Circuit Lifespan Research Articles

The comparison of circuit lifespan between integration and separation approach in extracorporeal membrane oxygenation (ECMO) patient requiring continuous renal replacement therapy (CRRT) support, (E-CRRT Trial)

Background: The estimated incidence of acute kidney injury requiring continuous renal replacement therapy (CRRT) in patients necessitating extracorporeal membrane oxygenation (ECMO) is approximately 50%. Currently, two well-known techniques—integration and separation—are utilized for combining CRRT and ECMO circuits. The efficacy of these two techniques is still unknown. Therefore, this study aimed to compare the circuit lifespan of CRRT between the integration and separation techniques. Methods: A multicentered randomized controlled study with an unblinded design will be conducted to determine circuit lifespan differences between integration and separation techniques. Hypothesis: We hypothesize that the integration technique will yield a longer circuit lifespan for CRRT compared to the separation technique. Trial registration: NCT05036616

Comparison of diluted vs concentrated regional citrate anticoagulation in continuous renal replacement therapy: A quasi-experimental study.

The incidence of coagulation of continuous renal replacement therapy circuits remains high. To the best of our knowledge, no scholar has published a protocol to avoid management errors when different types of citrates coexist in the same Intensive Care Unit. To assess the safety and efficacy of the unification of two protocols with different concentrations of citrate solution. A prospective, quasi-experimental study was carried out in the intensive care unit of a tertiary referral hospital (in Barcelona, Spain), over 3 years. Consecutive adult patients requiring continuous renal replacement therapy with citrate were included. The sample was divided into two groups, a control group (concentrated citrate) and an intervention group (diluted citrate). The decision to initiate anticoagulation with diluted (18 mmol/L) or concentrated (136 mmol/L) citrate was made based on the machine available and the decision of the doctor responsible for the patient. It was not possible to randomize the sample. Both protocols were matched with a starting citrate dose of 3.5 mmol/L, and a dialysis solution was used. Post-filter replacement was not used, and the citrate solution was the only fluid administered pre-filter. The analysis included 59 circuits in the concentrated citrate group and 40 circuits in the diluted citrate group. An increased need for electrolyte replacement was observed in the diluted group (p < .001). The concentrated citrate group had a longer filter life (p < .05), and there was a slight trend toward alkalosis. The diluted citrate group had a higher incidence of electrolyte replacement. The concentrated citrate group had longer circuit lifespan and a trend toward metabolic alkalosis, although this was not statistically significant. If these conclusions are considered, the protocol can be unified. The present work aims to provide information on the differences in the use of regional anticoagulation with diluted or concentrated citrate. The objective is to pay special attention to aspects that can lead to complications. The unified protocol proposed in this paper could be extrapolated to any machine on the market that uses either of these two types of citrate concentration.

#5409 FACTORS ASSOCIATED WITH THE CIRCUIT LIFESPAN OF CONTINUOUS KIDNEY REPLACEMENT THERAPY (CKRT)

Abstract Background and Aims Approximately half of patients in intensive care unit (ICU) experienced acute kidney injury (AKI). ICU patients with severe AKI and hemodynamic instability sometimes require continuous kidney replacement therapy (CKRT). Termination of CKRT circuits leads to blood loss, attenuation of therapeutic effects of CKRT, and a heavy workload and resource burden for medical staff. Identification of the factors which can prolong the lifespan of CKRT circuits is clinically essential. We aimed to elucidate the factors affecting the lifespan of CKRT circuits in ICU patients. Method We evaluated the lifespans of 559 CKRT circuits used for 63 ICU patients at the Okinawa Prefectural Nanbu Medical Center and Children's Medical Center from April 1st, 2021 to March 31st, 2022. We enrolled all ICU patients who required CKRT. Our research team prospectively collected information on the patients' basal characteristics, CKRT prescription, activated clotting time (ACT) after the hemofilter, CKRT circuit lifespan, and causes of termination of circuits prospectively. Effects of ACT were examined by grouping patients into three with their ACT values: &amp;lt;140, 140≦ and &amp;lt;180, and ≧180 seconds. The primary outcome of this study was a termination of the CKRT circuit within 24 hours after the initiation of the CKRT circuit. The secondary outcome was the cause of terminating CKRT circuits. Primarily, we examined the impacts of factors associated with CKRT circuit lifespan using multivariable Cox-proportional hazards regression. Results Our cohort's median follow-up period of CKRT hemofilter was 18.5 hours. The total number of participants was 63, and 63.5% were male. In the multivariate Cox regression analysis, targeting ACT between 140 to 180 seconds was associated with a longer circuit lifespan (HR = 2.11(1.43-3.11), p&amp;lt;0.0001) than the group of CKRT circuits with ACT&amp;lt;140 seconds. Based on our results, targeting ACT between 140 to 180 seconds extended the median survival time of the circuit lifespan to 1.4 times longer than the group of circuits with ACT less than 140 (Fig. 1). There were no differences in the causes of hemofilter occlusion among the three ACT groups. Notably, COVID-19 was not significantly associated with a reduction in circuit lifespans (HR = 0.63(0.35-1.11), p = 0.110). Conclusion Appropriate monitoring of ACT during CKRT may help prolong circuit lifespan, and the optimal ACT range was 140 to 180 seconds. In contrast, COVID-19 was not a risk factor for an early occlusion of CKRT circuits.

Efficacy of Prostacyclin Anticoagulation in Critically Ill Patients Requiring Extracorporeal Support: A Systematic Review and Meta-Analysis.

Extracorporeal support modalities are highly prothrombotic. Anticoagulation is frequently used for patients receiving Continuous Renal Replacement Therapy (CRRT), Molecular Adsorbent Recirculating System (MARS), and Extracorporeal Membrane Oxygenation (ECMO). The objective of this systematic review and meta-analysis is to determine if prostacyclin-based anticoagulation strategies are effective compared to other anticoagulation strategies, in critically ill children and adults who needs extracorporeal support, such as continuous renal replacement therapy. We conducted a systematic review and meta-analysis using multiple electronic databases and included studies from inception to June 1, 2022. Circuit lifespan, proportion of bleeding, thrombotic, and hypotensive events, and mortality were evaluated. Out of 2,078 studies that were screened, 17 studies (1,333 patients) were included. The mean circuit lifespan was 29.7 hours in the patients in the prostacyclin-based anticoagulation series and 27.3 hours in the patients in the heparin- or citrate-based anticoagulation series, with a mean difference of 2.5 hours (95%CI -12.0;16.9, p=0.74, I2=0.99, n=4,003 circuits). Bleeding occurred in 9.5% of the patients in the prostacyclin-based anticoagulation series and in 17.1%of the patients in the control series, which was a statistically significant decrease (LogOR -1.14 (95%CI -1.91;-0.37), p<0.001, I2=0.19, n=470). Thrombotic events occurred in 3.6% of the patients in the prostacyclin-based anticoagulation series and in 2.2% of the patients in the control series, which was not statistically different (LogOR 0.97 (95%CI -1.09;3.04), p=0.35, I2=0.0, n=115). Hypotensive events occurred in 13.4% of the patients in the prostacyclin-based anticoagulation series and in 11.0% of the patients in the control series, which was not statistically different (LogOR -0.56 (95%CI -1.87;0.74), p=0.40, I2=0.35, n=299). The mortality rate was 26.3% in the prostacyclin-based anticoagulation series, and 32.7% in the control series, which was not statistically different (LogOR -0.40 (95%CI -0.87;0.08), p=0.10, I2=0.00, n=390). The overall risk of bias was low to moderate. In this systematic review and meta-analysis of 17 studies, prostacyclin-based anticoagulation was associated with fewer bleeding events, but with similar circuit lifespans, thrombotic events, hypotensive events, and mortality rates. The potential benefits of prostacyclin-based anticoagulation should be explored in large randomized controlled trials.

Change in prefilter pressure as a key determinant in the decision to return blood in continuous renal replacement therapy: An observational study.

During continuous renal replacement therapy (CRRT), circuit coagulation is an important event that can result in suboptimal outcomes. Nurses must remain alert throughout the treatment and observe machine pressures. Transmembrane pressure (TMP) is commonly used for monitoring but it is sometimes too late to return blood to the patient. To compare the capacity of prefilter pressure (FP) versus TMP to predict the risk of circuit coagulation in adult patients with acute renal failure on CRRT. An observational, longitudinal, prospective study. This study was carried out in a tertiary referral hospital over 2 years. Data collected included the following variables: TMP, filter or FP, effluent pressure, venous and arterial pressure, filtration fraction, and ultrafiltration constant of each circuit. Means and their trends over time were collected, for both diffusive and convective therapy and for two membrane types. A total of 151 circuits (24 polysulfone and 127 acrylonitrile) were analysed, from 71 patients (n = 22 [34%] women; mean age, 66.5 [36-84] years). Of the total treatments, 80 were diffusive, and the rest were convective or mixed. In the diffusive circuits, a progressive rise in FP was observed without an increase in TMP and with an increasing trend in effluent pressure. Circuit lifespan was between 2 and 90 h. In 11% (n = 17) of the cases, the blood could not be returned to the patient. These findings allowed the creation of graphs that indicate the appropriate point to return blood to the patient. FP was a major determinant in this decision; in most cases, TMP was not a reliable parameter. Our findings are applicable to convective, diffusive, and mixed treatments as well as both types of membranes used in this acute setting. This study provides two clear reference graphs showing risk scales for the assessment of circuit pressures in CRRT. The graphs proposed here can be used to evaluate any machine on the market and the two types of membranes used in this acute setting. Both convective and diffusive circuits can be assessed, allowing safer evaluation in patients who change treatment.

Targeting the contact system in a rabbit model of extracorporeal membrane oxygenation.

Previous studies suggested that contact pathway factors drive thrombosis in mechanical circulation. We used a rabbit model of veno-arterial extracorporeal circulation (VA-ECMO) to evaluate the role of factors XI and XII in ECMO-associated thrombosis andorgan damage. Factors XI and XII (FXI, FXII) were depleted using established antisense oligonucleotides before placement on a blood-primed VA-ECMO circuit. Decreasing FXII or FXI to< 5% of baseline activity significantly prolonged ECMO circuit lifespan, limited the development of coagulopathy, and prevented fibrinogen consumption. Histological analysis suggested that FXII depletion mitigated interstitial pulmonary edema and hemorrhage whereas heparin and FXI depletion did not. Neither FXI nor FXII depletion was associated with significant hemorrhage in other organs. Invitro analysis showed that membrane oxygenator fibers (MOFs) alone are capable of driving significant thrombin generation in a FXII- and FXI-dependent manner. MOFs also augment thrombin generation triggered by low (1 pM) or high (5 pM) tissue factor concentrations. However, only FXI elimination completely prevented the increase in thrombin generation driven by MOFs, suggesting MOFs augment thrombin-mediated FXI activation. Together, these results suggest that therapies targeting FXII or FXI limit thromboembolic complications associated with ECMO. Further studies are needed to determine the contexts wherein targeting FXI and FXII, either alone or in combination, would be most beneficial in ECMO. Moreover, studies are also needed to determine the potential mechanisms coupling FXII to end-organ damage in ECMO.

Standard versus no post-filter ionized calcium monitoring in regional citrate anticoagulation for continuous renal replacement therapy (NPC trial).

Current guidelines recommend monitoring of post-filter ionized calcium (pfCa) when using regional citrate anticoagulation during continuous renal replacement therapy (RCA-CRRT) to determine citrate efficiency for the prevention of filter clotting. However, the reliability of pfCa raises the question of whether routine monitoring is required. Reducing the frequency of pfCa monitoring could potentially reduce costs and workload. Our objective was to test the efficacy and safety of no pfCa monitoring among critically ill patients receiving RCA-CRRT. This study was a non-inferiority randomized controlled trial conducted between January 2021 and October 2021 at King Chulalongkorn Memorial Hospital, Thailand. Critically ill patients who were treated with RCA-CRRT were randomized to receive either standard pfCa monitoring (aiming pfCa level of 0.25-0.35mmol/L), or no pfCa monitoring, in which a constant rate of citrate infusion was maintained at pre-determined citrate concentrations of 4mmol/L with blinding of pfCa levels to treating clinicians. The primary outcome was the filter lifespan. Non-inferiority would be demonstrated if the upper limit of the 95% confidence interval (CI) for the difference in filter lifespan between the groups was less than 20 h. Fifty patients were randomized to the standard pfCa monitoring group (n=25) or no pfCa monitoring group (n=25). The mean filter lifespan was 54±20 h in the standard pfCa monitoring group and 47±23 h in the no pfCa monitoring group (absolute difference 7.1 h; 95% CI -5.3, 19.5, P=.25). When restricting the analysis to circuits reaching the maximum duration of circuit lifespan at 72 h and clotted filters, the filter lifespan was 61±17 h in the standard pfCa group vs 60±19 h in the no pfCa monitoring group (absolute difference 0.9 h; 95% CI -11.5, 13.4, P=.88). Compared with the no pfCa monitoring group, the standard pfCa monitoring group had a significantly higher mean citrate concentrations (4.43±0.32 vs 4mmol/L, P<.001) and a higher rate of severe hypocalcemia (44% vs 20%, P=.13). No statistical differences were found in filter clotting, citrate accumulation, citrate overload and mortality between the two groups. Among critically ill patients receiving RCA-CRRT, no pfCa monitoring by maintaining the citrate concentrations of 4mmol/L is feasible. Larger randomized controlled trials should be conducted to ensure the efficacy, safety and cost-effectiveness of this strategy. ClinicalTrials.gov: NCT04792424 (registered 11 March 2021).

An evaluation of different dilution modes on circuit lifespan during continuous veno-venous hemodiafiltration without anticoagulation.

Circuit clotting remains a major problem during continuous kidney replacement therapy (CKRT), particularly in patients with contraindications to anticoagulant use. We hypothesized that the different options of alternative replacement fluid infusion sites might affect circuit lifespan. However, research-based evidence supporting an optimal replacement fluid infusion strategy is limited. Therefore, we aimed to evaluate the effect of three dilution modes (pre-dilution, post-dilution, and pre- to post-dilution) on circuit lifespan during continuous veno-venous hemodiafiltration (CVVHDF). This prospective cohort study was conducted between December 2019 and December 2020. Patients requiring CKRT were enrolled to receive pre-dilution, post-dilution, or pre- to post-dilution fluidinfusionwith CVVHDF. The primary endpoint was circuit lifespan, and the secondary outcomes included the clinical parameters of patients, such as changes in serum creatinine (Scr) and blood urea nitrogen (BUN) levels, 28-day all-cause mortality, and length of stay. For all patients included in this study, only the first circuit used was recorded. Among the 132 patients enrolled in this study, 40 were in the pre-dilution mode, 42 were in the post-dilution mode, and 50 were in the pre- to post-dilution mode. The mean circuit lifespan was significantly longer in the pre- to post-dilution group (45.72 h, 95% CI, 39.75-51.69 h) than in the pre-dilution group (31.58 h, 95% CI, 26.33-36.82 h) and the post-dilution group (35.20 h, 95% CI, 29.62-40.78 h). There was no significant difference between the pre- and post-dilution group circuit lifespan (p > 0.05). Kaplan-Meier survival analysis revealed a significant difference between the three dilution modes (p = 0.001). No significant differences were observed in terms of changes in the Scr and BUN levels, admission day, and 28-day all-cause mortality among the three dilution groups (p > 0.05). The pre- to post-dilution mode significantly prolonged circuit lifespan but did not reduce Scr and BUN levels, compared with the pre-dilution and post-dilution modes during CVVHDF when no anticoagulants were used.

The Japanese Pediatric Continuous Renal Replacement Therapy (jpCRRT) Registry: Study Protocol.

The use of continuous renal replacement therapy (CRRT) in critically ill children is rapidly increasing, but the standard of care has not yet been established and prognosis remains poor. To develop optimal CRRT strategies, we launched a research project generating the Japanese Pediatric CRRT registry, a multicenter registry of CRRT in Japanese pediatric intensive care units (PICUs), to investigate the actual status of CRRT in recent years in PICUs, where data are lacking. This manuscript presents a protocol for planning a multicenter prospective registry. As of April 2023, 15 Japanese PICUs are voluntarily participating. Patients enrolled are those <16 years of age who enter the PICUs of the collaborating institutions, require CRRT, and have the guardians' consent. CRRT is defined as anticipated to be required for >24 hours, and CRRT connected to extracorporeal membrane oxygenation is also included. The registry is an online registry system managed by the University Hospital Medical Information Network. The primary outcomes are Pediatric Cerebral Performance Category Scale at PICU discharge and 6 months post-discharge (deaths included), persistent need for dialysis, and PICU readmission within 6 months. The secondary outcomes are adverse events during and immediately after CRRT initiation, and initial circuit life span. This project will examine the differences in outcomes of CRRT in PICUs in specific patient and treatment groups and will be used to design future interventional studies. We will also aim to establish a platform for a multicenter registry study in Japanese PICUs, considering the current lack of such a platform.

Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation in Children with Liver Dysfunction/Failure.

Regional citrate anticoagulation (RCA) is an option but citrate accumulation is risk and it is a giving up cause for this situation. This retrospective study was conducted in the pediatric intensive care unit (PICU) between May 2019 and April 2021. We investigated 47 patients with liver failure (LF) in our PICU, and RCA during continuous renal replacement therapy (CRRT) was applied to 10 (21.3%) of them. Half of them were male (n: 5/10), their mean age was 104.7 ± 66.20 months. Nine of them needed vasoactive support during follow-up. The most common indication for CRRT was hepatorenal syndrome (40%). There was no significant difference between liver transaminases and liver function tests before and after CRRT (p > 0.05). In terms of citrate toxicity of the patients, there was no significant difference between total calcium/ionized calcium, lactate level, pH and bicarbonate values before and after CRRT (p > 0.05). The mean total CRRT time was 110.2 ± 118.2 h, and the mean circuit lifespan was 43.8 ± 48.7 h; the mean number of circuits was 2.7 ± 2.4. Total Ca/ionized Ca >2.5 was a clinically relevant endpoint, but no patient interrupted dialysis for this cause. There was no complication about RCA. This study did not observe any adverse effects on acid-base status, transaminases, an increase in bilirubin during RCA-CRRT treatment in pediatric patients with LF. Total calcium/ionized calcium ratio, serum lactate level and prothrombin time level should be closely monitored daily in terms of citrate accumulation in this patient group.

Validation of a Protocol for Continuous Hemodiafiltration with Regional Citrate Anticoagulation with Omni®

Introduction: Omni® (B Braun, Melsungen, Germany) is able to run continuous renal replacement therapy (CRRT) in continuous veno-venous hemofiltration (CVVH), hemodialysis (CVVHD), and hemodiafiltration (CVVHDF) modes. However, to date, there is no validated protocol to guide the use of Omni® in CVVHDF mode with regional citrate anticoagulation (RCA). Methods: We designed a protocol for CVVHDF-RCA tailored for Omni®. This protocol was tested in patients included in an observational study conducted in our center between January and March 2021. For all study patients, we collected baseline characteristics, laboratory results, CRRT circuit lifespan as well as plasma and effluent samples at 12, 24, 48, and 72 h of CRRT circuit initiation. At each study time point, we computed urea, creatinine, and β2-microglobulin clearance as well as effluent/blood ratios. Data from circuits in CVVHDF-RCA mode are compared with those in standard therapy (CVVHD-RCA) with the same device. Results: We analyzed ten circuits (5 patients) in CVVHDF-RCA mode and 32 (13 patients) in CVVHD-RCA mode. No adverse events related to the therapy were observed. In CVVHDF-RCA mode, median circuit running time was 68 (IQR 8.1) hours versus 46 (IQR 9.0) in CVVHD mode, p = 0.053. Therapy adaptations (dialysate rate and/or blood flow) were required in one (10%) circuit (15.6% in CVVHD mode, p = 0.56). Compared to CVVHD, CVVHDF was able to achieve similar clearance and effluent/blood ratio for urea, creatinine, and β2-microglobulin across the entire duration of circuit lifetime. Conclusion: The proposed protocol for CVVHDF-RCA for Omni® was associated with similar circuit lifetime, number of required adaptations and clearances to standard CVVHD-RCA. It appears to be safe and feasible.

Clinical Factors Affecting Continuous Renal Replacement Therapy Circuit Life Span

Clinical Factors Affecting Continuous Renal Replacement Therapy Circuit Life Span

Effect of Dynamic Circuit Pressures Monitoring on the Lifespan of Extracorporeal Circuit and the Efficiency of Solute Removal During Continuous Renal Replacement Therapy.

Objective: To observe the effects of dynamic pressure monitoring on the lifespan of the extracorporeal circuit and the efficiency of solute removal during continuous renal replacement therapy (CRRT).Materials and Methods: A prospective observational study was performed at the West China Hospital of Sichuan University in the ICU. Analyses of the downloaded pressure data recorded by CRRT machines and the solute removal efficiencies, calculated by 2*Ce/(Cpre+Cpost), where Ce, Cpre, and Cpost are the concentrations of the effluent, pre-filter blood, and post-filter blood, respectively, were performed. Samples were collected at 0, 2, 6, 12, and 24 h when continuous veno-venous hemodiafiltration (CVVHDF) was used after the initiation of CRRT. Measurements in concentrations of creatinine, blood urea nitrogen, and β2-microglobulin in the plasma and effluent were recorded.Results: Extracorporeal circuits characterized by moderate-to-severe (M–S) access outflow dysfunction (AOD) events, defined as access outflow pressure less than or equal to −200 mmHg for more than 5 min, had shorter median lifespans with no anticoagulation (32.3 vs. 10.90 h, P = 0.001) compared with the no M–S AOD events group. The significant outcome also existed in regional citrate anticoagulation (RCA) (72 vs. 42.47 h, P = 0.02). Moreover, Cox regression analysis revealed that the lack of M–S AOD events, RCA, or CVVHDF independently prolonged the circuit lifespan. All tested solutes removal efficiencies started to decline at 12 h. Furthermore, efficiencies of all solutes removal dropped obviously at 24 h when TMP ≥ 150 mmHg.Conclusion: RCA and CVVHDF predicted a longer circuit lifespan. M–S AOD events were associated with a shorter circuit lifespan when RCA or no anticoagulant was used. Replacement of extracorporeal circuit could be considered when running time of filter lasted up to 24 h with TMP ≥ 150 mmHg.

Non-pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy.

Non-pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy.

Decreased CRRT Filter Lifespan in COVID-19 ICU Patients.

(1) Background: Increased thromboembolic events and an increased need for continuous renal replacement therapy (CRRT) have been frequently reported in COVID-19 patients. Our aim was to investigate CRRT filter lifespan in intensive care unit (ICU) COVID-19 patients. (2) Methods: We compared CRRT adjusted circuit lifespan in COVID-19 patients admitted for SARS-CoV-2 infection to a control group of patients admitted for septic shock of pulmonary origin other than COVID-19. Both groups underwent at least one session of CRRT for AKI. (3) Results: Twenty-six patients (13 in each group) were included. We analysed 117 CRRT circuits (80 in the COVID-19 group and 37 in the control group). The adjusted filter lifespan was shorter in the COVID-19 group (17 vs. 39 h, p < 0.001). This trend persisted after adjustment for confounding factors (−14 h, p = 0.037). Before CRRT circuit clotting, the COVID-19 group had a more procoagulant profile despite higher heparin infusion rates. Furthermore, we reported a decreased relation between activated partial thromboplastin time (aPTT) and cumulative heparin dose in COVID-19 patients when compared to historical data of 23,058 patients, suggesting a heparin resistance. (4) Conclusion: COVID-19 patients displayed a shorter CRRT filter lifespan that could be related to a procoagulant profile and heparin resistance.

Feasibility and efficacy of modified fixed citrate concentration protocol using only commercial preparations in critically ill patients: a prospective cohort study with a historical control group

BackgroundThe cumbersome program and the shortage of commercial solution hindered the regular application of regional citrate anticoagulation (RCA). It is urgent to simplify the protocol using only commercial preparations. The aim of this study was to explore the feasibility and efficacy of the modified protocol for continuous veno-venous hemofiltration (CVVH) in unselected critically ill patients.MethodsA prospective cohort study was conducted in 66 patients who received a new protocol combining fixed citrate concentration with modified algorithm for supplements (i.e., fixed protocol), and compared the efficacy, safety and convenience for this group to a historical control group with a traditional protocol (n = 64), where citrate was titrated according to the circuit ionized calcium concentration (i.e., titrated protocol). The convenience was defined as the demand for monitoring test and dose adjustment of any supplement.ResultsThe filter lifespan was 63.2 ± 16.1 h in the fixed group and 51.9 ± 17.7 h in the titrated group, respectively. Kaplan-Meier survival analysis demonstrated longer circuit lifetime for fixed group (log-rank, p = 0.026). The incidence of circuit clotting was lower in the fixed protocol (15.2% vs. 29.7% in the titrated protocol, p = 0.047). Moreover, compared with the titrated group, patients with fixed protocol had less demand for monitoring test and dose adjustment of any supplement (the number of times per person per day) (3.3 [IQR 2.3–4.5] vs. 5.7 [IQR 3.3–6.9], p = 0.001 and 1.9 [IQR 0.5–2.7] vs. 6.3 [IQR 4.2–7.9], p < 0.001; respectively). No new onset bleeding complications occurred in all patients. The overall incidence of suspected citrate accumulation was 4.6% and there was no difference between the two groups (p = 0.969), yet a lower rate of metabolic alkalosis was found in the fixed group (3.0% vs. 14.1%, p = 0.024).ConclusionsOur modified fixed citrate concentration protocol is feasible, safe and effective to enhance the circuit lifespan and the convenience of implementation while maintaining a similar safety when compared to the traditional protocol. Using only commercial preparations may be helpful for widespread application of RCA.Trial registrationClinicaltrials.gov. NCT02663960. Registered 26 January 2016.

Dialysis Filter Life, Anticoagulation, and Inflammation in COVID-19 and Acute Kidney Injury.

In recent studies, 5%–20% of hospitalized patients with coronavirus disease 2019 (COVID-19) developed AKI requiring RRT (CoV-AKI-RRT) (1,2) (L. Chan et al., unpublished observations). Hypercoagulability has been recognized as a salient feature of COVID-19 in the critically ill (3,4) and there have been anecdotal accounts of unexpectedly frequent dialysis filter clotting. However, there are limited data describing the magnitude of the problem. A recent report described clotting events in 28 of 29 patients with CoV-AKI-RRT and shorter filter lifespan compared with a historical control, but no details were provided regarding anticoagulation (4). Our objective was to examine the delivery of RRT and circuit interruptions in patients with CoV-AKI-RRT in comparison with those in the pre-COVID-19 era. With approval of the Institutional Review Board, waiver of informed consent, and in accordance with the Declaration of Helsinki, we conducted a retrospective single-center study, ancillary from our previously reported cohort (2). We identified hospitalized patients with COVID-19 (positive severe acute respiratory syndrome coronavirus 2 RNA PCR by nasopharyngeal swab) and AKI, who underwent RRT by sustained low-efficiency dialysis (SLED) for ≥8 hours in an intensive care unit between March and April of 2020 (study period: 4 weeks) by either prolonged intermittent or continuous RRT modality (5,6) using Fresenius 2008K/K2 (Bad Homburg, Germany) machines. At our hospital, continuous venovenous hemodiafiltration (CVVHDF) with PrismaFlex (Deerfield, IL) machines was restricted to the neurointensive care unit and was not expanded during the pandemic due to logistics. As pre-COVID-19 control, we included consecutive patients (reverse chronological order) with AKI without COVID-19 who underwent SLED in December of 2019. Electronic medical records were accessed and RRT flowsheets were manually reviewed to extract timing of initiation and interruption, blood flow rate (BFR), dialysate flow rate, and filter transmembrane pressure (TMP). Standard BFR was 200 …

Affecting Factors on Circuit Lifespan in Continuous Renal Replacement Therapy

Affecting Factors on Circuit Lifespan in Continuous Renal Replacement Therapy

Regional citrate versus heparin anticoagulation in continuous renal replacement therapy in critically ill patients: a Meta-analysis

To evaluate the efficacy and safety of regional citrate and heparin anticoagulation in continuous renal replacement therapy (CRRT) in critically ill patients by Meta-analysis. Randomized controlled trials (RCT) comparing the efficacy and safety of regional citrate and heparin anticoagulation in English or Chinese were retrieved from Medline, Embase, Cochrane library, Web of Science, CNKI, Wanfang Database by electronic and manual search before December 2019. The primary outcomes were mortality and circuit life span, and the secondary outcomes were complications such as bleeding, heparin-induced thrombocytopenia (HIT), metabolic alkalosis, and hypocalcemia. Meta-analysis of the literature was conducted using the methods recommended by the Cochrane Collaboration's software RevMan 5.3 and funnel plot was used to analyze whether there was publication bias in each study. Sixteen RCTs with 1 229 patients were included. Meta-analysis showed that there was no significant difference in mortality between the regional citrate and heparin anticoagulation in CRRT [relative risk (RR) = 0.95, 95% confidence interval (95%CI) was 0.83-1.09, P = 0.47]. The circuit life span in the regional citrate group was 15.37 hours (95%CI was 10.09-20.65, P < 0.000 01) longer than that in the heparin group. Bleeding risk (RR = 0.29, 95%CI was 0.19-0.44, P < 0.000 01) and HIT (RR = 0.35, 95%CI was 0.16-0.74, P = 0.006) were lower in the regional citrate group than those in the heparin group, whereas the regional citrate anticoagulation could cause hypocalcemia (RR = 4.67, 95%CI was 1.88-11.60, P = 0.000 9). There was no significant difference in the incidence of metabolic alkalosis between the two groups (RR = 0.76, 95%CI was 0.42-1.37, P = 0.36). The funnel plot showed that there were no significant publication bias in the included studies. Regional citrate anticoagulation could significantly prolong circuit life span and decrease the risk of bleeding, and should be preferentially selected for the CRRT anticoagulation in critically ill patients.

The Effect of Patient- and Treatment-Related Factors on Circuit Lifespan During Continuous Renal Replacement Therapy in Critically Ill Children.

To examine the effects of patient and treatment variables on circuit lifespan in critically ill children requiring continuous renal replacement therapy. Retrospective observational study based on a prospective registry. Tertiary referral 30-bed PICU. One hundred sixty-one critically ill children undergoing continuous renal replacement therapy during an 8-year period (2007-2014) were included in the study. Continuous renal replacement therapy. During the study period, 161 patients received a total of 22,190 hours of continuous renal replacement therapy, with a median duration of 74.75 hours (interquartile range, 32-169.5) per patient. Of the 572 filter circuits used, 276 (48.3%) were changed due to circuit clotting and 262 (45.8%) were electively changed. Median circuit life was 24.62 hours (interquartile range, 10.6-55.3) for all filters and significantly longer for those electively removed as compared to those prematurely removed because of clotting (35.50 hr [interquartile range, 16.9-67.6] vs 22.00 hr [interquartile range, 13.8-42.5]; p < 0.001). Multivariate regression analyses revealed that admission diagnosis (p < 0.001), anticoagulation type (p < 0.001), access type (p = 0.016), and circuit size (p = 0.027) were associated with prolonged circuit life, as well as, in patients on heparin anticoagulation, with higher doses of heparin (p < 0.001) and a prolonged activated partial thromboplastin time (p < 0.001). In this study, circuit lifespan in pediatric continuous renal replacement therapy was low and appeared to depend upon the patient's diagnosis, the type of access and anticoagulation used as well as the size of the circuit used.