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Hiraku Tsujimoto
- Hospital Care Research Unit, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama-shi, Japan
| | - Yuki Kataoka
- Systematic Review Workshop Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoko Fujii
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
- ANZIC-RC, Monash University School of Public Health and Preventive Medicine, Melbourne, Australia
| |
Collapse
|
39
|
Gupta V, Aslam N, Chhabra ST, Makkar V, Mohan B, Kapoor S, Singh VP, Kumar R, Grover S, Kaur G, Sethi S, Kaur S, Goyal A, Singh B, Singh G, Ralhan S, Wander GS. Do anti-platelet drugs improve duration of continuous renal replacement therapy? A retrospective cohort study in cardiac ICU patients. Int J Artif Organs 2021; 44:651-657. [PMID: 34240632 DOI: 10.1177/03913988211031253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of this study was to investigate the impact of anti-platelet drug/s on duration of continuous renal replacement therapy (CRRT) in those patients where anti-coagulants were not used due to certain contraindications and in cases where patients were on anti-platelet drugs and were given anti-coagulant during CRRT. METHOD This single-center, retrospective cohort study was conducted using the medical records patients treated with CRRT in the cardiac ICU of the inpatient urban facility, located in North India. Data was collected from only those patients who received CRRT for the duration of at least 12 h. Patient's in NAC group were not on any anti-platelet/s and did not receive anti-coagulant during CRRT. AC and AP group patients received anti-coagulant alone or were already on anti-platelet/s and did not receive anti-coagulant respectively while ACAP group patients were on anti-platelet drug/s and also received anti-coagulant during CRRT. RESULT Patients in AC, AP, or ACAP group showed significantly (p < 0.001) higher CRRT filter life compared to NAC group. The median CRRT filter life was significantly higher in the ACAP group compared to AC (p < 0.05) and AP (p < 0.001) groups. CONCLUSION This study indicates that systemic anti-platelet therapy can provide additional support in critical patients undergoing CRRT even with or without anti-coagulant therapy. However, the increase in CRRT filter life was more profound in patients who were on anti-platelet/s and also received anti-coagulant drug/s during CRRT.
Collapse
Affiliation(s)
- Vivek Gupta
- Department of Cardiac Anaesthesia and Intensive Care, Hero DMC Heart Institute, Ludhiana, Punjab, India
| | - Naved Aslam
- Department of Cardiology, Hero DMC Heart Institute, Ludhiana, Punjab, India
| | | | - Vikas Makkar
- Department of Nephrology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Bishav Mohan
- Department of Cardiology, Hero DMC Heart Institute, Ludhiana, Punjab, India
| | - Samir Kapoor
- Department of Cardiovascular and Thoracic Surgery, Hero DMC Heart Institute, Ludhiana, Punjab, India
| | - Vikram Pal Singh
- Department of Cardiovascular and Thoracic Surgery, Hero DMC Heart Institute, Ludhiana, Punjab, India
| | - Rajiv Kumar
- Department of Cardiovascular and Thoracic Surgery, Hero DMC Heart Institute, Ludhiana, Punjab, India
| | - Suvir Grover
- Department of Cardiac Anaesthesia and Intensive Care, Hero DMC Heart Institute, Ludhiana, Punjab, India
| | - Gurkirat Kaur
- Department of Cardiac Anaesthesia and Intensive Care, Hero DMC Heart Institute, Ludhiana, Punjab, India
| | - Suman Sethi
- Department of Nephrology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Simran Kaur
- Department of Nephrology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Abhishek Goyal
- Department of Cardiology, Hero DMC Heart Institute, Ludhiana, Punjab, India
| | - Bhupinder Singh
- Department of Cardiology, Hero DMC Heart Institute, Ludhiana, Punjab, India
| | - Gurbhej Singh
- Department of Cardiology, Hero DMC Heart Institute, Ludhiana, Punjab, India
| | - Sarju Ralhan
- Department of Cardiovascular and Thoracic Surgery, Hero DMC Heart Institute, Ludhiana, Punjab, India
| | | |
Collapse
|
40
|
Sansom B, Sriram S, Presneill J, Bellomo R. Low Blood Flow Continuous Veno-Venous Haemodialysis Compared with Higher Blood Flow Continuous Veno-Venous Haemodiafiltration: Effect on Alarm Rates, Filter Life, and Azotaemic Control. Blood Purif 2021; 51:130-137. [PMID: 34010832 DOI: 10.1159/000516146] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/26/2021] [Indexed: 11/19/2022]
Abstract
TITLE Low blood flow continuous veno-venous haemodialysis (CVVHD) compared with higher blood flow continuous veno-venous haemodiafiltration (CVVHDF): effect on alarm rates, filter life, and azotaemic control. INTRODUCTION Continuous renal replacement therapy (CRRT) can be delivered via convective, diffusive, or mixed approaches. Higher blood flows have been advocated for convective clearance efficiency and promotion of filter life. It is unclear whether a lower blood flow predominantly diffusive approach may benefit filter life and alarm rates. MATERIALS AND METHODS Sequential cohort study of 284 patients undergoing 874 CRRT circuits from January 2015 to August 2018 in a single university-associated tertiary referral hospital in Australia. Patients underwent a protocol of either CVVHDF at blood flow 200-250 mL/min or CVVHD at blood flow 100-130 mL/min. Machine and patient data were analysed. Outcomes of azotaemic control, filter life, and warning alarm rates were log transformed and analysed with mixed linear modelling with patient as a random effect. RESULTS Both groups had similar azotaemic control (effect estimate on log creatinine CVVHD vs. CVVHDF 1.04 [0.87-1.25], p = 0.68) and median filter life (CVVHDF 16.8 [8.4-90.5] h and CVVHD 16.4 [9.4-82.3] h, p = 0.97). However, circuit pressures were less extreme with a narrower distribution during CVVHD. Multivariate analysis showed CVVHD had a reduced risk of warning alarms (incidence risk ratio [IRR] 0.51 [0.38-0.70]) and femoral access placement also had a reduced risk of alarms (IRR 0.55 [0.41-0.73]). CONCLUSION Low blood flow CVVHD and femoral vascular access reduce alarms while maintaining azotaemic control and circuit patency thus minimizing bedside clinician workload.
Collapse
Affiliation(s)
- Benjamin Sansom
- Department of Intensive Care, The Royal Melbourne Hospital, Parkville, Melbourne, Victoria, Australia, .,School of Medicine, University of Melbourne, Parkville, Melbourne, Victoria, Australia,
| | - Shyamala Sriram
- Department of Intensive Care, The Royal Melbourne Hospital, Parkville, Melbourne, Victoria, Australia
| | - Jeffrey Presneill
- Department of Intensive Care, The Royal Melbourne Hospital, Parkville, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Parkville, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, The Royal Melbourne Hospital, Parkville, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Parkville, Melbourne, Victoria, Australia
| |
Collapse
|
41
|
Legouis D, Montalbano MF, Siegenthaler N, Thieffry C, Assouline B, Marti PE, Sgardello SD, Andreetta C, Binvignat C, Pugin J, Heidegger C, Sangla F. Decreased CRRT Filter Lifespan in COVID-19 ICU Patients. J Clin Med 2021; 10:1873. [PMID: 33925999 PMCID: PMC8123645 DOI: 10.3390/jcm10091873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/17/2021] [Accepted: 04/22/2021] [Indexed: 11/18/2022] Open
Abstract
(1) Background: Increased thromboembolic events and an increased need for continuous renal replacement therapy (CRRT) have been frequently reported in COVID-19 patients. Our aim was to investigate CRRT filter lifespan in intensive care unit (ICU) COVID-19 patients. (2) Methods: We compared CRRT adjusted circuit lifespan in COVID-19 patients admitted for SARS-CoV-2 infection to a control group of patients admitted for septic shock of pulmonary origin other than COVID-19. Both groups underwent at least one session of CRRT for AKI. (3) Results: Twenty-six patients (13 in each group) were included. We analysed 117 CRRT circuits (80 in the COVID-19 group and 37 in the control group). The adjusted filter lifespan was shorter in the COVID-19 group (17 vs. 39 h, p < 0.001). This trend persisted after adjustment for confounding factors (-14 h, p = 0.037). Before CRRT circuit clotting, the COVID-19 group had a more procoagulant profile despite higher heparin infusion rates. Furthermore, we reported a decreased relation between activated partial thromboplastin time (aPTT) and cumulative heparin dose in COVID-19 patients when compared to historical data of 23,058 patients, suggesting a heparin resistance. (4) Conclusion: COVID-19 patients displayed a shorter CRRT filter lifespan that could be related to a procoagulant profile and heparin resistance.
Collapse
Affiliation(s)
- David Legouis
- Intensive Care Unit, Department of Acute Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil 4, CH-1211 Geneva, Switzerland; (D.L.); (M.F.M.); (N.S.); (C.T.); (B.A.); (P.E.M.); (S.D.S.); (C.A.); (C.B.); (J.P.); (C.H.)
- Laboratory of Nephrology, Department of Medicine and Cell Physiology and Metabolism, University of Geneva, Rue du Général-Dufour 24, CH-1211 Geneva, Switzerland
| | - Maria F. Montalbano
- Intensive Care Unit, Department of Acute Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil 4, CH-1211 Geneva, Switzerland; (D.L.); (M.F.M.); (N.S.); (C.T.); (B.A.); (P.E.M.); (S.D.S.); (C.A.); (C.B.); (J.P.); (C.H.)
| | - Nils Siegenthaler
- Intensive Care Unit, Department of Acute Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil 4, CH-1211 Geneva, Switzerland; (D.L.); (M.F.M.); (N.S.); (C.T.); (B.A.); (P.E.M.); (S.D.S.); (C.A.); (C.B.); (J.P.); (C.H.)
| | - Camille Thieffry
- Intensive Care Unit, Department of Acute Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil 4, CH-1211 Geneva, Switzerland; (D.L.); (M.F.M.); (N.S.); (C.T.); (B.A.); (P.E.M.); (S.D.S.); (C.A.); (C.B.); (J.P.); (C.H.)
| | - Benjamin Assouline
- Intensive Care Unit, Department of Acute Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil 4, CH-1211 Geneva, Switzerland; (D.L.); (M.F.M.); (N.S.); (C.T.); (B.A.); (P.E.M.); (S.D.S.); (C.A.); (C.B.); (J.P.); (C.H.)
| | - Pierre Emmanuel Marti
- Intensive Care Unit, Department of Acute Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil 4, CH-1211 Geneva, Switzerland; (D.L.); (M.F.M.); (N.S.); (C.T.); (B.A.); (P.E.M.); (S.D.S.); (C.A.); (C.B.); (J.P.); (C.H.)
| | - Sebastian D. Sgardello
- Intensive Care Unit, Department of Acute Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil 4, CH-1211 Geneva, Switzerland; (D.L.); (M.F.M.); (N.S.); (C.T.); (B.A.); (P.E.M.); (S.D.S.); (C.A.); (C.B.); (J.P.); (C.H.)
| | - Claudio Andreetta
- Intensive Care Unit, Department of Acute Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil 4, CH-1211 Geneva, Switzerland; (D.L.); (M.F.M.); (N.S.); (C.T.); (B.A.); (P.E.M.); (S.D.S.); (C.A.); (C.B.); (J.P.); (C.H.)
| | - Céline Binvignat
- Intensive Care Unit, Department of Acute Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil 4, CH-1211 Geneva, Switzerland; (D.L.); (M.F.M.); (N.S.); (C.T.); (B.A.); (P.E.M.); (S.D.S.); (C.A.); (C.B.); (J.P.); (C.H.)
| | - Jérôme Pugin
- Intensive Care Unit, Department of Acute Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil 4, CH-1211 Geneva, Switzerland; (D.L.); (M.F.M.); (N.S.); (C.T.); (B.A.); (P.E.M.); (S.D.S.); (C.A.); (C.B.); (J.P.); (C.H.)
- University of Geneva, Rue du Général-Dufour 24, CH-1211 Geneva, Switzerland
| | - Claudia Heidegger
- Intensive Care Unit, Department of Acute Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil 4, CH-1211 Geneva, Switzerland; (D.L.); (M.F.M.); (N.S.); (C.T.); (B.A.); (P.E.M.); (S.D.S.); (C.A.); (C.B.); (J.P.); (C.H.)
- University of Geneva, Rue du Général-Dufour 24, CH-1211 Geneva, Switzerland
| | - Frédéric Sangla
- Intensive Care Unit, Department of Acute Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil 4, CH-1211 Geneva, Switzerland; (D.L.); (M.F.M.); (N.S.); (C.T.); (B.A.); (P.E.M.); (S.D.S.); (C.A.); (C.B.); (J.P.); (C.H.)
| |
Collapse
|
42
|
Influence of recombinant human-soluble thrombomodulin on extracorporeal circuit clotting in septic patients undergoing blood purification: a propensity-matched cohort study. J Artif Organs 2021; 24:485-491. [PMID: 33856580 DOI: 10.1007/s10047-021-01268-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
Blood purification has been widely performed for critically ill patients, even in cases without renal failure. Effective anticoagulation of the extracorporeal circuit is necessary to prevent circuit clotting. We hypothesized that administration of recombinant human-soluble thrombomodulin (rhsTM) to septic patients undergoing blood purification may prevent circuit clotting, because this agent regulates coagulation. We performed a retrospective, single-center, propensity-matched cohort study in the intensive care unit of Nishichita General Hospital. We included septic patients admitted to the intensive care unit from May 2015 to August 2020 who underwent blood purification. Patients who received rhsTM during intensive care unit admission to the end of the first blood purification (rhsTM group) were matched 1:1 with other patients (control group). The primary outcome was the occurrence of circuit clotting during the first blood purification. A total of 138 patients were included in the study [43 patients (31%) in the rhsTM group and 95 patients (69%) in the control group]. After propensity score matching, 42 pairs of patients were selected, and patients in the rhsTM group had a lower incidence of circuit clotting (21 vs. 55%, P = 0.003). One case of major bleeding occurred in the rhsTM group, but there was no difference in the incidence of major bleeding between groups (2 vs. 0%, P = 1.0). In conclusion, this propensity-matched cohort study indicated that the administration of rhsTM to septic patients undergoing blood purification may prevent extracorporeal circuit clotting.
Collapse
|
43
|
Raina R, Agrawal N, Kusumi K, Pandey A, Tibrewal A, Botsch A. A Meta-Analysis of Extracorporeal Anticoagulants in Pediatric Continuous Kidney Replacement Therapy. J Intensive Care Med 2021; 37:577-594. [PMID: 33688766 DOI: 10.1177/0885066621992751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Continuous kidney replacement therapy (CKRT) is the primary therapeutic modality utilized in hemodynamically unstable patients with severe acute kidney injury. As the circuit is extracorporeal, it poses an increased risk of blood clotting and circuit loss; frequent circuit losses affect the provider's ability to provide optimal treatment. The objective of this meta-analysis is to evaluate the safety and efficacy of the extracorporeal anticoagulants in the pediatric CKRT population. DATA SOURCES We conducted a literature search on PubMed/Medline and Embase for relevant citations. STUDY SELECTION Studies were included if they involved patients under the age of 18 years undergoing CKRT, with the use of anticoagulation (heparin, citrate, or prostacyclin) as a part of therapy. Only English articles were included in the study. DATA EXTRACTION Initial search yielded 58 articles and a total of 24 articles were included and reviewed. A meta-analysis was performed focusing on the safety and effectiveness of regional citrate anticoagulation (RCA) vs unfractionated heparin (UFH) anticoagulants in children. DATA SYNTHESIS RCA had statistically significantly longer circuit life of 50.65 hours vs. UFH of 42.10 hours. Two major adverse effects metabolic alkalosis and electrolyte imbalance seen more commonly in RCA compared to UFH. There was not a significant difference in the risk of systemic bleeding when comparing RCA vs. UFH. CONCLUSION RCA is the preferred anticoagulant over UFH due to its significantly longer circuit life, although vigilant circuit monitoring is required due to the increased risk of electrolyte disturbances. Prostacyclin was not included in the meta-analysis due to the lack of data in pediatric patients. Additional studies are needed to strengthen the study results further.
Collapse
Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Nirav Agrawal
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.,Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Kirsten Kusumi
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Avisha Pandey
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Abhishek Tibrewal
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Alexander Botsch
- Division of Critical Care Medicine, Summa Health, Akron, OH, USA
| |
Collapse
|
44
|
Elbahlawan L, Bissler J, Morrison RR. Continuous Renal Replacement Therapy: A Review of Use and Application in Pediatric Hematopoietic Stem Cell Transplant Recipients. Front Oncol 2021; 11:632263. [PMID: 33718216 PMCID: PMC7953134 DOI: 10.3389/fonc.2021.632263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 01/28/2021] [Indexed: 12/29/2022] Open
Abstract
Hematopoietic stem cell transplant (HSCT) is a curative therapy for malignant and non-malignant conditions. However, complications post-HSCT contribute to significant morbidity and mortality in this population. Acute kidney injury (AKI) is common in the post-allogeneic transplant phase and contributes to morbidity in this population. Continuous renal replacement therapy (CRRT) is used often in the setting of AKI or multiorgan dysfunction in critically ill children. In addition, CRRT can be useful in many disease processes related to transplant and can potentially improve outcomes in this population. This review will focus on the use of CRRT in critically ill children in the post-HSCT setting outside the realm of acute renal failure and highlight the benefits and applications of this modality in this high-risk population.
Collapse
Affiliation(s)
- Lama Elbahlawan
- Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - John Bissler
- Department of Pediatrics, University of Tennessee Health Science Center and Le Bonheur Children’s Hospital, Memphis, TN, United States
- Department of Pediatrics, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - R. Ray Morrison
- Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| |
Collapse
|
45
|
Wong ETY, Ong V, Remani D, Wong WK, Haroon S, Lau T, Nyeo HQ, Mukhopadhyay A, Tan BH, Chua HR. Filter life and safety of heparin-grafted membrane for continuous renal replacement therapy - A randomized controlled trial. Semin Dial 2021; 34:300-308. [PMID: 33556204 DOI: 10.1111/sdi.12951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/25/2020] [Indexed: 11/27/2022]
Abstract
Polyethyleneimine-layered membrane with grafted heparin (oXiris) may improve filter life during continuous renal replacement therapy (CRRT) in addition to its immunoadsorptive capability, compared with that of conventional membrane. In this single center, prospective, open-label pilot study, we randomized critically ill patients with bleeding risk who underwent anticoagulation-free CRRT, to commence with oXiris or M150 filter with sequential crossover. We examined the filter life with each circuit and its effect on systemic coagulation parameters. We randomized 11 and nine patients to commence CRRT with oXiris and M150 respectively, with 19 oXiris and 20 M150 filter-circuits in all. Patient profiles in both arms were comparable for illness severity and comorbidities. Median filter lives for oXiris versus M150 circuits were 13 h versus 18 h (p = 0.10). Among 11 patients with paired crossover filters, filter lives for 14 oXiris-M150 circuit pairs were 13 h versus 16 h (p = 0.27), and corresponding transmembrane pressures increased to 111 mmHg versus 75 mmHg by 12 h (p = 0.02). Patients' coagulation parameters were comparable following both filter-circuits. CRRT with oXiris (vs. M150) was independently associated with shorter filter life, adjusted for prescribed dose, vascular access, and coagulopathy. Use of oXiris did not prolong filter life over conventional membrane with no evidence of systemic heparin exposure; significant membrane clogging is observed by 12 h with oXiris.
Collapse
Affiliation(s)
- Emmett Tsz-Yeung Wong
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Venetia Ong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore
| | - Deepa Remani
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore
| | - Weng-Kin Wong
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Sabrina Haroon
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Titus Lau
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hui-Qing Nyeo
- Nursing Administration, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Amartya Mukhopadhyay
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore
| | - Bee-Hong Tan
- Department of Anaesthesia, National University Hospital, Singapore, Singapore
| | - Horng-Ruey Chua
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| |
Collapse
|
46
|
Zhang W, Bai M, Yu Y, Chen X, Zhao L, Chen X. Continuous renal replacement therapy without anticoagulation in critically ill patients at high risk of bleeding: A systematic review and meta-analysis. Semin Dial 2021; 34:196-208. [PMID: 33400846 DOI: 10.1111/sdi.12946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/15/2020] [Indexed: 12/29/2022]
Abstract
The current clinical guideline recommends continuous renal replacement therapy (CRRT) proceed without anticoagulation in patients with contraindication to citrate and increased bleeding risk. Nevertheless, the efficacy of anticoagulation-free CRRT remains inconsistent. The purpose of our present systematic review is to evaluate the efficacy and safety of anticoagulant-free CRRT based on the current literatures. The primary outcomes were filter lifespan and risk factors for filter failure. Seventeen observational studies and three randomized controlled trials were included in our present meta-analysis. There was no significant difference in filter lifespan and azotemic control between the anticoagulation-free and systemic heparin group. The regional citrate anticoagulation (RCA) protocol seems to be superior to the anticoagulation-free protocol in terms of filter lifespan (WMD -23.01, 95% CI [-28.62, -17.39], p < 0.001; I2 = 0%, p = 0.53) and azotemic control. Nafamostat protocol could significantly prolong filter lifespan (WMD -8.4, 95% CI [-9.9, -6.9], p < 0.001; I2 = 33.7%, p = 0.21) as compared with anticoagulation-free protocol without better azotemic control. The conventional coagulation parameters showed poor predictive performence for filter failure and the necessity of anticoagulants use before CRRT. Currently, the optimal choice of anticoagulation strategy for critically ill patients with increased bleeding risk could be RCA under close monitoring.
Collapse
Affiliation(s)
- Wei Zhang
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China.,State Key Laboratory of Kidney Disease, Department of Nephrology, Chinese People's Liberation Army General Hospital and Military Medical Postgraduate College, Beijing, China
| | - Ming Bai
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yan Yu
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiaolan Chen
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Lijuan Zhao
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiangmei Chen
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China.,State Key Laboratory of Kidney Disease, Department of Nephrology, Chinese People's Liberation Army General Hospital and Military Medical Postgraduate College, Beijing, China
| |
Collapse
|
47
|
Development, implementation and outcomes of a quality assurance system for the provision of continuous renal replacement therapy in the intensive care unit. Sci Rep 2020; 10:20616. [PMID: 33244053 PMCID: PMC7692557 DOI: 10.1038/s41598-020-76785-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 10/21/2020] [Indexed: 01/06/2023] Open
Abstract
Critically ill patients with requirement of continuous renal replacement therapy (CRRT) represent a growing intensive care unit (ICU) population. Optimal CRRT delivery demands continuous communication between stakeholders, iterative adjustment of therapy, and quality assurance systems. This Quality Improvement (QI) study reports the development, implementation and outcomes of a quality assurance system to support the provision of CRRT in the ICU. This study was carried out at the University of Kentucky Medical Center between September 2016 and June 2019. We implemented a quality assurance system using a step-wise approach based on the (a) assembly of a multidisciplinary team, (b) standardization of the CRRT protocol, (c) creation of electronic CRRT flowsheets, (d) selection, monitoring and reporting of quality metrics of CRRT deliverables, and (e) enhancement of education. We examined 34-month data comprising 1185 adult patients on CRRT (~ 7420 patient-days of CRRT) and tracked selected QI outcomes/metrics of CRRT delivery. As a result of the QI interventions, we increased the number of multidisciplinary experts in the CRRT team and ensured a continuum of education to health care professionals. We maximized to 100% the use of continuous veno-venous hemodiafiltration and doubled the percentage of patients using regional citrate anticoagulation. The delivered CRRT effluent dose (~ 30 ml/kg/h) and the delivered/prescribed effluent dose ratio (~ 0.89) remained stable within the study period. The average filter life increased from 26 to 31 h (p = 0.020), reducing the mean utilization of filters per patient from 3.56 to 2.67 (p = 0.054) despite similar CRRT duration and mortality rates. The number of CRRT access alarms per treatment day was reduced by 43%. The improvement in filter utilization translated into ~ 20,000 USD gross savings in filter cost per 100-patient receiving CRRT. We satisfactorily developed and implemented a quality assurance system for the provision of CRRT in the ICU that enabled sustainable tracking of CRRT deliverables and reduced filter resource utilization at our institution.
Collapse
|
48
|
Chua HR, MacLaren G, Choong LHL, Chionh CY, Khoo BZE, Yeo SC, Sewa DW, Ng SY, Choo JCJ, Teo BW, Tan HK, Siow WT, Agrawal RV, Tan CS, Vathsala A, Tagore R, Seow TYY, Khatri P, Hong WZ, Kaushik M. Ensuring Sustainability of Continuous Kidney Replacement Therapy in the Face of Extraordinary Demand: Lessons From the COVID-19 Pandemic. Am J Kidney Dis 2020; 76:392-400. [PMID: 32505811 PMCID: PMC7272152 DOI: 10.1053/j.ajkd.2020.05.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 05/27/2020] [Indexed: 01/08/2023]
Abstract
With the exponential surge in patients with coronavirus disease 2019 (COVID-19) worldwide, the resources needed to provide continuous kidney replacement therapy (CKRT) for patients with acute kidney injury or kidney failure may be threatened. This article summarizes subsisting strategies that can be implemented immediately. Pre-emptive weekly multicenter projections of CKRT demand based on evolving COVID-19 epidemiology and routine workload should be made. Corresponding consumables should be quantified and acquired, with diversification of sources from multiple vendors. Supply procurement should be stepped up accordingly so that a several-week stock is amassed, with administrative oversight to prevent disproportionate hoarding by institutions. Consumption of CKRT resources can be made more efficient by optimizing circuit anticoagulation to preserve filters, extending use of each vascular access, lowering blood flows to reduce citrate consumption, moderating the CKRT intensity to conserve fluids, or running accelerated KRT at higher clearance to treat more patients per machine. If logistically feasible, earlier transition to intermittent hemodialysis with online-generated dialysate, or urgent peritoneal dialysis in selected patients, may help reduce CKRT dependency. These measures, coupled to multicenter collaboration and a corresponding increase in trained medical and nursing staffing levels, may avoid downstream rationing of care and save lives during the peak of the pandemic.
Collapse
Affiliation(s)
- Horng-Ruey Chua
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic & Vascular Surgery, National University Hospital, Singapore
| | - Lina Hui-Lin Choong
- Department of Renal Medicine, Singapore General Hospital, Singapore; Duke-NUS Medical School, Singapore
| | - Chang-Yin Chionh
- Department of Renal Medicine, Changi General Hospital, Singapore
| | | | - See-Cheng Yeo
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Duu-Wen Sewa
- Duke-NUS Medical School, Singapore; Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Shin-Yi Ng
- Duke-NUS Medical School, Singapore; Department of Surgical Intensive Care, Singapore General Hospital, Singapore
| | - Jason Chon-Jun Choo
- Department of Renal Medicine, Singapore General Hospital, Singapore; Duke-NUS Medical School, Singapore
| | - Boon-Wee Teo
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Han-Khim Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore; Duke-NUS Medical School, Singapore
| | - Wen-Ting Siow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore
| | - Rohit Vijay Agrawal
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Anaesthesia, National University Hospital, Singapore
| | - Chieh-Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore; Duke-NUS Medical School, Singapore
| | - Anantharaman Vathsala
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Rajat Tagore
- Division of Renal Medicine, Department of Medicine, Ng Teng Fong General Hospital, Singapore
| | - Terina Ying-Ying Seow
- Division of Renal Medicine, Department of Medicine, Sengkang General Hospital, Singapore
| | - Priyanka Khatri
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore; Fast and Chronic Programmes, Alexandra Hospital, Singapore
| | - Wei-Zhen Hong
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore; Fast and Chronic Programmes, Alexandra Hospital, Singapore
| | - Manish Kaushik
- Department of Renal Medicine, Singapore General Hospital, Singapore; Duke-NUS Medical School, Singapore.
| |
Collapse
|
49
|
Anton FI, Rus PA, Hagau N. Monitoring Anticoagulation with Unfractionated Heparin on Renal Replacement Therapy. Which is the Best aPTT Sampling Site? J Crit Care Med (Targu Mures) 2020; 6:159-166. [PMID: 32864461 PMCID: PMC7430360 DOI: 10.2478/jccm-2020-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 06/26/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Controlled anticoagulation is key to maintaining continuous blood filtration therapies. Objective: The study aimed to compare different blood sampling sites for activated partial thromboplastin time (aPTT) to evaluate anticoagulation with unfractionated heparin (UFH) in continuous renal replacement therapy (CRRT) and identify the most appropriate sampling site for safe patient anticoagulation and increased filter life span. METHOD The study was a prospective observational single-centre investigation targeting intensive care unit (ICU) patients on CRRT using an anticoagulation protocol based on patient characteristics and a weight-based modified nomogram. Eighty-four patients were included in the study. Four sampling sites were assessed: heparin free central venous nondialysis catheter (CVC), an arterial line with heparinised flush (Artery), a circuit access line (Access), and a circuit return line (Postfilter). Blood was sampled from each of four different sites on every patient, four hours after the first heparin bolus. aPTT was determined using a rapid clot detector, point of care device. RESULTS A high positive correlation was obtained for aPTT values between CVC and Access sampling sites (r (84) =0.72; p <0 .05) and a low positive correlation between CVC and Arterial sampling site (r (84) =0.46, p < 0.05). When correlated by artery age, the young Artery (1-3 day old) correlates with CVC, Access and Postfilter (r (45) = 0.74, p >0.05). The aPTT values were significantly higher at Postfilter and Arterial sampling site, older than three days, compared to the CVC sampling site (p<0.05). CONCLUSION Considering patient bleeding risks and filter life span, the optimal sampling sites for safe assessment of unfractionated heparin anticoagulation on CRRT during CVVHDF were the central venous catheter using heparin free lavage saline solution, a heparinised flushed arterial catheter not older than three days, and a circuit access line.
Collapse
Affiliation(s)
| | - Paul Adrian Rus
- Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Emergency Clinical County Hospital, Cluj-Napoca, Romania
| | - Natalia Hagau
- Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Regina Maria Hospital, Cluj-Napoca, Romania
| |
Collapse
|
50
|
The Effect of Patient- and Treatment-Related Factors on Circuit Lifespan During Continuous Renal Replacement Therapy in Critically Ill Children. Pediatr Crit Care Med 2020; 21:578-585. [PMID: 32343111 DOI: 10.1097/pcc.0000000000002305] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To examine the effects of patient and treatment variables on circuit lifespan in critically ill children requiring continuous renal replacement therapy. DESIGN Retrospective observational study based on a prospective registry. SETTING Tertiary referral 30-bed PICU. PATIENTS One hundred sixty-one critically ill children undergoing continuous renal replacement therapy during an 8-year period (2007-2014) were included in the study. INTERVENTIONS Continuous renal replacement therapy. MEASUREMENTS AND MAIN RESULTS During the study period, 161 patients received a total of 22,190 hours of continuous renal replacement therapy, with a median duration of 74.75 hours (interquartile range, 32-169.5) per patient. Of the 572 filter circuits used, 276 (48.3%) were changed due to circuit clotting and 262 (45.8%) were electively changed. Median circuit life was 24.62 hours (interquartile range, 10.6-55.3) for all filters and significantly longer for those electively removed as compared to those prematurely removed because of clotting (35.50 hr [interquartile range, 16.9-67.6] vs 22.00 hr [interquartile range, 13.8-42.5]; p < 0.001). Multivariate regression analyses revealed that admission diagnosis (p < 0.001), anticoagulation type (p < 0.001), access type (p = 0.016), and circuit size (p = 0.027) were associated with prolonged circuit life, as well as, in patients on heparin anticoagulation, with higher doses of heparin (p < 0.001) and a prolonged activated partial thromboplastin time (p < 0.001). CONCLUSIONS In this study, circuit lifespan in pediatric continuous renal replacement therapy was low and appeared to depend upon the patient's diagnosis, the type of access and anticoagulation used as well as the size of the circuit used.
Collapse
|