Application Of Continuous Renal Replacement Therapy Research Articles

Tracking longitudinal biomarkers in burn patients with sepsis and acute kidney injury: an unsupervised clustering approach

BackgroundSepsis is a grave medical disorder characterized by a systemic inflammatory response to infection. Furthermore, it is a leading cause of morbidity and mortality, especially in hospitalized patients. Acute kidney injury (AKI) is a common complication of sepsis and is associated with increased morbidity and mortality. Patients with burns are particularly vulnerable to developing sepsis and AKI due to the extensive tissue damage and immune suppression resulting from burn injury. In this study, unsupervised clustering algorithms were used to track longitudinal biomarkers in patients with burns and assess their impact on mortality.MethodsThis retrospective study included adult patients with burns aged ≥ 18 years, who were admitted to the burn intensive care unit of Hallym University and Hangang Sacred Heart Hospital between July 2010 and December 2021. The patients were divided into two subgroups: those with sepsis (538 patients) and those without sepsis (826 patients). The longitudinal biomarkers were grouped into three clusters using the k-means clustering algorithm. Each cluster was assigned a letter from A to C according to its mortality rate.ResultsThe odds ratio (OR) of pH was 9.992 in the positive group and 31.745 in the negative group in cluster C. The OR for lactate dehydrogenase (LD) was 3.704 in the positive group and 6.631 in the negative group in cluster C. The OR for creatinine was 2.784 in the positive group and 8.796 in the negative group in cluster C. The OR for blood urea nitrogen (BUN) in the negative group was 0.348, indicating a negative predictor of mortality. Regarding the application of Continuous Renal Replacement Therapy (CRRT) and ventilation, ventilation was significant in both groups. In contrast, CRRT application was not significant in the sepsis-positive group. Furthermore, it was not selected as a variable in the negative group.ConclusionsThe pH, LD, and creatinine were significant in both groups, while lactate and platelets were significant in the sepsis-positive group. In addition, albumin, glucose, and BUN were significant in the sepsis-negative group. Continuous renal replacement therapy was not significant in either group. However, the use of a ventilator was associated with poor prognosis.

Risk factors associated with in-hospital mortality in patients requiring extracorporeal membrane oxygenation in the perioperative period of heart transplantation

Objective: To explore risk factors associated with in-hospital mortality in patients requiring extracorporeal membrane oxygenation (ECMO) in the perioperative period of heart transplantation. Methods: The data of ECMO cases in the perioperative period of heart transplantation from the Chinese Society of Extracorporeal Life Support (CSECLS) between January 2017 and December 2021 were retrospectively analyzed. These patients were divided into the survival group and non-survival group according to their outcomes at discharge. The demographics, indications and complications of ECMO between the two groups were compared, and the related risk factors of poor prognosis were analyzed. Results: A total of 77 patients were included in the study, including 67 males and 10 females, with a median age [M(Q1, Q3)] of 48 (36, 59) years. Sixty-three patients (81.8%) were successfully withdrawn from the ECMO and 46 patients (59.7%) survived to discharge. The median ECMO time was 139 (92, 253) hours. Compared with the survival group, the non-survival group (n=31) had more patients with chronic kidney disease before surgery [22.6% (7/31) vs 4.3% (2/46), P=0.034], and a higher proportion of continuous renal replacement therapy (CRRT) during ECMO [74.2% (23/31) vs 50.0% (23/46), P=0.034]. Moreover, the non-survival group had longer duration of extracorporeal circulation [262 (195, 312) vs 201 (155, 261) min, P=0.056] and higher lactate value in the first 24 hours of ECMO support [2.7 (2.1, 4.7) vs 2.3 (1.4, 3.8) mmol/L, P=0.060], but the differences were not statistically significant. Multivariate logistic regression analysis showed that perioperative application of CRRT was an independent risk factor for poor prognosis in ECMO patients during heart transplantation (OR=19.345, 95%CI: 1.209-309.440, P=0.036). Conclusion: CRRT treatment during ECMO is a risk factor for in-hospital mortality in patients undergoing heart transplantation.

#4870 MORTALITY OF ELDERLY PATIENTS WITH ACUTE KIDNEY INJURY UNDERGOING CONTINUOUS RENAL REPLACEMENT THERAPY: IS AGE A RISK FACTOR?

Abstract Background and Aims The incidence of elderly patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) is increasing. However, there is little evidence on the difference of mortality rates according to age in elderly patients. This study aimed to evaluate the age effect and predictors for mortality in elderly patients with AKI requiring CRRT. Method A retrospective analysis was performed in elderly patients with AKI who underwent CRRT. A total of 480 patients aged ≥ 65 years were stratified into three groups according to age: youngest-old (age 65 - 74 years, n = 205), middle-old (age 75 - 84 years, n = 217), and oldest-old (age ≥ 85 years, n = 58). The 28-day and 90-day survival rates were compared between three groups and predictors for mortality were analysed. Results The 28-day and 90-day survival rates were not different between three age groups (P = 0.156 and P = 0.189, respectively). The oldest-old group did not show an inferior survival rate to other two groups. For 28-day mortality, prothrombin time [hazard ratio (HR) = 1.37, 95% confidence interval (CI) = 1.01 – 1.88, P = 0.046] and urine output at the start of CRRT (HR = 0.999, 95% CI = 0.998 – 1.000, P = 0.012) and CRRT duration (HR = 0.89, 95% CI = 0.83 – 0.95, P = 0.001) were predictors. For 90-day mortality, mean arterial pressure (HR = 1.02, 95% CI = 1.00 – 1.05, P = 0.019), admission duration (HR = 0.97, 95% CI = 0.95 – 0.99, P < 0.001) and CRRT duration (HR = 0.96, 95% CI = 0.91 – 0.99, P = 0.036) were predictors. The middle-old group or the oldest-old group did not exhibit higher risk compared to the youngest-old group for 28-day and 90-day mortality. Conclusion An older age was not a risk factor for mortality in elderly patients with AKI undergoing CRRT. This implicates the importance of active management and application of CRRT in critically ill elderly patients with AKI.

Population pharmacokinetics and limited sampling strategies of polymyxin B in critically ill patients.

To characterize the pharmacokinetics (PK) of polymyxin B in Chinese critically ill patients. The factors significantly affecting PK parameters are identified, and a limited sampling strategy for therapeutic drug monitoring of polymyxin B is explored. Thirty patients (212 samples) were included in a population PK analysis. A limited sampling strategy was developed using Bayesian estimation, multiple linear regression and modified integral equations. Non-linear mixed-effects models were developed using Phoenix NLME software. A two-compartment population PK model was used to describe polymyxin B PK. Population estimates of the volumes of central compartment distribution (V) and peripheral compartment distribution (V2), central compartment clearance (CL) and intercompartmental clearance (Q) were 7.857 L, 12.668 L, 1.672 L/h and 7.009 L/h. Continuous renal replacement therapy (CRRT) significantly affected CL, and body weight significantly affected CL and Q. The AUC0-12h of polymyxin B in patients with CRRT was significantly lower than in patients without CRRT. CL and Q increased with increasing body weight. A limited sampling strategy was suggested using a two-sample scheme with plasma at 0.5h and 8h after the end of infusion (C0.5 and C8) for therapeutic drug monitoring in the clinic. A dosing regimen should be based on body weight and the application of CRRT. A two-sample strategy for therapeutic drug monitoring could facilitate individualized treatment with polymyxin B in critically ill patients.

Ultrasound dynamic monitoring of IVCD to guide application of CRRT in patients with renal failure combined with acute heart failure

We explored the application value of bedside ultrasound dynamic monitoring of the inferior vena cava diameter (IVCD) and collapse with sniff (inferior vena cava collapsibility index [IVCCI]) to guide dehydration adjustment in continuous renal replacement therapy (CRRT) in patients with combined renal failure and acute heart failure. We selected 90 patients with combined renal and acute heart failure who required CRRT in the intensive care unit (ICU) from January 2019 to June 2021. According to different blood volume assessment methods, patients were randomly divided into ultrasound, experience, and control groups. We compared serum creatinine, potassium, and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels; time to improved heart failure symptoms; CRRT time; ventilator use; ICU length of stay; vasopressor use; and incidence of adverse events among groups. There were no significant differences in serum creatinine, potassium, and NT-proBNP levels in pairwise comparisons among groups before and after CRRT (P > 0.05). The time to improved heart failure symptoms, CRRT time, and ICU length of stay in the ultrasound and experience groups were lower than those in the control group; the differences were statistically significant (P < 0.05). Ventilator use duration was lower in the ultrasound and experience groups compared with the control group, with a statistically significant difference between the ultrasound and control groups (P < 0.05). The duration of vasopressor use in the ultrasound and control groups was lower than that in the experience group; the difference was statistically significant (P < 0.05). The incidence of adverse events was lower in the ultrasound group compared with the experience and control groups; the difference was statistically significant (P < 0.05). Ultrasound dynamic monitoring of IVCD and collapse with sniff can accurately assess blood volume status, and provide guidance for dehydration adjustments in CRRT and rapid relief of heart failure symptoms in patients with combined renal and acute heart failure.

Risk Factors Associated with 30-day Mortality in Patients with Postoperative Acute Kidney Injury Who Underwent Continuous Renal Replacement Therapy in the Intensive Care Unit

Purpose: To evaluate the risk factors associated with 30-day mortality in patients with postoperative acute kidney injury who underwent continuous renal replacement therapy (CRRT).Methods: Retrospective analysis of the medical charts of patients with postoperative acute kidney injury who underwent CRRT in the intensive care unit between April 2012 and May 2019 was conducted.Results: There were 71 patients whose average age was 64.8 years, and average Acute Physiology and Chronic Health Evaluation 2 score was 26.2. There were 37 patients who had non-trauma emergency surgery, 16 who required trauma surgery, and 18 who had elective major surgery. In most patients, CRRT was started based on Stage 3 Acute Kidney Injury Network criteria, and the mean creatinine level at the time of CRRT initiation (3.62 mg/dL). The median period from surgery to CRRT was 3 days, and the median CRRT application was 4 days. Forty-seven patients died within 30 days of receiving CRRT. Age, elective major surgery, creatinine level on initiation of CRRT, use of norepinephrine upon the initiation of CRRT, and average daily fluid balance/body weight for 3 days following the initiation of CRRT were associated with increasing 30-day mortality in univariate analysis. In multivariate analysis, age, major elective surgery, and norepinephrine use upon initiation of CRRT were identified as independent risk factors for 30-day mortality.Conclusion: Surgical patients who underwent CRRT postoperatively had a poor prognosis. The risk of death in elderly patients who have undergone major elective surgery, or are receiving norepinephrine upon initiation of CRRT should be considered.

Association of HLA-DPA1 polymorphism with prolonged mechanical ventilation in patients undergoing liver transplantation.

BackgroundProlonged mechanical ventilation (PMV) is a common complication after liver transplantation surgery. However, owing to the clinical and economic benefits of early extubation, many efforts have been used to assess the clinical predictors for PMV. The aim of our study was to explore the impact of perioperative risk factors, including candidate gene polymorphisms, for PMV in patients undergoing liver transplantation.MethodsOne hundred forty patients who underwent liver transplantation surgery were enrolled. The duration of mechanical ventilation after surgery was examined, along with the length of intensive care unit and hospital stay, and 30-day mortality. Patient-related clinical factors and single nucleotide polymorphisms of candidate genes were assessed with regard to PMV, which was defined as mechanical ventilation for > 48 h. ResultsTwenty-six (19%) patients continued to receive mechanical ventilation at 48 h after surgery. Intraoperative continuous renal replacement therapy (CRRT) and an elevated serum lactate level during the postoperative period were significantly associated with the PMV group, compared to the non-PMV group (odds ratio [OR] = 24.731 [1.077, 567.915] versus OR = 3.008 [1.497, 6.045]). A significant association existed between the HLA-DPA1 rs8486 polymorphism and the risk of PMV under the allele model (OR = 8.060 [1.451, 44.765]).ConclusionsThe rs8486 polymorphism in HLA-DPA1 can independently affect the risk of PMV in liver transplantation recipients, along with intraoperative CRRT application, and elevated lactate level during the postoperative period.

Postcardiotomy Extracorporeal Membrane Oxygenation Support in Patients with Congenital Heart Disease.

BackgroundThis study investigated mortality and morbidity in patients requiring postcardiotomy extracorporeal membrane oxygenation (ECMO) support after operations for congenital heart disease (CHD).MethodsCHD patients requiring postoperative ECMO support between May 2011 and May 2021 were retrospectively reviewed. Patients were divided into non-survivors and survivors to hospital discharge. Survival outcomes and associations of various factors with in-hospital death were analyzed.ResultsFifty patients required postoperative ECMO support. Patients’ median age and weight at the time of ECMO insertion were 1.85 months (interquartile range [IQR], 0.23–14.5 months) and 3.84 kg (IQR, 3.08–7.88 kg), respectively. Twenty-nine patients (58%) were male. The median duration of ECMO support was 6 days (IQR, 3–12 days). Twenty-nine patients (58%) died on ECMO support or after ECMO weaning, and 21 (42%) survived to hospital discharge. Postoperative complications included renal failure (n=33, 66%), bleeding (n=11, 22%), and sepsis (n=15, 30%). Prolonged ECMO support (p=0.017), renal failure (p=0.005), continuous renal replacement therapy (CRRT) application (p=0.001), sepsis (p=0.012), bleeding (p=0.032), and high serum lactate (p=0.002) and total bilirubin (p=0.017) levels during ECMO support were associated with higher mortality risk in a univariate analysis. A multivariable analysis identified CRRT application (p=0.013) and a high serum total bilirubin level (p=0.001) as independent risk factors for death.ConclusionPostcardiotomy ECMO should be considered as an important therapeutic modality for patients unresponsive to conventional management. ECMO implementation strategies and management in appropriate patients without severe complications, particularly renal failure and/or liver failure, are crucial for achieving positive outcomes.

Continuous Renal Replacement Therapy in Critically Ill Children in the Pediatric Intensive Care Unit: A Retrospective Analysis of Real-Life Prescriptions, Complications, and Outcomes.

Introduction: Severe acute kidney injury is a common finding in the Pediatric Intensive Care Unit (PICU), however, Continuous Renal Replacement Therapy (CRRT) is rarely applied in this setting. This study aims to describe our experience in the rate of application of CRRT, patients' clinical characteristics at admission and CRRT initiation, CRRT prescription, predictors of circuit clotting, short- and long-term outcomes.Methods: A 6-year single center retrospective study in a tertiary PICU.Results: Twenty-eight critically ill patients aged 0 to 18 years received CRRT between January 2012 and December 2017 (1.4% of all patients admitted to PICU). Complete clinical and CRRT technical information were available for 23/28 patients for a total of 101 CRRT sessions. CRRT was started, on average, 40 h (20–160) after PICU admission, mostly because of fluid overload. Continuous veno-venous hemodiafiltration and systemic heparinization were applied in 83.2 and 71.3% of sessions, respectively. Fifty-nine sessions (58.4%) were complicated by circuit clotting. At multivariate Cox-regression analysis, vascular access caliber larger than 8 Fr [HR 0.37 (0.19–0.72), p = 0.004] and regional citrate anticoagulation strategy [HR 0.14 (0.03–0.60), p = 0.008] were independent protective factors for clotting. PICU mortality rate was 42.8%, and six survivors developed chronic kidney disease (CKD), within an average follow up of 3.5 years.Conclusions: CRRT is uncommonly applied in our PICU, mostly within 2 days after admission and because of fluid overload. Larger vascular access and citrate anticoagulation are independent protective factors for circuit clotting. Patients' PICU mortality rate is high and survival often complicated by CKD development.

The future of continuous renal replacement therapy.

Over the last 40years, acute renal replacement therapy (RRT) in the intensive care units (ICUs) of high-income countries has transitioned from the predominant use of intermittent hemodialysis (and the much less common use of peritoneal dialysis) to the almost exclusive use of continuous renal replacement therapy (CRRT). Accordingly, CRRT has become the most common form of vital organ support delivered to critically ill patients. A series of clinical and technical advances has enabled the transformation of basic CRRT machines into highly sophisticated and customized devices. Recent work has focused on using evidence from clinical trials to enhance the application of CRRT with regard to timing of initiation, choice of modality, dose, and anticoagulation. However, many questions remain unanswered. Uncertainty surrounding volume control and the utility of strategies to minimize circulatory stress are key areas for future development. Advances in membrane technology, combination with other extracorporeal therapies, and personalization of CRRT delivery may provide additional benefit to certain subgroups. Development of quality metrics and use of data analytics to audit and benchmark could provide important insight into practice, while biofeedback and automated CRRT prescription could increase safety. In this review, we summarize the evolution of CRRT and highlight several future areas for development.

Continuous renal replacement therapy rescues severe haemorrhagic fever with renal syndrome in pregnancy: a case report

BackgroundHaemorrhagic fever with renal syndrome (HFRS) is a natural epidemic disease caused by various types of viruses of the genus Hantavirus, which are mainly transmitted by contact with the infected rodents and their droppings. Pregnancy complicated with HFRS is rare; however, adverse maternal and foetal outcomes may be noted. In this report, we describe a case involving a pregnant woman with HFRS who was in a state of multiple organ dysfunction syndrome (MODS) and was successfully treated with continuous renal replacement therapy (CRRT).Case presentationA 32-year-old pregnant woman at 29 weeks of gestation was hospitalised for a fever and upper respiratory tract infection due to HFRS in winter. Persistent fever, coagulation disorder, thrombocytopenia, electrolyte imbalance, abnormal liver function, and renal failure were noted during the progression of the disease. The patient was treated with CRRT. She recovered after 21 days, and delivered a live infant by caesarean section at 38 weeks of gestation. Furthermore, obvious abnormalities were not detected during the follow-up of the mother and infant at 42 days, 3 months, 6 months, and 1 year after the delivery.ConclusionsEarly diagnosis, timely application of CRRT, and comprehensive treatment may be essential for the successful treatment of patients with HFRS during pregnancy.

Effect of continuous renal replacement therapy during percutaneous drainage in severe acute pancreatitis patients: a retrospective cohort study

To evaluate the clinical efficacy and safety of continuous renal replacement therapy (CRRT) in patients with severe acute pancreatitis (SAP) receiving percutaneous drainage (PCD). Clinical data of SAP patients receiving PCD admitted to department of hepatobiliary surgery of the First Affiliated Hospital of Xi'an Jiaotong University from November 11th 2015 to May 13th 2018 were retrospectively analyzed. The patients were divided into CRRT group and control group according to whether or not receiving CRRT. Demographic data, relevant variables before and after PCD, complication and outcome were all compared. A total of 75 patients were included in the study, 30 were treated with application of CRRT and 45 without CRRT. (1) There was no significant difference in gender, age, body mass index (BMI), medical history (smoking, drinking), complications (cardiovascular disease, chronic lung disease, diabetes, chronic renal insufficiency), etiology (gallstone, alcohol abuse, hyperlipidemia and others), or white blood cell count (WBC), C-reactive protein (CRP), serum procalcitonin (PCT), fluid resuscitation, mechanical ventilation, vasoactive agent or intra-abdominal pressure within 48 hours after admission between the two groups. However, acute physiology and chronic health evaluation II (APACHE II) score within 48 hours after admission of CRRT group was significantly higher than that of control group (18.3±4.5 vs. 12.8±6.2, P < 0.05). (2) There was no significant difference in WBC, PCT, APACHE II score or computed tomography severity index (CTSI) before PCD between the two groups. There was no significant difference in the position or times of PCD procedure between the two groups, but the time interval of PCD in the CRRT group was significantly longer than that in the control group (days: 19.4±5.4 vs. 12.8±2.2, P < 0.05). Meanwhile, there was no significant difference in drainage of fluid properties, incidence of abdominal bleeding, infection, gastrointestinal fistula, endoscopic removal of necrotic tissue, laparotomy for removal of necrotic tissue or the time from PCD to endoscopy or laparotomy between two groups. However, the length of intensive care unit (ICU) stay and the length of hospital stay in the CRRT group were significantly longer than those in the control group (days: 23.2±8.5 vs. 15.3±12.1, 51.2±21.2 vs. 31.2±14.0, both P < 0.01). (3) Kaplan-Meier survival analysis showed that there was no significant differences in 1-year or 3-year cumulative survival rates between the two groups (χ21 = 0.097, P1 = 0.755; χ22 = 0.013, P2 = 0.908). CRRT is safe and feasible in the treatment of SAP patients receiving PCD procedure. It does not increase the risk of bleeding and may delay the time interval of PCD intervention. However, it may prolong the length of ICU stay and the length of hospital stay. It should be worthy of much attention for clinicians.

Indications and Timing of Continuous Renal Replacement Therapy Application.

Renal replacement therapy (RRT) is increasingly utilized to support critically ill patients with severe acute kidney injury (AKI). The clinical dilemma of when to ideally start RRT in these patients has been a longstanding issue that is in need of higher quality evidence to guide clinical practice. When clinicians are confronted with patients with life-threatening complications of AKI, the decision to start RRT is straightforward. However, in the absence of clear indications, the ideal circumstances and timing that balance the perceived benefits and risks of early versus delayed RRT remain uncertain. Survey data have confirmed substantial practice variation in the timing of RRT initiation. Most observational data and small clinical trials have limitations related to confounding by indication, heterogeneity in case-mix and illness severity, and variation in defining timing thresholds for starting RRT. Recently published trials have further added to the clinical uncertainty. This concise review provides an overview of prevailing and evolving evidence on the optimal time to start RRT in critically ill patients with AKI.

Subgroup analysis of continuous renal replacement therapy in severely burned patients.

Continuous renal replacement therapy (CRRT) is administered to critically ill patients with renal injuries as renal replacement or renal support. We aimed to identify predictors of mortality among burn patients receiving CRRT, and to investigate clinical differences according to acute kidney injury (AKI) status. This retrospective observational study evaluated 216 Korean burn patients who received CRRT at a burn intensive care unit. Patients were categorized by AKI status. Data were collected regarding arterial pH, laboratory results, ratio of arterial oxygen partial pressure to fractional inspired oxygen (PF ratio), and urine production. Among surviving patients, CRRT duration and the sequential organ failure assessment score were 6.5 days and 4.7 in the non-AKI group and 23.4 days and 7.4 in the AKI group, respectively (p = 0.003 and p = 0.008). On logistic regression analyses, mortality was significantly associated with a pH of <7.2 (p = 0.004), potassium levels of >5.0 mEg/L (p = 0.045), creatinine levels of >2.0 mg/dL (p = 0.011), lactate levels of >2 mmol/L (p<0.001), a PF ratio of <200 (p = 0.042), and a platelet count of <100,000/μL (p<0.001). In the AKI group, poor outcomes were associated with a pH of <7.2, potassium levels of <5.0 mEg/L, lactate levels of >2 mmol/L, and a platelet count of <100,000/μL, while good outcomes were associated with creatinine levels of >2 mg/dL. In the non-AKI group, poor outcomes were associated with lactate levels of >1.5 mmol/L, a PF ratio of <200, and a platelet count of <100,000/μL, while good outcomes were associated with creatinine levels of >1.2 mg/dL. Duration of the CRRT application and the requirement for either renal replacement or renal support at the initiation of CRRT application are important considerations depending on its application.

Assessment of Plasma Neutrophil Gelatinase-Associated Lipocalin for Early Detection of Acute Kidney Injury and Prediction of Mortality in Severely Burned Patients

The purpose of this study was to assess the plasma neutrophil gelatinase-associated lipocalin (NGAL) for early detection of acute kidney injury (AKI) and prediction of mortality in severely burned patients. From January 2014 to September 2015, 76 consecutive patients with more than 20% of TBSA burned were enrolled. Blood samples for plasma NGAL were collected at 0, 7, 14, 21, and 28 days after admission and analyzed with injury severity, clinical outcome, and AKI development. Plasma NGAL was significantly affected by the TBSA burned, AKI, and mortality, and it was significantly increased after operation and septic shock. Plasma NGAL was significantly increased within 7 days before AKI development in total patients (P < .001) and septic shock patients (P < .001) but not significantly increased in patients without septic shock (P = .167). Though, in a receiver operating characteristic curve analysis for predicting AKI, continuous renal replacement therapy application, and mortality, plasma NGAL was statistically significant; plasma NGAL was not independently associated with mortality in a multivariate logistic regression analysis. Plasma NGAL should be interpreted carefully in the major burn patients because it can reflect both inflammatory condition and AKI.

Analysis of prognostic factors for acute kidney injury with continuous renal replacement therapy in severely burned patients

Acute kidney injury (AKI) is a critical complications in severely burned patients associated with high morbidity and mortality. The purpose of this study was to investigate the impact of severity of AKI at the time of continuous renal replacement therapy (CRRT) start on patient outcome and to identify the prognostic factors in severely burned patients with CRRT application. From January 2007 to June 2010, 84 burn patients with more than 40% of total body surface area (TBSA) burned who treated with continuous renal replacement therapy for acute kidney injury were analyzed retrospectively. There was no significant difference of mortality by the severity of AKI at the time of CRRT start. However, the mean TBSA burned, abbreviated burn severity index, arterial pH, partial pressure of carbon dioxide (PaCO2) and blood urea nitrogen (BUN)/creatinine (Cr) ratio had a statistical significance to predict mortality in receiver operation characteristic curve. In a multivariate logistic regression analysis, only sepsis had an independent association with mortality. The severity of the AKI at the time of CRRT start did not have significant relationship with patient outcome. CRRT can be applied to minimize the complication of AKI including electrolyte imbalance and volume overload. Because only the presence of sepsis was independently associated with mortality, treatment for sepsis should be focused to improve the survival of the severely burned patients with CRRT.

Continuous Renal Replacement Therapy Applications on Extracorporeal Membrane Oxygenation Circuit.

Background and Aims:Continuous venovenous hemofiltration or hemodiafiltration is used frequently in pediatric patients, but experience of continuous renal replacement therapy (CRRT) application on extracorporeal membrane oxygenation (ECMO) circuit is still limited. Among several methods used for applying CRRT on ECMO patients, we aim to share our experience on inclusion of a CRRT device in the ECMO circuit which we believe is easier and safer to apply.Materials and Methods:The data were collected on demographics, outcomes, and details of the treatment of ECMO patients who had CRRT. During the study period of 3 years, venous cannula of ECMO circuit before pump was used for CRRT access for both the filter inlet and outlet of CRRT machine to minimize the thromboembolic complications. The common indication for CRRT was fluid overload.Results:CRRT was used in 3.68% of a total number of patients admitted and 43% of patients on ECMO. The patients have undergone renal replacement therapy for periods of time ranging between 24 h and 25 days (260 h mean). The survival rate of this group of patients with multiorgan failure was 33%. Renal recovery occurred in all of the survivors. Complications such as electrolyte imbalance, hypothermia, and bradykinin syndrome were easily managed.Conclusions:Adding a CRRT device on ECMO circuit is a safe and effective technique. The major advantages of this technique are easy to access, applying CRRT without extra anticoagulation process, preventing potential hemodynamic disturbances, and increased clearance of solutes and fluid overload using larger hemofilter.

Survey of continuous renal replacement therapy application status

Objective: To investigate the condition of implementation of continuous renal replacement therapy (CRRT) in quality control center of critical care medicine. Methods: Questionnaire mails were issued to all of the quality control respondents to survey the application of CRRT in June 2015 from Jiangsu quality control center of critical care medicine. Results: Among the 69 quality control respondents, 62 were equipped with CRRT devices, and in 58 of which patients were treated with CRRT. There were 195 doctors and 253 nurses in 62 quality control respondents attended CRRT training at or above the provincial level; the proportions of hospitals in southern, central and northern regions of Jiangsu were 63%, 79% and 86% respectively with trained doctors (more than 2), and 34%, 38% and 43% respectively with trained nurses (more than 3). The preferred material for CRRT filter were AN69 and acrylic, accounting for 48% and 45% respectively. The average life span was less than 12 h for 21% filters, 12-24 h for 34% filters, and more than 72 h for only 2% filters. Manual displacement liquids were currently mainly used in our province, accounting for 75%. Heparin is the most frequently used anticoagulants, accounting for 48%. Citrate and low molecular weight heparin used for anticoagulation accounted for 31% and 21% respectively. Bleeding was the most common clinical complication (43%) in patients with CRRT, followed by low temperature (22%). The average hospitalization expenses for patients with CRRT amounted to 69 643 yuan RMB per person, in which the cost for CRRT accounted for 19 525 yuan RMB per person. Conclusion: The application of CRRT varies in filter materials, anticoagulants, replacement frequencies and dilution mode. Bleeding is the most common clinical complication in patients with CRRT. Besides, the proportion of trained doctors and nurses at the provincial level is still very low. It will be improved with intensive training and reasonable implementation for us to prolong the lifespan of the filters and reduce the cost for patients with CRRT.

Association of systolic blood pressure drop with intravenous administration of itraconazole in children with hemato-oncologic disease.

PurposeAlthough few adverse effects have been reported for itraconazole, a widely used antifungal therapy for febrile neutropenia, we found intravenous (IV) itraconazole to be associated with serious cases of blood pressure (BP) drop. We therefore evaluated the incidence and risk factors for BP drop during IV administration of the drug.Materials and methodsWe reviewed the medical records of children with hemato-oncologic disease who were treated with IV itraconazole from January 2012 to December 2013. By analyzing systolic BP (SBP) measurements made from 4 hours before through to 4 hours after itraconazole administration, we evaluated the changes in SBP and the risk factors for an SBP drop, especially clinically meaningful (≥20%) drops.ResultsItraconazole was administered 2,627 times to 180 patients. The SBP during the 4 hours following itraconazole administration was lower than during the 4 hours before administration (104 [53.0–160.33 mmHg] versus 105 [59.8–148.3 mmHg]; P<0.001). The decrease in SBP was associated with the application of continuous renal replacement therapy (CRRT) (P=0.012) and the use of inotropic (P=0.005) and hypotensive drugs (P=0.021). A clinically meaningful SBP drop was seen in 5.37% (141 out of 2,627) of the administrations, and the use of inotropics (odds ratio [OR] 6.70, 95% confidence interval [CI] 3.22–13.92; P<0.001), reducing the dose of inotropics (OR 8.08; 95% CI 1.39–46.94; P=0.02), CRRT (OR 3.10, 95% CI 1.41–6.81; P=0.005), and bacteremia (OR 2.70, 95% CI 1.32–5.51; P=0.007) were risk factors, while age was a protective factor (OR 0.93, 95% CI 0.89–0.97; P<0.001).ConclusionA decrease in SBP was associated with IV administration of itraconazole. It was particularly significant in younger patients with bacteremia using inotropic agents and during application of CRRT. Careful attention to hypotension is warranted during IV administration of itraconazole in this group of patients.

(R)evolution in the Management of Acute Kidney Injury in Newborns

The application of continuous renal replacement therapy (CRRT) in children, before roller pumps and dialysis monitors were available in the intensive care unit, was realized by continuous arteriovenous hemofiltration. Then hemofiltration was coupled with dialysis in order to increase dialytic dose and system efficiency, and the circuit and filters were specifically modified to optimize patency and session life span. After about 30 years, another revolution is ongoing, in that pediatric acute kidney injury (AKI) and fluid accumulation (for which critically ill newborns and children with multiple-organ dysfunction are greatly at risk) are recognized as independently associated with mortality and identified as primary conditions to prevent and aggressively treat. Today, novel technology specifically dedicated for very young patients will allow feasible and straightfoward application of CRRT to infants and children. This article discusses the authors' personal perspectives on how clinical and technical issues of dialysis in children have been addressed and how today, severe pediatric AKI can be managed with accurate and safe CRRT machines that will likely yield outcome improvements in the coming decades.