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Sethi S, Mangat G, Soundararajan A, Marakini AB, Pecoits-Filho R, Shah R, Davenport A, Raina R. Archetypal sustained low-efficiency daily diafiltration (SLEDD-f) for critically ill patients requiring kidney replacement therapy: towards an adequate therapy. J Nephrol 2023; 36:1789-1804. [PMID: 37341966 DOI: 10.1007/s40620-023-01665-1] [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: 02/07/2023] [Accepted: 04/29/2023] [Indexed: 06/22/2023]
Abstract
Sustained low-efficiency dialysis is a hybrid form of kidney replacement therapy that has gained increasing popularity as an alternative to continuous forms of kidney replacement therapy in intensive care unit settings. During the COVID-19 pandemic, the shortage of continuous kidney replacement therapy equipment led to increasing usage of sustained low-efficiency dialysis as an alternative treatment for acute kidney injury. Sustained low-efficiency dialysis is an efficient method for treating hemodynamically unstable patients and is quite widely available, making it especially useful in resource-limited settings. In this review, we aim to discuss the various attributes of sustained low-efficiency dialysis and how it is comparable to continuous kidney replacement therapy in efficacy, in terms of solute kinetics and urea clearance, and the various formulae used to compare intermittent and continuous forms of kidney replacement therapy, along with hemodynamic stability. During the COVID-19 pandemic, there was increased clotting of continuous kidney replacement therapy circuits, which led to increased use of sustained low-efficiency dialysis alone or together with extra corporeal membrane oxygenation circuits. Although sustained low-efficiency dialysis can be delivered with continuous kidney replacement therapy machines, most centers use standard hemodialysis machines or batch dialysis systems. Even though antibiotic dosing differs between continuous kidney replacement therapy and sustained low-efficiency dialysis, reports of patient survival and renal recovery are similar for continuous kidney replacement therapy and sustained low-efficiency dialysis. Health care studies indicate that sustained low-efficiency dialysis has emerged as a cost-effective alternative to continuous kidney replacement therapy. Although there is considerable data to support sustained low-efficiency dialysis treatments for critically ill adult patients with acute kidney injury, there are fewer pediatric data, even so, currently available studies support the use of sustained low-efficiency dialysis for pediatric patients, particularly in resource-limited settings.
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Affiliation(s)
- Sidharth Sethi
- Department of Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Guneive Mangat
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Anvitha Soundararajan
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Abhilash Bhat Marakini
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Catolica Do Parana, Curitiba, Brazil
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Raghav Shah
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK
| | - Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
- Department of Pediatric Nephrology, Akron Children's Hospital, Akron, OH, USA.
- Department of Internal Medicine, Northeast Ohio Medical University, Rootstown, OH, USA.
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Abstract
Prolonged Intermittent Renal Replacement Therapy (PIRRT) is the term used to define 'hybrid' forms of renal replacement therapy. PIRRT can be provided using an intermittent hemodialysis machine or a continuous renal replacement therapy (CRRT) machine. Treatments are provided for a longer duration than typical intermittent hemodialysis treatments (6-12 h vs. 3-4 h, respectively) but not 24 h per day as is done for continuous renal replacement therapy (CRRT). Usually, PIRRT treatments are provided 4 to 7 times per week. PIRRT is a cost-effective and flexible modality with which to safely provide RRT for critically ill patients. We present a brief review on the use of PIRRT in the ICU with a focus on how we prescribe it in that setting.
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Affiliation(s)
- Edward G Clark
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Canada.
| | - Anitha Vijayan
- Division of Nephrology, Washington University in St. Louis, St. Louis, MO, USA
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Morales Castro D, Dresser L, Granton J, Fan E. Pharmacokinetic Alterations Associated with Critical Illness. Clin Pharmacokinet 2023; 62:209-220. [PMID: 36732476 PMCID: PMC9894673 DOI: 10.1007/s40262-023-01213-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2023] [Indexed: 02/04/2023]
Abstract
Haemodynamic, metabolic, and biochemical derangements in critically ill patients affect drug pharmacokinetics and pharmacodynamics making dose optimisation particularly challenging. Appropriate therapeutic dosing depends on the knowledge of the physiologic changes caused by the patient's comorbidities, underlying disease, resuscitation strategies, and polypharmacy. Critical illness will result in altered drug protein binding, ionisation, and volume of distribution; it will also decrease oral drug absorption, intestinal and hepatic metabolism, and renal clearance. In contrast, the resuscitation strategies and the use of vasoactive drugs may oppose these effects by leading to a hyperdynamic state that will increase blood flow towards the major organs including the brain, heart, kidneys, and liver, with the subsequent increase of drug hepatic metabolism and renal excretion. Metabolism is the main mechanism for drug clearance and is one of the main pharmacokinetic processes affected; it is influenced by patient-specific factors, such as comorbidities and genetics; therapeutic-specific factors, including drug characteristics and interactions; and disease-specific factors, like organ dysfunction. Moreover, organ support such as mechanical ventilation, renal replacement therapy, and extracorporeal membrane oxygenation may contribute to both inter- and intra-patient variability of drug pharmacokinetics. The combination of these competing factors makes it difficult to predict drug response in critically ill patients. Pharmacotherapy targeted to therapeutic goals and therapeutic drug monitoring is currently the best option for the safe care of the critically ill. The aim of this paper is to review the alterations in drug pharmacokinetics associated with critical illness and to summarise the available evidence.
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Affiliation(s)
- Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, 585 University Avenue, 9-MaRS, Toronto, ON, M5G 2N2, Canada. .,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.
| | - Linda Dresser
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - John Granton
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, 585 University Avenue, 9-MaRS, Toronto, ON, M5G 2N2, Canada.,Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, 585 University Avenue, 9-MaRS, Toronto, ON, M5G 2N2, Canada.,Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Rawlins MDM, Misko J, Roberts JA. Antimicrobial dosing in prolonged intermittent renal replacement therapy: a systematic review. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2021. [DOI: 10.1002/jppr.1723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Matthew D. M. Rawlins
- Senior Pharmacist Antimicrobial Stewardship Pharmacy Department Fiona Stanley Hospital Murdoch Australia
| | - Jeanie Misko
- Medicines Information Senior Pharmacist Pharmacy Department Fiona Stanley Hospital Murdoch Australia
| | - Jason A. Roberts
- Faculty of Medicine University of Queensland Centre for Clinical Research The University of Queensland Brisbane Australia
- Departments of Pharmacy and Intensive Care Medicine Royal Brisbane and Women's Hospital Brisbane Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine Nîmes University Hospital University of Montpellier Nîmes France
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