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Ferrari F, Milla P, Sartori M, Zanza C, Tesauro M, Longhitano Y, De Silvestri A, Abbruzzese C, De Rosa S, Lassola S, Samoni S, Brendolan A, Zanella M, Scaravilli V, Grasselli G, Arpicco S, Ronco C. Antibiotics Removal during Continuous Renal Replacement Therapy in Septic Shock Patients: Mixed Modality Versus "Expanded Haemodialysis". Clin Pharmacokinet 2024:10.1007/s40262-024-01397-w. [PMID: 39102092 DOI: 10.1007/s40262-024-01397-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND AND OBJECTIVE Renal replacement therapy (RRT) plays a critical role in antimicrobial removal, particularly for low-molecular-weight drugs with low plasma protein binding, low distribution volume and hydrophilicity. Medium cut-off (MCO) membranes represent a new generation in dialysis technology, enhancing diffusive modality efficacy and increasing the cut-off from 30 to 45 kDa, crucial for middle molecule removal. This monocentric randomized crossover pilot study aimed to evaluate the impact of continuous haemodialysis with MCO membrane (MCO-CVVHD) on the removal of piperacillin, tazobactam and meropenem compared with continuous veno-venous hemodiafiltration with standard high-flux membrane (HFM-CVVHDF). METHODS Twenty patients were randomized to undergo MCO-CVVHD followed by HFM-CVVHDF or vice versa. Extraction ratio (ER), effluent clearance (Cleff) and treatment efficiency were assessed at various intervals. Antibiotic nadir plasma levels were measured for both treatment days. RESULTS HFM-CVVHDF showed greater ER compared with MCO-CVVHD for meropenem (β = - 8.90 (95% CI - 12.9 to - 4.87), p < 0.001) and tazobactam (β = - 8.29 (95% CI - 13.5 to - 3.08), p = 0.002) and Cleff for each antibiotic (meropenem β = - 10,206 (95% CI - 14,787 to - 5787), p = 0.001); tazobactam (β = - 4551 (95% CI - 7781 to - 1322), p = 0.012); piperacillin (β = - 3913 (95% CI - 6388 to - 1437), p = 0.002), even if the carryover effect influenced the Cleff for meropenem and tazobactam. No difference was observed in nadir plasma concentrations or efficiency for any antibiotic. Piperacillin (β = - 38.1 (95% CI - 47.9 to - 28.3), p < 0.001) and tazobactam (β = - 4.45 (95% CI - 6.17 to - 2.72), p < 0.001) showed lower nadir plasma concentrations the second day compared with the first day, regardless the filter type. CONCLUSION MCO demonstrated comparable in vivo removal of piperacillin, tazobactam and meropenem to HFM.
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Affiliation(s)
- Fiorenza Ferrari
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Milla
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Marco Sartori
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Christian Zanza
- Geriatric Medicine Residency Program, University of Rome "Tor Vergata", 00133, Rome, Italy.
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA.
| | - Manfredi Tesauro
- Geriatric Medicine Residency Program, University of Rome "Tor Vergata", 00133, Rome, Italy
- Department of Systems Medicine, University of Rome "Tor Vergata", 00133, Rome, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Department of Emergency Medicine-Emergency Medicine Residency Program, Humanitas University-Research Hospital, 20089, Rozzano, Italy
| | - Annalisa De Silvestri
- SSD Biostatistica e Clinical Trial Center, Direzione Scientifica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chiara Abbruzzese
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia De Rosa
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy
- Centre for Medical Sciences-CISMed, University of Trento, Trento, Italy
| | - Sergio Lassola
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy
| | - Sara Samoni
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
- Departement of Nephrology, Dialysis and Renal Transplantation, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Brendolan
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Monica Zanella
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Vittorio Scaravilli
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Giacomo Grasselli
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Silvia Arpicco
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
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2
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Ramírez-Guerrero G, Ronco C, Lorenzin A, Brendolan A, Sgarabotto L, Zanella M, Reis T. Development of a new miniaturized system for ultrafiltration. Heart Fail Rev 2024; 29:615-630. [PMID: 38289525 DOI: 10.1007/s10741-024-10384-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 04/23/2024]
Abstract
Acute decompensated heart failure and fluid overload are the most common causes of hospitalization in heart failure patients, and often, they contribute to disease progression. Initial treatment encompasses intravenous diuretics although there might be a percentual of patients refractory to this pharmacological approach. New technologies have been developed to perform extracorporeal ultrafiltration in fluid overloaded patients. Current equipment allows to perform ultrafiltration in most hospital and acute care settings. Extracorporeal ultrafiltration is then prescribed and conducted by specialized teams, and fluid removal is planned to restore a status of hydration close to normal. Recent clinical trials and European and North American practice guidelines suggest that ultrafiltration is indicated for patients with refractory congestion not responding to medical therapy. Close interaction between nephrologists and cardiologists may be the key to a collaborative therapeutic effort in heart failure patients. Further studies are today suggesting that wearable technologies might become available soon to treat patients in ambulatory and de-hospitalized settings. These new technologies may help to cope with the increasing demand for the care of chronic heart failure patients. Herein, we provide a state-of-the-art review on extracorporeal ultrafiltration and describe the steps in the development of a new miniaturized system for ultrafiltration, called AD1 (Artificial Diuresis).
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Affiliation(s)
- Gonzalo Ramírez-Guerrero
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
- Nephrology and Dialysis Unit, Carlos Van Buren Hospital, Valparaíso, Chile
- Departamento de Medicina Interna, Universidad de Valparaíso, Valparaíso, Chile
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy.
- Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy.
- Department of Medicine (DIMED), Università degli Studi di Padova, Padua, Italy.
| | - Anna Lorenzin
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
- Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Alessandra Brendolan
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
- Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Luca Sgarabotto
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
- Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy
- Department of Medicine (DIMED), Università degli Studi di Padova, Padua, Italy
| | - Monica Zanella
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
- Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Thiago Reis
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
- Laboratory of Molecular Pharmacology, Faculty of Health Sciences, University of Brasília, Brasília, Brazil
- Department of Nephrology and Kidney Transplantation, Fenix Group, Sao Paulo, Brazil
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3
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Bellomo R, Kellum JA, Reis T, Forni LG, Ronco C. "Renal": The First Forbidden Word in the Medical Lexicon. Blood Purif 2024; 53:686-690. [PMID: 38679015 DOI: 10.1159/000536677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/29/2024] [Indexed: 05/01/2024]
Affiliation(s)
- Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Thiago Reis
- Department of Nephrology, Dialysis and Kidney Transplantation, Fenix Nephrology, São Paulo, Brazil
- Department of Intensive Care Nephrology, Syrian-Lebanese Hospital, São Paulo, Brazil
- Laboratory of Molecular Pharmacology, Faculty of Health Sciences, University of Brasília, Brasília, Brazil
| | - Lui G Forni
- Department of Critical Care, Royal Surrey Hospital Foundation Trust, Guilford, Surrey, UK
- Faculty of Health Sciences, University of Surrey, Guilford, Surrey, UK
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRV), Vicenza, Italy
- Department of Nephrology, San Bortolo Hospital, Vicenza, Italy
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Rosner MH, Ronco C. It Is All in the Name: Standard Nomenclature for Extracorporeal Purification. Blood Purif 2024; 53:327-328. [PMID: 38412842 DOI: 10.1159/000537909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 02/15/2024] [Indexed: 02/29/2024]
Affiliation(s)
- Mitchell H Rosner
- Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy,
- Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy,
- Department of Medicine (DIMED), Università Degli Studi di Padova, Padua, Italy,
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Cicchinelli S, Pignataro G, Gemma S, Piccioni A, Picozzi D, Ojetti V, Franceschi F, Candelli M. PAMPs and DAMPs in Sepsis: A Review of Their Molecular Features and Potential Clinical Implications. Int J Mol Sci 2024; 25:962. [PMID: 38256033 PMCID: PMC10815927 DOI: 10.3390/ijms25020962] [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: 11/26/2023] [Revised: 12/31/2023] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
Sepsis is a serious organ dysfunction caused by a dysregulated immune host reaction to a pathogen. The innate immunity is programmed to react immediately to conserved molecules, released by the pathogens (PAMPs), and the host (DAMPs). We aimed to review the molecular mechanisms of the early phases of sepsis, focusing on PAMPs, DAMPs, and their related pathways, to identify potential biomarkers. We included studies published in English and searched on PubMed® and Cochrane®. After a detailed discussion on the actual knowledge of PAMPs/DAMPs, we analyzed their role in the different organs affected by sepsis, trying to elucidate the molecular basis of some of the most-used prognostic scores for sepsis. Furthermore, we described a chronological trend for the release of PAMPs/DAMPs that may be useful to identify different subsets of septic patients, who may benefit from targeted therapies. These findings are preliminary since these pathways seem to be strongly influenced by the peculiar characteristics of different pathogens and host features. Due to these reasons, while initial findings are promising, additional studies are necessary to clarify the potential involvement of these molecular patterns in the natural evolution of sepsis and to facilitate their transition into the clinical setting.
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Affiliation(s)
- Sara Cicchinelli
- Department of Emergency, S.S. Filippo e Nicola Hospital, 67051 Avezzano, Italy;
| | - Giulia Pignataro
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli—IRRCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (G.P.); (S.G.); (A.P.); (D.P.); (V.O.); (F.F.)
| | - Stefania Gemma
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli—IRRCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (G.P.); (S.G.); (A.P.); (D.P.); (V.O.); (F.F.)
| | - Andrea Piccioni
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli—IRRCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (G.P.); (S.G.); (A.P.); (D.P.); (V.O.); (F.F.)
| | - Domitilla Picozzi
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli—IRRCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (G.P.); (S.G.); (A.P.); (D.P.); (V.O.); (F.F.)
| | - Veronica Ojetti
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli—IRRCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (G.P.); (S.G.); (A.P.); (D.P.); (V.O.); (F.F.)
| | - Francesco Franceschi
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli—IRRCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (G.P.); (S.G.); (A.P.); (D.P.); (V.O.); (F.F.)
| | - Marcello Candelli
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli—IRRCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (G.P.); (S.G.); (A.P.); (D.P.); (V.O.); (F.F.)
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6
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Baud FJ, Jullien V, Desnos-Ollivier M, Lamhaut L, Lortholary O. Caspofungin sequestration in a polyacrylonitrile-derived filter: Increasing the dose does not mitigate sequestration. Int J Antimicrob Agents 2023; 62:107007. [PMID: 37839719 DOI: 10.1016/j.ijantimicag.2023.107007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 09/10/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVES Critically ill patients frequently require continuous renal replacement therapy. Echinocandins are recommended as first-line treatment of candidemia. Preliminary results suggested echinocandin sequestration in a polyacrylonitrile filter. The present study aimed to determine whether increasing the dose might balance sequestration. METHODS An STX filter (Baxter-Gambro) was used. A liquid chromatography-mass spectrometry method was used for dosage of caspofungin. In vitro drug disposition was evaluated by NeckEpur (Neckepur, Versailles, France) technology using a crystalloid medium instead of diluted/reconstituted blood, focusing on the disposition of the unbound fraction of drugs. Two concentrations were assessed. RESULTS At the low dose, the mean measured initial concentration in the central compartment (CC) was 5.1 ± 0.6 mg/L. One hundred percent of the initial amount was eliminated from the CC within the 6-h session. The mean total clearance from the CC was 9.6 ± 2.5 L/h. The mean percentages of elimination resulting from sequestration and diafiltration were 96.0 ± 5.0 and 4.0 ± 5.2%, respectively. At high dose, the mean measured initial concentration in the CC was 13.1 mg/L. One hundred percent of the initial amount was eliminated from the CC within the 6-h session. The mean total clearance from the CC was 9.5 L/h. The mean percentages of elimination resulting from sequestration and filtration were 88.5% and 11.5%, respectively. CONCLUSION Increasing the dose does not mitigate caspofungin sequestration in the STX filter. The results raise caution about the simultaneous use of caspofungin and polyacrylonitrile-derived filters. Intermittent modes of renal replacement therapy might be considered. For sensitive species, fluconazole might be an alternative.
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Affiliation(s)
- Frédéric J Baud
- Département d'Anesthésie-Réanimation Adulte-SAMU de Paris, Hôpital Necker; Assistance Publique-Hôpitaux de Paris, University Paris Cité, Paris, France.
| | - Vincent Jullien
- Université Sorbonne Paris Nord, IAME, INSERM, Paris, France; UF de Pharmacologie, Hôpital Jean Verdier, APHP, Bondy, France
| | | | - Lionel Lamhaut
- Département d'Anesthésie-Réanimation Adulte-SAMU de Paris, Hôpital Necker; Assistance Publique-Hôpitaux de Paris, University Paris Cité, Paris, France
| | - Olivier Lortholary
- Necker Pasteur Centre for Infectious Diseases and Tropical Medicine, IHU Imagine, Necker Enfants Malades, University Hospital, Paris, France; Institut Pasteur, Université Paris Cité, Paris, France
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7
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Murugan R, Kashani K, Palevsky PM. Precision net ultrafiltration dosing in continuous kidney replacement therapy: a practical approach. Intensive Care Med Exp 2023; 11:83. [PMID: 38015332 PMCID: PMC10684837 DOI: 10.1186/s40635-023-00566-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023] Open
Affiliation(s)
- Raghavan Murugan
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America.
- The Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America.
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Paul M Palevsky
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
- Kidney Medicine Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States of America
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8
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Ostermann M, Ankawi G, Cantaluppi V, Madarasu R, Dolan K, Husain-Syed F, Kashani K, Mehta R, Prowle J, Reis T, Rimmelé T, Zarbock A, Kellum JA, Ronco C. Nomenclature of Extracorporeal Blood Purification Therapies for Acute Indications: The Nomenclature Standardization Conference. Blood Purif 2023; 53:358-372. [PMID: 38038238 DOI: 10.1159/000533468] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/28/2023] [Indexed: 12/02/2023]
Abstract
The development of new extracorporeal blood purification (EBP) techniques has led to increased application in clinical practice but also inconsistencies in nomenclature and misunderstanding. In November 2022, an international consensus conference was held to establish consensus on the terminology of EBP therapies. It was agreed to define EBP therapies as techniques that use an extracorporeal circuit to remove and/or modulate circulating substances to achieve physiological homeostasis, including support of the function of specific organs and/or detoxification. Specific acute EBP techniques include renal replacement therapy, isolated ultrafiltration, hemoadsorption, and plasma therapies, all of which can be applied in isolation and combination. This paper summarizes the proposed nomenclature of EBP therapies and serves as a framework for clinical practice and future research.
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care and Nephrology, Guy's and St Thomas' Hospital, London, UK
| | - Ghada Ankawi
- Department of Internal Medicine and Nephrology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale, "Maggiore della Carità" University Hospital, Novara, Italy
| | - Rajasekara Madarasu
- Department of Nephrology, Star Hospitals, Renown Clinical Services, Hyderabad, India
| | - Kristin Dolan
- Department of Paediatrics, Mercy Children's Hospital Kansas City, Kansas City, Kansas, USA
| | - Faeq Husain-Syed
- Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Giessen, Germany
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ravindra Mehta
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - John Prowle
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Thiago Reis
- Department of Nephrology and Kidney Transplantation, Fenix Group, São Paulo, Brazil
- Laboratory of Molecular Pharmacology, University of Brasília, Brasília, Brazil
- Division of Nephrology, Syrian-Lebanese Hospital, São Paulo, Brazil
| | - Thomas Rimmelé
- Department of Anaesthesiology and Critical Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
- Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy
- Department of Medicine (DIMED), Università degli Studi di Padova, Padua, Italy
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9
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Bellomo R, Ronco C, Kellum J, Reis T, Forni L. How renal is the kidney? Lancet 2023; 402:1527. [PMID: 37898530 DOI: 10.1016/s0140-6736(23)01068-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 05/12/2023] [Indexed: 10/30/2023]
Affiliation(s)
- Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Parkville, VIC 3052, Australia.
| | - Claudio Ronco
- Department of Nephrology, International Renal Research Institutes of Vicenza, Vicenza, Italy
| | - John Kellum
- Department of Critical Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thiago Reis
- Department of Nephrology, University of Brasilia, Brasilia, Brazil
| | - Lui Forni
- Department of Intensive Care, University of Surrey, Surrey, UK
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10
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Reis T, Ronco C, Soranno DE, Clark W, De Rosa S, Forni LG, Lorenzin A, Ricci Z, Villa G, Kellum JA, Mehta R, Rosner MH. Standardization of Nomenclature for the Mechanisms and Materials Utilized for Extracorporeal Blood Purification. Blood Purif 2023; 53:329-342. [PMID: 37703868 DOI: 10.1159/000533330] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/28/2023] [Indexed: 09/15/2023]
Abstract
In order to develop a standardized nomenclature for the mechanisms and materials utilized during extracorporeal blood purification, a consensus expert conference was convened in November 2022. Standardized nomenclature serves as a common language for reporting research findings, new device development, and education. It is also critically important to support patient safety, allow comparisons between techniques, materials, and devices, and be essential for defining and naming innovative technologies and classifying devices for regulatory approval. The multidisciplinary conference developed detailed descriptions of the performance characteristics of devices (membranes, filters, and sorbents), solute and fluid transport mechanisms, flow parameters, and methods of treatment evaluation. In addition, nomenclature for adsorptive blood purification techniques was proposed. This report summarizes these activities and highlights the need for standardization of nomenclature in the future to harmonize research, education, and innovation in extracorporeal blood purification therapies.
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Affiliation(s)
- Thiago Reis
- Department of Nephrology and Kidney Transplantation, Fenix Group, São Paulo, Brazil
- Laboratory of Molecular Pharmacology, University of Brasília, Brasília, Brazil
- Division of Nephrology, Syrian-Lebanese Hospital, São Paulo, Brazil
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
- Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy
- Department of Medicine (DIMED), Università degli Studi di Padova, Padua, Italy
| | - Danielle E Soranno
- Section of Nephrology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - William Clark
- Davidson School of Chemical Engineering, Purdue University College of Engineering, West Lafayette, Indiana, USA
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Silvia De Rosa
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS, Trento, Italy
| | - Lui G Forni
- Department of Critical Care, Royal Surrey Hospital Foundation Trust, Guildford, UK
- Faculty of Health Sciences, University of Surrey, Guildford, UK
| | - Anna Lorenzin
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
- Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Zaccaria Ricci
- Department of Health Sciences, Section of Anesthesia, Intensive Care and Pain Medicine, University of Florence, Florence, Italy
- Pediatric Intensive Care Unit, Meyer Children's Hospital, IRCCS, Florence, Italy
| | - Gianluca Villa
- Department of Health Sciences, Section of Anesthesia, Intensive Care and Pain Medicine, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Section of Pain Therapy and Palliative Care, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ravindra Mehta
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Mitchell H Rosner
- Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
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11
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Nalesso F, Bettin E, Bogo M, Cacciapuoti M, Cattarin L, Scaparrotta G, Calò LA. Safety of Citrate Anticoagulation in CKRT: Monocentric Experience of a Dynamic Protocol of Calcium Monitoring. J Clin Med 2023; 12:5201. [PMID: 37629242 PMCID: PMC10455350 DOI: 10.3390/jcm12165201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/05/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Regional Citrate Anticoagulation (RCA) is considered the first-line anticoagulation for Continuous Kidney Replacement Therapy (CKRT). The RCA requires strict protocols and trained staff to avoid unsafe use and ensure its benefit. We have analyzed all our CKRT prescriptions from December 2020 to April 2022 anonymously, collecting data on CKRT, lab tests, clinical conditions, and complications of RCA. In addition, in order to better detect citrate accumulation, we have performed an RCA protocol by reducing the CaTot/Ca2+ ratio cut-off from 2.50 to 2.40 and increasing the number of calcium checks according to its trend. Among the 374 patients in CKRT, 104 received RCA prescriptions, of which 11 (10.6%) were discontinued: 4 for the suspicion of citrate accumulation, 1 for the development of metabolic alkalosis, 1 for the shift to a different CKRT procedure due to the need for a higher bicarbonate dose, 4 for the elevation of hepatocytolysis indexes, and 1 due to a preemptive discontinuation following massive post-surgery bleeding. None of the patients have had citrate toxicity as indicated by a CaTot/Ca2+ greater than 2.50, and our protocol has allowed the early identification of patients who might develop clinical citrate toxicity.
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Affiliation(s)
- Federico Nalesso
- Department of Medicine, Nephrology, Dialysis and Transplant, University of Padua, 35128 Padua, Italy (L.A.C.)
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12
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Zhai Y, Liu X, Li Y, Hu Q, Zhang Z, Hu T. Role of platelet to albumin ratio for predicting persistent acute kidney injury in patients admitted to the intensive care unit. BMC Anesthesiol 2023; 23:242. [PMID: 37468887 PMCID: PMC10354882 DOI: 10.1186/s12871-023-02137-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 05/12/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND The aim of this study was to investigate the prognostic role of platelet to albumin ratio (PAR) and in persistent acute kidney injury (pAKI) of patients admitted to the intensive care unit (ICU). METHODS We involved pAKI patients from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database and eICU Collaborative Research Database (eICU-CRD). Receiver operating curve (ROC) analysis was performed to evaluate the optimal cut-off PAR. RESULTS A total of 7,646 patients were finally included in the present study. The optimal cut-off value of PAR was 7.2. The high-PAR group was associated with pAKI (hazard ratio [HR]: 3.25, 95% CI: 2.85-3.72, P < 0.001). We also performed this in the validation cohort, the results further confirmed that the high-PAR group was associated with pAKI (HR: 2.24, 95% CI: 1.86-2.71, P < 0.001). The PAR exhibited good pAKI predictive abilities in the original cohort (C-index: 0.726, 95%CI: 0.714-0.739) and in the validation cohort (C-index: 0.744, 95%CI:0.722-0.766) Moreover, as a systemic inflammatory indicator, PAR depicted better predictive ability compared to other systemic inflammatory indicators. CONCLUSION The present study manifested that elevated PAR could predicts pAKI in patients admitted to ICU. PAR may be an easily obtained and useful biomarker to clinicians for the early identification of pAKI.
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Affiliation(s)
- Yuanwei Zhai
- Department of Medical Imaging, the First People's Hospital of Ziyang, Ziyang, Sichuan, China
| | - Xiaoqiang Liu
- Department of Orthopedic Surgery, Anyue County People's Hospital, Ziyang, Sichuan, China
| | - Yu Li
- Department of Nephrology, Bishan Hospital Affiliated to Chongqing Medical University, Chongqing, China
| | - Qionghua Hu
- Department of Critical Care Medicine, Chengdu Second People's Hospital, 10 Qingyunnan Street, Jinjiang District, Chengdu, 610017, Sichuan, China
| | - Zhengwei Zhang
- Department of Critical Care Medicine, Chengdu Second People's Hospital, 10 Qingyunnan Street, Jinjiang District, Chengdu, 610017, Sichuan, China.
| | - Tianyang Hu
- Precision Medicine Center, the Second Affiliated Hospital, Chongqing Medical University, 74 Linjiang Road, Yuzhong District, Chongqing, 400010, China.
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13
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Urbani A, Pensotti F, Provera A, Galassi A, Guazzi M, Castini D. Extracorporeal veno-venous ultrafiltration in congestive heart failure: What’s the state of the art? A mini-review. World J Cardiol 2023; 15:205-216. [PMID: 37274372 PMCID: PMC10237006 DOI: 10.4330/wjc.v15.i5.205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/19/2023] [Accepted: 04/24/2023] [Indexed: 05/19/2023] Open
Abstract
Hospitalizations for heart failure exceed 1 million per year in both the United States and Europe and more than 90% are due to symptoms and signs of fluid overload. Rates of rehospitalizations or emergency department visit at 60 days are remarkable regardless of whether loop diuretics were administered at low vs high doses or by bolus injection vs continuous infusion. Ultrafiltration (UF) has been considered a promising alternative to stepped diuretic therapy and it consists in the mechanical, adjustable removal of iso-tonic plasma water across a semipermeable membrane with the application of hydrostatic pressure gradient generated by a pump. Fluid removal with ultrafiltration presents several advantages such as elimination of higher amount of sodium with less neurohormonal activation. However, the conflicting results from UF studies highlight that patient selection and fluid removal targets are not completely understood. The best way to assess fluid status and therefore establish the fluid removal target is also still a matter of debate. Herein, we provide an up-to-date systematic review about the role of ultrafiltration among patients with fluid overload and its gaps in daily practice.
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Affiliation(s)
- Andrea Urbani
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Filippo Pensotti
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Andrea Provera
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Andrea Galassi
- Nephrology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Marco Guazzi
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Diego Castini
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
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14
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Baud FJ, Houzé P, Raphalen JH, Philippe P, Lamhaut L. Vancomycin Sequestration in ST Filters: An In Vitro Study. Antibiotics (Basel) 2023; 12:antibiotics12030620. [PMID: 36978488 PMCID: PMC10045619 DOI: 10.3390/antibiotics12030620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/05/2023] [Accepted: 03/14/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Sequestration of vancomycin in ST® filters used in continuous renal therapy is a pending question. Direct vancomycin-ST® interaction was assessed using the in vitro NeckEpur® technology. METHOD ST150® filter and Prismaflex dialyzer, Baxter-Gambro, were used. Two modes were assessed in duplicate: (i) continuous diafiltration (CDF): 4 L/h, (ii) continuous dialysis (CD): 2.5 L/h post-filtration. RESULTS The mean initial vancomycin concentration in the central compartment (CC) was 51.4 +/- 5.0 mg/L. The mean percentage eliminated from the CC over 6 h was 91 +/- 4%. The mean clearances from the CC by CDF and CD were 2.8 and 1.9 L/h, respectively. The mean clearances assessed using cumulative effluents were 4.4 and 2.2 L/h, respectively. The mean percentages of the initial dose eliminated in the effluents from the CC by CDF and CD were 114 and 108% with no detectable sequestration of vancomycin in both modes of elimination. DISCUSSION Significant sequestration adds a clearance to that provided by CDF and CD. The study provides multiple evidence from the CC, the filter, and the effluents of the lack of an increase in total clearance in comparison with the flow rates without significant sequestration in the ST® filter comparing cumulative effluents to the initial dose in the CC. CONCLUSIONS There is no evidence ST® filters directly sequestrate vancomycin.
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Affiliation(s)
- Frédéric J Baud
- Département d'Anesthésie et de Réanimation, Adult Intensive Care Unit, Necker Hospital, 75015 Paris, France
- EA7323, Université de Paris, 75006 Paris, France
| | - Pascal Houzé
- CNRS UMR 8258-U1022, Laboratoire de Biochimie, Necker Hospital, 75015 Paris, France
| | - Jean-Herlé Raphalen
- Département d'Anesthésie et de Réanimation, Adult Intensive Care Unit, Necker Hospital, 75015 Paris, France
| | - Pascal Philippe
- Département d'Anesthésie et de Réanimation, Adult Intensive Care Unit, Necker Hospital, 75015 Paris, France
| | - Lionel Lamhaut
- Département d'Anesthésie et de Réanimation, Adult Intensive Care Unit, Necker Hospital, 75015 Paris, France
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15
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Cutuli SL, Cascarano L, Lazzaro P, Tanzarella ES, Pintaudi G, Grieco DL, De Pascale G, Antonelli M. Antimicrobial Exposure in Critically Ill Patients with Sepsis-Associated Multi-Organ Dysfunction Requiring Extracorporeal Organ Support: A Narrative Review. Microorganisms 2023; 11:microorganisms11020473. [PMID: 36838438 PMCID: PMC9965524 DOI: 10.3390/microorganisms11020473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/06/2023] [Accepted: 02/12/2023] [Indexed: 02/16/2023] Open
Abstract
Sepsis is a leading cause of disability and mortality worldwide. The pathophysiology of sepsis relies on the maladaptive host response to pathogens that fosters unbalanced organ crosstalk and induces multi-organ dysfunction, whose severity was directly associated with mortality. In septic patients, etiologic interventions aiming to reduce the pathogen load via appropriate antimicrobial therapy and the effective control of the source infection were demonstrated to improve clinical outcomes. Nonetheless, extracorporeal organ support represents a complementary intervention that may play a role in mitigating life-threatening complications caused by sepsis-associated multi-organ dysfunction. In this setting, an increasing amount of research raised concerns about the risk of suboptimal antimicrobial exposure in critically ill patients with sepsis, which may be worsened by the concomitant delivery of extracorporeal organ support. Accordingly, several strategies have been implemented to overcome this issue. In this narrative review, we discussed the pharmacokinetic features of antimicrobials and mechanisms that may favor drug removal during renal replacement therapy, coupled plasma filtration and absorption, therapeutic plasma exchange, hemoperfusion, extracorporeal CO2 removal and extracorporeal membrane oxygenation. We also provided an overview of evidence-based strategies that may help the physician to safely prescribe effective antimicrobial doses in critically ill patients with sepsis-associated multi-organ dysfunction who receive extracorporeal organ support.
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Affiliation(s)
- Salvatore Lucio Cutuli
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base Cliniche Intensivologiche e Perioperatorie, Universita’ Cattolica del Sacro Cuore, Rome, L.go F. Vito 1, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-063-015-4490
| | - Laura Cascarano
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base Cliniche Intensivologiche e Perioperatorie, Universita’ Cattolica del Sacro Cuore, Rome, L.go F. Vito 1, 00168 Rome, Italy
| | - Paolo Lazzaro
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base Cliniche Intensivologiche e Perioperatorie, Universita’ Cattolica del Sacro Cuore, Rome, L.go F. Vito 1, 00168 Rome, Italy
| | - Eloisa Sofia Tanzarella
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base Cliniche Intensivologiche e Perioperatorie, Universita’ Cattolica del Sacro Cuore, Rome, L.go F. Vito 1, 00168 Rome, Italy
| | - Gabriele Pintaudi
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base Cliniche Intensivologiche e Perioperatorie, Universita’ Cattolica del Sacro Cuore, Rome, L.go F. Vito 1, 00168 Rome, Italy
| | - Domenico Luca Grieco
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base Cliniche Intensivologiche e Perioperatorie, Universita’ Cattolica del Sacro Cuore, Rome, L.go F. Vito 1, 00168 Rome, Italy
| | - Gennaro De Pascale
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base Cliniche Intensivologiche e Perioperatorie, Universita’ Cattolica del Sacro Cuore, Rome, L.go F. Vito 1, 00168 Rome, Italy
| | - Massimo Antonelli
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base Cliniche Intensivologiche e Perioperatorie, Universita’ Cattolica del Sacro Cuore, Rome, L.go F. Vito 1, 00168 Rome, Italy
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16
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Yoo BM, Hong SY, Hong SK, Ahn YH, Kang HG, Lee S, Suh S, Han ES, Lee JM, Choi Y, Lee KW, Suh KS, Yi NJ. Posttransplant renal replacement therapy is an alarm signal for survival outcomes in pediatric liver transplantation. Pediatr Transplant 2023; 27:e14422. [PMID: 36325595 DOI: 10.1111/petr.14422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 08/28/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The impact of renal replacement therapy (RRT) on the long-term survival outcomes of pediatric liver recipients remains controversial. METHODS A total of 224 patients aged <18 years, who underwent liver transplantation (LT), were divided into two groups: patients who underwent renal replacement therapy (RRT) (group R, n = 25, 11.2%) and those who did not (group N, n = 199, 88.8%). The posttransplant patient survival outcomes according to RRT use constituted the primary end-point. RRT was initiated preoperatively in 12 patients (48.0%) and postoperatively in 13 [early: <6 months after LT (n = 5, 20.0%) and late: ≥6 months after LT (n = 8, 32.0%)]. The indications for RRT included liver disease involving the kidney (44.0%) and hepatorenal syndrome (56.0%). RESULTS The age at the time of LT (71.6 vs. 19.1 months) was higher, the pediatric end-stage liver disease score was lower (9.9 vs. 21.2), and the duration of hospitalization posttransplantation (41.0 vs. 27.0 days) was longer, while the rates of hepatic artery thrombosis (8.0% vs. 3.5%) were higher in group R (p < .05). The number of patients (60.0% vs. 93.0%; p < .001) and graft survival rates (68.0% vs. 93.0%; p < .001) were significantly lower in group R. Multivariate analysis revealed that posttransplant RRT and hepatic artery complications were risk factors for patient survival outcomes. Renal function was recovered in 7 patients (28.0%) in group R, and 9 (36.0%) eventually underwent kidney transplantation. CONCLUSION The survival outcomes of children requiring posttransplant RRT were significantly worse than those of children, who did not undergo RRT. Physicians should pay meticulous attention to patients requiring post-LT RRT.
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Affiliation(s)
- Byung Min Yoo
- Seoul National University College of Medicine, Seoul, South Korea
| | - Su Young Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Yo Han Ahn
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Sola Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Sanggyun Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Eui Soo Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Jeong-Moo Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
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17
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A novel pump-free ultrafiltration rate modulation system for continuous renal replacement therapy applications. HEALTH AND TECHNOLOGY 2023. [DOI: 10.1007/s12553-022-00717-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Abstract
Purpose
Extracorporeal ultrafiltration is an attractive alternative to diuretics for removing excess plasma water in critically ill patients suffering from fluid overload. In continuous renal replacement therapy (CRRT), ultrafiltration occurs in isolated form (SCUF) or supplemented by replacement fluid infusion (CVVH) and the net fluid removal rate is controlled by peristaltic pumps. In this work, a pump-free solution for regulating the ultrafiltration rate in CRRT applications is presented.
Methods
The system consists of a motorized clamp on the ultrafiltration line, whose intermittent opening is modulated with a closed-loop control system based on monitoring of ultrafiltrate collected and any replacement fluid infused. The system was tested on two platforms for SCUF and CVVH, with “low-flux” and “high-flux” hemofilter, with various ultrafiltration setpoints and patient net weight loss targets.
Results
In all configurations the set ultrafiltration rate was achieved with a maximum error of 5% and the values recorded were kept within ± 100 ml/h with respect to the setpoint, as recommended by international standard IEC 60601-2-16. The net fluid removal trend was highly correlated with that expected (95%<R2<99%) and the weight loss target was reached in the expected time. For low ultrafiltration rates (60-150 ml/h) the system accuracy was better with the “low-flux” hemofilter.
Conclusion
The developed clamp system represents a valid alternative to state-of-the-art solutions with peristaltic pumps in terms of performance, with potential usability advantages. The compliance with safety requirements given by international standard IEC 60601-2-16 is a prerequisite for clinical use.
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18
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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.
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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
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19
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Zhou Z, Kuang H, Wang F, Liu L, Zhang L, Fu P. High cut-off membranes in patients requiring renal replacement therapy: a systematic review and meta-analysis. Chin Med J (Engl) 2023; 136:34-44. [PMID: 36848147 PMCID: PMC10106154 DOI: 10.1097/cm9.0000000000002150] [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: 01/12/2022] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Whether high cut-off (HCO) membranes are more effective than high-flux (HF) membranes in patients requiring renal replacement therapy (RRT) remains controversial. The aim of this systematic review was to investigate the efficacy of HCO membranes regarding the clearance of inflammation-related mediators, β2-microglobulin and urea; albumin loss; and all-cause mortality in patients requiring RRT. METHODS We searched all relevant studies on PubMed, Embase, Web of Science, the Cochrane Library, and China National Knowledge Infrastructure, with no language or publication year restrictions. Two reviewers independently selected studies and extracted data using a prespecified extraction instrument. Only randomized controlled trials (RCTs) were included. Summary estimates of standardized mean differences (SMDs) or weighted mean differences (WMDs) and risk ratios (RRs) were obtained by fixed-effects or random-effects models. Sensitivity analyses and subgroup analyses were performed to determine the source of heterogeneity. RESULTS Nineteen RCTs involving 710 participants were included in this systematic review. Compared with HF membranes, HCO membranes were more effective in reducing the plasma level of interleukin-6 (IL-6) (SMD -0.25, 95% confidence interval (CI) -0.48 to -0.01, P = 0.04, I2 = 63.8%); however, no difference was observed in the clearance of tumor necrosis factor-α (TNF-α) (SMD 0.03, 95% CI -0.27 to 0.33, P = 0.84, I2 = 4.3%), IL-10 (SMD 0.22, 95% CI -0.12 to 0.55, P = 0.21, I2 = 0.0%), or urea (WMD -0.27, 95% CI -2.77 to 2.23, P = 0.83, I2 = 19.6%). In addition, a more significant reduction ratio of β 2 -microglobulin (WMD 14.8, 95% CI 3.78 to 25.82, P = 0.01, I2 = 88.3%) and a more obvious loss of albumin (WMD -0.25, 95% CI -0.35 to -0.16, P < 0.01, I2 = 40.8%) could be observed with the treatment of HCO membranes. For all-cause mortality, there was no difference between the two groups (risk ratio [RR] 1.10, 95% CI 0.87 to 1.40, P = 0.43, I2 = 0.0%). CONCLUSIONS Compared with HF membranes, HCO membranes might have additional benefits on the clearance of IL-6 and β 2-microglobulin but not on TNF-α, IL-10, and urea. Albumin loss is more serious with the treatment of HCO membranes. There was no difference in all-cause mortality between HCO and HF membranes. Further larger high-quality RCTs are needed to strengthen the effects of HCO membranes.
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Affiliation(s)
- Zhifeng Zhou
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Huang Kuang
- Division of Nephrology, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, China
| | - Fang Wang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Lu Liu
- Preventive Medicine, West China School of Public Health, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ling Zhang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Ping Fu
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
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Xie J, Ma X, Zheng Y, Mao N, Ren S, Fan J. Panax notoginseng saponins alleviate damage to the intestinal barrier and regulate levels of intestinal microbes in a rat model of chronic kidney disease. Ren Fail 2022; 44:1948-1960. [PMID: 36354128 PMCID: PMC9662016 DOI: 10.1080/0886022x.2022.2143378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objectives Chronic kidney disease (CKD) is a long-term condition characterized by poor prognosis and a high mortality rate. Panax notoginseng saponins (PNS) are the main active ingredient of the traditional Chinese herb Panaxnotoginseng(Burk.)F.H.Chen, which has been widely reported to have various pharmacological effects. Here, we examined the effect of PNS on renal function and the modulation of intestinal flora and intestinal barrier in a rat model of adenine-induced CKD. Methods Adenine was used to establish a rat model of CKD, biochemical testing, histopathologic examination, ELISA, immunohistochemical assay, western blot assay, and fecal microbiota 16s rRNA analysis was used to test the effect of PNS on CKD rats. Results Adenine induced a significant decrease in glomerular filtration rate, an increase in urinary protein excretion rate, and pathological damage to renal tissue in CKD rats. TNF-α, MCP-1, IL-1β, IL-18, TMAO, and endotoxin levels were increased in the blood of the model rats. Application of PNS countered the effects of adenine, restoring the above parameters to the level observed in healthy rats. In addition, activation of the inflammatory proteins NF-κB (p65) and NLRP3 and the fibrosis-associated proteins α-SMA and smad3 were inhibited in the kidneys of CKD rats. Furthermore, PNS promoted the expression of the tight junction proteins Occludin and ZO-1, increased SIgA levels, strengthened intestinal immunity, reduced mechanical damage to the intestine, was reduced levels of DAO and D-LA. Our data suggest PNS may delay CKD by restoring gut microbiota, and through the subsequent generation of a microbial barrier and modulation of microbiota metabolites. Conclusions In conclusion, PNS may inhibit the development of inflammation and fibrosis in the kidney tissue through regulation of intestinal microorganisms and inhibition of the activation of pro-inflammatory and pro-fibrotic proteins in the kidney.
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Affiliation(s)
- Jing Xie
- Clinical Medical College of Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
- Department of Nephrology No.1, the Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
| | - Xin Ma
- Department of Nephrology, the First Affiliated Hospital of Chengdu Medical College, Chengdu, PR China
| | - Yixuan Zheng
- Clinical Medical College of Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
- Department of Nephrology No.1, the Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
| | - Nan Mao
- Department of Nephrology, the First Affiliated Hospital of Chengdu Medical College, Chengdu, PR China
| | - Sichong Ren
- Department of Nephrology, the First Affiliated Hospital of Chengdu Medical College, Chengdu, PR China
- Clinical Medical College of Chengdu Medical College, Chengdu, PR China
| | - Junming Fan
- Department of Nephrology, the First Affiliated Hospital of Chengdu Medical College, Chengdu, PR China
- Clinical Medical College of Chengdu Medical College, Chengdu, PR China
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21
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Wei Z, Peng G, Zhao Y, Chen S, Wang R, Mao H, Xie Y, Zhao C. Engineering Antioxidative Cascade Metal-Phenolic Nanozymes for Alleviating Oxidative Stress during Extracorporeal Blood Purification. ACS NANO 2022; 16:18329-18343. [PMID: 36356207 DOI: 10.1021/acsnano.2c06186] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Oxidative stress is a compelling risk factor in chronic kidney diseases and is further aggravated for individuals during extracorporeal blood purification, ultimately leading to multiple complications. Herein, antioxidative cascade metal-phenolic nanozymes (metal-tannic acid nanozymes, M-TA NMs) are synthesized via metal ions-mediated oxidative coupling of polyphenols; then M-TA NMs engineered hemoperfusion microspheres (Cu-TAn@PMS) are constructed for alleviating oxidative stress. M-TA NMs show adjustable broad-spectrum antioxidative activities toward multiple reactive nitrogen and oxygen species (RNOS) due to the adjustable catalytic active centers. Importantly, M-TA NMs could mimic the cascade processes of superoxide dismutase and catalase to maintain intracellular redox balance. Detailed structural and spectral analyses reveal that the existence of a transition metal could decrease the electronic energy band gaps of M-TA NMs to offer better electron transfers for RNOS scavenging. Notably, dynamic blood experiments demonstrate that Cu-TAn@PMS could serve as an antioxidant defense system for blood in hemoperfusion to scavenge intracellular reactive oxygen species (ROS) effectively even in the complex blood environment and further protect endogenous antioxidative enzymes and molecules. In general, this work developed antioxidative cascade nanozymes engineered microspheres with excellent therapeutic efficacy for the treatment of oxidative stress-related diseases, which exhibited potential for clinical blood purification and extended the biomedical applications of nanozymes.
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Affiliation(s)
| | | | | | | | - Rui Wang
- State Key Laboratory of Solid Lubrication, Lanzhou Institute of Chemical Physics, Chinese Academy of Sciences, Lanzhou 730000, China
- Shandong Laboratory of Yantai Advanced Materials and Green Manufacturing, Yantai 264000, China
| | | | - Yi Xie
- Shandong Laboratory of Yantai Advanced Materials and Green Manufacturing, Yantai 264000, China
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22
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Chen H, Klainbart S, Kelmer E, Segev G. Continuous renal replacement therapy is a safe and effective modality for the initial management of dogs with acute kidney injury. J Am Vet Med Assoc 2022; 261:87-96. [PMID: 36288204 DOI: 10.2460/javma.22.07.0294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe the management of dogs with acute kidney injury (AKI) by continuous renal replacement therapy (CRRT), and to investigate the relationship between a prescribed CRRT dose, the hourly urea reduction ratio (URR), and the overall efficacy. ANIMALS 45 client-owned dogs diagnosed with severe AKI, receiving 48 CRRT treatments at a veterinary teaching hospital. PROCEDURES Retrospective study. Search of medical records of dogs with AKI managed by CRRT. RESULTS Median serum urea and creatinine at CRRT initiation were 252 mg/dL [Inter quartile range (IQR), 148 mg/dL; range, 64 to 603 mg/dL] and 9.0 mg/dL (IQR, 7 mg/dL; range, 4.3 to 42.2 mg/dL), respectively. Median treatment duration was 21 hours (IQR, 8.8 hours; range, 3 to 32 hours). Systemic heparinization and regional citrate anticoagulation were used in 24 treatments each (50%). The prescribed median CRRT dose for the entire treatment was 1 mL/kg/min (IQR, 0.4 mL/kg/min; range, 0.3 to 2.5 mL/kg/min). The median hourly URR was 4% (IQR, 1%; range, 2% to 12%), overall URR was 76% (IQR, 30%; range, 11% to 92%) and median Kt/V was 2.34 (IQR, 1.9; range, 0.24 to 7.02). The CRRT dose was increased gradually from 0.9 mL/kg/min to 1.4 mL/kg/min (P < .001) and the hourly URR decreased from 6.5% to 5.5% (P = .05). The main complication was clotting of the extra-corporeal circuit, occurring in 6/48 treatments (13%). Twenty-four dogs (53%) survived to discharge. CLINICAL RELEVANCE CRRT is safe when the prescription is based on the current veterinary guidelines for gradual urea reduction. Treatment efficacy can be maximized by gradually increasing the dose according to the actual URR.
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Affiliation(s)
- Hilla Chen
- Veterinary Teaching Hospital, Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Sigal Klainbart
- Veterinary Teaching Hospital, Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Efrat Kelmer
- Veterinary Teaching Hospital, Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Gilad Segev
- Veterinary Teaching Hospital, Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
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23
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Liu Y, Han Q, Li G, Lin H, Liu F, Li Q, Deng G. Anticoagulation polyvinyl chloride extracorporeal circulation catheters for heparin-free treatment. J Mater Chem B 2022; 10:8302-8314. [PMID: 36165336 DOI: 10.1039/d2tb01584f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Extracorporeal circulation (ECC) catheters have potential to be blood compatible and could be used to prevent thrombotic occlusion. Here, we produced heparin-mimicking anticoagulation PVC tubing on a large scale by synthesizing a heparin-mimicking polymer (HMP) and co-extruding. The PVC@HMP catheter was evaluated using whole human blood in vitro, which indicated it could prevent plasma protein attachment, reduce platelet adhesion and activation, and inhibit coagulation factors (XII, XI, IX, and VIII). Moreover, the anticoagulation PVC tubing was assembled into extracorporeal circulation with a New Zealand rabbit model, manifesting excellent real-time antithrombogenic properties without systemic heparin anticoagulation in vivo. The rapid recovery of coagulation factors after operation further confirmed its superiority over heparin, which would not completely inactivate the activity of those coagulation factors (XII, XI, IX and VIII). In addition, the PVC@HMP-1 catheters remain patent after being implanted in rats for 28 days without apparent inflammation and mortality complications. The anticoagulation PVC tubes could be used to construct various systemic and integrative anticlotting biomedical devices, which would dramatically reduce the introduction of heparin into blood circulation, thus preventing side effects and promoting the development of heparin-free treatment.
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Affiliation(s)
- Yang Liu
- Key Laboratory of Bio-based Polymeric Materials Technology and Application of Zhejiang Province, Ningbo Institute of Materials Technology & Engineering, Chinese Academy of Sciences, No. 1219 Zhongguan West Rd, Ningbo 315201, P. R. China. .,University of Chinese Academy of Sciences, 19 A Yuquan Rd, Shijingshan District, Beijing 100049, P. R. China
| | - Qiu Han
- Key Laboratory of Bio-based Polymeric Materials Technology and Application of Zhejiang Province, Ningbo Institute of Materials Technology & Engineering, Chinese Academy of Sciences, No. 1219 Zhongguan West Rd, Ningbo 315201, P. R. China.
| | - Guiliang Li
- Key Laboratory of Bio-based Polymeric Materials Technology and Application of Zhejiang Province, Ningbo Institute of Materials Technology & Engineering, Chinese Academy of Sciences, No. 1219 Zhongguan West Rd, Ningbo 315201, P. R. China. .,University of Chinese Academy of Sciences, 19 A Yuquan Rd, Shijingshan District, Beijing 100049, P. R. China
| | - Haibo Lin
- Key Laboratory of Bio-based Polymeric Materials Technology and Application of Zhejiang Province, Ningbo Institute of Materials Technology & Engineering, Chinese Academy of Sciences, No. 1219 Zhongguan West Rd, Ningbo 315201, P. R. China.
| | - Fu Liu
- Key Laboratory of Bio-based Polymeric Materials Technology and Application of Zhejiang Province, Ningbo Institute of Materials Technology & Engineering, Chinese Academy of Sciences, No. 1219 Zhongguan West Rd, Ningbo 315201, P. R. China. .,University of Chinese Academy of Sciences, 19 A Yuquan Rd, Shijingshan District, Beijing 100049, P. R. China
| | - Qiang Li
- Department of Laboratory Medicine, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, 310006, P. R. China
| | - Gang Deng
- The Ningbo Central Blood Station, Ningbo, 315201, P. R. China
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24
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Advances in Apheresis Techniques and Therapies in the Pediatric Setting. CURRENT PEDIATRICS REPORTS 2022. [DOI: 10.1007/s40124-022-00275-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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25
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Sansom B, Tonkin-Hill G, Kalfas S, Park S, Presneill J, Bellomo R. The relationship between commencement of continuous renal replacement therapy and urine output, fluid balance, mean arterial pressure and vasopressor dose. CRIT CARE RESUSC 2022; 24:259-267. [PMID: 38046211 PMCID: PMC10692613 DOI: 10.51893/2022.3.oa5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Background and objectives: The effect of initiating continuous renal replacement therapy (CRRT) on urine output, fluid balance and mean arterial pressure (MAP) in adult intensive care unit (ICU) patients is unclear. We aimed to evaluate the impact of CRRT on urine output, MAP, vasopressor requirements and fluid balance, and to identify factors affecting urine output during CRRT. Design: Retrospective cohort study using data from existing databases and CRRT machines. Setting: Medical and surgical ICUs at a single university-associated centre. Participants: Patients undergoing CRRT between 2015 and 2018. Main outcome measures: Hourly urine output, fluid balance, MAP and vasopressor dose 24 hours before and after CRRT commencement. Missing values were estimated via Kaplan smoothing univariate time-series imputation. Mixed linear modelling was performed with noradrenaline equivalent dose and urine output as outcomes. Results: In 215 patients, CRRT initiation was associated with a reduction in urine output. Multivariate analysis confirmed an immediate urine output decrease (-0.092 mL/kg/h; 95% confidence interval [CI], -0.150 to -0.034 mL/kg/h) and subsequent progressive urine output decline (effect estimate, -0.01 mL/kg/h; 95% CI, -0.02 to -0.01 mL/kg/h). Age and greater vasopressor dose were associated with lower post-CRRT urine output. Higher MAP and lower rates of net ultrafiltration were associated with higher post-CRRT urine output. With MAP unchanged, vasopressor dose increased in the 24 hours before CRRT, then plateaued and declined in the 24 hours thereafter (effect estimate, -0.004 μg/kg/ min per hour; 95% CI, -0.005 to -0.004 μg/kg/min per hour). Fluid balance remained positive but declined towards neutrality following CRRT implementation. Conclusions: CRRT was associated with decreased urine output despite a gradual decline in vasopressor and a positive fluid balance. The mechanisms behind the reduction in urine output associated with commencement of CRRT requires further investigation.
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Affiliation(s)
- Benjamin Sansom
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Gina Tonkin-Hill
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Stefanie Kalfas
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Seunga Park
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jeffrey Presneill
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
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26
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Nalesso F, Garzotto F, Martello T, Contessa C, Cattarin L, Protti M, Di Vico V, Stefanelli LF, Scaparrotta G, Calò LA. The patient safety in extracorporeal blood purification treatments of critical patients. FRONTIERS IN NEPHROLOGY 2022; 2:871480. [PMID: 37675020 PMCID: PMC10479693 DOI: 10.3389/fneph.2022.871480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/27/2022] [Indexed: 09/08/2023]
Abstract
Today, health systems are complex due to both the technological development in diagnostic and therapeutic procedures and the complexity of the patients that are increasingly older with several comorbidities. In any care setting, latent, organizational, and systematic errors can occur causing critical incident harmful for patients. Management of patients with acute kidney injury (AKI) requires a multidisciplinary approach for the diagnostic-therapeutic-rehabilitative path that can also require an extracorporeal blood purification treatment (EBPT). The complexity of these patients and EBPT require a clinical risk analysis and the introduction of protocols, procedures, operating instructions, and checklists to reduce clinical risk through promotion of the safety culture for all care providers. Caregivers must acquire a series of tools to evaluate the clinical risk in their reality to prevent incidents and customize patient safety in a proactive and reactive way. Established procedures that are made more needed by the COVID-19 pandemic can help to better manage patients in critical care area with intrinsic higher clinical risk. This review analyzes the communication and organizational aspects that need to be taken into consideration in the management of EBPT in a critical care setting by providing tools that can be used to reduce the clinical risk. This review is mostly addressed to all the caregivers involved in the EBPT in Critical Care Nephrology and in the Intensive Care Units.
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Affiliation(s)
- Federico Nalesso
- Nephrology, Dialysis and Transplant Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Francesco Garzotto
- Department of Cardiac Thoracic Vascular Sciences and Public Health, Unit of Biostatistics, Epidemiology and Public Health, University of Padova, Padova, Italy
| | - Tiziano Martello
- Department of Directional Hospital Management, Medical Directorate, Padua University Hospital, Padua, Italy
| | - Cristina Contessa
- Department of Directional Hospital Management, Medical Directorate, Padua University Hospital, Padua, Italy
| | - Leda Cattarin
- Nephrology, Dialysis and Transplant Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Mariapaola Protti
- Nephrology, Dialysis and Transplant Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Valentina Di Vico
- Nephrology, Dialysis and Transplant Unit, Department of Medicine, University of Padua, Padua, Italy
| | | | - Giuseppe Scaparrotta
- Nephrology, Dialysis and Transplant Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Lorenzo A. Calò
- Nephrology, Dialysis and Transplant Unit, Department of Medicine, University of Padua, Padua, Italy
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Reis T, Colares VS, Rocha E, Younes-Ibrahim M, Lima EQD, Andrade LDC, Ponce D, Suassuna JHR, Yu L. Acute kidney injury and renal replacement therapy: terminology standardization. J Bras Nefrol 2022; 44:434-442. [PMID: 35579341 PMCID: PMC9518623 DOI: 10.1590/2175-8239-jbn-2021-0284en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/09/2022] [Indexed: 11/22/2022] Open
Abstract
The Department of Acute Kidney Injury (IRA) of the Brazilian Society of Nephrology prepared this document for the purpose of standardizing AKI terminology and dialysis modalities in the Portuguese language for Brazil. Several terms with similar meanings have been used in AKI and its dialysis modalities, causing confusion and disparities among patients, nephrologists, health institutions, private care companies, insurance companies and government entities. These disparities can impact medical care, hospital organization and care, as well as the funding and reimbursement of AKI-related procedures. Thus, consensual nomenclature and definitions were developed, including the definitions of AKI, acute kidney disease (AKD) and chronic kidney disease (CKD). Additionally, we addressed all dialysis modalities and extracorporeal procedures related to AKI, currently approved and available in the country. The Brazilian Society of Nephrology hopes that this Consensus can standardize the terminology and provide technical support to all involved in AKI care in Brazil.
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Affiliation(s)
- Thiago Reis
- Universidade de Brasília, Laboratório de Farmacologia Molecular, Brasília, DF, Brasil.,Hospital DF Star, Clínica de Doenças Renais de Brasília, Brasília, DF, Brasil
| | | | - Eduardo Rocha
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Mauricio Younes-Ibrahim
- Universidade do Estado do Rio de Janeiro, Faculdade de Ciências Médicas, Rio de Janeiro, RJ, Brasil
| | | | | | - Daniela Ponce
- Universidade Estadual de São Paulo, Departamento de Clínica Médica, São Paulo, SP, Brasil
| | - José H Rocco Suassuna
- Universidade do Estado do Rio de Janeiro, Faculdade de Ciências Médicas, Rio de Janeiro, RJ, Brasil
| | - Luis Yu
- Universidade de São Paulo, Faculdade de Medicina, São Paulo, SP
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28
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Reis T, Colares VS, Rocha E, Younes-Ibrahim M, Lima EQD, Andrade LDC, Ponce D, Suassuna JHR, Yu L. Injúria renal aguda e métodos de suporte: padronização da nomenclatura. J Bras Nefrol 2022. [DOI: 10.1590/2175-8239-jbn-2021-0284pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Resumo O Departamento de Injúria Renal Aguda (IRA) da Sociedade Brasileira de Nefrologia elaborou o presente documento para fins de padronização da terminologia em IRA e modalidades dialíticas na língua portuguesa para o Brasil. Diversos termos com significados semelhantes têm sido empregados em IRA e suas modalidades dialíticas, causando confusão e disparidades entre pacientes, nefrologistas, instituições de saúde, empresas privadas de assistência, seguradoras e entidades governamentais. Essas disparidades podem impactar a assistência médica, a organização e o atendimento hospitalares, assim como o financiamento e reembolso dos procedimentos relacionados com a IRA. Assim, nomenclatura e definições consensuais foram elaboradas, incluindo-se as definições de IRA, doença renal aguda (DRA) e doença renal crônica (DRC). Adicionalmente, todas as modalidades dialíticas e os procedimentos extracorpóreos relacionados a IRA, atualmente aprovados e disponíveis no país, foram abordados. A Sociedade Brasileira de Nefrologia espera que este Consenso possa padronizar a nomenclatura e prover suporte técnico para todos os atores envolvidos na assistência à IRA no Brasil.
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Affiliation(s)
- Thiago Reis
- Universidade de Brasília, Brasil; Hospital DF Star, Brasil
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Zhai X, Lou H, Hu J. Five-gene signature predicts acute kidney injury in early kidney transplant patients. Aging (Albany NY) 2022; 14:2628-2644. [PMID: 35320116 PMCID: PMC9004575 DOI: 10.18632/aging.203962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 09/18/2021] [Indexed: 12/04/2022]
Abstract
Patients with acute kidney injury (AKI) show high morbidity and mortality, and a lack of effective biomarkers increases difficulty in its early detection. Weighted gene co-expression network analysis (WGCNA) detected a total of 22 gene modules and 6 miRNA modules, of which 4 gene modules and 3 miRNA modules were phenotypically co-related. Functional analysis revealed that these modules were related to different molecular pathways, which mainly involved PI3K-Akt signaling pathway and ECM-receptor interaction. The brown modules related to transplantation mainly involved immune-related pathways. Finally, five genes with the highest AUC were used to establish a diagnosis and prediction model of AKI. The model showed a high area under curve (AUC) in the training set and validation set, and their prediction accuracy for AKI was as high as 100%. Similarly, the prediction accuracy of AKI after 24 h in the 0 h transplant sample was 100%. This study may provide new features for the diagnosis and prediction of AKI after kidney transplantation, and facilitate the diagnosis and drug development of AKI in kidney transplant patients.
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Affiliation(s)
- Xia Zhai
- Medical Molecular Biology Laboratory, School of Medicine, Jinhua Polytechnic, Jinhua 321000, China
| | - Hongqiang Lou
- Medical Molecular Biology Laboratory, School of Medicine, Jinhua Polytechnic, Jinhua 321000, China
| | - Jing Hu
- Medical Molecular Biology Laboratory, School of Medicine, Jinhua Polytechnic, Jinhua 321000, China
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30
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Bowry SK, Kircelli F, Misra M. Flummoxed by flux: the indeterminate principles of haemodialysis. Clin Kidney J 2022; 14:i32-i44. [PMID: 34987784 PMCID: PMC8711754 DOI: 10.1093/ckj/sfab182] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Indexed: 11/22/2022] Open
Abstract
In haemodialysis (HD), unwanted substances (uraemic retention solutes or ‘uraemic toxins’) that accumulate in uraemia are removed from blood by transport across the semipermeable membrane. Like all membrane separation processes, the transport requires driving forces to facilitate the transfer of molecules across the membrane. The magnitude of the transport is quantified by the phenomenon of ‘flux’, a finite parameter defined as the volume of fluid (or permeate) transferred per unit area of membrane surface per unit time. In HD, as transmembrane pressure is applied to facilitate fluid flow or flux across the membrane to enhance solute removal, flux is defined by the ultrafiltration coefficient (KUF; mL/h/mmHg) reflecting the hydraulic permeability of the membrane. However, in HD, the designation of flux has come to be used in a much broader sense and the term is commonly used interchangeably and erroneously with other measures of membrane separation processes, resulting in considerable confusion. Increased flux is perceived to reflect more ‘porous’ membranes having ‘larger’ pores, even though other membrane and therapy attributes determine the magnitude of flux achieved during HD. Adjectival designations of flux (low-, mid-, high-, super-, ultra-) have found indiscriminate usage in the scientific literature to qualify a parameter that influences clinical decision making and prescription of therapy modalities (low-flux or high-flux HD). Over the years the concept and definition of flux has undergone arbitrary and periodic adjustment and redefinition by authors in publications, regulatory bodies (US Food and Drug Administration) and professional association guidelines (European Renal Association, Kidney Disease Outcomes Quality Initiative), with little consensus. Industry has stretched the boundaries of flux to derive marketing advantages, justify increased reimbursement or contrive new classes of therapy modalities when in fact flux is just one of several specifications that determine membrane or dialyser performance. Membranes considered as high-flux previously are today at the lower end of the flux spectrum. Further, additional parameters unrelated to the rate of diffusive or convective transport (flux) are used in conjunction with or in place of KUF to allude to flux: clearance (mL/min, e.g. of β2-microglobulin) or sieving coefficients (dimensionless). Considering that clinical trials in nephrology, designed to make therapy recommendations and guide policy with economic repercussions, are based on the parameter flux they merit clarification—by regulatory authorities and scientists alike—to avoid further misappropriation.
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Affiliation(s)
- Sudhir K Bowry
- Dialysis-at-Crossroads (D@X) Advisory, Bad Nauheim, Germany
| | - Fatih Kircelli
- Global Medical Information and Education, Fresenius Medical Care, Bad Homburg, Germany
| | - Madhukar Misra
- Department of Medicine, Division of Nephrology, University of Missouri, Columbia, MO, USA
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Raina R, Sethi S, Khooblall A, Kher V, Deshpande S, Yerigeri K, Pandya A, Nair N, Datla N, McCulloch M, Bunchman T, Davenport A. Non-anticoagulation pediatric continuous renal replacement therapy methods to increase circuit life. Hemodial Int 2022; 26:147-159. [PMID: 34989465 DOI: 10.1111/hdi.13003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Acute kidney injury (AKI) is a clinical condition characterized by an abrupt increase in serum creatinine levels due to functional changes in the kidneys from a newfound insult or injury. For supportive treatment, continuous renal replacement therapy (CRRT) is one of the most widely used modalities due to its precise control of fluid balance over extended periods of time. However, its complications include circuit clotting, the most frequent cause for CRRT interruption. Vascular access and circuit management were found to be major determinants of performance efficiency. Anticoagulation required to prevent clotting has the downside of increasing the risk of bleeding, especially in the setting of overdosage. Hence, a delicate balance needs to be maintained consistently. METHODS This study explores the adequacy of non-anticoagulation measures in the prevention of circuit clotting. A comprehensive literature search was conducted using PubMed/Medline and Embase databases to include all relevant studies. FINDINGS The most-effective CRRT catheter would be made of nonthrombogenic material, noncuffed and nontunneled with separate lumens for arterial and venous blood. Further, studies show that blood flow during the process is optimized at 200 ml/min, which can be lowered in the pediatric population due to more narrow catheters. Platelet count and hematocrit need to be closely monitored as levels above 450,000 × 106 /L and 0.40, respectively, increase risk of clotting. Predilution is a non-anticoagulation technique to reduce the risk of clotting by returning replacement solution to the blood before it reaches the filter. Also, biocompatible membranes such as polyacrylonitrile or polysulfone activate the coagulation cascade significantly less than the conventional cellulose-based membranes, thereby reducing clotting chances. DISCUSSIONS With the advent of such techniques and maneuvers, anticoagulation can be efficiently maintained in patients undergoing CRRT without increasing the risk of bleeding.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Sidharth Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Amrit Khooblall
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Vijay Kher
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Shweta Deshpande
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Keval Yerigeri
- Department of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Aadi Pandya
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Nikhil Nair
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Nithin Datla
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Mignon McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Timothy Bunchman
- Pediatric Nephrology & Transplantation, Children's Hospital of Richmond at VCU, Richmond, Virginia, USA
| | - Andrew Davenport
- University College London Centre for Nephrology, Division of Medicine, University College London Medical School, Royal Free Hospital, London, UK
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32
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Hang C. Optimal indicator for changing the filter during the continuous renal replacement therapy in intensive care unit patients with acute kidney injury: A crossover randomized trial. World J Emerg Med 2022; 13:196-201. [DOI: 10.5847/wjem.j.1920-8642.2022.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 01/12/2022] [Indexed: 11/19/2022] Open
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Roberts JA, Bellomo R, Cotta MO, Koch BCP, Lyster H, Ostermann M, Roger C, Shekar K, Watt K, Abdul-Aziz MH. Machines that help machines to help patients: optimising antimicrobial dosing in patients receiving extracorporeal membrane oxygenation and renal replacement therapy using dosing software. Intensive Care Med 2022; 48:1338-1351. [PMID: 35997793 PMCID: PMC9467945 DOI: 10.1007/s00134-022-06847-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
Intensive care unit (ICU) patients with end-organ failure will require specialised machines or extracorporeal therapies to support the failing organs that would otherwise lead to death. ICU patients with severe acute kidney injury may require renal replacement therapy (RRT) to remove fluid and wastes from the body, and patients with severe cardiorespiratory failure will require extracorporeal membrane oxygenation (ECMO) to maintain adequate oxygen delivery whilst the underlying pathology is evaluated and managed. The presence of ECMO and RRT machines can further augment the existing pharmacokinetic (PK) alterations during critical illness. Significant changes in the apparent volume of distribution (Vd) and drug clearance (CL) for many important drugs have been reported during ECMO and RRT. Conventional antimicrobial dosing regimens rarely consider the impact of these changes and consequently, are unlikely to achieve effective antimicrobial exposures in critically ill patients receiving ECMO and/or RRT. Therefore, an in-depth understanding on potential PK changes during ECMO and/or RRT is required to inform antimicrobial dosing strategies in patients receiving ECMO and/or RRT. In this narrative review, we aim to discuss the potential impact of ECMO and RRT on the PK of antimicrobials and antimicrobial dosing requirements whilst receiving these extracorporeal therapies. The potential benefits of therapeutic drug monitoring (TDM) and dosing software to facilitate antimicrobial therapy for critically ill patients receiving ECMO and/or RRT are also reviewed and highlighted.
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Affiliation(s)
- Jason A. Roberts
- grid.1003.20000 0000 9320 7537Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD 4029 Australia ,Herston Infectious Diseases (HeIDI), Metro North Health, Brisbane, QLD Australia ,grid.416100.20000 0001 0688 4634Department of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD Australia ,grid.121334.60000 0001 2097 0141Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Rinaldo Bellomo
- grid.1008.90000 0001 2179 088XDepartment of Critical Care, The University of Melbourne, Melbourne, Australia ,grid.1002.30000 0004 1936 7857Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia ,grid.414094.c0000 0001 0162 7225Department of Intensive Care, Austin Hospital, Melbourne, Australia ,grid.416153.40000 0004 0624 1200Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Menino O. Cotta
- grid.1003.20000 0000 9320 7537Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD 4029 Australia
| | - Birgit C. P. Koch
- grid.5645.2000000040459992XDepartment of Hospital Pharmacy, Erasmus University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Haifa Lyster
- Pharmacy Department, Royal Brompton and Harefield Hospitals, London, SW3 6NP UK ,Cardiothoracic Transplant Unit, Royal Brompton and Harefield Hospitals, London, SW3 6NP UK
| | - Marlies Ostermann
- grid.425213.3Department of Critical Care, King’s College London, Guy’s and St Thomas Hospital, London, SE1 7EH UK
| | - Claire Roger
- Department of Anaesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Place du Professeur Robert Debré, 30 029 Nîmes cedex 9, France ,grid.121334.60000 0001 2097 0141UR UM 103 IMAGINE, Faculty of Medicine, University of Montpellier, Nîmes, France
| | - Kiran Shekar
- grid.415184.d0000 0004 0614 0266Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD Australia ,grid.1003.20000 0000 9320 7537Faculty of Medicine, The University of Queensland, Brisbane, QLD Australia ,grid.1024.70000000089150953Faculty of Health, Queensland University of Technology, Brisbane, QLD Australia ,grid.1033.10000 0004 0405 3820Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD Australia
| | - Kevin Watt
- grid.46078.3d0000 0000 8644 1405School of Pharmacy, University of Waterloo, 10 Victoria St S. Kitchener, Waterloo, ON N2G 1C5 Canada ,grid.223827.e0000 0001 2193 0096Department of Paediatrics, University of Utah School of Medicine, Salt Lake City, UT USA
| | - Mohd H. Abdul-Aziz
- grid.1003.20000 0000 9320 7537Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD 4029 Australia
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Samoni S, Husain-Syed F, Villa G, Ronco C. Continuous Renal Replacement Therapy in the Critically Ill Patient: From Garage Technology to Artificial Intelligence. J Clin Med 2021; 11:172. [PMID: 35011913 PMCID: PMC8745413 DOI: 10.3390/jcm11010172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/24/2021] [Accepted: 12/26/2021] [Indexed: 11/17/2022] Open
Abstract
The history of continuous renal replacement therapy (CRRT) is marked by technological advances linked to improvements in the knowledge of the mechanisms and kinetics of extracorporeal removal of solutes, and the pathophysiology of acute kidney injury (AKI) and other critical illnesses. In the present article, we review the main steps in the history of CRRT, from the discovery of continuous arteriovenous hemofiltration to its evolution into the current treatments and its early use in the treatment of AKI, to the novel sequential extracorporeal therapy. Beyond the technological advances, we describe the development of new medical specialties and a shared nomenclature to support clinicians and researchers in the broad and still evolving field of CRRT.
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Affiliation(s)
- Sara Samoni
- Department of Nephrology and Dialysis, S. Anna Hospital, ASST Lariana, 22042 Como, Italy;
| | - Faeq Husain-Syed
- Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, 35392 Giessen, Germany;
| | - Gianluca Villa
- Department of Health Sciences, Section of Anesthesiology, Intensive Care and Pain Medicine, University of Florence, 50134 Florence, Italy
| | - Claudio Ronco
- Department of Medicine (DIMED), University of Padova, 35121 Padova, Italy;
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), St. Bortolo Hospital, 36100 Vicenza, Italy
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35
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Canaud B, Stuard S, Laukhuf F, Yan G, Canabal MIG, Lim PS, Kraus MA. Choices in hemodialysis therapies: variants, personalized therapy and application of evidence-based medicine. Clin Kidney J 2021; 14:i45-i58. [PMID: 34987785 PMCID: PMC8711767 DOI: 10.1093/ckj/sfab198] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Indexed: 11/17/2022] Open
Abstract
The extent of removal of the uremic toxins in hemodialysis (HD) therapies depends primarily on the dialysis membrane characteristics and the solute transport mechanisms involved. While designation of ‘flux’ of membranes as well toxicity of compounds that need to be targeted for removal remain unresolved issues, the relative role, efficiency and utilization of solute removal principles to optimize HD treatment are better delineated. Through the combination and intensity of diffusive and convective removal forces, levels of concentrations of a broad spectrum of uremic toxins can be lowered significantly and successfully. Extended clinical experience as well as data from several clinical trials attest to the benefits of convection-based HD treatment modalities. However, the mode of delivery of HD can further enhance the effectiveness of therapies. Other than treatment time, frequency and location that offer clinical benefits and increase patient well-being, treatment- and patient-specific criteria may be tailored for the therapy delivered: electrolytic composition, dialysate buffer and concentration and choice of anticoagulating agent are crucial for dialysis tolerance and efficacy. Evidence-based medicine (EBM) relies on three tenets, i.e. clinical expertise (i.e. doctor), patient-centered values (i.e. patient) and relevant scientific evidence (i.e. science), that have deviated from their initial aim and summarized to scientific evidence, leading to tyranny of randomized controlled trials. One must recognize that practice patterns as shown by Dialysis Outcomes and Practice Patterns Study and personalization of HD care are the main driving force for improving outcomes. Based on a combination of the three pillars of EBM, and particularly on bedside patient–clinician interaction, we summarize what we have learned over the last 6 decades in terms of best practices to improve outcomes in HD patients. Management of initiation of dialysis, vascular access, preservation of kidney function, selection of biocompatible dialysers and use of dialysis fluids of high microbiological purity to restrict inflammation are just some of the approaches where clinical experience is vital in the absence of definitive scientific evidence. Further, HD adequacy needs to be considered as a broad and multitarget approach covering not just the dose of dialysis provided, but meeting individual patient needs (e.g. fluid volume, acid–base, blood pressure, bone disease metabolism control) through regular assessment—and adjustment—of a series of indicators of treatment efficiency. Finally, in whichever way new technologies (i.e. artificial intelligence, connected health) are embraced in the future to improve the delivery of dialysis, the human dimension of the patient–doctor interaction is irreplaceable. Kidney medicine should remain ‘an art’ and will never be just ‘a science’.
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Affiliation(s)
- Bernard Canaud
- Montpellier University, Montpellier, France
- Global Medical Office, FMC Deutschland, Bad Homburg, Germany
| | - Stefano Stuard
- Global Medical Office, Fresenius Medical Care, Bad Homburg, Germany
| | - Frank Laukhuf
- Global Medical Office, Fresenius Medical Care, Bad Homburg, Germany
| | | | | | | | - Michael A Kraus
- Indiana University Medical School, Indianapolis, Indiana, USA
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts, USA
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36
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Macedo E, Cerdá J. Choosing a CRRT machine and modality. Semin Dial 2021; 34:423-431. [PMID: 34699085 DOI: 10.1111/sdi.13029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 08/20/2021] [Accepted: 09/25/2021] [Indexed: 11/30/2022]
Abstract
Expanded use and steady improvements in continuous renal replacement techniques (CRRT) have enhanced the safety of the application of kidney replacement therapy (KRT) to hemodynamically unstable intensive care unit (ICU) patients. The longer duration of therapy and the personalized prescription provided by continuous therapies are associated with greater hemodynamic stability and a modestly higher likelihood of kidney recovery than standard intermittent hemodialysis (IHD). Studies designed to evaluate the effect on mortality over intermittent therapies lack evidence of benefit. A lack of standardization and considerable variation in how CRRT is performed leads to wide variation in how the technique is prescribed, delivered, and optimized. Technology has progressed in critical care nephrology, and more progress is coming. New CRRT machines are equipped with a friendly user interface that allows easy performance and monitoring, permitting outcome measurements and improved patient quality control. This review discusses the key concepts necessary to guide nephrologists to prescribe and deliver KRT to critically ill ICU patients.
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Affiliation(s)
- Etienne Macedo
- Division of Nephrology, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Jorge Cerdá
- Division of Nephrology, Department of Medicine, Albany Medical College, and St Peter's Healthcare Partners, Albany, New York, USA
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37
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Song X, Ji H, Li Y, Xiong Y, Qiu L, Zhong R, Tian M, Kizhakkedathu JN, Su B, Wei Q, Zhao W, Zhao C. Transient blood thinning during extracorporeal blood purification via the inactivation of coagulation factors by hydrogel microspheres. Nat Biomed Eng 2021; 5:1143-1156. [PMID: 33495638 DOI: 10.1038/s41551-020-00673-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 12/09/2020] [Indexed: 02/07/2023]
Abstract
During extracorporeal blood purification, anticoagulants are administered to prevent thrombogenesis. However, haemorrhagic complications owing to near-complete inactivation of blood coagulation and delayed recovery of haemostasis pose serious risks to patients. Here, we show in vitro and in beagle dogs that hydrogel microspheres that adsorb the coagulation factors VIII, IX and XI provide transient blood thinning when placed in the extracorporeal circuit before blood purification. The microspheres inhibited the activities of the coagulation factors by levels (~8-30%) similar to those occurring in mild haemophilia. On its reintroduction into the animal, the purified pseudo-haemophilic blood favoured faster recovery of haemostasis. The transient blood-thinning strategy may increase the safety of clinical blood-purification procedures.
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Affiliation(s)
- Xin Song
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, China
| | - Haifeng Ji
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, China
| | - Yupei Li
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China.,Sichuan University-the Hong Kong Polytechnic University Institute for Disaster Management and Reconstruction, Chengdu, China
| | - Yuqin Xiong
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Li Qiu
- Department of Ultrasound, West China School of Medicine/West China Hospital, Sichuan University, Chengdu, China
| | - Rui Zhong
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences, Peking Union Medical College, Chengdu, China
| | - Meng Tian
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jayachandran N Kizhakkedathu
- Department of Pathology and Laboratory Medicine, Center for Blood Research and Life Science Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Baihai Su
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China.,Sichuan University-the Hong Kong Polytechnic University Institute for Disaster Management and Reconstruction, Chengdu, China
| | - Qiang Wei
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, China.,Department of Cellular Biophysics, Max Planck Institute for Medical Research, Heidelberg, Heidelberg, Germany.,Department of Biophysical Chemistry, University of Heidelberg, Heidelberg, Germany
| | - Weifeng Zhao
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, China.
| | - Changsheng Zhao
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, China.
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Hellman T, Uusalo P, Järvisalo MJ. Renal Replacement Techniques in Septic Shock. Int J Mol Sci 2021; 22:10238. [PMID: 34638575 PMCID: PMC8508758 DOI: 10.3390/ijms221910238] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/16/2021] [Accepted: 09/21/2021] [Indexed: 12/15/2022] Open
Abstract
Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to an infection; it carries a risk for mortality, considerably exceeding that of a mere infection. Sepsis is the leading cause for acute kidney injury (AKI) and the requirement for renal replacement therapy (RRT) in intensive care unit (ICU) patients. Almost every second critically ill patient with sepsis will develop AKI. In septic shock, the dysregulated host response to infectious pathogens leads to a cytokine storm with uncontrolled production and release of humoral proinflammatory mediators that evoke cellular toxicity and promote the development of organ dysfunction and increased mortality. In addition to treating AKI, RRT techniques can be employed for extracorporeal adsorption of inflammatory mediators using specifically developed adsorption membranes, hemoperfusion sorbent cartridges or columns; these techniques are intended to decrease the level and early deleterious effects of circulating proinflammatory cytokines and endotoxins during the first hours and days of septic shock treatment, in order to improve patient outcomes. Several methods and devices, such as high cut-off membranes, the Oxiris®-AN69 membrane, CytoSorb® and HA380 cytokine hemoadsorption, polymyxin B endotoxin adsorption, and plasmapheresis have been examined in small study series or are under evaluation as ways of improving patient outcomes in septic shock. However, to date, the data on actual outcome benefits have remained controversial, as discussed in this review.
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Affiliation(s)
- Tapio Hellman
- Kidney Center, Turku University Hospital and University of Turku, Building 4, AA7, Kiinanmyllynkatu 4-8, FIN-20521 Turku, Finland;
| | - Panu Uusalo
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Building 18, TG3B, Hämeentie 11, FIN-20521 Turku, Finland;
- Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, Building 18, TG3B, Hämeentie 11, FIN-20521 Turku, Finland
| | - Mikko J. Järvisalo
- Kidney Center, Turku University Hospital and University of Turku, Building 4, AA7, Kiinanmyllynkatu 4-8, FIN-20521 Turku, Finland;
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Building 18, TG3B, Hämeentie 11, FIN-20521 Turku, Finland;
- Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, Building 18, TG3B, Hämeentie 11, FIN-20521 Turku, Finland
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The Effect of Long-Term Duration Renal Replacement Therapy on Outcomes of Critically Ill Patients with Acute Kidney Injury: A Retrospective Cohort Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:6623667. [PMID: 34504539 PMCID: PMC8423547 DOI: 10.1155/2021/6623667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 06/29/2021] [Accepted: 07/28/2021] [Indexed: 11/17/2022]
Abstract
Background Renal replacement therapy (RRT), as a cornerstone of supportive treatment, has long been performed in critically ill patients with acute kidney injury (AKI). However, the majority of studies may have neglected the effect of the duration of RRT on the outcome of AKI patients. This paper is aiming to explore the effect of the long duration of RRT on the outcome of critically ill patients with AKI. Methods This retrospective study was conducted by using the Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC-II) database. The primary outcome measure of this study was the mortality at 28 days, 60 days, and 90 days in the long-duration RRT group and the non-long-duration RRT group. The secondary outcomes assessed the difference in clinical outcome in these two groups. Lastly, the effect of the duration of RRT on mortality in AKI patients was determined as the third outcome. Results We selected 1,020 patients in total who received RRT according to the MIMIC-II database. According to the inclusion and exclusion criteria, we finally selected 506 patients with AKI: 286 AKI patients in the non-long-duration RRT group and 220 in the long-duration RRT group. After 28 days, there was a significant difference in all-cause mortality between the long-duration RRT group and the non-long-duration RRT group (P=0.001). However, the difference disappeared after 60 days and 90 days (P=0.803 and P=0.925, respectively). The length of ICU stay, length of hospital stay, and duration of mechanical ventilation were significantly longer in the long-duration RRT group than those in the non-long-duration RRT group. Considering 28-day mortality, the longer duration of RRT was shown to be a protective factor (HR = 0.995, 95% CI 0.993-0.997, P < 0.0001), while 60-day and 90-day mortality were not correlated with improved protection. Conclusions The long duration of RRT can improve the short-term prognosis of AKI patients, but it does not affect the long-term prognosis of these patients. Prognosis is determined by the severity of the illness itself. This suggests that RRT can protect AKI patients through the most critical time; however, the final outcome cannot be altered.
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Ye Z, Liu H, Zhao B, Fu H, Li Y, Chen L. Correlation and Diagnostic Value of Serum Cys-C, RBP4, and NGAL with the Condition of Patients with Traumatic Acute Kidney Injury. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2021; 2021:4990941. [PMID: 34518769 PMCID: PMC8434901 DOI: 10.1155/2021/4990941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/25/2021] [Indexed: 11/18/2022]
Abstract
There is a lack of targeted biomarkers that can diagnose Acute Kidney Injury (AKI) early and accurately, which leads to deterioration of renal function and even death in patients who do not receive timely and effective treatment. In recent years, an increasing number of studies have shown that AKI-related markers such as cystatin C (Cys-C) and retinol-binding protein (RBP) can be used for early diagnosis of AKI to a certain extent. A total of 262 subjects were included in this study, of which 132 patients with traumatic AKI were enrolled in one group and named as the AKI group; 130 healthy subjects were enrolled in another group and named as the healthy group. AKI patients with different conditions were classified into AKI phase I, II, and III according to the KDIGO AKI diagnostic criteria, with 45, 59, and 28 in each group. In this study, we examined and compared serum Cys-C, RBP4, and neutrophil gelatinase-associated lipid transport protein (NGAL) levels between the AKI and healthy groups and between patients with AKI of different conditions, and the correlation and diagnostic value of three serum markers with the condition of traumatic AKI patients were also analyzed. The results showed that serum Cys-C, RBP4, and NGAL were significantly higher in the AKI group compared with the healthy group (P < 0.05), and the mean concentrations of the three serum markers increased as the severity of the disease increased, while correlation analysis showed that all three serum markers were positively correlated with serum Scr levels (P < 0.001). Further ROC curve analysis was performed, and the diagnostic values of serum Cys C, RBP4, and NGAL alone and in combination for traumatic AKI were 0.769, 0.741, 0.771, and 0.905, respectively. In short, serum Cys C, RBP4, NGAL have important value for the assessment and diagnosis of traumatic AKI patients.
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Affiliation(s)
- Zufeng Ye
- The Affiliated Nanhua Hospital, Department of Clinical Laboratory, Hengyang Medical School, University of South China, Hengyang, Hunan 421001, China
| | - Hui Liu
- The Affiliated Nanhua Hospital, Department of Emergency, Hengyang Medical School, University of South China, Hengyang, Hunan 421001, China
| | - Bixia Zhao
- The Affiliated Nanhua Hospital, Department of Urology, Hengyang Medical School, University of South China, Hengyang, Hunan 421001, China
| | - Hao Fu
- The Affiliated Nanhua Hospital, Department of Urology, Hengyang Medical School, University of South China, Hengyang, Hunan 421001, China
| | - Ying Li
- The Affiliated Nanhua Hospital, Department of Anesthesiology, Hengyang Medical School, University of South China, Hengyang, Hunan 421001, China
| | - Li Chen
- The Affiliated Nanhua Hospital, Department of Nursing, Hengyang Medical School, University of South China, Hengyang, Hunan 421001, China
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42
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Mateos-Dávila A, Betbesé AJ, Guix-Comellas EM. Fundamental concepts for the management of continuous replacement therapies. ENFERMERIA INTENSIVA 2021; 33:S1130-2399(21)00078-X. [PMID: 34364776 DOI: 10.1016/j.enfi.2021.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Affiliation(s)
- A Mateos-Dávila
- Máster Universitario de Investigación en Cuidados Enfermeros, Doctoranda en el programa de Enfermería y Salud de la UB, Enfermera gestora de la UCI de adultos del Hospital de la Santa Creu i Sant Pau.
| | - A J Betbesé
- Jefe clínico del servicio de Medicina Intensiva del Hospital de la Santa Creu i Sant Pau, Doctor en medicina y profesor agregado interino de la UAB, Campus Sant Pau
| | - E M Guix-Comellas
- Doctora en Enfermería y Salud, Profesora del Departamento de Enfermería Fundamental y Medicoquirúrgica, Escuela de Enfermería, Facultad de Medicina y Ciencias de la Salud, Campus Clínic, Universidad de Barcelona
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43
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Bouajram RH, Awdishu L. A Clinician's Guide to Dosing Analgesics, Anticonvulsants, and Psychotropic Medications in Continuous Renal Replacement Therapy. Kidney Int Rep 2021; 6:2033-2048. [PMID: 34386653 PMCID: PMC8343808 DOI: 10.1016/j.ekir.2021.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/29/2021] [Accepted: 05/03/2021] [Indexed: 11/30/2022] Open
Abstract
Acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) is a common complication in critical illness and has a significant impact on pharmacokinetic factors determining drug exposure, including absorption, distribution, transport, metabolism, and clearance. In this review, we provide a practical guide to drug dosing considerations in critically ill patients undergoing CRRT, focusing on the most commonly used analgesic, anticonvulsant, and psychotropic medications in the clinical care of critically ill patients. A literature search was conducted to identify articles in which drug dosing was evaluated in adult patients receiving CRRT between the years 1980 and 2020. We included articles with pharmacokinetic/pharmacodynamic analyses and those that described medication clearance via CRRT. A summary of the data focused on practical pharmacokinetic and pharmacodynamic principles is presented, with recommendations for drug dosing of analgesics, anticonvulsants, and psychotropic medications. Pharmacokinetic and pharmacodynamic studies to guide drug dosing of analgesics, anticonvulsants, and psychotropic medications in critically ill patients receiving CRRT are sparse. Considering the widespread use of these medications, narrow therapeutic index of these drug classes, and risks of over- and underdosing, additional studies in patients receiving CRRT are needed to inform drug dosing.
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Affiliation(s)
- Rima H. Bouajram
- Department of Pharmaceutical Services, University of California, San Francisco Medical Center, San Francisco, California, USA
| | - Linda Awdishu
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, California, USA
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44
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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.
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Affiliation(s)
- Ian Baldwin
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Theresa Mottes
- Ann and Robert Lurie Children's Hospital, Chicago, IL, USA
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45
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König C, Kluge S, Fuhrmann V, Jarczak D. Pharmacokinetics of meropenem during advanced organ support (ADVOS ®) and continuous renal replacement therapy. Int J Artif Organs 2021; 44:783-786. [PMID: 34144656 DOI: 10.1177/03913988211021101] [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] [Indexed: 01/11/2023]
Abstract
The advanced organ support (ADVOS) system allows to eliminate water-soluble as well as protein-bound molecules. Despite its clinical features, to date nothing is known about the elimination of clinically relevant drugs such as antiinfectives. Therefore, we report a case treated with ADVOS, continuous renal replacement therapy (CRRT), and meropenem (1 g 8-hourly) for empiric sepsis therapy monitored by meropenem drug levels. ADVOS showed more efficient elimination of meropenem compared to CRRT which has to be considered when evaluating dosing regimens.
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Affiliation(s)
- Christina König
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Medicine, Evangelisches Klinikum Niederrhein, Duisburg, Germany
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Doan NTT, Lai QD. Ultrafiltration for recovery of rice protein: Fouling analysis and technical assessment. INNOV FOOD SCI EMERG 2021. [DOI: 10.1016/j.ifset.2021.102692] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Villa G, Fabbri S, Samoni S, Cecchi M, Fioccola A, Scirè-Calabrisotto C, Mari G, Pomarè Montin D, Romagnoli S. Methods for dose quantification in continuous renal replacement therapy: Toward a more precise approach. Artif Organs 2021; 45:1300-1307. [PMID: 33948973 PMCID: PMC8597082 DOI: 10.1111/aor.13991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/27/2021] [Accepted: 04/13/2021] [Indexed: 11/29/2022]
Abstract
Periodic dose assessment is quintessential for dynamic dose adjustment and quality control of continuous renal replacement therapy (CRRT) in critically ill patients with acute kidney injury (AKI). The flows‐based methods to estimate dose are easy and reproducible methods to quantify (estimate) CRRT dose at the bedside. In particular, quantification of effluent flow and, mainly, the current dose (adjusted for dialysate, replacement, blood flows, and net ultrafiltration) is routinely used in clinical practice. Unfortunately, these methods are critically influenced by several external unpredictable factors; the estimated dose often overestimates the real biological delivered dose quantified through the measurement of urea clearance (the current effective delivered dose). Although the current effective delivered dose is undoubtedly more precise than the flows‐based dose estimation in quantifying CRRT efficacy, some limitations are reported for the urea‐based measurement of dose. This article aims to describe the standard of practice for dose quantification in critically ill patients with AKI undergoing CRRT in the intensive care unit. Pitfalls of current methods will be underlined, along with solutions potentially applicable to obtain more precise results in terms of (a) adequate marker solutes that should be used in accordance with the clinical scenario, (b) correct sampling procedures depending on the chosen indicator of transmembrane removal, (c) formulas for calculations, and (d) quality controls and benchmark indicators.
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Affiliation(s)
- Gianluca Villa
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Florence, Italy.,Department of Anaesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Sergio Fabbri
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Florence, Italy
| | - Sara Samoni
- Department of Nephrology and Dialysis, ASST Lariana, S. Anna Hospital, Como, Italy
| | - Matteo Cecchi
- Department of Experimental and Clinical Medicine, Industrial PhD in Clinical Science, University of Florence, Florence, Italy
| | - Antonio Fioccola
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Florence, Italy
| | - Caterina Scirè-Calabrisotto
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Florence, Italy
| | - Gaia Mari
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Florence, Italy
| | - Diego Pomarè Montin
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Florence, Italy
| | - Stefano Romagnoli
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Florence, Italy.,Department of Anaesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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48
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Neyra JA, Tolwani A. CRRT prescription and delivery of dose. Semin Dial 2021; 34:432-439. [PMID: 33909931 DOI: 10.1111/sdi.12974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/22/2021] [Accepted: 03/30/2021] [Indexed: 12/31/2022]
Abstract
Continuous renal replacement therapy (CRRT) is the preferred modality of extracorporeal renal support for critically ill patients with acute kidney injury (AKI). The dose of CRRT is reported as effluent flow in ml/kg body weight per hour (ml/kg/h). Solid evidence supports that the delivered CRRT effluent dose for critically ill patients with AKI should be 20-25 ml/kg/h on average. To account for treatment interruptions and the natural decline in filter efficiency over time, it is recommended to prescribe 25-30 ml/kg/h of effluent dose. However, transient higher doses of CRRT in specific clinical scenarios may be needed to accommodate specific solute control needs of a particular patient at a given time. Consequently, there should be consideration of the potential adverse consequences of non-selective clearance such as undesired antimicrobials and nutrients removal. In this manuscript, we provide a summary of evidence related to CRRT dose, practical aspects for its calculation at the time of prescribing CRRT, and considerations for addressing the expected gap between prescribed and delivered CRRT dose. We also provide a framework for monitoring and implementation of CRRT dose as a quality indicator of CRRT delivery.
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Affiliation(s)
- Javier A Neyra
- Department of Internal Medicine, Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - Ashita Tolwani
- Department of Internal Medicine, Division of Nephrology, University of Alabama, Birmingham, AL, USA
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Khoo BZE, Lim RS, See YP, Yeo SC. Dialysis circuit clotting in critically ill patients with COVID-19 infection. BMC Nephrol 2021; 22:141. [PMID: 33879086 PMCID: PMC8056790 DOI: 10.1186/s12882-021-02357-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/12/2021] [Indexed: 12/22/2022] Open
Abstract
Background Coronavirus Disease 2019 (COVID-19) infection has been associated with a hypercoagulable state with increased reports of thrombotic events. Acute kidney injury requiring dialysis is common in critically ill patients and circuit clotting compromises efficacy of treatment. This study aims to analyze the circuit life and circuit clotting during continuous kidney replacement therapy (CKRT) and intermittent hemodialysis in patients with and without COVID-19. Methods This is a single-center, retrospective cohort study in critically ill patients undergoing CKRT or intermittent hemodialysis between 1 February 2020 to 22 May 2020. Patients in the intensive care unit (ICU) with COVID-19 infection and contemporary controls who tested negative were included. Co-primary outcomes were functional circuit life for patients on CKRT and all circuit clotting events for patients on CKRT and/or intermittent hemodialysis. Results Seventy CKRT circuits and 32 intermittent hemodialysis sessions for 12 COVID-19 cases and 22 CKRT circuits and 18 intermittent hemodialysis sessions for 15 controls were analyzed. CKRT circuit clotting was more common in the COVID-19 group compared to the control group (64% vs 36%, p = 0.02), despite higher anticoagulation use in the COVID-19 group (41% vs 14%, p = 0.02). Functional CKRT circuit life was similar in COVID-19 patients and controls (median 11 vs 12 h, p = 0.69). On Cox regression analysis, circuit clotting was similar with hazard ratio (HR) 1.90 [95% confidence interval (CI): 0.89–4.04]; however, clotting was increased in COVID-19 patients after adjustment for anticoagulation use (HR: 3.31 [95% CI 1.49–7.33]). In patients with COVID-19, CKRT circuits with anticoagulation had a longer circuit life compared to CKRT circuits without anticoagulation (median 22 versus 7 h respectively, p < 0.001). Circuit clotting was similar in both groups undergoing intermittent hemodialysis. Conclusion Dialysis clotting amongst COVID-19 patients is increased despite more anticoagulation use and the hazard for clotting is greater especially after adjusting for anticoagulation use. Circuit life was suboptimal in COVID-19 patients on circuits without anticoagulation and therefore routine use of anticoagulation amongst COVID-19 patients should be considered whenever possible. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02357-3.
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Affiliation(s)
- Benjamin Zhi En Khoo
- Department of Renal Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
| | - Regina Shaoying Lim
- Department of Renal Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yong Pey See
- Department of Renal Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - See Cheng Yeo
- Department of Renal Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
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50
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Claure-Del Granado R, Clark WR. Continuous renal replacement therapy principles. Semin Dial 2021; 34:398-405. [PMID: 33819361 DOI: 10.1111/sdi.12967] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/24/2021] [Accepted: 02/28/2021] [Indexed: 11/27/2022]
Abstract
Continuous renal replacement therapy (CRRT) is an extracorporeal blood purification therapy that aims to support kidney function over an extended period of time. One of the main objectives of CRRT is the removal of excess fluid and solutes retained as a consequence of acute kidney injury. Because prescription of CRRT requires goals to be set with regard to the rate and extent of solute and fluid removal, a comprehensive understanding of the mechanism by which solute and fluid removal occurs during CRRT is essential. Basic mechanisms of fluid transport and solute removal (ultrafiltration, diffusion, convection, and adsorption) and the factors influencing these processes in CRRT are described. From the combination of the different transport mechanisms, a number of CRRT modalities are identified and described. Finally, these principles are applied to provide a brief overview of the concept of effluent-based CRRT dose.
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Affiliation(s)
- Rolando Claure-Del Granado
- Division of Nephrology, Hospital Obrero No 2 - CNS, Cochabamba, Bolivia.,Universidad Mayor de San Simon School of Medicine, Cochabamba, Bolivia
| | - William R Clark
- Davidson School of Chemical Engineering, Purdue University, West Lafayette, IN, USA
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