Erratum: Management for Electrolytes Disturbances during Continuous Renal Replacement Therapy.

Renal Support for Acute Kidney Injury in the Developing World

Metabolic aspects of continuous renal replacement therapies

Lately, in Russia, the number of patients with severe stage of acute renal failure requiring renal replacement therapy is increasing. Intermittent hemodialysis is the most common type of this therapy, however, the continuous methods of renal replacement therapy also started to be more often used in clinical practice despite of their high basic cost. The subject of this study is to investigate of pharmaco-economic results reflecting direct medical and indirect non-medical costs when using these technologies versus the maximum effective use of funds while treating patients with severe renal dysfunctions. Objective: to perform comparative clinical and economic analysis of intermittent and continuous renal replacement therapy in the intensive care wards of medical units in Russia. Methods. The study was conducted in compliance with acting Standards on Clinical Economic Studies used in Russian Federation. The study methods included evaluation of existing randomized clinical studies and trials which included data from network meta-analyses and systematic reviews of the investigated technologies. The direct medical and indirect non-medical costs were calculated and analyzed in respect of cost-effectiveness and costs-utility and budget impact analyses, utility, expressed in the number of saved quality-adjusted life years. Result: Simulation and comparative healtheconomic analysis of intermittent (IRRT) and continuous (CRRT) renal replacement therapy showed that the use continuous (CRRT) renal replacement therapy resulted in reduction of direct medical and indirect non-medical costs even within the first year. By the end of the third year savings can achieve 341,129.5 RUR per patient, and of this amount, savings in direct medical costs show 279,646.3 RUR and savings of indirect non-medical costs show 61,483.1 RUR. Budget impact analysis identified that using continuous renal replacement therapy (CRRT) allowed to save more than 230 million RUR for the whole country during 3 years per 1,740 patients with acute renal failure. Conclusion: Despite its high initial costs, the use of CRRT results in the reduction of costs and maximum efficient use of funds, and thus CRRT can be recommended for wider use in the Russian practice.

Introduction The rehospitalization rate for decompensated heart failure (HF) is high and can be ascribed also to a suboptimal decongestion before discharge. Congestion can be treated with diuretics or continuous renal replacement therapy (CRRT). Aim of this study was to evaluate if diuretics and CRRT, used in agreement to international guidelines, may have a dissimilar decongestion ability in patients with decompensated HF with diff erent baseline characteristics.Methods In 88 patients with HF (NYHA class III-IV) we evaluated the eff ect of CRRT (n = 46) and intravenous diuretics (n = 42) on clinical and instrumental signs of congestion. A clinical score was obtained as the sum of signs and symptoms of HF to estimate the severity of each patient’s clinical condition. The choice of diuretics or CRRT was guided by renal impairment or diuretics’ resistance.Results A signifi cant reduction in clinical HF score was observed in the CRRT group at discharge vs admission (1.3 ± 1.9 vs 5.7 ± 2.3, P < 0.001) and in the diuretic group (1.8 ± 1.4 vs 3.7 ± 1.6, P < 0.001), while a signifi cant reduction in radiographic signs of pulmonary congestion, pleural eff usion, echocardiographic systolic arterial pulmonary pressure (43.4 ± 13.6 vs 50.5 ± 20.2 mmHg, P < 0.005) and NT-proBNP (6,676 vs 15,492 pg/ml, P < 0.05) were observed only in CRRT patients. Moreover, also urine output signifi cantly increased only in CRRT patients (1.8 ± 0.8 vs 0.9 ± 0.6 ml/h/kg, P < 0.001).Conclusions CRRT and diuretics showed an equivalent ability in relieving clinical signs and symptoms of HF but only CRRT was able to signifi cantly improve several instrumental and biohumoral indicators of congestion.

Anticoagulation is usually indicated in patients receiving continuous renal replacement therapy (CRRT) to prevent clotting of the extra-corporeal circuit. While heparin is the most frequently used anticoagulant, regional citrate anticoagulation is becoming the preferred choice in those patients at high risk for bleeding. However, it has been widely claimed that to avoid citrate toxicity, CRRT with citrate anticoagulation should utilize diffusive clearance (e.g., continuous venovenous hemodialysis). We studied citrate clearance in five children who received citrate anticoagulation during CRRT with a COBE PRISMA machine and an M-60 (AN-69) filter. The blood flow rate ranged from 50 to 150 ml/min (2.1-8.0 ml/kg per min). Citrate was infused in the circuit circulation as an acid citrate dextrose (ACD) solution at a rate of 1.6-3.7% of the blood flow rate to maintain the circuit ionized calcium (iCa) <0.5 mmol/l. Calcium-free replacement fluid with reduced alkali (NaHCO3 20 mEq/l) was infused in pre-filter mode at a rate of 1,800-2,000 ml/h per 1.73 m(2). In a separate central line, CaCl2 (0.8%) was infused (rate 25-50% of ACD infusion) to maintain systemic iCa between 1.0 and 1.3 mmol/l. Citrate concentration was measured using an enzymatic assay. Total CRRT duration was 1,224 h. Twenty-four filters were changed due to clotting, with a mean filter life of 51 h. Mean (range) citrate levels (mmol/l) were (1) before initiating CRRT ( n=2): patient baseline 0.13 (0.1-0.15), (2) during CRRT ( n=7): circuit 4.54 (3.95-6.25), effluent 4.31 (3.95-5.46), and patient 0.69 (0.30-1.13). Sieving coefficients for urea and citrate were 0.88-0.97 and 0.88-1.0, respectively. Citrate clearance (31-38 ml/min per 1.73 m(2)) was similar to that of urea (31-38 ml/min per 1.73 m(2)), and when evaluated in two patients, remained unchanged after substituting half of the convective clearance [continuous venovenous hemofiltration (CVVH)] by diffusive clearance [continuous venovenous hemodiafiltration (CVVHDF)]. The post-filter citrate load (mean+/-SD) delivered to the five patients during CRRT was 1.06+/-0.62 mmol/kg per hour. With the exception of alkalosis in one patient, no other complications were observed. Renal function recovered in all patients. We conclude that citrate anticoagulation in children is feasible, effective, and safe. Sufficient citrate clearance to prevent its toxic accumulation is achieved by convective clearance (CVVH) alone and diffusive clearance (CVVHDF) does not appear to be mandatory when utilizing citrate anticoagulation during CRRT.

Objective To investigate the timing and efficacy of continuous renal replacement therapy (CRRT) in neonatal acute kidney injury (AKI). Methods Nineteen AKI neonates treated with CRRT were enrolled during hospitalization in the Department of Neonatology of the Children's Hospital of Shanghai from June 2011 to June 2018. Their clinical data were retrospectively analyzed. According to their baseline renal function, these neonates were divided into two groups using an improved RIFLE (Risk, Injury, Failure, Loss and End-stage renal disease) standard: AKI stage 1-2 group and AKI stage 3 group. CRRT included continuous veno-venous hemodiafiltration (CVVHDF) and plasma exchange (PE). Several parameters included blood pressure (BP), renal function, electrolyte, blood gas and hemodynamic indicators were analyzed before, 12 h, 24 h, and 48 h after the initiation of CRRT and at the end of CRRT. Changes in neonatal renal function before, 24 h after the initiation of CRRT and at the end of CRRT were compared between the two groups. Efficacy of CRRT was evaluated, and clinical outcomes were analyzed. Kruskal-Wallis H-test or t-test was applied for statistic analysis. Results (1) Among the 19 neonates with AKI, there were 12 in stage 1-2 and seven in stage 3. Seventeen cases were treated with CVVHDF, and the other two underwent plasma exchange. The duration of CRRT was 49-190 h with an average of (89.2±33.9) h. (2) After 12 h of CRRT, the blood pressure of all 19 AKI neonates returned to normal (40-60 mmHg, 1 mmHg=0.133 kPa) and was maintained at that level during the treatment. The blood pH value also increased to a normal range (7.35-7.45) at the same time. The oxygenation index reached 200 mmHg after 12 h of CRRT and rose to over 300 mmHg after 24 h. The levels of serum potassium, urea nitrogen, and creatinine decreased significantly after 12 h of CRRT and reached the normal range after 24 h of CRRT. After 24 h of CRRT, the urine volume significantly increased. (3) Serum levels of urea nitrogen and creatinine in neonates with AKI stage 1-2 decreased significantly after 24 h of CRRT. At any time points before and after CRRT (24 h before, 24 h after and at the end of CRRT), serum levels of urea nitrogen and creatinine in AKI stage 3 neonates were higher than those in AKI stage 1-2 neonates [urea nitrogen: (15.8±4.1) mmol/L vs (10.2±5.1) mmol/L, (11.5±2.4) mmol/L vs (6.3±2.3) mmol/L, (9.8±2.1) mmol/L vs (5.1±2.2) mmol/L, t=2.468, 2.226 and 2.171, respectively; creatinine: (184±32) μmol/L vs (152±26) μmol/L, (110±35) μmol/L vs (87±25) μmol/L, (63±12) μmol/L vs (44±9) μmol/L, t= 2.404, 2.423 and 3.972, respectively; all P<0.05]. (4) Venous catheterization was successful in the 19 AKI neonates. Three cases were complicated with thrombocytopenia, two with obstruction and two with hypotension during CRRT. Complications such as hypothermia, hemorrhage, thrombosis, and infection were not reported. (5) Among the 19 AKI neonates, 12 (including five of severe asphyxia, five of septic sepsis and two of inherited metabolic disorders and in metabolic crisis) were cured and discharged. The other seven cases (two in stage 1-2 and five in stage 3) lived through the oliguria stage but died after their family members gave up the treatment. Conclusions CRRT is a safe and effective management for neonatal AKI. The optimal opportunity for CRRT treatment in AKI neonates should be at stage 1-2. Key words: Acute kidney injury; Renal replacement therapy; Infant, newborn; Treatment outcome

Patients with critical illness commonly develop acute renal failure requiring mechanical support in the form of either continuous renal replacement therapy (CRRT) or intermittent hemodialysis (IRRT). As controversy exists regarding which modality should be used for most patients with critically illness, we sought to determine whether CRRT or IRRT is associated with better survival. We performed a meta-analysis of all prior randomized and observational studies that compared CRRT with IRRT. Studies were identified through a MEDLINE search, the authors' files, bibliographies of review articles, abstracts and proceedings of scientific meetings. Studies were assessed for baseline characteristics, intervention, outcome and overall quality through blinded review. The primary end-point was hospital mortality, assessed by cumulative relative risk (RR). We identified 13 studies ( n=1400), only three of which were randomized. Overall there was no difference in mortality (RR 0.93 (0.79-1.09), p=0.29). However, study quality was poor and only six studies compared groups of equal severity of illness at baseline (time of enrollment). Adjusting for study quality and severity of illness, mortality was lower in patients treated with CRRT (RR 0.72 (0.60-0.87), p<0.01). In the six studies with similar baseline severity, unadjusted mortality was also lower with CRRT (RR 0.48 (0.34 -0.69), p<0.0005). Current evidence is insufficient to draw strong conclusions regarding the mode of replacement therapy for acute renal failure in the critically ill. However, the life-saving potential with CRRT suggested in our secondary analyses warrants further investigation by a large, randomized trial.

Objective To evaluate the application effect of self-made double checklist on quality control before the start of treatment of continuous renal replacement therapy (CRRT) . Methods Using the convenience sampling method, a number of 200 cases undergoing CRRT were chosen as control group in the Department of Geriatric Critical Care Medicine of a Class Ⅲ Grade A hospital in Guangzhou from January to May 2016. Another 200 cases undertaking CRRT from June to September 2016 were treated as observation group. CRRT quality control of the control group was implemented in accordance with the department principle, while the observation group had an extra double checklist before the start of treatment of CRRT. CRRT risk events, time duration before starting treatment of CRRT, CRRT treatment time, and satisfaction of both doctors and nurses before and after the checklist using of two groups were compared. Results The incidence of risk events before, during and after CRRT of the observation group were lower than those of the control group (P<0.01) . Time duration before starting treatment of CRRT and CRRT treatment time of the observation group were superior than those of the control group [ (10.84±3.34) vs. (18.38±6.44) min, (20.88±6.45) vs. (18.48±7.51) h; P<0.01]. Satisfaction of the observation group of doctors to nurses' CRRT technical operation and nurses to double checklist using for CRRT quality control were higher than those of the control group (P<0.01) . Conclusions Application of double checklist on quality control before the start of treatment of CRRT could greatly reduce the incidence of CRRT risk events, shorten time duration before starting treatment of CRRT, extend the CRRT treatment time, improve the medical and nursing satisfaction and ensure quality control of CRRT as well. Key words: Quality control; Double checklist; Continuous renal replacement therapy

Use of adsorptive mechanisms in continuous renal replacement therapies in the critically ill

Objective To comparie the effects of pre-dilution with post-dilution continuous renal replacement therapy (CRRT) for patients with MODS. Method Thirty-two MODS patients admitted to ICU (Intensive Care Unit ) were randomized and treated with different modes of CRRT. The results of creatinine clearance, acid-base equilibrium, haemodynamic variables before and post therapy were recorded.The maximal pre-filter pressure, the duration of filter unworn out and mortality of patients treated with different modes of CRRT were also recorded. Results Seventeen patients were treated with pre-dilution mode of CRRT and 15 patients treated with post-dilution mode of CRRT. After 24 hours of pre- and postdilution modes of CRRT, the net increase in Ccr (namely the rate of replacement creatinine clearance) were (15.6±4.6) vs. (22.7 ±4. 1) mL/min respectively (P＜0.01); after 48-hour, they were (14.9±3.3)vs. ( 18. 9 ±2. 3) mL/min (p ＜0. 05) . Both dilution modes could improve the blood PH、 HCO3- and BE( P ＜ 0. 05 ) without significant differences between two groups after CRRT therapy ( P ＞ 0. 05 ) . The MAP of patients treated with pre-dilution modes of CRRT therapy for 24 hours and the MAP of patients before therapy were 69. 2 ± 4. 6 and 56. 7 + 9. 1 mmHg respectively ( P ＜ 0. 05 ), and dosage of dopamine used in patients before CRRT therapy and that after CRRT for 24 hours were ( 11.20 +3.45 ) vs (6. 12 +3.41 ) μg ·kg-1 min -1(P＜0.05).The maximal pre-filter pressures of pre-and post-dilution modes were (82.23+9.11) cm H2O, (110.56 +28. 14) cmH2O respectively (P＜0.05), and the durations of lasting effect of filter used in two modes of CRRT were ( 39 + 28. 12 ) vs. ( 25 + 14. 45 ) h respectively ( P ＜0. 05) . Both dilution modes could improve APACHE Scores. There were no significant differences in APACHE Scores and mortalities between two groups after CRRT therapy. Conclusions Post-dilution mode of CRRT has higher filtration rate, but have higher maximal pre-filter pressure and shorter longevity of filter.Pre-dilution mode of CRRT has better effect on improving hemodynamics, reducing usage of vasopressor.Both modes of CRRT can correct acid base equilibrium disorder rapidly. There are no differences in the results of blood gas analysis improved、 APACHE scores and mortality between the two groups. Key words: Continuous renal replacement therapy (CRRT); Multiple organs dysfunction syndrome (MODS); Predilution; Postdilution

Influence of renal replacement therapy on outcome of patients with acute renal failure

BackgroundDespite aggressive application of continuous renal replacement therapy (CRRT) in critically ill patients with acute kidney injury (AKI), there is no consensus on diuretic therapy when discontinuation of CRRT is attempted. The effect of diuretics on discontinuation of CRRT in critically ill patients was evaluated.MethodsThis retrospective cohort study enrolled 1176 adult patients who survived for more than 3 days after discontinuing CRRT between 2009 and 2014. Patients were categorized depending on the re-initiation of renal replacement therapy within 3 days after discontinuing CRRT or use of diuretics. Changes in urine output (UO) and renal function after discontinuing CRRT were outcomes. Predictive factors for successful discontinuation of CRRT were also analyzed.ResultsThe CRRT discontinuation group had a shorter duration of CRRT, more frequent use of diuretics after discontinuing CRRT, and greater UO on the day before CRRT discontinuation [day minus 1 (day − 1)]. The diuretics group had greater increases in UO and serum creatinine elevation after discontinuing CRRT. In the CRRT discontinuation group, continuous infusion of furosemide tended to increase UO more effectively. Multivariable regression analysis identified high day − 1 UO and use of diuretics as significant predictors of successful discontinuation of CRRT. Day − 1 UO of 125 mL/day was the cutoff value for predicting successful discontinuation of CRRT in oliguric patients treated with diuretics following CRRT.ConclusionsDay − 1 UO and aggressive diuretic therapy were associated with successful CRRT discontinuation. Diuretic therapy may be helpful when attempting CRRT discontinuation in critically ill patients with AKI, by inducing a favorable fluid balance, especially in oliguric patients.

IntroductionBurn shock is a consequence of burns that cover ≥20% TBSA and may be complicated by acute kidney injury, which is commonly treated with continuous renal replacement therapy (CRRT). However, early initiation of CRRT has not been clinically evaluated for the treatment of burn shock.MethodsData were obtained from the Renal Replacement Therapy in Severe Burns: A Multicenter Observational Study. In that study, baseline (t0) measurements were taken at the time of CRRT initiation and ~24 (t1) and ~48 (t2) hours thereafter. Patients were included in this analysis if they had ≥20% TBSA and began CRRT within 2 days of injury. Patients were categorized as Group A (began CRRT on same day as injury), Group B (began CRRT on day 1 postburn), and Group C (began CRRT on day 2 postburn). Outcomes measured at t0, t1, and t2 and hospital and ICU length of stay (LOS) were analyzed using generalized linear mixed models. Cox proportional hazards models were used to assess survival to hospital discharge (HD). All models were adjusted, e.g. for age, % full thickness, etc. Burn center was included as a random effect.ResultsMore than half of the 48 patients included were treated at just 2 burn centers. Timing of CRRT initiation varied by center, with all patients at one center starting CRRT on either the day of injury or the day after injury. Nearly 96% of patients had AKI at CRRT start and, of those, 22 were at stage 1 or 2. Patients generally had severe burns; Group A had more inhalation injuries and higher %TBSA, % full thickness, and Baux scores than Groups B and C. Shock index (SI) was persistently elevated across all 3 time points and did not vary by timing of CRRT initiation (p=0.37). Vasopressor dependency index (VDI) was also not associated with timing of CRRT initiation (p >0.99), although mean VDI for Groups B and C declined over time. For all 3 groups, fluid balance decreased from t0, but there were no differences among the groups (all p >0.30). Survival to HD was better for patients with lower TBSA (i.e. 20-49%) compared to those with TBSA ≥50% (hazard ratio=0.37; 95% CI=0.15-0.91). In contrast, timing of CRRT initiation was not associated with survival (p=0.73). Among patients that survived to HD, the mean hospital LOS was shorter for Groups A (13 days; p=0.01) and B (39 days; p=0.03) compared to Group C (131 days). Mean ICU LOS was also shorter for Groups A (13 days; p=0.01) and B (52 days; p=0.03) than for Group C (168 days).ConclusionsIn this analysis, earlier initiation of CRRT did not improve survival to hospital discharge. Nonetheless, starting patients on CRRT early may be advantageous for reducing ICU and hospital LOS for those patients that do survive.

Congestive heart failure as an indication for continuous renal replacement therapy

Objective To explore the effect of building continuous renal replacement therapy (CRRT) professional nursing team in emergency intensive care unit (EICU).Methods To establish CRRT professional nursing team in EICU,define the duties,responsibilities and job contents,and provide theory and manipulative skill training about CRRT care,make processes and guides,accumulate cases,strengthen CRRT nursing quality control.The scores of theory knowledge and manipulative skill in CRRT and the incidence rate of CRRT nursing associated complication were respectively compared before and after the establishment of the CRRT professional nursing team.Results The scores of theory knowledge and manipulative skill in CRRT were respectively (95.53 ± 1.78),(97.00 ± 1.20) after the establishment of CRRT professional nursing team,and higher than (85.95 ±-3.82),(89.68 ± 2.85) before the establishment,and the differences were statistically significant (t =14.55,14.57,respectively; P ＜ 0.01).The incidence rate of CRRT nursing associated complication was decreased from 5.26％ to 1.44％,and the difference was statistically significant (x2 =4.59,P ＜ 0.05).Conclusions The establishment of CRRT professional nursing team in EICU can improve nurses' theory and clinical skill,standardize nurses' professional nursing behaviors,mobilize nurses' enthusiasm for the job and initiative in learning,and improve nursing quality. Key words: Continuous renal replacement therapy ; CRRT; On-the-job training; Professional nursing team; Emergency ICU