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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.
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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
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Kim T, Kim DE, Jo EM, Lee Y, Kim DW, Kim HJ, Seong EY, Song SH, Rhee H. The role of nafamostat mesylate anticoagulation in continuous kidney replacement therapy for critically ill patients with bleeding tendencies: a retrospective study on patient outcomes and safety. Kidney Res Clin Pract 2024; 43:469-479. [PMID: 38934038 PMCID: PMC11237322 DOI: 10.23876/j.krcp.23.310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/23/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Continuous kidney replacement therapy (CKRT) is crucial in the management of acute kidney injury in intensive care units (ICUs). Nonetheless, the optimal anticoagulation strategy for patients with bleeding tendencies remains debated. This study aimed to evaluate patient outcomes and safety of nafamostat mesylate (NM) compared with no anticoagulation (NA) in critically ill patients with bleeding tendencies who were undergoing CKRT. METHODS This retrospective study enrolled 2,313 patients who underwent CKRT between March 2013 and December 2022 at the third affiliated hospital in South Korea. After applying the exclusion criteria, 490 patients were included in the final analysis, with 245 patients in the NM and NA groups each, following 1:1 propensity score matching. Subsequently, in-hospital mortality, incidence of bleeding complications, agranulocytosis, hyperkalemia, and length of hospital stay were assessed. RESULTS No significant differences were observed between the groups regarding the lengths of hospital and ICU stays or the incidence of agranulocytosis and hyperkalemia. The NM group showed a smaller decrease in hemoglobin levels during CKRT (-1.90 g/dL vs. -2.39 g/dL) and less need for blood product transfusions than the NA group. Furthermore, the NM group exhibited a survival benefit in patients who required transfusion of all three blood products. CONCLUSION NM is an effective and safe anticoagulant for CKRT in critically ill patients, especially those requiring transfusion of all three blood products. Although these findings are promising, further multicenter studies are needed to validate them and explore the mechanisms underlying the observed benefits.
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Affiliation(s)
- Taeil Kim
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Dong Eon Kim
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Eun Mi Jo
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Yeji Lee
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Da Woon Kim
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Hyo Jin Kim
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Eun Young Seong
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Sang Heon Song
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Harin Rhee
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
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Hadley S, Thompson J, Beltramo F, Marcum J, Reuter-Rice K. Impact of Continuous Renal Replacement Therapy Initiation Time, Kidney Injury, and Hypervolemia in Critically Ill Children. Crit Care Nurse 2024; 44:28-35. [PMID: 38821525 DOI: 10.4037/ccn2024440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
BACKGROUND The mortality rate of pediatric patients who require continuous renal replacement therapy is approximately 42%, and outcomes vary considerably depending on underlying disease, illness severity, and time of dialysis initiation. Delay in the initiation of such therapy may increase mortality risk, prolong intensive care unit stay, and worsen clinical outcomes. LOCAL PROBLEM In the pediatric intensive care unit of an urban level I trauma children's hospital, continuous renal replacement therapy initiation times and factors associated with delays in therapy were unknown. METHODS This quality improvement process involved a retrospective review of data on patients who received continuous dialysis in the pediatric intensive care unit from January 1, 2017, to December 31, 2021. The objectives were to examine the characteristics of the children requiring continuous renal replacement therapy, therapy initiation times, and factors associated with initiation delays that might affect unit length of stay and mortality. RESULTS During the study period, 175 patients received continuous renal replacement therapy, with an average initiation time of 11.9 hours. Statistically significant associations were found between the degree of fluid overload and mortality (P < .001) and between the presence of acute kidney injury and prolonged length of stay (P = .04). No significant association was found between therapy initiation time and unit length of stay or mortality, although the average initiation time of survivors was 5.9 hours shorter than that of nonsurvivors. CONCLUSION Future studies are needed to assess real time delays and to evaluate if the implementation of a standardized initiation process decreases initiation time.
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Affiliation(s)
- Sierra Hadley
- Sierra Hadley is an acute care pediatric nurse practitioner in the pediatric intensive care unit at Children's Hospital Los Angeles, California
| | - Julie Thompson
- Julie Thompson is a consulting associate at the Duke University School of Nursing, Durham, North Carolina
| | - Fernando Beltramo
- Fernando Beltramo is an attending physician, an intensivist, and Director of the pediatric intensive care unit at Children's Hospital Los Angeles and an assistant professor of clinical pediatrics at the Keck School of Medicine of USC, Los Angeles, California
| | - John Marcum
- John Marcum is an attending physician and an intensivist at Children's Hospital Los Angeles and an assistant professor of clinical pediatrics at the Keck School of Medicine of USC
| | - Karin Reuter-Rice
- Karin Reuter-Rice is an associate professor at the Duke University School of Nursing, School of Medicine, and the Duke Institute for Brain Sciences. She is also faculty in the Division of Pediatric Critical Care, Duke University Health System
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Crismale JF, Kim T, Schiano TD. Utilization of aquapheresis among hospitalized patients with end-stage liver disease: A case series and literature review. Clin Transplant 2024; 38:e15221. [PMID: 38109221 DOI: 10.1111/ctr.15221] [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: 03/09/2023] [Revised: 11/04/2023] [Accepted: 11/26/2023] [Indexed: 12/20/2023]
Abstract
Third-spacing of fluid is a common complication in hospitalized patients with decompensated cirrhosis. In addition to ascites, patients with advanced cirrhosis may develop significant peripheral edema, which may limit mobility and exacerbate debility and muscle wasting. Concomitant kidney failure and cardiac dysfunction may lead to worsening hypervolemia, which may ultimately result in pulmonary edema and respiratory compromise. Diuretic use in such patients may be limited by kidney dysfunction and electrolyte abnormalities, including hyponatremia and hypokalemia. A slow, continuous form of ultrafiltration known as aquapheresis is a method of extracorporeal fluid removal whereby a pump generates a transmembrane pressure that forces an isotonic ultrafiltrate across a semipermeable membrane. This leads to removal of an ultrafiltrate that is isotonic to blood without the need for dialysate or replacement fluid as is necessary in other forms of continuous kidney replacement therapy. This technique has been utilized in other conditions including acute decompensated heart failure, with trials showing mixed, but generally favorable results. Herein, we present a series of our own experience using aquapheresis among patients with cirrhosis, review the literature regarding its use in other hypervolemic states, and discuss how we may apply lessons learned from use of aquapheresis in heart failure to patients with end-stage liver disease.
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Affiliation(s)
- James F Crismale
- Division of Liver Diseases, Recanati/Miller Transplantation Institute, The Mount Sinai Hospital, New York, USA
| | - Tonia Kim
- Division of Nephrology, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, USA
| | - Thomas D Schiano
- Division of Liver Diseases, Recanati/Miller Transplantation Institute, The Mount Sinai Hospital, New York, USA
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Sepsis-associated acute kidney injury: consensus report of the 28th Acute Disease Quality Initiative workgroup. Nat Rev Nephrol 2023; 19:401-417. [PMID: 36823168 DOI: 10.1038/s41581-023-00683-3] [Citation(s) in RCA: 84] [Impact Index Per Article: 84.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 02/25/2023]
Abstract
Sepsis-associated acute kidney injury (SA-AKI) is common in critically ill patients and is strongly associated with adverse outcomes, including an increased risk of chronic kidney disease, cardiovascular events and death. The pathophysiology of SA-AKI remains elusive, although microcirculatory dysfunction, cellular metabolic reprogramming and dysregulated inflammatory responses have been implicated in preclinical studies. SA-AKI is best defined as the occurrence of AKI within 7 days of sepsis onset (diagnosed according to Kidney Disease Improving Global Outcome criteria and Sepsis 3 criteria, respectively). Improving outcomes in SA-AKI is challenging, as patients can present with either clinical or subclinical AKI. Early identification of patients at risk of AKI, or at risk of progressing to severe and/or persistent AKI, is crucial to the timely initiation of adequate supportive measures, including limiting further insults to the kidney. Accordingly, the discovery of biomarkers associated with AKI that can aid in early diagnosis is an area of intensive investigation. Additionally, high-quality evidence on best-practice care of patients with AKI, sepsis and SA-AKI has continued to accrue. Although specific therapeutic options are limited, several clinical trials have evaluated the use of care bundles and extracorporeal techniques as potential therapeutic approaches. Here we provide graded recommendations for managing SA-AKI and highlight priorities for future research.
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Daverio M, Cortina G, Jones A, Ricci Z, Demirkol D, Raymakers-Janssen P, Lion F, Camilo C, Stojanovic V, Grazioli S, Zaoral T, Masjosthusmann K, Vankessel I, Deep A. Continuous Kidney Replacement Therapy Practices in Pediatric Intensive Care Units Across Europe. JAMA Netw Open 2022; 5:e2246901. [PMID: 36520438 PMCID: PMC9856326 DOI: 10.1001/jamanetworkopen.2022.46901] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Continuous kidney replacement therapy (CKRT) is the preferred method of kidney support for children with critical illness in pediatric intensive care units (PICUs). However, there are no data on the current CKRT management practices in European PICUs. OBJECTIVE To describe current CKRT practices across European PICUs. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional survey of PICUs in 20 European countries was conducted by the Critical Care Nephrology Section of the European Society of Pediatric and Neonatal Intensive Care from April 1, 2020, to May 31, 2022. Participants included intensivists and nurses working in European PICUs. The survey was developed in English and distributed using SurveyMonkey. One response from each PICU that provided CKRT was included in the analysis. Data were analyzed from June 1 to June 30, 2022. MAIN OUTCOME AND MEASURES Demographic characteristics of European PICUs along with organizational and delivery aspects of CKRT (including prescription, liberation from CKRT, and training and education) were assessed. RESULTS Of 283 survey responses received, 161 were included in the analysis (response rate, 76%). The attending PICU consultant (70%) and the PICU team (77%) were mainly responsible for CKRT prescription, whereas the PICU nurses were responsible for circuit setup (49%) and bedside machine running (67%). Sixty-one percent of permanent nurses received training to use CKRT, with no need for certification or recertification in 36% of PICUs. Continuous venovenous hemodiafiltration was the preferred dialytic modality (51%). Circuit priming was performed with normal saline (67%) and blood priming in children weighing less than 10 kg (56%). Median (IQR) CKRT dose was 35 (30-50) mL/kg/h in neonates and 30 (30-40) mL/kg/h in children aged 1 month to 18 years. Forty-one percent of PICUs used regional unfractionated heparin infusion, whereas 35% used citrate-based regional anticoagulation. Filters were changed for filter clotting (53%) and increased transmembrane pressure (47%). For routine circuit changes, 72 hours was the cutoff in 62% of PICUs. Some PICUs (34%) monitored fluid removal goals every 4 hours, with variation from 12 hours (17%) to 24 hours (13%). Fluid removal goals ranged from 1 to 3 mL/kg/h. Liberation from CKRT was performed with a diuretic bolus followed by an infusion (32%) or a diuretic bolus alone (19%). CONCLUSIONS AND RELEVANCE This survey study found a wide variation in current CKRT practice, including organizational aspects, education and training, prescription, and liberation from CKRT, in European PICUs. This finding calls for concerted efforts on the part of the pediatric critical care and nephrology communities to streamline CKRT education and training, research, and guidelines to reduce variation in practice.
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Affiliation(s)
- Marco Daverio
- Pediatric Intensive Care Unit, Department of Woman’s and Child’s Health, University Hospital of Padua, Padua, Italy
| | - Gerard Cortina
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Andrew Jones
- Children’s Acute Transport Service, Great Ormond Street Hospital for Children, National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Zaccaria Ricci
- Pediatric Intensive Care Unit, Meyer Children’s Hospital, Florence, Italy
| | - Demet Demirkol
- Pediatric Intensive Care Medicine, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Paulien Raymakers-Janssen
- Department of Pediatric Intensive Care, Wilhelmina Children’s Hospital/University Medical Center Utrecht, Utrecht, the Netherlands
| | - Francois Lion
- Department of Cardiothoracic Surgery, Centre Hospitalier Universitaire of Martinique, Fort-de-France, Martinique
| | - Cristina Camilo
- Pediatric Intensive Care Unit, Pediatric Department, Hospital de Santa Maria–North Lisbon University Hospital Center, Lisbon, Portugal
| | - Vesna Stojanovic
- Institute for Child and Youth Health Care of Vojvodina Medical Faculty, University of Novi Sad, Novi Sad, Serbia
| | - Serge Grazioli
- Division of Neonatal and Pediatric Intensive Care, Department of Pediatrics, Gynecology and Obstetrics, Children’s Hospital, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Tomas Zaoral
- Pediatric Intensive Care Unit, Department of Pediatrics, University Hospital of Ostrava, Faculty of Medicine Ostrava, Ostrava, Czech Republic
| | - Katja Masjosthusmann
- Department of General Pediatrics, University Children’s Hospital Muenster, Muenster, Germany
| | - Inge Vankessel
- Department of Pediatric Intensive Care, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Utrecht, the Netherlands
| | - Akash Deep
- Paediatric Intensive Care Unit, King’s College Hospital, NHS Foundation Trust, Denmark Hill, London, United Kingdom
- Department of Women and Children’s Health, School of Life Course Sciences, King’s College London, London, United Kingdom
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Santana-Padilla Y, Berrocal-Tomé F, Santana-López B. Las terapias adsortivas como coadyuvante al soporte vital en el paciente crítico. ENFERMERIA INTENSIVA 2022. [DOI: 10.1016/j.enfi.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Santana-Padilla Y, Fernández-Castillo J, Mateos-Dávila A. La clasificación de la lesión renal aguda: una herramienta para las enfermeras de críticos. ENFERMERIA INTENSIVA 2022. [DOI: 10.1016/j.enfi.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Rhee H, Jang GS, Kim S, Lee W, Jeon H, Kim DW, Ye BM, Kim HJ, Kim MJ, Kim SR, Kim IY, Song SH, Seong EY, Lee DW, Lee SB. Worsening or improving hypoalbuminemia during continuous renal replacement therapy is predictive of patient outcome: a single-center retrospective study. J Intensive Care 2022; 10:25. [PMID: 35672868 PMCID: PMC9171968 DOI: 10.1186/s40560-022-00620-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/31/2022] [Indexed: 12/17/2022] Open
Abstract
Abstract
Background
Hypoalbuminemia at the initiation of continuous renal replacement therapy (CRRT) is a risk factor for poor patient outcomes. However, it is unknown whether the patterns of changes in serum albumin levels during CRRT can be used to predict patient outcomes.
Methods
This retrospective study analyzed data that had been consecutively collected from January 2016 to December 2020 at the Third Affiliated Hospital. We included patients with acute kidney injury who received CRRT for ≥ 72 h. We divided the patients into four groups based on their serum albumin levels (albumin ≥ 3.0 g/dL or < 3.0 g/dL) at the initiation and termination of CRRT.
Results
The 793 patients in this study were categorized into the following albumin groups: persistently low, 299 patients (37.7%); increasing, 85 patients (10.4%); decreasing, 195 patients (24.6%); and persistently high, 214 patients (27.1%). In-hospital mortality rates were highest in the persistently low and decreasing groups, followed by the increasing and persistently high groups. The hazard ratio for in-hospital mortality was 0.481 (0.340–0.680) in the increasing group compared to the persistently low group; it was 1.911 (1.394–2.620) in the decreasing group compared to the persistently high group. The length of ICU stay was 3.55 days longer in the persistently low group than in the persistently high group.
Conclusions
Serum albumin levels changed during CRRT, and monitoring of patterns of change in serum albumin levels is useful for predicting in-hospital mortality and the length of ICU stay.
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Foglia MJ, Pelletier JH, Bayir H, Fleck A, Konyk L, McSteen C, Fisher D, Fuhrman DY. Tandem Therapeutic Plasma Exchange Reduces Continuous Renal Replacement Therapy Downtime. Blood Purif 2022; 51:523-530. [PMID: 34515068 PMCID: PMC8885923 DOI: 10.1159/000518348] [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: 04/02/2021] [Accepted: 07/06/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Continuous renal replacement therapy (CRRT) has become a primary treatment of severe acute kidney injury in children admitted to the intensive care unit. CRRT "downtime" (when the circuit is not active) can represent a significant portion of the prescribed treatment time and adversely affects clearance. The objective of this study was to evaluate factors associated with CRRT "downtime" and to determine whether instituting a tandem therapeutic plasma exchange (TPE) protocol could significantly and robustly decrease circuit downtime in patients receiving both therapies. METHODS This is a retrospective cohort study of 116 patients undergoing CRRT in the pediatric, neonatal, or cardiac ICU at UPMC Children's Hospital of Pittsburgh from January 2014 to July 2020. We performed multivariable logistic regression to determine factors associated with CRRT downtime. We instituted a tandem TPE protocol whereby TPE and CRRT could run in parallel without pausing CRRT in April 2018. We analyzed the effect of the protocol change by plotting downtime for patients undergoing CRRT and TPE on a run chart. The effect of initiating tandem TPE on downtime was assessed by special cause variation. RESULTS For 108/139 (77.7%) sessions with downtime data available, the median (IQR) percentage of downtime was 6.2% (1.7-12.7%). Multivariable logistic regression showed that TPE was significantly associated with CRRT downtime (p = 0.003), and that age, sex, race, catheter size, and anticoagulation were not. For patients undergoing TPE, the median (IQR) percentage of downtime was 14.7% (10.5-26%) and 3.4% (1.3-4.9%) before and after initiation of tandem TPE, respectively (p < 0.001). The difference in downtime percentage met criteria for special cause variation. CONCLUSIONS Interruptions for TPE increase CRRT downtime. Tandem TPE significantly reduces CRRT downtime in patients undergoing both procedures concomitantly.
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Affiliation(s)
- Matthew J. Foglia
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan H. Pelletier
- Division of Pediatric Critical Care, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Hülya Bayir
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Division of Pediatric Critical Care, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Pediatric CRRT Program, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Children’s Neuroscience Institute, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Annette Fleck
- Division of Pediatric Critical Care, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Pediatric CRRT Program, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Leslie Konyk
- Division of Pediatric Critical Care, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Pediatric CRRT Program, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Coleen McSteen
- Division of Pediatric Critical Care, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Pediatric CRRT Program, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Dawn Fisher
- Division of Pediatric Critical Care, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Pediatric CRRT Program, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Dana Y. Fuhrman
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Division of Pediatric Critical Care, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Pediatric CRRT Program, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
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do Nascimento JC, Sanches MB, Souza RCS. Validation of guidelines for the care of patients undergoing continuous renal replacement therapy. Nurs Crit Care 2021; 28:379-387. [PMID: 34585485 DOI: 10.1111/nicc.12718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Continuous renal replacement therapy is one of the most frequently used treatments for acute kidney injury (AKI) in intensive care units (ICUs). It requires professionals with specialized knowledge, specific facilities, and care guidelines to ensure appropriate clinical practice. AIMS AND OBJECTIVES To validate the care guidelines for patients undergoing continuous renal replacement therapy. METHOD This is a methodological study regarding consensual validation of the directives of care. These directives followed the formulation of the research question, a literature review, elaboration of the directive, and validation of the agreement by a committee consisting of seven expert judges. RESULTS The data were analysed based on the content validity index and described in four categories. Among 40 care-related items, 95% showed a degree of agreement above 80% for adequacy and 82.5% showed a degree of agreement above 75% for relevance. CONCLUSION The care-related items identified in the literature showed a high percentage of agreement among the judges and reflected the treatment requirements of these patients. RELEVANCE TO CLINICAL PRACTICE The guideline will be important to assist in the care process regarding patient safety and quality of care.
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Li B, Chen QL, Yao BC, Jiang N, Zhao F, Ren M, Sun J, Xu LN, Guo ZG. Risk factors of continuous renal replacement therapy following total aortic arch replacement under moderate hypothermia. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1448. [PMID: 34734000 PMCID: PMC8506709 DOI: 10.21037/atm-21-3905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/30/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Stanford type A aortic dissection (TAAD) has a sudden onset and high mortality, and emergency total aortic arch replacement (TAAR) is the main treatment option for TAAD. The mortality rate of patients with postoperative acute kidney injury (AKI) combined with continuous renal replacement therapy (CRRT) is remarkable higher than that of patients without AKI. However, incidence of AKI and risk factors for CRRT following TAAR isn't entirely understood. METHODS From October 2018 to March 2021, all patients with Stanford type A dissection who underwent total arch replacement surgery under MHCA were enrolled. According to whether CRRT treatment was performed, participants were divided into a CRRT group (n=49) and control group (n=72). Both groups incorporated the brain protection strategy of moderate hypothermia, and the left common carotid artery and the innominate artery were perfused anteriorly. Relevant medical data was collected. RESULTS Age, gender, and a history of smoking and drinking were not significantly different between the 2 groups (P>0.1). There were statistical differences between the 2 groups in aortic sinus diameter and Bentall procedure (P≤0.05). Univariate analysis revealed that fresh frozen plasma was a protective factor (P<0.05) and the intraoperative transfusion volume of red blood cells, platelets, fresh frozen plasma, autologous blood used for intraoperative bleeding, aortic sinus diameter, and Bentall procedure were risk factors (P<0.1). Multivariate analysis showed that the Bentall procedure and intraoperative bleeding were risk factors for CRRT (P<0.05), and the aortic sinus diameter and intraoperative transfusion score were also risk factors for CRRT (P<0.05). Receiver operating characteristic (ROC) analysis demonstrated that the model of aortic sinus diameter and intraoperative transfusion score had more significantly different discriminatory powers. CONCLUSIONS The Bentall procedure, intraoperative bleeding, aortic sinus diameter, and intraoperative transfusion score were risk factors for postoperative CRRT. The model of aortic sinus diameter and intraoperative transfusion score had more significantly different discriminatory powers.
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Affiliation(s)
- Bo Li
- Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Qing-Liang Chen
- Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Bo-Chen Yao
- Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Nan Jiang
- Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Feng Zhao
- Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Min Ren
- Tianjin Institute of Cardiovascular Diseases, Tianjin, China
| | - Jing Sun
- Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Li-Na Xu
- Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Zhi-Gang Guo
- Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin, China
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Impact of Downtime on Clinical Outcomes in Critically Ill Patients with Acute Kidney Injury Receiving Continuous Renal Replacement Therapy. ASAIO J 2021; 68:744-752. [PMID: 34506331 DOI: 10.1097/mat.0000000000001549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Continuous renal replacement therapy (CRRT) downtime is considered a quality indicator; however, it remains uncertain whether downtime affects outcomes. This study retrospectively investigated the impact of downtime on clinical outcomes. Patients were classified as downtime <20% or ≥20% of potential operative time over 4 days from CRRT initiation. Patients with ≥20% downtime were matched to those with <20% downtime using 1:2 propensity score matching. There were 88 patients with <20% downtime and 44 patients with ≥20% downtime. The cumulative effluent volume was lower in patients with ≥20% downtime (p < 0.001). The difference in levels of urea and creatinine widened over time (p = 0.004 and <0.001). At days 2 and 3, daily fluid balance differed (p = 0.046 and 0.031), and the levels of total carbon dioxide were lower in those with ≥20% downtime (p = 0.038 and 0.020). Based on our results, ≥20% downtime was not associated with increased 28 day mortality; however, a subgroup analysis showed the interaction between downtime and daily fluid balance (p = 0.004). In conclusion, increased downtime could impair fluid and uremic control and acidosis management. Moreover, the adverse effect of downtime on fluid control may increase mortality rate. Further studies are needed to verify the value of downtime in critically ill patients requiring CRRT.
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Mateos-Dávila A, Betbesé AJ, Guix-Comellas EM. Fundamental concepts for the management of continuous replacement therapies. ENFERMERIA INTENSIVA 2021; 33:S1130-2399(21)00078-X. [PMID: 34364776 DOI: 10.1016/j.enfi.2021.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Affiliation(s)
- A Mateos-Dávila
- Máster Universitario de Investigación en Cuidados Enfermeros, Doctoranda en el programa de Enfermería y Salud de la UB, Enfermera gestora de la UCI de adultos del Hospital de la Santa Creu i Sant Pau.
| | - A J Betbesé
- Jefe clínico del servicio de Medicina Intensiva del Hospital de la Santa Creu i Sant Pau, Doctor en medicina y profesor agregado interino de la UAB, Campus Sant Pau
| | - E M Guix-Comellas
- Doctora en Enfermería y Salud, Profesora del Departamento de Enfermería Fundamental y Medicoquirúrgica, Escuela de Enfermería, Facultad de Medicina y Ciencias de la Salud, Campus Clínic, Universidad de Barcelona
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15
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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.
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16
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Affiliation(s)
- Marci Ebberts
- Marci Ebberts is a clinical education specialist, Saint Luke's Health System, Kansas City, Missouri
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17
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Jentzer JC, Bihorac A, Brusca SB, Del Rio-Pertuz G, Kashani K, Kazory A, Kellum JA, Mao M, Moriyama B, Morrow DA, Patel HN, Rali AS, van Diepen S, Solomon MA. Contemporary Management of Severe Acute Kidney Injury and Refractory Cardiorenal Syndrome: JACC Council Perspectives. J Am Coll Cardiol 2020; 76:1084-1101. [PMID: 32854844 PMCID: PMC11032174 DOI: 10.1016/j.jacc.2020.06.070] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 12/14/2022]
Abstract
Acute kidney injury (AKI) and cardiorenal syndrome (CRS) are increasingly prevalent in hospitalized patients with cardiovascular disease and remain associated with poor short- and long-term outcomes. There are no specific therapies to reduce mortality related to either AKI or CRS, apart from supportive care and volume status management. Acute renal replacement therapies (RRTs), including ultrafiltration, intermittent hemodialysis, and continuous RRT are used to manage complications of medically refractory AKI and CRS and may restore normal electrolyte, acid-base, and fluid balance before renal recovery. Patients who require acute RRT have a significant risk of mortality and long-term dialysis dependence, emphasizing the importance of appropriate patient selection. Despite the growing use of RRT in the cardiac intensive care unit, there are few resources for the cardiovascular specialist that integrate the epidemiology, diagnostic workup, and medical management of AKI and CRS with an overview of indications, multidisciplinary team management, and transition off of RRT.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Azra Bihorac
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida
| | - Samuel B Brusca
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Gaspar Del Rio-Pertuz
- Department of Critical Care Medicine and Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Amir Kazory
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida
| | - John A Kellum
- Department of Critical Care Medicine and Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
| | - Brad Moriyama
- Department of Critical Care Medicine, Special Volunteer, National Institutes of Health, Bethesda, Maryland
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hena N Patel
- Division of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Aniket S Rali
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland; Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
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18
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Rhee H, Jang GS, An YJ, Han M, Park I, Kim IY, Seong EY, Lee DW, Lee SB, Kwak IS, Song SH. Long-term outcomes in acute kidney injury patients who underwent continuous renal replacement therapy: a single-center experience. Clin Exp Nephrol 2018; 22:1411-1419. [PMID: 29948445 DOI: 10.1007/s10157-018-1595-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 05/29/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) is the most severe form of AKI associated with poor short- and long-term patient outcomes. The aim of this study was to evaluate the variables associated with long-term patient survival in our clinic. METHODS This was a single-center retrospective study with AKI survivors who received CRRT from March 2011 to February 2015. During the study period, all consecutive AKI survivors who underwent CRRT were included. Patients on maintenance dialysis prior to CRRT were excluded. Data were collected by reviewing the patients' medical charts. Long-term follow-up data were gathered through February 2018. RESULTS A total of 430 patients were included, and 62.8% of the patients were male. The mean age of the patients was 63.4 ± 14.6 years. The mean serum creatinine level at the time of CRRT initiation was 3.5 ± 2.5 mg/dL. At the time of discharge, the mean eGFR and serum creatinine levels were 58.4 ± 46.7 and 1.7 ± 1.6 mg/dL, respectively. After 3 years, 44.9% of the patients had survived. When we investigated the factors associated with long-term patient mortality, a longer stay in the ICU [OR 1.034 (1.016-1.053), p < 0.001], a history of cancer [OR 3.830 (1.037-3.308), p = 0.037], a prolonged prothrombin time [OR 1.852 (1.037-3.308), p = 0.037] and a lower eGFR at the time of discharge [OR 0.988 (0.982-0.995), p = 0.001] were independently associated with long-term patient mortality. CONCLUSION Our study demonstrates that long-term mortality after CRRT is associated with longer ICU stays and lower eGFRs at the time of hospital discharge. Our data imply the importance of renal recovery for long-term survival of AKI patients treated with CRRT.
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Affiliation(s)
- Harin Rhee
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan, Republic of Korea.,Division of Nephrology, Biomedical Research Institute, Pusan National University Hospital, Gudeok-ro179, Seo-gu, Pusan, 602-739, Republic of Korea
| | - Gum Sook Jang
- Department of Nursing, Pusan National University Hospital, Pusan, Republic of Korea
| | - Yeo Jin An
- Department of Nursing, Pusan National University Hospital, Pusan, Republic of Korea
| | - Miyeun Han
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan, Republic of Korea.,Division of Nephrology, Biomedical Research Institute, Pusan National University Hospital, Gudeok-ro179, Seo-gu, Pusan, 602-739, Republic of Korea
| | - Inseong Park
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan, Republic of Korea.,Division of Nephrology, Biomedical Research Institute, Pusan National University Hospital, Gudeok-ro179, Seo-gu, Pusan, 602-739, Republic of Korea
| | - Il Young Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan, Republic of Korea
| | - Eun Young Seong
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan, Republic of Korea.,Division of Nephrology, Biomedical Research Institute, Pusan National University Hospital, Gudeok-ro179, Seo-gu, Pusan, 602-739, Republic of Korea
| | - Dong Won Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan, Republic of Korea
| | - Soo Bong Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan, Republic of Korea
| | - Ihm Soo Kwak
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan, Republic of Korea.,Division of Nephrology, Biomedical Research Institute, Pusan National University Hospital, Gudeok-ro179, Seo-gu, Pusan, 602-739, Republic of Korea
| | - Sang Heon Song
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan, Republic of Korea. .,Division of Nephrology, Biomedical Research Institute, Pusan National University Hospital, Gudeok-ro179, Seo-gu, Pusan, 602-739, Republic of Korea.
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