1
|
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
|
2
|
Neumayr TM, Bayrakci B, Chanchlani R, Deep A, Morgan J, Arikan AA, Basu RK, Goldstein SL, Askenazi DJ. Programs and processes for advancing pediatric acute kidney support therapy in hospitalized and critically ill children: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference. Pediatr Nephrol 2024; 39:993-1004. [PMID: 37930418 PMCID: PMC10817827 DOI: 10.1007/s00467-023-06186-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/24/2023] [Accepted: 09/25/2023] [Indexed: 11/07/2023]
Abstract
Pediatric acute kidney support therapy (paKST) programs aim to reliably provide safe, effective, and timely extracorporeal supportive care for acutely and critically ill pediatric patients with acute kidney injury (AKI), fluid and electrolyte derangements, and/or toxin accumulation with a goal of improving both hospital-based and lifelong outcomes. Little is known about optimal ways to configure paKST teams and programs, pediatric-specific aspects of delivering high-quality paKST, strategies for transitioning from acute continuous modes of paKST to facilitate rehabilitation, or providing effective short- and long-term follow-up. As part of the 26th Acute Disease Quality Initiative Conference, the first to focus on a pediatric population, we summarize here the current state of knowledge in paKST programs and technology, identify key knowledge gaps in the field, and propose a framework for current best practices and future research in paKST.
Collapse
Affiliation(s)
- Tara M Neumayr
- Department of Pediatrics, Divisions of Pediatric Critical Care Medicine and Pediatric Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Benan Bayrakci
- Department of Pediatric Intensive Care Medicine, The Center for Life Support Practice and Research, Hacettepe University, Ankara, Türkiye
| | - Rahul Chanchlani
- Department of Pediatrics, Division of Pediatric Nephrology, McMaster University, McMaster Children's Hospital, Hamilton, ON, Canada
| | - Akash Deep
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK.
- Pediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK.
| | - Jolyn Morgan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ayse Akcan Arikan
- Department of Pediatrics, Divisions of Critical Care Medicine and Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Rajit K Basu
- Department of Pediatrics, Division of Critical Care Medicine, Northwestern University Feinberg School of Medicine, Ann & Robert Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Stuart L Goldstein
- Department of Pediatrics, Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David J Askenazi
- Department of Pediatrics, Division of Pediatric Nephrology, Pediatric and Infant Center for Acute Nephrology, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
3
|
Vieira JAM, Reinheimer IC, Dos Santos AC, Halperin FK, Susin LA, Staub LP, Ribeiro RJE, da Silveira JB, Fontoura LF, de Souza DC, Nunes KP, de Souza VC, da Silva Selistre L, Poli-de-Figueiredo CE. Quality indicators in prolonged hemodialysis with regional citrate anticoagulation with the genius system: retrospective cohort of critical patients with acute kidney injury. BMC Nephrol 2023; 24:353. [PMID: 38036951 PMCID: PMC10691098 DOI: 10.1186/s12882-023-03342-8] [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: 06/11/2023] [Accepted: 09/21/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Prolonged hemodialysis (HD) is performed from 6 to 12 h and can last up to 24 h. To prevent system clotting some studies suggest that Regional Citrate Anticoagulation (RCA) use reduces bleeding rates relative to systemic heparin. However, there may be difficulties in the patient's clinical management and completing the prescribed HD with Genius system using RCA. OBJECTIVE To analyze safety Quality Indicators (IQs) and follow up on prolonged HD with 4% sodium citrate solution in a Genius® hybrid system. METHODS This is a retrospective cohort conducted in an intensive care unit. RESULTS 53 random sessions of prolonged HD with 4% sodium citrate solution of critically ill patients with AKI assessed. Evaluated safety indicators were dysnatremia and metabolic alkalosis, observed in 15% and 9.4% of the sessions, respectively. Indicators of effectiveness were system clotting which occurred in 17.3%, and the minimum completion of the prescribed HD time, which was 75.5%. CONCLUSION The assessment of the indicators showed that the use of RCA with a 4% sodium citrate solution in prolonged HD with the Genius system in critically ill patients with AKI can be performed in a simple, safe, and effective way.
Collapse
Affiliation(s)
- Jorge Alberto Menegasso Vieira
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil.
| | - Isabel Cristina Reinheimer
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
| | - Amanda Corrêa Dos Santos
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
| | - Fernando Kowarick Halperin
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
| | - Luiza Aguirre Susin
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
| | - Lia Portella Staub
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
| | - Raquel Jaqueline Eder Ribeiro
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
| | - Julia Braga da Silveira
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
| | - Lucas Friedrich Fontoura
- Academic Master's and Doctorate Degree in Health Sciences, Universidade de Caxias do Sul (UCS), Street Francisco Getúlio Vargas, 1130, Caxias do Sul, Rio Grande do Sul, 95070-560, Brazil
| | - Diego Candido de Souza
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
| | - Karen Patrícia Nunes
- Academic Master's and Doctorate Degree in Health Sciences, Universidade de Caxias do Sul (UCS), Street Francisco Getúlio Vargas, 1130, Caxias do Sul, Rio Grande do Sul, 95070-560, Brazil
| | - Vandrea Carla de Souza
- Academic Master's and Doctorate Degree in Health Sciences, Universidade de Caxias do Sul (UCS), Street Francisco Getúlio Vargas, 1130, Caxias do Sul, Rio Grande do Sul, 95070-560, Brazil
| | - Luciano da Silva Selistre
- Academic Master's and Doctorate Degree in Health Sciences, Universidade de Caxias do Sul (UCS), Street Francisco Getúlio Vargas, 1130, Caxias do Sul, Rio Grande do Sul, 95070-560, Brazil
| | - Carlos Eduardo Poli-de-Figueiredo
- Department: Nephrology Service, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Av. Ipiranga, 6681 - Escola de Medicina - Prédio 12, Porto Alegre, Rio Grande do Sul, CEP 90619-900, Brazil
| |
Collapse
|
4
|
Neyra JA, Mehta RL, Murugan R. Fluid Management during Continuous Renal Replacement Therapy: A Case-Based Approach. Nephron Clin Pract 2023; 147:782-787. [PMID: 37793364 DOI: 10.1159/000534395] [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: 07/05/2023] [Accepted: 09/05/2023] [Indexed: 10/06/2023] Open
Abstract
Continuous renal replacement therapy (CRRT) is frequently used for fluid management of critically ill patients with acute or chronic kidney failure. There is significant practice variation worldwide in fluid management during CRRT. Multiple clinical studies have suggested that both the magnitude and duration of fluid overload are associated with morbidity and mortality in critically ill patients. Therefore, timely and effective fluid management with CRRT is paramount in managing critically ill patients with fluid overload. While the optimal method of fluid management during CRRT is still unclear and warrants further investigation, observational data have suggested a U-shape relationship between net ultrafiltration rate and mortality. Furthermore, recent clinical data have underpinned a significant gap in prescribed versus achieved fluid balance during CRRT, which is also associated with mortality. This review uses a case-based approach to discuss two fluid management strategies based on net ultrafiltration rate and fluid balance goals during CRRT and harmonizes operational definitions.
Collapse
Affiliation(s)
- Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ravindra L Mehta
- Division of Nephrology, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Raghavan Murugan
- Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
5
|
Fuhrman DY, Gist KM, Akcan-Arikan A. Current practices in pediatric continuous kidney replacement therapy: a systematic review-guided multinational modified Delphi consensus study. Pediatr Nephrol 2023; 38:2817-2826. [PMID: 36625932 PMCID: PMC11069347 DOI: 10.1007/s00467-022-05864-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/25/2022] [Accepted: 12/14/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Continuous kidney replacement therapy (CKRT) has become an integral part of the care of critically ill children. However, uncertainty exists regarding the current state of how CKRT is prescribed and delivered in children. The main objective of this study was to identify the current practices for pediatric CKRT. METHODS We conducted a systematic review of the literature from 2012 to 2022 to identify data regarding CKRT timing of initiation, dosing, anticoagulation, fluid removal, and quality monitoring. Using this data, we then performed a two-round modified Delphi process using a multinational internet-assisted survey of prescribers of CKRT. RESULTS The survey was constructed using 172 articles that met inclusion criteria (12% of studies were pediatric focused). A total of 147 and 126 practitioners completed the survey in rounds 1 and 2, respectively. Participants represented Europe (9.5-11.6%) and North America including pediatric intensivists, nephrologists, and advance practice providers. Consensus (defined as a ≥ 75% participant response of "sometimes" or "always") was achieved for 26 statements. There was consensus in the practices of CKRT initiation, dosing, method of anticoagulation, and fluid removal. In contrast, there appears to be greater variability in the methods used for monitoring anticoagulation and the quality of the delivered treatment. CONCLUSIONS Our study results suggest that the current state of pediatric CKRT practice is reflective of the literature over the last 10 years, which is largely based on the care of adult patients. This data provides a framework to study best practices to further improve outcomes for children receiving CKRT. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Dana Y Fuhrman
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
- Department of Pediatrics, Division of Nephrology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
- University of Pittsburgh Children's Hospital of Pittsburgh, 4401 Penn Avenue, Suite 2000, Pittsburgh, PA, 15224, USA.
| | - Katja M Gist
- Department of Pediatrics, Division of Cardiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Department of Pediatrics, Division of Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| |
Collapse
|
6
|
Claure-Del Granado R, Neyra JA, Basu RK. Acute Kidney Injury: Gaps and Opportunities for Knowledge and Growth. Semin Nephrol 2023; 43:151439. [PMID: 37968179 DOI: 10.1016/j.semnephrol.2023.151439] [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: 11/17/2023]
Abstract
Acute kidney injury (AKI) occurs frequently in hospitalized patients, regardless of age or prior medical history. Increasing awareness of the epidemiologic problem of AKI has directly led to increased study of global recognition, diagnostic tools, both reactive and proactive management, and analysis of long-term sequelae. Many gaps remain, however, and in this article we highlight opportunities to add significantly to the increasing bodies of evidence surrounding AKI. Practical considerations related to initiation, prescription, anticoagulation, and monitoring are discussed. In addition, the importance of AKI follow-up evaluation, particularly for those surviving the receipt of renal replacement therapy, is highlighted as a push for global equity in the realm of critical care nephrology is broached. Addressing these gaps presents an opportunity to impact patient care directly and improve patient outcomes.
Collapse
Affiliation(s)
- Rolando Claure-Del Granado
- Department of Medicine, Division of Nephrology, Hospital Obrero No 2-Caja Nacional de Salud, Cochabamba, Bolivia; Biomedical Research Institute, Facultad de Medicina, Universidad Mayor de San Simon, Cochabamba, Bolivia
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Rajit K Basu
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University, Ann and Robert Lurie Children's Hospital of Chicago, Chicago, IL.
| |
Collapse
|
7
|
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
|
8
|
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
|
9
|
Liu ZX, Song HH, Yang Y, Wang XD. Formulation and application of a prelaunch nursing evaluation form for continuous renal replacement therapy. Asian J Surg 2022:S1015-9584(22)01734-1. [PMID: 36577586 DOI: 10.1016/j.asjsur.2022.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 12/08/2022] [Indexed: 12/27/2022] Open
Affiliation(s)
- Zhan-Xiao Liu
- Department of Emergency, Aerospace Center Hospital, Beijing, 100049, China
| | - Huan-Huan Song
- Department of Emergency, Aerospace Center Hospital, Beijing, 100049, China
| | - Ya Yang
- Department of Emergency, Aerospace Center Hospital, Beijing, 100049, China
| | - Xu-Dong Wang
- Department of Emergency, Aerospace Center Hospital, Beijing, 100049, China.
| |
Collapse
|
10
|
Quality, safety, and implementation science in acute kidney care. Curr Opin Crit Care 2022; 28:613-621. [PMID: 36226720 DOI: 10.1097/mcc.0000000000000999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Quality and safety are important themes in acute kidney care (AKC). There have been many recent initiatives highlighting these aspects. However, for these to become part of clinical practice, a rigorous implementation science methodology must be followed. This review will present these practices and will highlight recent initiatives in acute kidney injury (AKI), kidney replacement therapy (KRT) and recovery from AKI. RECENT FINDINGS The 22nd Acute Disease Quality Initiative (ADQI) focused on achieving a framework for improving AKI care. This has led to various quality improvement (QI) initiatives that have been implemented following a robust implementation science methodology. In AKI, QI initiatives have been focused on implementing care bundles and early detection systems for patients at risk or with AKI. KRT initiatives have focused on measuring and reporting key performance indicators (KPIs), and providing targeted feedback and education to improve delivery of KRT. Finally, it has been recognized that post-AKI care is vitally important, and ongoing work has been focused on implementing pathways to ensure continuing kidney-focused care. SUMMARY Quality and safety continue to be important focuses in AKC. Although recent work have focused on initiatives to improve these themes, additional work is necessary to further develop these items as we strive to improve the care to patients with AKI.
Collapse
|
11
|
Opgenorth D, Bagshaw SM, Lau V, Graham MM, Fraser N, Klarenbach S, Morrin L, Norris C, Pannu N, Sinnadurai S, Valaire S, Wang X, Rewa OG. A study protocol for improving the delivery of acute kidney replacement therapy (KRT) to critically ill patients in Alberta – DIALYZING WISELY. BMC Nephrol 2022; 23:369. [DOI: 10.1186/s12882-022-02990-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/24/2022] [Indexed: 11/17/2022] Open
Abstract
Abstract
Background
Acute kidney replacement therapy (KRT) is delivered to acutely ill patients to support organ function and life in the Intensive Care Unit (ICU). Implementing standardized acute KRT pathways can ensure its safe and effective management. At present, there is no standardized approach to the management of acute KRT in Alberta ICUs.
Methods
Dialyzing Wisely is a registry embedded, stepped-wedge, interrupted time-series evaluation of the implementation of a standardized, stakeholder-informed, and evidence-based acute KRT pathway into Alberta ICUs. The acute KRT pathway will consist of two distinct phases. First, we will implement routine monitoring of evidence-informed key performance indicators (KPIs) of acute KRT. Second, we will provide prescriber and program reports for acute KRT initiation patterns. After the implementation of both phases of the pathway, we will evaluate acute KRT performance quarterly and implement a customized suite of interventions aimed at improving performance. We will compare this with baseline and evaluate iterative post implementation effects of the care pathway.
Discussion
Dialyzing Wisely will implement, monitor, and report a suite of KPIs of acute KRT, coupled with a care pathway that will transform the quality of acute KRT across ICUs in Alberta. This program will provide a framework for scaling evidence-informed approaches to monitoring and management of acute KRT in other jurisdictions. We anticipate improvements in acute KRT performance, decreased healthcare system costs and improved patient quality of life by decreasing patient dependence on maintenance dialysis.
Trial registration
Clinicaltrials.gov, NCT05186636. Registered 11, January, 2022.
Collapse
|
12
|
Mohamed TH, Morgan J, Mottes TA, Askenazi D, Jetton JG, Menon S. Kidney support for babies: building a comprehensive and integrated neonatal kidney support therapy program. Pediatr Nephrol 2022:10.1007/s00467-022-05768-y. [PMID: 36227440 DOI: 10.1007/s00467-022-05768-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/01/2022] [Accepted: 09/08/2022] [Indexed: 11/26/2022]
Abstract
Kidney support therapy (KST), previously referred to as Renal Replacement Therapy, is utilized to treat children and adults with severe acute kidney injury (AKI), fluid overload, inborn errors of metabolism, and kidney failure. Several forms of KST are available including peritoneal dialysis (PD), intermittent hemodialysis (iHD), and continuous kidney support therapy (CKST). Traditionally, extracorporeal KST (CKST and iHD) in neonates has had unique challenges related to small patient size, lack of neonatal-specific devices, and risk of hemodynamic instability due to large extracorporeal circuit volume relative to patient total blood volume. Thus, PD has been the most commonly used modality in infants, followed by CKST and iHD. In recent years, CKST machines designed for small children and novel filters with smaller extracorporeal circuit volumes have emerged and are being used in many centers to provide neonatal KST for toxin removal and to achieve fluid and electrolyte homeostasis, increasing the options available for this unique and vulnerable group. These new treatment options create a dramatic paradigm shift with recalibration of the benefit: risk equation. Renewed focus on the infrastructure required to deliver neonatal KST safely and effectively is essential, especially in programs/units that do not traditionally provide KST to neonates. Building and implementing a neonatal KST program requires an expert multidisciplinary team with strong institutional support. In this review, we first describe the available neonatal KST modalities including newer neonatal and infant-specific platforms. Then, we describe the steps needed to develop and sustain a neonatal KST team, including recommendations for provider and nursing staff training. Finally, we describe how quality improvement initiatives can be integrated into programs.
Collapse
Affiliation(s)
- Tahagod H Mohamed
- Division of Nephrology and Hypertension, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA.
- The Kidney and Urinary Tract Center, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH, 430205, USA.
| | - Jolyn Morgan
- The Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Theresa A Mottes
- Division of Nephrology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - David Askenazi
- Pediatric and Infant Center for Acute Nephrology, Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jennifer G Jetton
- Section of Nephrology, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Shina Menon
- Division of Pediatric Nephrology, Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| |
Collapse
|
13
|
Hammouda N, Neyra JA. Can Artificial Intelligence Assist in Delivering Continuous Renal Replacement Therapy? Adv Chronic Kidney Dis 2022; 29:439-449. [PMID: 36253027 PMCID: PMC9586461 DOI: 10.1053/j.ackd.2022.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/02/2022] [Accepted: 08/11/2022] [Indexed: 01/25/2023]
Abstract
Continuous renal replacement therapy (CRRT) is widely utilized to support critically ill patients with acute kidney injury. Artificial intelligence (AI) has the potential to enhance CRRT delivery, but evidence is limited. We reviewed existing literature on the utilization of AI in CRRT with the objective of identifying current gaps in evidence and research considerations. We conducted a scoping review focusing on the development or use of AI-based tools in patients receiving CRRT. Ten papers were identified; 6 of 10 (60%) published in 2021, and 6 of 10 (60%) focused on machine learning models to augment CRRT delivery. All innovations were in the design/early validation phase of development. Primary research interests focused on early indicators of CRRT need, prognostication of mortality and kidney recovery, and identification of risk factors for mortality. Secondary research priorities included dynamic CRRT monitoring, predicting CRRT-related complications, and automated data pooling for point-of-care analysis. Literature gaps included prospective validation and implementation, biases ascertainment, and evaluation of AI-generated health care disparities. Research on AI applications to enhance CRRT delivery has grown exponentially in the last years, but the field remains premature. There is a need to evaluate how these applications could enhance bedside decision-making capacity and assist structure and processes of CRRT delivery.
Collapse
Affiliation(s)
- Nada Hammouda
- Department of Applied Clinical Research, University of Texas, Southwestern, Dallas, TX
| | - Javier A Neyra
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL.
| |
Collapse
|
14
|
Goldstein SL, Akcan-Arikan A, Alobaidi R, Askenazi DJ, Bagshaw SM, Barhight M, Barreto E, Bayrakci B, Bignall ONR, Bjornstad E, Brophy PD, Chanchlani R, Charlton JR, Conroy AL, Deep A, Devarajan P, Dolan K, Fuhrman DY, Gist KM, Gorga SM, Greenberg JH, Hasson D, Ulrich EH, Iyengar A, Jetton JG, Krawczeski C, Meigs L, Menon S, Morgan J, Morgan CJ, Mottes T, Neumayr TM, Ricci Z, Selewski D, Soranno DE, Starr M, Stanski NL, Sutherland SM, Symons J, Tavares MS, Vega MW, Zappitelli M, Ronco C, Mehta RL, Kellum J, Ostermann M, Basu RK. Consensus-Based Recommendations on Priority Activities to Address Acute Kidney Injury in Children: A Modified Delphi Consensus Statement. JAMA Netw Open 2022; 5:e2229442. [PMID: 36178697 PMCID: PMC9756303 DOI: 10.1001/jamanetworkopen.2022.29442] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Increasing evidence indicates that acute kidney injury (AKI) occurs frequently in children and young adults and is associated with poor short-term and long-term outcomes. Guidance is required to focus efforts related to expansion of pediatric AKI knowledge. OBJECTIVE To develop expert-driven pediatric specific recommendations on needed AKI research, education, practice, and advocacy. EVIDENCE REVIEW At the 26th Acute Disease Quality Initiative meeting conducted in November 2021 by 47 multiprofessional international experts in general pediatrics, nephrology, and critical care, the panel focused on 6 areas: (1) epidemiology; (2) diagnostics; (3) fluid overload; (4) kidney support therapies; (5) biology, pharmacology, and nutrition; and (6) education and advocacy. An objective scientific review and distillation of literature through September 2021 was performed of (1) epidemiology, (2) risk assessment and diagnosis, (3) fluid assessment, (4) kidney support and extracorporeal therapies, (5) pathobiology, nutrition, and pharmacology, and (6) education and advocacy. Using an established modified Delphi process based on existing data, workgroups derived consensus statements with recommendations. FINDINGS The meeting developed 12 consensus statements and 29 research recommendations. Principal suggestions were to address gaps of knowledge by including data from varying socioeconomic groups, broadening definition of AKI phenotypes, adjudicating fluid balance by disease severity, integrating biopathology of child growth and development, and partnering with families and communities in AKI advocacy. CONCLUSIONS AND RELEVANCE Existing evidence across observational study supports further efforts to increase knowledge related to AKI in childhood. Significant gaps of knowledge may be addressed by focused efforts.
Collapse
Affiliation(s)
- Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ayse Akcan-Arikan
- Division of Critical Care Medicine and Nephrology, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Rashid Alobaidi
- Alberta Health Sciences University, Edmonton, Alberta, Canada
| | | | - Sean M Bagshaw
- Alberta Health Sciences University, Edmonton, Alberta, Canada
| | - Matthew Barhight
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | | | - Benan Bayrakci
- Department of Pediatric Intensive Care Medicine, Life Support Center, Hacettepe University, Ankara, Turkey
| | | | | | - Patrick D Brophy
- Golisano Children's Hospital, Rochester University Medical Center, Rochester, New York
| | | | | | | | - Akash Deep
- King's College London, London, United Kingdom
| | - Prasad Devarajan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kristin Dolan
- Mercy Children's Hospital Kansas City, Kansas City, Missouri
| | - Dana Y Fuhrman
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Katja M Gist
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephen M Gorga
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor
| | | | - Denise Hasson
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Arpana Iyengar
- St John's Academy of Health Sciences, Bangalore, Karnataka, India
| | | | | | - Leslie Meigs
- Stead Family Children's Hospital, The University of Iowa, Iowa City
| | - Shina Menon
- Seattle Children's Hospital, Seattle, Washington
| | - Jolyn Morgan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Theresa Mottes
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Tara M Neumayr
- Washington University School of Medicine, St Louis, Missouri
| | | | | | | | - Michelle Starr
- Riley Children's Hospital, Indiana University, Bloomington
| | - Natalja L Stanski
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Scott M Sutherland
- Lucille Packard Children's Hospital, Stanford University, Stanford, California
| | | | | | - Molly Wong Vega
- Division of Nephrology, Texas Children's Hospital, Baylor College of Medicine, Houston
| | | | - Claudio Ronco
- Universiti di Padova, San Bartolo Hospital, Vicenza, Italy
| | | | - John Kellum
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Rajit K Basu
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | | |
Collapse
|
15
|
Neyra JA, Lambert J, Ortiz-Soriano V, Cleland D, Colquitt J, Adams P, Bissell BD, Chan L, Nadkarni GN, Tolwani A, Goldstein SL. Assessment of prescribed vs. achieved fluid balance during continuous renal replacement therapy and mortality outcome. PLoS One 2022; 17:e0272913. [PMID: 36006963 PMCID: PMC9409548 DOI: 10.1371/journal.pone.0272913] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 07/28/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Fluid management during continuous renal replacement therapy (CRRT) requires accuracy in the prescription of desired patient fluid balance (FBGoal) and precision in the attainable patient fluid balance (FBAchieved). Herein, we examined the association of the gap between prescribed vs. achieved patient fluid balance during CRRT (%FBGap) with hospital mortality in critically ill patients. METHODS Cohort study of critically ill adults with acute kidney injury (AKI) requiring CRRT and a prescription of negative fluid balance (mean patient fluid balance goal of negative ≥0.5 liters per day). Fluid management parameters included: 1) NUF (net ultrafiltration rate); 2) FBGoal; 3) FBAchieved; and 4) FBGap (% gap of fluid balance achieved vs. goal), all adjusted by patient's weight (kg) and duration of CRRT (hours). RESULTS Data from 653 patients (median of 102.2 patient-hours of CRRT) were analyzed. Mean (SD) age was 56.7 (14.6) years and 61.9% were male. Hospital mortality rate was 64%. Despite FBGoal was similar in patients who died vs. survived, survivors achieved greater negative fluid balance during CRRT than non-survivors: median FBAchieved -0.25 [-0.52 to -0.05] vs. 0.06 [-0.26 to 0.62] ml/kg/h, p<0.001. Median NUF was lower in patients who died vs. survived: 1.06 [0.63-1.47] vs. 1.22 [0.82-1.69] ml/kg/h, p<0.001, and median %FBGap was higher in patients who died (112.8%, 61.5 to 165.7) vs. survived (64.2%, 30.5 to 91.8), p<0.001. In multivariable models, higher %FBGap was independently associated with increased risk of hospital mortality: aOR (95% CI) 1.01 (1.01-1.02), p<0.001. NUF was not associated with hospital mortality when adjusted by %FBGap and other clinical parameters: aOR 0.96 (0.72-1.28), p = 0.771. CONCLUSIONS Higher %FBGap was independently associated with an increased risk of hospital mortality in critically ill adults with AKI on CRRT in whom clinicians prescribed negative fluid balance via CRRT. %FBGap represents a novel quality indicator of CRRT delivery that could assist with operationalizing fluid management interventions during CRRT.
Collapse
Affiliation(s)
- Javier A. Neyra
- Division of Nephrology, Department of Internal Medicine, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, United States of America
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Joshua Lambert
- College of Nursing, University of Cincinnati, Cincinnati, Ohio, United States of America
| | - Victor Ortiz-Soriano
- Division of Nephrology, Department of Internal Medicine, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, United States of America
| | - Daniel Cleland
- Performance Analytics Center of Excellence, University of Kentucky, Lexington, Kentucky, United States of America
| | - Jon Colquitt
- Performance Analytics Center of Excellence, University of Kentucky, Lexington, Kentucky, United States of America
| | - Paul Adams
- Division of Nephrology, Department of Internal Medicine, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, United States of America
| | - Brittany D. Bissell
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky, United States of America
- Division of Pulmonary, Department of Internal Medicine, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, Kentucky, United States of America
| | - Lili Chan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai New York, New York, NY, United States of America
| | - Girish N. Nadkarni
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai New York, New York, NY, United States of America
- Charles Bronfman Institute of Personalized Medicine Hasso Plattner Institute of Digital Health Mount Sinai Clinical Intelligence Center, New York, NY, United States of America
| | - Ashita Tolwani
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Stuart L. Goldstein
- Center for Acute Care Nephrology, Cincinnati Children’s Hospital and Medical Center, University of Cincinnati, Cincinnati, Ohio, United States of America
| |
Collapse
|
16
|
Wu HHL, Chinnadurai R. Quality Assessment on the delivery of Acute Kidney Replacement Therapy in Intensive Care. Ther Apher Dial 2022; 26:840-843. [PMID: 35199963 DOI: 10.1111/1744-9987.13819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 01/30/2022] [Accepted: 02/23/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Henry H L Wu
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK.,Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Rajkumar Chinnadurai
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,Department of Renal Medicine, Salford Royal Hospital, Northern Care Alliance Foundation Trust, Salford, UK
| |
Collapse
|
17
|
Opgenorth D, Reil E, Lau V, Fraser N, Zuege D, Wang X, Bagshaw SM, Rewa O. Improving the quality of the performance and delivery of continuous renal replacement therapy (CRRT) to critically ill patients across a healthcare system: QUALITY CRRT: a study protocol. BMJ Open 2022; 12:e054583. [PMID: 35121604 PMCID: PMC8819828 DOI: 10.1136/bmjopen-2021-054583] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Continuous renal replacement therapy (CRRT) is a continuous form of dialysis used to support critically ill patients with acute kidney injury. The ideal delivery of CRRT requires ongoing monitoring and reporting to adjust practice and deliver optimal therapy. However, this practice occurs variably. METHODS QUALITY CRRT is a multicentre, prospective, stepped-wedged, interrupted time series (ITS) evaluation of the effectiveness, safety and cost of implementing a multifaceted CRRT quality assurance and improvement programme across an entire healthcare system. This study will focus on the standardisation of CRRT programmes with similar structure, process and outcome metrics by the reporting of CRRT key performance indicators (KPIs). The primary outcome will be the quarterly performance of CRRT KPIs. Secondary outcomes will include patient-centred outcomes and economic outcomes. Analysis will compare pre-implementation and post-implementation groups as well as for the performance of KPIs using an ITS methodology. The health economic evaluation will include a within-study analysis and a longer-term model-based analysis. DISCUSSION The effective delivery of CRRT to critically ill patients ideally requires a standardised approach of best practice assessment and ongoing audit and feedback of standardised performance measures. QUALITY CRRT will test the application of this strategy stakeholder engagement and stepped-wedged implementation across an entire healthcare system. ETHICS AND DISSEMINATION This study has received ethics approval. We will plan to publish the results in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04221932. PROTOCOL VERSION 1.0 (15 June 2020).
Collapse
Affiliation(s)
- Dawn Opgenorth
- Faculty of Medicine and Dentistry, Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ellen Reil
- Alberta Health Services, Edmonton, Alberta, Canada
| | - Vincent Lau
- Faculty of Medicine and Dentistry, Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nancy Fraser
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - Danny Zuege
- Department of Critical Care Medicine and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Sean M Bagshaw
- Faculty of Medicine and Dentistry, Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Oleksa Rewa
- Faculty of Medicine and Dentistry, Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
18
|
Tsang JY, Peek N, Buchan I, van der Veer SN, Brown B. OUP accepted manuscript. J Am Med Inform Assoc 2022; 29:1106-1119. [PMID: 35271724 PMCID: PMC9093027 DOI: 10.1093/jamia/ocac031] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/08/2021] [Accepted: 02/24/2022] [Indexed: 11/26/2022] Open
Abstract
Objectives (1) Systematically review the literature on computerized audit and feedback (e-A&F) systems in healthcare. (2) Compare features of current systems against e-A&F best practices. (3) Generate hypotheses on how e-A&F systems may impact patient care and outcomes. Methods We searched MEDLINE (Ovid), EMBASE (Ovid), and CINAHL (Ebsco) databases to December 31, 2020. Two reviewers independently performed selection, extraction, and quality appraisal (Mixed Methods Appraisal Tool). System features were compared with 18 best practices derived from Clinical Performance Feedback Intervention Theory. We then used realist concepts to generate hypotheses on mechanisms of e-A&F impact. Results are reported in accordance with the PRISMA statement. Results Our search yielded 4301 unique articles. We included 88 studies evaluating 65 e-A&F systems, spanning a diverse range of clinical areas, including medical, surgical, general practice, etc. Systems adopted a median of 8 best practices (interquartile range 6–10), with 32 systems providing near real-time feedback data and 20 systems incorporating action planning. High-confidence hypotheses suggested that favorable e-A&F systems prompted specific actions, particularly enabled by timely and role-specific feedback (including patient lists and individual performance data) and embedded action plans, in order to improve system usage, care quality, and patient outcomes. Conclusions e-A&F systems continue to be developed for many clinical applications. Yet, several systems still lack basic features recommended by best practice, such as timely feedback and action planning. Systems should focus on actionability, by providing real-time data for feedback that is specific to user roles, with embedded action plans. Protocol Registration PROSPERO CRD42016048695.
Collapse
Affiliation(s)
- Jung Yin Tsang
- Corresponding Author: Jung Yin Tsang, Centre for Primary Care and Health Services Research, University of Manchester, 6th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK;
| | - Niels Peek
- Centre for Health Informatics, Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre (GMPSTRC), University of Manchester, Manchester, UK
- NIHR Applied Research Collaboration Greater Manchester, University of Manchester, Manchester, UK
| | - Iain Buchan
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Sabine N van der Veer
- Centre for Health Informatics, Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Benjamin Brown
- Centre for Health Informatics, Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre (GMPSTRC), University of Manchester, Manchester, UK
| |
Collapse
|
19
|
Anticoagulation strategies in continuous kidney replacement therapy - does one size fit all? Pediatr Nephrol 2022; 37:2525-2529. [PMID: 35585368 PMCID: PMC9116706 DOI: 10.1007/s00467-022-05567-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 11/01/2022]
|
20
|
Cordoza M, Rachinski K, Nathan K, Crain EB, Braxmeyer D, Gore S, Dubuc SD, Wright J. A Quality Improvement Initiative to Reduce the Frequency of Delays in Initiation and Restarts of Continuous Renal Replacement Therapy. J Nurs Care Qual 2021; 36:308-314. [PMID: 33852528 PMCID: PMC8439559 DOI: 10.1097/ncq.0000000000000557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) is a lifesaving intervention for critically ill patients. Delays in initiation, or an inability to resume CRRT following a temporary suspension in therapy (CRRT restart), can result in suboptimal CRRT delivery. LOCAL PROBLEM Intensive care units across the health care system were experiencing significant delays in CRRT initiation and restarts. APPROACH A multimodal quality improvement initiative was implemented across 7 adult intensive care units, which allowed unit-based staff nurses to initiate and restart CRRT, a task that had previously been delegated to non-unit-based dialysis nurses. OUTCOMES A 75% reduction in CRRT initiation delays and a 90% reduction in CRRT restart delays were observed in the 12 months following the initiative. There were no adverse events or increased disposable CRRT circuit usage following the initiative. CONCLUSIONS Implementation of CRRT initiation and restarts by unit-based nurses were achievable and resulted in substantial improvements in timeliness of CRRT delivery.
Collapse
Affiliation(s)
- Makayla Cordoza
- Postdoctoral Fellow, Division of Sleep and Chronobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristen Rachinski
- Nursing Professional Development Consultant Critical Care, Arena Kaiser Permanente Sunnyside Medical Center, Clackamas, OR, USA
| | | | - Elisa B. Crain
- Clinical Nurse, Critical Care Resource Team, Legacy Health, Portland, OR, USA
| | - Diane Braxmeyer
- Clinical Nurse, Neurotrauma Intensive Care Unit, Legacy Health, Portland, OR, USA
| | - Sarah Gore
- Clinical Nurse, Medical-Surgical Intensive Care Unit, Legacy Health, Portland, OR, USA
| | | | - Joel Wright
- Clinical Nurse, Critical Care Resource Team, Legacy Health, Portland, OR, USA
| |
Collapse
|
21
|
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.
Collapse
|
22
|
Connor MJ, Lischer E, Cerdá J. Organizational and financial aspects of a continuous renal replacement therapy program. Semin Dial 2021; 34:510-517. [PMID: 34423866 DOI: 10.1111/sdi.13013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 07/23/2021] [Accepted: 07/31/2021] [Indexed: 11/27/2022]
Abstract
Critically ill patients who develop severe acute kidney injury in the intensive care unit often require treatment with renal replacement therapies (RRTs). This complication is associated with severe morbidity and mortality and high costs, both during hospitalization and postdischarge. This article discusses the operational requirements to develop and conduct a RRT program, as well as the financial implications of this complex form of patient care. The management of these programs must occur in a context where a clear organizational and educational framework and a multidisciplinary team ensures safety, effectiveness, cost-control, and a clear quality control framework.
Collapse
Affiliation(s)
- Michael J Connor
- Division of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Division of Renal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Jorge Cerdá
- Department of Medicine, Division of Nephrology, Albany Medical College, Albany, New York, USA
| |
Collapse
|
23
|
|
24
|
Baldwin I, Mottes T. Acute kidney injury and continuous renal replacement therapy: A nursing perspective for my shift today in the intensive care unit. Semin Dial 2021; 34:518-529. [PMID: 34218451 DOI: 10.1111/sdi.12992] [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: 02/11/2021] [Accepted: 05/10/2021] [Indexed: 01/12/2023]
Abstract
Handover, clinical discussion, and care for patients in the Intensive Care Unit (ICU) require visual cues to a verbal "story" in an attempt to quickly understand the patient status. Continuous renal replacement therapy (CRRT) is often associated with sepsis or a toxic cause and "kidney attack" not apparent to the patient; "silent" with no pain, discomfort, or vital sign changes initially. Language, terminology, and definitions for this acute kidney injury (AKI) are a graded classification with guidelines. CRRT and dialysis techniques use the physiological principles of diffusion and or convection for solute removal providing a replacement for the basic kidney functions to sustain life until function returns. When to stop CRRT is based on clinical assessment of the patient overall status and urine production re-starting. The medical treatment is focused on the key interventions of resuscitation, remove the cause, support with CRRT or dialysis and monitor for recovery of function. CRRT requires a multidisciplinary team and quality process, local policies, education, and competency pathways to promote best outcomes and efficacy.
Collapse
Affiliation(s)
- Ian Baldwin
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Theresa Mottes
- Ann and Robert Lurie Children's Hospital, Chicago, IL, USA
| |
Collapse
|
25
|
Fluid Balance Management Informs Renal Replacement Therapy Use During Pediatric Extracorporeal Membrane Oxygenation: A Survey Report From the Kidney Intervention During Extracorporeal Membrane Oxygenation Group. ASAIO J 2021; 68:407-412. [PMID: 34570725 DOI: 10.1097/mat.0000000000001471] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Fluid overload (FO) and acute kidney injury (AKI) occur commonly in children supported with extracorporeal membrane oxygenation (ECMO). Continuous renal replacement therapy (CRRT) may be used to manage AKI and FO in children on ECMO. In 2012, our group surveyed ECMO centers to begin to understand the practice patterns around CRRT and ECMO. Since then, more centers are initiating ECMO for increasingly diverse indications and an increased volume of research quantifies the detrimental impacts of AKI and FO. We, therefore, investigated practice patterns of CRRT utilization during ECMO in children. A multi-point survey instrument was distributed to 116 international neonatal and pediatric ECMO centers. Sixty of 116 (51.7%) international neonatal and pediatric ECMO centers responded. All reports using CRRT on ECMO, compared with 75% from the 2012 survey. Eighty-five percent use CRRT to treat or prevent FO, an increased from 59%. The modality of CRRT therapy differed between in-line (slow continuous ultrafiltration, 84.4%) and machine-based (continuous venovenous hemodiafiltration, 87.3%) methods. Most (65%) do not have protocols for fluid management, AKI, or CRRT on ECMO. Trialing off CRRT is dictated by physician preference in 90% (54/60), with varying definitions of success. In this survey study, we found that CRRT use during pediatric ECMO has increased since 2012 with fluid management representing the predominant indication for initiation. Despite the expanded utilization of CRRT with ECMO, there remains significant practice variation in terms of method, modality, indication, the timing of initiation, fluid management, and discontinuation.
Collapse
|
26
|
Askenazi D, Basu RK. Kidney support therapy in the pediatric patient: Unique considerations for a unique population. Semin Dial 2021; 34:530-536. [PMID: 33909936 DOI: 10.1111/sdi.12978] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 11/29/2022]
Abstract
The use of kidney support therapy (KST) for use in managing patients with acute kidney injury (AKI) has expanded greatly in the last several decades. The growing use of KST modalities in children, and now in neonates, has been associated with opportunities for education, clinical research, clinical practice improvements, and outcomes research. A multitude of controversies exist in the field of pediatric KST-many of which are shared by adult critical care nephrology practice. Simultaneously, pediatric KST has led the way to a burgeoning exploration of the importance of fluid overload as it relates to KST initiation and management and also with quality improvement. In this review, we will explore and describe the paradigms contained with pediatric KST used to support children with AKI. In addition to the governing principles related to the mechanics of KST, we will describe the novel aspects of newer support machines and ethical considerations of KST provision. Anticoagulation, dose, and modality will be discussed as well as priming procedures for special considerations. The utilization of KST across pediatric populations represents the next frontier of critical care nephrology.
Collapse
Affiliation(s)
- David Askenazi
- Pediatric and Infant Center for Acute Nephrology Children's of Alabama, Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rajit K Basu
- Division of Critical Care, Children's Healthcare of Atlanta, Department of Pediatrics, Emory University, Atlanta, GA, USA
| |
Collapse
|
27
|
Neyra JA, Kashani K. Improving the quality of care for patients requiring continuous renal replacement therapy. Semin Dial 2021; 34:501-509. [PMID: 33811790 DOI: 10.1111/sdi.12968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 02/12/2021] [Accepted: 03/08/2021] [Indexed: 12/16/2022]
Abstract
Continuous renal replacement therapy (CRRT) is the preferred extracorporeal kidney support therapy employed to support critically ill patients with acute or chronic kidney dysfunction in intensive care units. Significant heterogeneity in CRRT practice exists in part due to variable logistics, resources, and scarcity of evidence-based CRRT practices. Importantly, homogenization of practice patterns by developing substantial evidence and effective dissemination among providers is essential for optimizing CRRT practices. The emphasis on quality of CRRT delivery has prompted identification of potential quality indicators, development of multifaceted quality improvement initiatives, effective computer science utilization, and a surge of multidisciplinary quality assurance teams that advocate for "best" CRRT practices. This manuscript provides an overview of quality improvement methodologies and reviews candidate quality indicators of CRRT and the impact of quality improvement on enhancing CRRT delivery practices.
Collapse
Affiliation(s)
- Javier A Neyra
- Department of Internal Medicine, Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
28
|
Murugan R, Bellomo R, Palevsky PM, Kellum JA. Ultrafiltration in critically ill patients treated with kidney replacement therapy. Nat Rev Nephrol 2021; 17:262-276. [PMID: 33177700 PMCID: PMC9826716 DOI: 10.1038/s41581-020-00358-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2020] [Indexed: 01/30/2023]
Abstract
Management of fluid overload is one of the most challenging problems in the care of critically ill patients with oliguric acute kidney injury. Various clinical practice guidelines support fluid removal using ultrafiltration during kidney replacement therapy. However, ultrafiltration is associated with considerable risks. Emerging evidence from observational studies suggests that both slow and fast rates of net fluid removal (that is, net ultrafiltration (UFNET)) during continuous kidney replacement therapy are associated with increased mortality compared with moderate UFNET rates. In addition, fast UFNET rates are associated with an increased risk of cardiac arrhythmias. Experimental studies in patients with kidney failure who were treated with intermittent haemodialysis suggest that fast UFNET rates are also associated with ischaemic injury to the heart, brain, kidney and gut. The UFNET rate should be prescribed based on patient body weight in millilitres per kilogramme per hour with close monitoring of patient haemodynamics and fluid balance. Dialysate cooling and sodium modelling may prevent haemodynamic instability and facilitate large volumes of fluid removal in patients with kidney failure who are treated with intermittent haemodialysis, but the effects of this strategy on organ injury are less well studied in critically ill patients treated with continuous kidney replacement therapy. Randomized trials are required to examine whether moderate UFNET rates are associated with a reduced risk of haemodynamic instability, organ injury and improved outcomes in critically ill patients.
Collapse
Affiliation(s)
- Raghavan Murugan
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, The University of Melbourne, Austin Hospital, Melbourne, Victoria, Australia
| | - Paul M Palevsky
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John A Kellum
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
29
|
Selewski DT, Askenazi DJ, Kashani K, Basu RK, Gist KM, Harer MW, Jetton JG, Sutherland SM, Zappitelli M, Ronco C, Goldstein SL, Mottes TA. Quality improvement goals for pediatric acute kidney injury: pediatric applications of the 22nd Acute Disease Quality Initiative (ADQI) conference. Pediatr Nephrol 2021; 36:733-746. [PMID: 33433708 DOI: 10.1007/s00467-020-04828-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/24/2020] [Accepted: 10/15/2020] [Indexed: 02/07/2023]
Affiliation(s)
- David T Selewski
- Department of Pediatric, Medical University of South Carolina, 96 Jonathan Lucas St, CSB 428 MSC 608, Charleston, SC, 29425, USA.
| | - David J Askenazi
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL, USA
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rajit K Basu
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Katja M Gist
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew W Harer
- Division of Neonatology, Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Jennifer G Jetton
- Division of Nephrology, Dialysis, and Transplantation, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Scott M Sutherland
- Department of Pediatrics, Division of Nephrology, Stanford University, Stanford, CA, USA
| | - Michael Zappitelli
- Department of Pediatrics, Toronto Hospital for Sick Children, Toronto, Canada
| | - Claudio Ronco
- Department of Medicine, Department. Nephrology Dialysis & Transplantation, International Renal Research Institute, San Bortolo Hospital, University of Padova, Vicenza, Italy
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | |
Collapse
|
30
|
Abstract
Emerging evidence from observational studies suggests that both slower and faster net ultrafiltration rates during kidney replacement therapy are associated with increased mortality in critically ill patients with acute kidney injury and fluid overload. Faster rates are associated with ischemic organ injury. The net ultrafiltration rate should be prescribed based on patient body weight in milliliters per kilogram per hour, with close monitoring of patient hemodynamics and fluid balance. Randomized trials are required to examine whether moderate net ultrafiltration rates compared with slower and faster rates are associated with reduced risk of hemodynamic instability, organ injury, and improved outcomes.
Collapse
Affiliation(s)
- Vikram Balakumar
- Department of Critical Care Medicine, Mercy Hospitals, Springfield, MO, USA; Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. https://twitter.com/vikrambalakumar
| | - Raghavan Murugan
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, University of Pittsburgh, 3347 Forbes Avenue, Suite 220, Room 206, Pittsburgh, PA 15261, USA.
| |
Collapse
|
31
|
See E, Ronco C, Bellomo R. The future of continuous renal replacement therapy. Semin Dial 2021; 34:576-585. [DOI: 10.1111/sdi.12961] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/07/2021] [Accepted: 01/23/2021] [Indexed: 12/17/2022]
Affiliation(s)
- Emily See
- Department of Intensive Care Austin Hospital Heidelberg Vic. Australia
- Department of Nephrology The Royal Melbourne Hospital Parkville Vic. Australia
- Centre for Integrated Critical Care School of Medicine University of Melbourne Parkville Vic. Australia
| | - Claudio Ronco
- Chair of Nephrology Department of Medicine University of Padova Padova Italy
- International Renal Research Institute of Vicenza (IRRIV) Vicenza Italy
- Department of Nephrology San Bortolo Hospital Vicenza Italy
| | - Rinaldo Bellomo
- Department of Intensive Care Austin Hospital Heidelberg Vic. Australia
- Centre for Integrated Critical Care School of Medicine University of Melbourne Parkville Vic. Australia
- Department of Intensive Care The Royal Melbourne Hospital Parkville Vic. Australia
| |
Collapse
|
32
|
Vásquez Jiménez E, Anumudu SJ, Neyra JA. Dose of Continuous Renal Replacement Therapy in Critically Ill Patients: A Bona Fide Quality Indicator. Nephron Clin Pract 2021; 145:91-98. [PMID: 33540417 DOI: 10.1159/000512846] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 10/24/2020] [Indexed: 11/19/2022] Open
Abstract
Acute kidney injury (AKI) is common in critically ill patients, and renal replacement therapy (RRT) constitutes an important aspect of acute management during critical illness. Continuous RRT (CRRT) is frequently utilized in intensive care unit settings, particularly in patients with severe AKI, fluid overload, and hemodynamic instability. The main goal of CRRT is to timely optimize solute control, acid-base, and volume status. Total effluent dose of CRRT is a deliverable that depends on multiple factors and therefore should be systematically monitored (prescribed vs. delivered) and iteratively adjusted in a sustainable mode. In this manuscript, we review current evidence of CRRT dosing and provide recommendations for its implementation as a quality indicator of CRRT delivery.
Collapse
Affiliation(s)
- Enzo Vásquez Jiménez
- Department of Nephrology, National Institute of Cardiology Mexico, Mexico City, Mexico
| | - Samaya J Anumudu
- Division of Nephrology, Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Internal Medicine, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA,
| |
Collapse
|
33
|
Improving the quality of neonatal acute kidney injury care: neonatal-specific response to the 22nd Acute Disease Quality Initiative (ADQI) conference. J Perinatol 2021; 41:185-195. [PMID: 32892210 DOI: 10.1038/s41372-020-00810-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/03/2020] [Accepted: 08/27/2020] [Indexed: 12/31/2022]
Abstract
With the adoption of standardized neonatal acute kidney injury (AKI) definitions over the past decade and the concomitant surge in research studies, the epidemiology of and risk factors for neonatal AKI have become much better understood. Thus, there is now a need to focus on strategies designed to improve AKI care processes with the goal of reducing the morbidity and mortality associated with neonatal AKI. The 22nd Acute Dialysis/Disease Quality Improvement (ADQI) report provides a framework for such quality improvement in adults at risk for AKI and its sequelae. While many of the concepts can be translated to neonates, there are a number of specific nuances which differ in neonatal AKI care. A group of experts in pediatric nephrology and neonatology came together to provide neonatal-specific responses to each of the 22nd ADQI consensus statements.
Collapse
|
34
|
Neyra JA, Nadkarni GN. Continuous Kidney Replacement Therapy of the Future: Innovations in Information Technology, Data Analytics, and Quality Assurance Systems. Adv Chronic Kidney Dis 2021; 28:13-19. [PMID: 34389132 DOI: 10.1053/j.ackd.2021.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 03/20/2021] [Accepted: 03/24/2021] [Indexed: 11/11/2022]
Abstract
Continuous kidney replacement therapy is commonly used in the critically ill population. Despite the recent development in continuous kidney replacement therapy technology and clinical informatics, many aspects of continuous kidney replacement therapy delivery are still not fully standardized, and quality assurance programs for the provision of continuous kidney replacement therapy are not fully developed. This is in part explained by practice variations, suboptimal integration between machine and clinical data, and the lack of validated continuous kidney replacement therapy quality indicators that are feasible for measurement and monitoring. The further development and sustainable implementation of quality assurance systems that support continuous kidney replacement therapy delivery rely on the collaborative work of the critical care nephrology community and the continuous evolution of clinical informatics. In this article, we describe the present status of information technology and quality assurance systems for continuous kidney replacement therapy delivery and provide a framework for technology development and implementation which is in the pipeline of enhanced continuous kidney replacement therapy delivery.
Collapse
|
35
|
Lee HJ, Son YJ. Factors Associated with In-Hospital Mortality after Continuous Renal Replacement Therapy for Critically Ill Patients: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E8781. [PMID: 33256008 PMCID: PMC7730748 DOI: 10.3390/ijerph17238781] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 12/15/2022]
Abstract
Continuous renal replacement therapy (CRRT) is a broadly-accepted treatment for critically ill patients with acute kidney injury to optimize fluid and electrolyte management. Despite intensive dialysis care, there is a high mortality rate among these patients. There is uncertainty regarding the factors associated with in-hospital mortality among patients requiring CRRT. This review evaluates how various risk factors influence the in-hospital mortality of critically ill patients who require CRRT. Five databases were surveyed to gather relevant publications up to 30 June 2020. We identified 752 works, of which we retrieved 38 in full text. Finally, six cohort studies that evaluated 1190 patients were eligible. The in-hospital mortality rate in these studies ranged from 38.6 to 62.4%. Our meta-analysis results showed that older age, lower body mass index, higher APACHE II and SOFA scores, lower systolic and diastolic blood pressure, decreased serum creatinine level, and increased serum sodium level were significantly associated with increased in-hospital mortality in critically ill patients who received CRRT. These results suggest that there are multiple modifiable factors that influence the risk of in-hospital mortality in critically ill patients undergoing CRRT. Further, healthcare professionals should take more care when CRRT is performed on older adults.
Collapse
Affiliation(s)
- Hyeon-Ju Lee
- Department of Nursing, Tongmyong University, Busan 48520, Korea;
| | - Youn-Jung Son
- Red Cross College of Nursing, Chung-Ang University, Seoul 06974, Korea
| |
Collapse
|
36
|
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
|
37
|
Swee ML, Sanders ML, Phisitkul K, Bailey G, Thumann A, Neuzil N, Kumar B, O'Shea AMJ, Dixon BS. Development and implementation of a Telenephrology dashboard for active surveillance of kidney disease: a quality improvement project. BMC Nephrol 2020; 21:424. [PMID: 33023489 PMCID: PMC7539521 DOI: 10.1186/s12882-020-02077-0] [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: 03/30/2020] [Accepted: 09/23/2020] [Indexed: 11/14/2022] Open
Abstract
Background Kidney disease accounts for more than 49 billion dollars in healthcare expenditures annually. Early detection and intervention may reduce the burden of disease. We describe a quality improvement project to develop a telenephrology dashboard that proactively monitors kidney disease. Methods One hundred eighty-four thousands Veterans within the Iowa City Veterans Affairs Health Care System were eligible for telenephrology consultation. The dashboard accessed the charts of 53,085 Veterans at risk for kidney disease. We utilized Lean-Six Sigma tools and principles and the Define-Measure-Analyze-Improve-Control Framework to develop and deploy a telenephrology dashboard in 4 community-based outpatient clinics (CBOCs). The primary measure was the number of days to complete consultation. Secondary measures included number of electronic consultations per month, distance and cost of Veteran travel saved, and number of steps for completion of consult. Results The data of 1384 Veterans at the 4 CBOCs were analyzed by the telenephrology dashboard, of which 459 generated telenephrology consults. The number of days to complete any type of consultation was unchanged (48.9 days in 2019, compared to 41.6 days in 2017). The average Veteran saved between $21.60 to $63.90 per trip to Iowa City. Between March 2019 and August 2019, there were 27.3 telenephrology consults per month. The number of steps needed to complete the consult request was decreased from 13 to 9. Conclusions Utilization of the telenephrology dashboard system contributed to an increase in consultations completed through electronic means without decreasing face-to-face consults. Electronic consults now outnumber traditional face-to-face consultations at our institution. Telenephrology consultation improved early detection and identification of kidney disease and saved time and costs for Veterans in travel, but did not decrease the average number of days to complete consultation requests.
Collapse
Affiliation(s)
- Melissa L Swee
- Division of Nephrology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52245, USA. .,Iowa City Veterans Affairs Health Care System, Iowa City, USA.
| | - M Lee Sanders
- Division of Nephrology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52245, USA.,Iowa City Veterans Affairs Health Care System, Iowa City, USA
| | - Kantima Phisitkul
- Division of Nephrology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52245, USA.,Iowa City Veterans Affairs Health Care System, Iowa City, USA
| | - George Bailey
- Iowa City Veterans Affairs Health Care System, Iowa City, USA
| | - Angie Thumann
- Iowa City Veterans Affairs Health Care System, Iowa City, USA
| | - Nikki Neuzil
- Iowa City Veterans Affairs Health Care System, Iowa City, USA
| | - Bharat Kumar
- Division of Immunology, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Amy M J O'Shea
- Iowa City Veterans Affairs Health Care System, Iowa City, USA.,Division of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Bradley S Dixon
- Division of Nephrology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52245, USA.,Iowa City Veterans Affairs Health Care System, Iowa City, USA
| |
Collapse
|
38
|
Ostermann M, Bellomo R, Burdmann EA, Doi K, Endre ZH, Goldstein SL, Kane-Gill SL, Liu KD, Prowle JR, Shaw AD, Srisawat N, Cheung M, Jadoul M, Winkelmayer WC, Kellum JA. Controversies in acute kidney injury: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Conference. Kidney Int 2020; 98:294-309. [PMID: 32709292 PMCID: PMC8481001 DOI: 10.1016/j.kint.2020.04.020] [Citation(s) in RCA: 229] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/31/2020] [Accepted: 04/09/2020] [Indexed: 12/19/2022]
Abstract
In 2012, Kidney Disease: Improving Global Outcomes (KDIGO) published a guideline on the classification and management of acute kidney injury (AKI). The guideline was derived from evidence available through February 2011. Since then, new evidence has emerged that has important implications for clinical practice in diagnosing and managing AKI. In April of 2019, KDIGO held a controversies conference entitled Acute Kidney Injury with the following goals: determine best practices and areas of uncertainty in treating AKI; review key relevant literature published since the 2012 KDIGO AKI guideline; address ongoing controversial issues; identify new topics or issues to be revisited for the next iteration of the KDIGO AKI guideline; and outline research needed to improve AKI management. Here, we present the findings of this conference and describe key areas that future guidelines may address.
Collapse
Affiliation(s)
- Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St. Thomas' Hospital, King's College London, London, UK.
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Emmanuel A Burdmann
- Laboratório de Investigação Médica 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo, Japan
| | - Zoltan H Endre
- Prince of Wales Hospital and Clinical School, University of New South Wales, Randwick, NSW, Australia
| | - Stuart L Goldstein
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Kathleen D Liu
- Department of Medicine, Division of Nephrology, University of California, San Francisco, San Francisco, California, USA; Department of Anesthesia, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, California, USA
| | - John R Prowle
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Andrew D Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand; Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Academy of Science, Royal Society of Thailand, Bangkok, Thailand
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
| |
Collapse
|
39
|
Mottes TA. Does Your Program Know Its AKI and CRRT Epidemiology? The Case for a Dashboard. Front Pediatr 2020; 8:80. [PMID: 32211353 PMCID: PMC7068810 DOI: 10.3389/fped.2020.00080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 02/18/2020] [Indexed: 11/16/2022] Open
Abstract
Current acute kidney injury (AKI) literature focuses on diagnosis, treatment, and outcomes. While little literature exists studying the quality of care delivered to patients with AKI. However, improving outcomes for patients is dependent on the specifics of the delivered care (i.e., the who, what, when, and how). Therefore, it is necessary to direct attention to process measures to assess the relationship between care and outcomes. The application of quality improvement science to the care of AKI, uses a series of metrics encompassing both processes and outcomes to better understand, evaluate, and ensure the delivery high quality care.
Collapse
Affiliation(s)
- Theresa A Mottes
- Texas Children's Hospital, Renal Section, Houston, TX, United States
| |
Collapse
|
40
|
Ren H, Ge Y, He X, Li C, Xu B, Gong D, Liu Z. Vascular Access in Patients Treated with Continuous Renal Replacement Therapy: A Report from a Single Center in China. Ther Apher Dial 2019; 23:562-569. [PMID: 30843338 DOI: 10.1111/1744-9987.12799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/02/2019] [Accepted: 03/05/2019] [Indexed: 12/24/2022]
Abstract
Our aim was to analyze the practice pattern of vascular access use and complication rates in patients receiving continuous renal replacement therapy from a large Chinese urban medical center. Patients who had received continuous renal replacement therapy (CRRT) from April to October 2014 in our center were included in this study. Demographic data, primary disease, department for hospitalization, blood pressure, heart rate, Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation (APACHE II) score, presence of mechanical ventilation, CRRT modalities, choice of functioning vascular access, site and duration of catheter insertion, presence of recatheterization, cumulative catheter indwelling time, catheter malfunction and catheter-related infections, as well as laboratory test results, were collected. A total of 292 patients were enrolled in our study, including 175 males (59.9%) and 117 females (40.1%), aged 50.8 ± 18.6 years (range, 12 to 94 years). Acute kidney injury, multiple organ dysfunction syndrome, and systemic inflammatory response syndrome were the main indications for treatment with CRRT. Initial vascular access was non-cuffed temporary catheters in 280 patients and was preferentially obtained in the right internal jugular vein (54.3%). There were 32 (11.4%) patients requiring re-catheterization. Catheter malfunction occurred in 7.14% of all patients, and the median time of catheter malfunction was found at the 5th day. By multivariate analysis, it was found that the main risk factors of catheter malfunction were cumulative treatment time of CRRT and the level of hemoglobin. The average time of catheter-related infections was 10.7 days after insertion and the catheter-related infections occurred at a rate of 7.19 per 1000 catheter days. The main risk factors for catheter-related infections were cumulative time of catheterization and the level of serum albumin. In this cohort of critically ill patients, the main risk factors for catheter malfunction were cumulative CRRT time and the level of hemoglobin. In addition, the main risk factors for catheter-related infections were cumulative time of catheterization and the level of serum albumin.
Collapse
Affiliation(s)
- Hongqi Ren
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China.,Department of Nephrology, Huaihai Hospital affiliated with Xuzhou Medical University, Xuzhou, China
| | - Yongchun Ge
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xu He
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Chuan Li
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Bin Xu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Dehua Gong
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| |
Collapse
|