Nursing competence in continuous renal replacement therapy: development and validation of a measurement tool.

Acute Renal Failure is an essential condition frequently encountered in intensive care units and requires targeted treatment. The nursing team must be adequately trained in the management of the patient undergoing CRRT. To build and validate the CRRT-MCT (Continuous Renal Replacement Therapy -Measurement Competency Tool), which aims to measure nursing competence in managing patients undergoing renal replacement techniques. The most current guidelines for CRRT techniques were used to create an instrument to measure nursing competence. A pool of 10 experts evaluated this instrument. The pilot study examined content and face validity. Test-retest reliability with r-Person correlation and internal consistency reliability with Crombach's was assessed. The CRRT-MCT achieved good content and face validity (S-CVI= 0.96; I-CVI=70%-100%), good internal consistency reliability (Crombach's = 0.83). Two hundred and forty nurses employed in intensive care units did pilot testing and test-retesting. The t-test showed no significant difference between test and retest results, confirming the stability of the tool (Pearson's r = 0.984) CONCLUSIONS: The instrument assesses nursing competence concerning CRRT techniques in the ICU and is valid, reliable and understandable. The creation and validation of this tool enables nurses to understand their level of competence for the care of patients undergoing CRRT with the ultimate aim of becoming aware of their gaps and undertaking training to fill them to provide the best possible nursing care.

Renal replacement therapy modalities and techniques in intensive care units: An international survey.

Introduction: Continuous renal replacement therapy (CRRT) can be used to treat hyperammonaemia. However, no study has assessed the effect of different CRRT techniques on ammonia clearance. Methods: We compared 3 different CRRT techniques in adult patients with hyperammonaemia, liver failure, and acute kidney injury. We protocolized CRRT to progressively deliver continuous veno-venous haemofiltration (CVVH), haemodialysis (CVVHD) or haemodiafiltration (CVVHDF). Ammonia was simultaneously sampled from the patient’s arterial blood and effluent fluid for each technique. We applied accepted equations to calculate clearance. Results: We studied 12 patients with a median age of 47 years (interquartile range [IQR] 25–79). Acute liver failure was present in 4 (25%) and acute-on-chronic liver failure in 8 (75%). There was no significant difference in median ammonia clearance between CRRT technique; CVVH: 27 (IQR 23–32) mL/min versus CVVHD: 21 (IQR 17–28) mL/min versus CVVHDF: 20 (IQR 14–28) mL/min, p = 0.32. Moreover, for all techniques, ammonia clearance was significantly less than urea and creatinine clearance; urea 50 (47–54) mL/min versus creatinine 42 (IQR 38–46) mL/min versus ammonia 25 (IQR 18–29) mL/min, p = 0.0001. Conclusion: We found no significant difference in ammonia clearance according to CRRT technique and demonstrated that ammonia clearance is significantly less than urea or creatinine clearance.

Atlas of Hemofiltration

Renal Support for Acute Kidney Injury in the Developing World

Antibiotics are frequently used in patients receiving intermittent or continuous renal replacement therapy (RRT). Continuous renal replacement may alter the pharmacokinetics (PK) and the ability to achieve PK/pharmacodynamic (PD) targets. Therapeutic drug monitoring (TDM) could help evaluate drug exposure and guide antibiotic dosage adjustment. The present review describes recent TDM data on antibiotic exposure and PK/PD target attainment (TA) in patients receiving intermittent or continuous RRT, proposing practical guidelines for performing TDM. Studies on antibiotic TDM performed in patients receiving intermittent or continuous RRT published between 2000 and 2020 were searched and assessed. The authors focused on studies that reported data on PK/PD TA. TDM recommendations were based on clinically relevant PK/PD relationships and previously published guidelines. In total, 2383 reports were retrieved. After excluding nonrelevant publications, 139 articles were selected. Overall, 107 studies reported PK/PD TA for 24 agents. Data were available for various intermittent and continuous RRT techniques. The study design, TDM practice, and definition of PK/PD targets were inconsistent across studies. Drug exposure and TA rates were highly variable. TDM seems to be necessary to control drug exposure in patients receiving intermittent and continuous RRT techniques, especially for antibiotics with narrow therapeutic margins and in critically ill patients. Practical recommendations can provide insights on relevant PK/PD targets, sampling, and timing of TDM for various antibiotic classes. Highly variable antibiotic exposure and TA have been reported in patients receiving intermittent or continuous RRT. TDM for aminoglycosides, beta-lactams, glycopeptides, linezolid, and colistin is recommended in patients receiving RRT and suggested for daptomycin, fluoroquinolones, and tigecycline in critically ill patients on RRT.

BACKGROUND AND AIMSAcute kidney injury (AKI) is a common complication of coronavirus disease-19 (COVID-19), which, particularly in critically ill patients requiring continuous renal replacement therapy (CRRT), is associated with an elevated mortality risk [1, 2]. However, knowledge about COVID-19 pathogenesis and management is evolving, and clinical practice is changing rapidly. Here, we evaluated if this process had an impact on the management and outcome of AKI patients.METHODSWe performed a retrospective observational study on critically ill adult COVID-19 patients who received CRRT in the intensive care unit (ICU) during the first two pandemic waves before the availability of COVID-19 vaccines: the first one from March to August 2020 (first) and the second one (second) from September to December 2020.RESULTSOverall, we considered 63 patients, aged 65 (60–69) years, 76.2% males. The main comorbidities were diabetes (DM), cardiovascular disease (CVD) and chronic kidney disease (CKD). Among them, 28 (44%) were in the first group and 35 (66%) in the second group. There were no significant differences in general characteristics, such as in comorbidities, except for a higher prevalence of CVD in the first group (Fig. 1). Lab examinations at ICU admission, including serum creatinine level (sCr), were not different between the two groups. While all patients required respiratory support, non-invasive ventilation was more prevalent in the second wave. Notably, during this period, decapneization combined with CRRT was introduced. Regarding drugs, we found that in the second group, hydroxychloroquine was abandoned, tocilizumab use was reduced and heparin administration significantly increased. The AKI time course was similar between the patients of the two waves (Fig. 2). There were no significant differences in CRRT techniques. However, in the second, the use of additional CRRT-devices, in particular adsorption-based filters, significantly increased. In most cases, citrate anticoagulation was used in both groups. Looking at the outcomes, we found no significant difference between the two waves. Indeed, 17 (60.2%) and 22 (62.8%) patients died in the ICU in the first and second groups, respectively. The length of ICU hospitalization, days on CRRT, invasive ventilation and DM were significantly related to overall mortality; time of ICU hospitalization was the only remaining significant at multivariate Cox regression. Overall, 21 (33%) patients survived hospitalization. At the 6 months after the discharge, 3 of them died, 3 were on HD and 15 were dialysis-free, even if 6 of them presented CKD.FIGURE 1:Clinical characteristics and ICU management of critically ill COVID-19 patients undergoing CRRT.FIGURE 2:Kidney function and management of critically ill COVID-19 patients undergoing CRRT.CONCLUSIONOur data confirm the high complexity and mortality of COVID-19 patients undergoing CRRT. Comparing the first two pandemic waves, we found that the patients also presented similar characteristics in terms of renal function and AKI time course. Regarding treatments, we observed some significant modifications in the management of ventilation, drug administration and dialysis membranes, mainly because of the results of ongoing clinical trials. However, these changes did not impact patients’ outcomes.These data support the view that only game-change strategies, such as vaccination or infection-specific drugs, may impact the presentation and outcome of COVID-19 patients undergoing CRRT.Finally, patients surviving this condition deserve special attention in the follow-up.

Hemostasis in patients with acute kidney injury secondary to acute liver failure

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

The current role of nurses in the management of critically ill patients needing continuous renal replacement therapies is clearly fundamental. The care of these complex patients is typically shared by critical care and dialysis nurses: their precise duties may vary from country to country. To clarify this issue we conducted a national-level survey at a recent Italian course on nursing practices during continuous renal replacement therapies. A total of 119 questionnaires were analysed. The participants, who were equally divided between critical care and dialysis nurses, came from 44 different hospitals and 35 Italian cities. Overall, 23% of participants answered that "the dialysis staff" were responsible for continuous renal replacement therapies in the Intensive Care Unit, while 39% answered "the critical care nurse", and 38% "a shared organization". Interestingly, less than the half of participants claimed specific continuous renal replacement therapies training was provided to employees before handling an acute dialysis machine. Finally, about 60% of participants had experience of extra-corporeal membrane oxygenation machines used in conjunction with continuous renal replacement therapies. Workload coordination and management of critically ill patients undergoing continuous renal replacement therapies in Italy is not standardized. At present, the duties of critical care and dialysis nurses vary significantly across the country. They frequently overlap or leave gaps in the assistance received by patients. The role of nurses involved in the care of continuous renal replacement therapies patients in Italy currently requires better organization, possibly starting with intensive standardized training and educational programs.

Effect of early and intensive continuous venovenous hemofiltration on patients with cardiogenic shock and acute kidney injury after cardiac surgery

High clearance continuous renal replacement therapy with a modified dialysis machine

Background/Objectives: Continuous renal replacement therapy (CRRT) is a critical intervention for managing acute kidney injury (AKI) in critically ill patients. Critical care nurses (CCNs) play a pivotal role in its implementation, requiring adequate knowledge, a positive attitude, and practice proficiency. This study aimed to assess the levels and factors affecting CCNs’ knowledge, attitudes, and practices (KAPs) regarding the care of patients receiving CRRT in Hail Hospitals, Saudi Arabia. Methods: A cross-sectional study was conducted with 190 registered CCNs from the critical care units of Hail Hospitals, Saudi Arabia, from March to May 2025. Data were collected using a sociodemographic characteristics sheet and the knowledge, attitudes, and practices questionnaire on CRRT. Non-parametric statistical tests (Mann–Whitney U, Kruskal–Wallis, and Spearman’s correlation tests) were used to determine the relationships between variables. A multiple linear regression analysis was used to explore the factors affecting the study variables. Results: The majority of CCNs had a high level of knowledge regarding CRRT management (66.3%), followed by moderate (21.1%) and low (16.6%) levels. Additionally, the majority had a high level of attitude regarding CRRT management (74.7%), followed by moderate (18.4%) and low (6.9%) levels. The majority of CCNs had a high level of practice regarding CRRT management (66.8%), followed by low (23.7%) and moderate (9.5%) levels. There was a significant positive correlation between CCNs’ knowledge, attitudes (rs = 0.230, p < 0.001), and practices (rs = 0.192, p < 0.001). Additionally, there was a significant positive correlation between CCNs’ attitudes and practices (r = 0.419, p < 0.001). Multiple linear regression revealed a significant model (p < 0.001) when sociodemographic and work-related factors were analyzed as predictors of CCNs’ levels of knowledge, attitudes, and practices regarding CRRT: Having more experience, working with a nurse-to-patient ratio of 1:2, and frequently using CVVHDF as a CRRT modality were significant factors for higher knowledge levels when compared to the reference categories. In addition, having a bachelor’s degree and frequently using CVVHD, CVVHDF, or SCUF as a CRRT modality were significant factors for higher attitude levels regarding CRRT when compared to the reference categories. Having a bachelor’s degree and frequently using CVVHD or CVVHDF as a CRRT modality were significant factors for higher practice levels regarding CRRT when compared to the reference categories. Conclusions: CCNs in Hail Hospitals self-reported high levels of knowledge, attitudes, and practices regarding CRRT management, followed by moderate levels. Targeted educational programs, standardized protocols, and organizational support are recommended to improve CCN care for CRRT and to optimize patient outcomes.

Abstract: We describe the theoretical features and in vivo assay of an original computer-based program, which describes Na and HCO3 kinetics with acetate-free biofiltration® performed as a continuous veno-venous renal replacement therapy (CVVAFB). In 14 patients, CVVAFB sessions were performed as follows. Machine Hospal Prisma®, membrane AN69 0.9 m2, blood circuit Hospal M100pre Set, dialysate bags of electrolyte solution with basic composition of: Na 139 mEq/L, K 2 mEq/L, Ca 3.0 mEq/L, Mg 2 mEq/L, Cl 146 mEq/L, and glucose 5.5 mmol/L. Predilutional infusion bags of 167 mEq/L of NaHCO3 solution (Hospal Biosol). To guide the prescription of the dialysate (QD) and the infusate (QInf) flow rates we designed a suitable computer program, which calculated Na and HCO3 kinetics and predicted their plasma profiles at equilibrium. Prescribed flow rates were QB 150 ml/min, QD 1636 ± 42 ml/hr, QInf 639 ± 74 ml/hr and ultrafiltration (UF) rate 110 ± 41 ml/hr. During CVVAFB, plasma profiles of HCO3 and Na became stable after 24 hr. With HCO3, the average predicted and observed plasma levels at equilibrium were 27.1 ± 1.5 and 27.3 ± 1.5 mEq/L, respectively (p=ns); with Na, the predicted and observed levels at equilibrium were 140.2 ± 1.8 and 141.3 ± 1.7 mEq/L, respectively (p=ns). There was a good correlation between predicted and observed values for both Na (p&amp;lt;0.01, r=0.78) and HCO3 (p&amp;lt;0.01, r=0.87). These results confirmed the reliability of our mathematical model for CVVAFB. A Long-term trial is needed to obtain more information on its clinical effects and compare CVVAFB with other continuous renal replacement therapy techniques.

47. Continuous renal replacement therapy