Continuous Renal Replacement Therapy Treatment Research Articles

Effect of continuous renal replacement therapy on the clinical efficacy and pharmacokinetics of polymyxin B in the treatment of severe pulmonary infection

ObjectiveThis study aimed to evaluate the pharmacokinetics of polymyxin B in patients with ventilator-associated pneumonia caused by multi-drug resistant bacteria, and to analyze the effect of continuous renal replacement therapy (CRRT) on pharmacokinetics of polymyxin B. MethodsThirty-five patients with ventilator-associated pneumonia caused by multi-drug resistant bacteria admitted to our hospital from June 2021 to January 2022 were selected as the subjects. The patients were divided into the standard group (n = 20) and the non-standard group (n = 15) based on the factors affecting the compliance of polymyxin B plasma concentration. The patients received with polymyxin B and the plasma concentration was monitored. According to the monitoring results, they were divided into the standard group and the non-standard group, to analyze the influencing factors of polymyxin B on the blood concentration. Besides, the patients were then divided into the control group (n = 28) and the observation group (n = 7) according to whether the patients received CRRT treatment. Patients in the control group treated with polymyxin B alone, while patients in the observation group received with polymyxin B and CRRT. The general data of patients in the two groups were compared. The levels of plasma concentration of polymyxin B measured before the next administration (Cmin), peak plasma concentration of polymyxin B measured immediately after end of infusion (Cmax) and intermediate plasma concentration measured 6 h after administration (midpoint of the dosing interval) (C1/2t) were detected and compared between the two groups. Correlation between pharmacokinetics and efficacy was analyzed by Spearman correlation. The incidence of complications and the 28-day mortality rate of the two groups were recorded. ResultsThe age, body mass index (BMI) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores in the non-standard group were higher than these in the standard group (p < 0.05). BMI and APACHE II scores were independent risk factors affecting the pharmacokinetics of polymyxin B in patients with severe pulmonary infection (p < 0.05). There were no significant differences in age, BMI, APACHEII score, alanine aminotransferase level, aspartate aminotransferase level, albumin level, gender and diabetes ratio between the control group and the observation group (p > 0.05). The levels of Cmin, Cmax, and C1/2t in the observation group were lower than these in the control group (p < 0.001). The response rate was 50.00% in the control group and 36.36% in the observation group (p > 0.05). The levels of Cmin, Cmax, and C1/2t in the observation group were no significant correlation with the clinical efficacy (p > 0.05), while these in the control group were positive correlation with the clinical efficacy (r = 0.485, p < 0.05). There was no significant difference in the incidence of skin pigmentation, nephrotoxicity and 28-day mortality between the two groups (p > 0.05). ConclusionIn patients with ventilator-associated pneumonia not receiving multidrug-resistant bacteria, the rate of achieving blood drug concentration with the usual recommended dose of polymyxin B was satisfactory. However, the proportion of patients with a 6-h plasma concentration exceeding the maximum plasma concentration was high. BMI and APACHE II scores were important factors affecting the pharmacokinetics of polymyxin B. In patients undergoing CRRT, the plasma concentration of polymyxin B was significantly reduced, suggesting that in patients with severe disease, plasma concentration monitoring played an important role in drug efficacy and patient safety. In patients treated with CRRT, the dose of polymyxin B may need to be increased.

Early Net Ultrafiltration during Continuous Renal Replacement Therapy: Impact of Admission Diagnosis and Association with Mortality

Introduction: Continuous renal replacement therapy (CRRT) is common in the intensive care unit (ICU) but a high net ultrafiltration rate (UF_NET) calculated with daily data may increase mortality. We aimed to study early UF_NET practice using minute-by-minute CRRT machine recordings and to assess its association with admission diagnosis and mortality. Methods: We studied CRRT treatments in three adult ICUs over 7 years. We calculated early UF_NET rates minute-by-minute and categorized UF_NET into tertiles of mean UF_NET in the first 72 h and admission diagnosis. We applied Cox-proportional hazards modelling with censoring of patients who died within 72 h. Results: We studied 1,218 patients, 154,712 h, and 9,282,729 min of CRRT (5,702 circuits). Mean early UF_NET was 1.52 (1.46–1.57) mL/kg/h. Early UF_NET tertiles were similar to, but somewhat higher than, previously reported values at 0.00–1.20 mL/kg/h, 1.21–1.93 mL/kg/h, and >1.93 mL/kg/h. UF_NET values were similar whether evaluated at 24 or 72 h or for the entire duration of CRRT. There was, however, significant variation in UF_NET practice by admission diagnosis: higher in respiratory diseases (pneumonia p = 0.01, other p < 0.0001) and cardiovascular disease (p = 0.005) but lower in cardiothoracic surgery (p = 0.04), renal (p = 0.0003) and toxicology-associated diagnoses (p = 0.01). Higher UF_NET was associated with an increased hazard of death, HR 1.24 (1.13–1.37), independent of admission diagnosis, weight, age, sex, presence of end-stage kidney disease, and severity of illness. Conclusion: Early UF_NET practice varies significantly by admission diagnosis. Higher early UF_NET is independently associated with mortality. Impacts of UF_NET on mortality may vary by admission diagnosis. Further work is required to elucidate the nature and mechanisms responsible for this association.

Predictions of Serum Phosphate Concentration during Continuous Renal Replacement Therapy Using a Steady-State Mass Balance Model

Introduction: Hypophosphatemia is common during continuous renal replacement therapy (CRRT), but serum phosphate levels can potentially be maintained during treatment by either intravenous phosphate supplementation or addition of phosphate to renal replacement therapy (RRT) solutions. Methods: We developed a steady-state phosphate mass balance model to assess the effects of CRRT dose on serum phosphate concentration when using both phosphate-free and phosphate-containing RRT solutions, with emphasis on low CRRT doses. Results: The model predicted that measurements of serum phosphate concentration prior to (initial) and during CRRT (final) together with clinical data on CRRT dose, treatment duration, and phosphate supplementation can determine model patient parameters, that is, both the initial generation rate and clearance of phosphate prior to CRRT. Model parameters were then calculated from average patient data reported in several previous publications with a standard or high CRRT dose. Using representative model parameters for typical patients, predictions were then made of the effect of low CRRT dose on the change in serum phosphate levels after implementation of CRRT. The model predicted that CRRT at a low dose using phosphate-free RRT solutions will limit, but not eliminate, the incidence of hypophosphatemia. Further, the model predicted that CRRT at a low dose will have virtually no influence on the incidence of hyperphosphatemia when using phosphate-containing RRT solutions. Conclusions: This report identifies the clinical measurements to be used with the proposed model for individualizing the CRRT dose and RRT phosphate concentration to maintain serum phosphate concentrations in a desired range.

Hemolytic Uremic Syndrome-Induced Acute Kidney Injury Treated via Immunomodulation with the Selective Cytopheretic Device

Introduction: Shiga-toxin associated-hemolytic uremic syndrome (STEC-HUS) is a severe cause of acute kidney injury (AKI) in children. Although most children recover, about 5% die and 30% develop chronic renal morbidity. HUS pathophysiology includes activated neutrophils damaging vascular endothelial cells. Therapeutic immunomodulation of activated neutrophils may alter the progression of disease. We present 3 pediatric patients treated with the selective cytopheretic device (SCD). Methods: We describe a 12 y.o. (patient 1) and two 2 y.o. twins (patients 2 and 3) with STEC-HUS requiring continuous renal replacement therapy (CRRT) who were enrolled in two separate studies of the SCD. Results: Patient 1 presented with STEC-HUS causing AKI and multisystem organ failure and received 7 days of SCD and CRRT treatment. After SCD initiation, the patient had gradual recovery of multi-organ dysfunction, with normal kidney and hematologic parameters at 60-day follow-up. Patients 2 and 3 presented with STEC-HUS with AKI requiring dialysis. Each received 24 h of SCD therapy. Thereafter, both gradually improved, with normalization (patient 2) and near-normalization (patient 3) of kidney function at 60-day follow-up. Conclusion: Immunomodulatory treatment with the SCD was associated with improvements in multisystem stigmata of STEC-HUS-induced AKI and was well-tolerated without any device-related adverse events.

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.

Combined Therapeutic Plasma Exchange and Continuous Renal Replacement Therapy in Children With Dengue-Associated Acute Liver Failure and Shock Syndrome: Single-Center Cohort From Vietnam.

Pediatric acute liver failure (PALF) is a fatal complication in patients with severe dengue. To date, clinical data on the combination of therapeutic plasma exchange (TPE) and continuous renal replacement therapy (CRRT) for managing dengue-associated PALF concomitant with shock syndrome are limited. Retrospective cohort study (January 2013 to June 2022). Thirty-four children. PICU of tertiary Children's Hospital No. 2 in Vietnam. We assessed a before-versus-after practice change at our center of using combined TPE and CRRT (2018 to 2022) versus CRRT alone (2013 to 2017) in managing children with dengue-associated acute liver failure and shock syndrome. Clinical and laboratory data were reviewed from PICU admission, before and 24 h after CRRT and TPE treatments. The main study outcomes were 28-day in-hospital mortality, hemodynamics, clinical hepatoencephalopathy, and liver function normalization. A total of 34 children with a median age of 10 years (interquartile range: 7-11 yr) underwent standard-volume TPE and/or CRRT treatments. Combined TPE and CRRT ( n = 19), versus CRRT alone ( n = 15), was associated with lower proportion of mortality 7 of 19 (37%) versus 13 of 15 (87%), difference 50% (95% CI, 22-78; p < 0.01). Use of combined TPE and CRRT was associated with substantial advancements in clinical hepatoencephalopathy, liver transaminases, coagulation profiles, and blood lactate and ammonia levels (all p values < 0.001). In our experience of children with dengue-associated PALF and shock syndrome, combined use of TPE and CRRT, versus CRRT alone, is associated with better outcomes. Such combination intervention was associated with normalization of liver function, neurological status, and biochemistry. In our center we continue to use combined TPE and CRRT rather than CRRT alone.

Safety and efficacy of perioperative continuous renal replacement therapy for percutaneous coronary intervention in severe acute myocardial infarction patients.

This retrospective study aimed to evaluate the safety and efficacy of continuous renal replacement therapy (CRRT) during percutaneous coronary intervention (PCI) in patients with severe acute myocardial infarction (AMI). The study analyzed data from 945 AMI patients hospitalized between January 2016 and December 2017, out of which 21 patients underwent perioperative CRRT for PCI. We assessed the baseline characteristics of severe AMI patients before and after CRRT and examined the effect of CRRT on cardiac, renal, and liver function, as well as other indicators. The heart rate of patients undergoing CRRT was significantly lower at 24 h and 48 h after CRRT than before CRRT (p=0.038). There was a moderate but not significant decrease in the mean systolic blood pressure or diastolic blood pressure (p>0.05). Importantly, we found that significantly more patients showed Killip class I-II and significantly improved cardiac function after CRRT (23.8% vs. 57.1%, p=0.001). The levels of urea nitrogen, creatinine, aspartate aminotransferase, glutamic pyruvic transaminase, and total bilirubin were significantly lowered after CRRT treatment (p<0.05). Perioperative management of CRRT was safe and effective for severe AMI patients.

Influence of continuous renal replacement therapy on the plasma concentration of tigecycline in patients with septic shock: A prospective observational study.

Objective: The influence of continuous renal replacement therapy (CRRT) on the steady-state plasma concentration of high-dose tigecycline was investigated in septic shock patients to provide references for drug dosing. Methods: In this prospective observational study, 17 septic shock patients presenting with severe infections needing a broad-spectrum antibiotic therapy with high-dose tigecycline (100mg per 12h) in the intensive care unit were included and divided into CRRT group (n = 6) or non-CRRT group (n = 11). The blood samples were collected and plasma drug concentration was determined by SHIMADZU LC-20A and SHIMADZU LCMS 8040. The steady-state plasma concentration was compared between groups using unpaired t-test. Furthermore, between-groups comparisons adjusted for baseline value was also done using multivariate linear regression model. Results: Peak concentration (Cmax) of tigecycline was increased in CRRT group compared to non-CRRT group, but there were no statistical differences (505.11 ± 143.84 vs. 406.29 ± 108.00ng/mL, p-value: 0.129). Trough concentration (Cmin) of tigecycline was significantly higher in CRRT group than in non-CRRT group, with statistical differences (287.92 ± 41.91 vs. 174.79 ± 33.15ng/mL, p-value: 0.000, adjusted p-value: 0.000). In safety, Cmin was reported to be a useful predictor of hepatotoxicity with a cut-off of 474.8ng/mL. In our studies, Cmin of all patients in CRRT group was lower than 474.8ng/mL. Conclusion: The plasma concentration of tigecycline was increased in septic shock patients with CRRT treatment and only Cmin shown statistical differences. No dose adjustment seems needed in the view of hepatotoxicity. Clinical Trial Registration: https://www.chictr.org.cn/, identifier ChiCTR2000037475.

Diagnosis and treatment of brain injury complicated by hypernatremia.

Hypernatremia is a common electrolyte disorder in patients with brain injury. The mortality of brain injury patients with severe hypernatremia may be as high as 86.8%. The efficacy of conventional treatment for hypernatremia is limited. Continuous renal replacement therapy (CRRT) can slowly, controllably, and continuously reduce the blood sodium concentration and gradually become an important treatment for severe hypernatremia patients. This review aims to provide important information for clinicians and clinical researchers by describing the etiology, diagnosis, hazards, conventional treatment, and CRRT treatment of hypernatremia in patients with traumatic brain injury.

Optimal stage of initiating continuous renal replacement therapy in the treatment of neonatal acute kidney injury.

To explore the optimal stage of initiating continuous renal replacement therapy (CRRT) in the treatment of neonatal acute kidney injury (AKI), a total of 25 AKI neonates treated with CRRT were hospitalized at the Department of Neonatology of Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University (Shanghai, China) from November 2016 to June 2021. According to the renal function, the AKI neonates prior to CRRT were divided into two groups as follows: AKI stage 0-1 and AKI stage 2-3. The changes noted in specific indicators including renal function, electrolyte concentration, and acid-base balance index were analyzed at 0, 12, 24 and 48 h, and at the end of the CRRT treatment. Among the 25 neonates with AKI, serum potassium, urea nitrogen and creatinine levels were significantly decreased following 12 h of CRRT treatment and reached the normal range following 24 h of CRRT treatment with a significant increase in the volume of urine. The serum creatinine levels of the neonates in the AKI stage 0-1 group were significantly decreased following 24 h of CRRT treatment and urine output was significantly increased. At 24 h and following CRRT treatment, the levels of serum creatinine of AKI stage 2-3 neonates were higher than those of AKI stage 0-1 neonates (F=3.013, 5.005; P<0.05), and at all time-points, the urine output of AKI stage 0-1 was higher than that of AKI stage 2-3 (F=13.785, 4.008, 0.965; P<0.05). A total of four cases of thrombocytopenia, two cases of obstruction, and two cases of hypotension were noted in the course of CRRT treatment (the occurrence rate was 8/25). Therefore, it was concluded that CRRT could be an effective measure for the treatment of AKI neonates. Thus, ideally CRRT treatment of AKI neonates should be initiated in cases characterized as AKI stages 0-1.

Application of Different Continuous Renal Replacement Therapy Hemofilter in Patients with Septic Shock Complicated with Acute Renal Injury.

We aimed to compare the clinical effects of continuous renal replacement therapy (CRRT) with different hemofilters in patients with septic shock and acute kidney injury (AKI). Thirty patients with septic shock complicated with AKI admitted to The Fourth Affiliated Hospital of Anhui Medical University from 2018-2020 were selected and divided into the control and observation groups. The control group was treated with CRRT using the conventional ST-100 hemofilter. The observation group was treated with CRRT using the oXiris hemofilter for 48 hours, followed by CRRT with the conventional ST-100 hemofilter. Infection indexes, sepsis-related organ failure assessment (SOFA), changes in corresponding organ function indexes, duration of each treatment, and death were compared between the two groups during CRRT. The white blood cells (WBC) count, high-sensitivity C-reactive protein (hs-CRP), and procalcitonin (PCT) levels were significantly decreased in the oXiris group 48 hours after CRRT (P= 0.048, 0.036, 0.031, respectively). After 48 hours of CRRT, SOFA score, serum lactic acid, and norepinephrine dose in the oXiris group were significantly lower than those in the control group (P= 0.039, 0.002, 0.021, respectively). The use time of vasoactive drugs and the treatment time of CRRT in the oXiris group was significantly shortened (P= 0.031 and 0.029, respectively). However, there were no significant differences in mechanical ventilation duration, intensive care unit (ICU) hospitalization time, total hospitalization time, ICU mortality, and in-hospital mortality. For patients with septic shock complicated by AKI, CRRT treatment with the oXiris hemofilter could effectively clear inflammatory cytokine levels and quickly correct hemodynamic disorders, thus accelerating the recovery of organ function.

Continuous renal replacement therapy is a safe and effective modality for the initial management of dogs with acute kidney injury.

To describe the management of dogs with acute kidney injury (AKI) by continuous renal replacement therapy (CRRT), and to investigate the relationship between a prescribed CRRT dose, the hourly urea reduction ratio (URR), and the overall efficacy. 45 client-owned dogs diagnosed with severe AKI, receiving 48 CRRT treatments at a veterinary teaching hospital. Retrospective study. Search of medical records of dogs with AKI managed by CRRT. Median serum urea and creatinine at CRRT initiation were 252 mg/dL [Inter quartile range (IQR), 148 mg/dL; range, 64 to 603 mg/dL] and 9.0 mg/dL (IQR, 7 mg/dL; range, 4.3 to 42.2 mg/dL), respectively. Median treatment duration was 21 hours (IQR, 8.8 hours; range, 3 to 32 hours). Systemic heparinization and regional citrate anticoagulation were used in 24 treatments each (50%). The prescribed median CRRT dose for the entire treatment was 1 mL/kg/min (IQR, 0.4 mL/kg/min; range, 0.3 to 2.5 mL/kg/min). The median hourly URR was 4% (IQR, 1%; range, 2% to 12%), overall URR was 76% (IQR, 30%; range, 11% to 92%) and median Kt/V was 2.34 (IQR, 1.9; range, 0.24 to 7.02). The CRRT dose was increased gradually from 0.9 mL/kg/min to 1.4 mL/kg/min (P < .001) and the hourly URR decreased from 6.5% to 5.5% (P = .05). The main complication was clotting of the extra-corporeal circuit, occurring in 6/48 treatments (13%). Twenty-four dogs (53%) survived to discharge. CRRT is safe when the prescription is based on the current veterinary guidelines for gradual urea reduction. Treatment efficacy can be maximized by gradually increasing the dose according to the actual URR.

Nursing Countermeasures of Continuous Renal Replacement Treatment in End-Stage Renal Disease with Refractory Hypotension in the Context of Smart Health.

This work is aimed at exploring the nursing strategies and effects of continuous renal replacement therapy (CRRT) for end-stage renal disease (ESRD) with refractory hypotension under the background of smart health. 40 ESRD patients with refractory hypotension who received CRRT treatment were enrolled as the research objects and were randomly rolled into the intervention group and the control group, with 20 cases in each group. Patients in the control group received routine nursing, and those in the intervention group received individualized nursing. The incidence of hypotension, dry body weight, serous cavity effusion, renal function indicators (blood urea nitrogen (BUN) and creatinine (Cre)), and patient satisfaction were compared between the two groups. The results showed that the probability of hypotension in the intervention group was 9.38%, which was lower than that in the control group (34.38%). The probability of early termination of dialysis in the intervention group was 0%, which was lower than that in the control group (18.75%), and the difference was statistically significant (P < 0.05). The decreases of BUN and Cre in the intervention group were significantly greater than those in the control group, and the differences were statistically significant (P < 0.05). The proportion of water growth less than 10% during dialysis in the intervention group was 98.44%, which was greater than that in the control group (93.45%), and the difference was statistically significant (P < 0.05). The ultrafiltration volume after dialysis in the intervention group was 2850 ± 400 mL, which was greater than that in the control group 2350 ± 350 mL. After intervention, the proportion of patients with pleural effusion in the intervention group was 10% less than that in the control group (20%), and the difference was statistically significant (P < 0.05). The satisfaction rate of the intervention group was 97.66%, which was higher than that of the control group (65.63%). In conclusion, individualized nursing was more helpful to the recovery of ESRD patients with refractory hypotension treated with CRRT than routine nursing.

Continuous Renal Replacement Therapy in Pediatric Patients With Acute Kidney Injury After Liver Transplantation.

ObjectiveThis study aimed to explore the clinical application of continuous renal replacement therapy (CRRT) in pediatric patients with acute kidney injury (AKI) after liver transplantation.MethodsPediatric patients who underwent liver transplantation were retrospectively investigated. Those who developed AKI within 1 year after the surgery were included and divided into a CRRT group and a non-CRRT group. The perioperative conditions and postoperative complications of the two groups were compared along with the prognoses of the groups to analyze the high-risk factors of the postoperative CRRT.Results189 (36.91%) patients developed AKI within 1 year after the liver transplantation surgery. There were 18 patients in the CRRT group and 171 in the non-CRRT group. The differences in the preoperative conditions were not statistically significant between the two groups. Compared with the non-CRRT group, patients in the CRRT group had significantly longer transplantation times, higher volumes of intraoperative hemorrhage, and increased incidence of postoperative unscheduled surgery, postoperative primary nonfunction of the transplanted liver, secondary liver transplantation, hepatic artery occlusion, and intestinal fistula (P < 0.05). Moreover, the proportion of patients in AKI stage 3 is higher in the CRRT group (83.33%) than that in the non-CRRT group (11.11%), P < 0.001. The median time to initiate CRRT was 10 days postoperatively, the median number of CRRT treatments per patient was 2 times, the average duration of each CRRT treatment was 10.1 h, and the average rate of the decrease in blood creatinine per treatment was 25.6%. Results of multivariate logistic regression analysis showed that AKI stage 3 [OR=40.000, 95%CI (10.598, 150.969), P = 0.016], postoperative unscheduled surgery [OR=6.269, 95%CI (3.051, 26.379), P = 0.007], and hepatic artery occlusion [OR = 17.682, 95%CI (1.707, 40.843), P = 0.001] were recognized as risk factors for postoperative AKI with CRRT therapy. The one- and two-year survival rates were 72.22% and 72.22% in the CRRT group, respectively; and 97.08% and 96.49% in the non-CRRT group, accordingly. There were statistically significant differences in the one- and two-year survival rates between the two groups (P < 0.001).ConclusionThe incidence of AKI after liver transplantation in pediatric patients was high. Patients with AKI stage 3, hepatic artery occlusion, and underwent unscheduled surgery postoperatively were with a high likelihood of receiving CRRT, which was related to a lower one- and two-year survival rates. CRRT effectively improved the one- and two-year survival rates.

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.

Cost-effectiveness of the TherMax blood warmer during continuous renal replacement therapy.

Hypothermia is a common adverse event during continuous renal replacement therapy (CRRT), affecting multiple organ systems and increasing risk of poor health outcomes among patients with acute kidney injury (AKI) undergoing CRRT. TheraMax blood warmers are the next generation of extracorporeal blood warmers which reduce risk of hypothermia during CRRT. The purpose of this study is to elucidate the potential health economic impacts of avoiding CRRT-induced hypothermia by using the novel TherMax blood warming device. This study compares health care costs associated with use of the new TherMax blood warmer unit integrated with the PrisMax system compared to CRRT with a standalone blood warming device to avoid hypothermia in continuous renal replacement therapy (CRRT). An economic model was developed in which relevant health states for each intervention were normothermia, hypothermia, discharge, and death. Clinical inputs and costs were obtained from a combination of retrospective chart review and publicly available summary estimates. The proportion of AKI patients treated with CRRT who became hypothermic (<36°C) during CRRT treatment was 34.5% in the TherMax group compared to 71.9% in the 'standalone warmer' group. Given the 78.7-year average life expectancy in the US and the assumed average patient age at discharge/death of 65.4 years, the total life-years gained by avoiding mortality related to hypothermia was 9.0 in the TherMax group compared to 8.0 in the 'standalone warmer' group. Cost per life-year gained was $8,615 in the TherMax group versus $10,115 in the 'standalone warmer' group for a difference of -$1,501 favoring TherMax. The incremental cost-effectiveness ratio was negative, indicating superior cost-effectiveness for TherMax versus 'standalone warmer'. The TherMax blood warming device used with the PrisMax system is associated with lower risk of hypothermia, which our model indicates leads to lower costs, lower risk of mortality due to hypothermia, and superior cost-effectiveness.

Application of continuous renal replacement therapy in infants with acute kidney injury after liver transplantation

To investigate the clinical application of continuous renal replacement therapy (CRRT) in infants with acute kidney injury (AKI) after liver transplantation. A retrospective study was conducted on infants with AKI after liver transplantation in Tianjin First Center Hospital from January 1, 2019 to June 1, 2021. Infants with AKI within 1 year after liver transplantation were divided into CRRT group and non-CRRT group according to whether CRRT was performed. The preoperative and intraoperative condition, the postoperative complications were compared, the risk factors of CRRT for AKI infants, the clinical characteristics of CRRT were analyzed, and the prognosis between CRRT group and non-CRRT group were compared. (1) A total of 512 cases of pediatric liver transplantation were performed. A total of 189 cases (36.9%) developed AKI within 1 year after surgery, including 18 cases in CRRT group and 171 cases in non-CRRT group. (2) There was no significant difference in preoperative conditions between the two groups. The duration of liver transplantation (hours: 8.8±1.5 vs. 7.5±1.3) and intraoperative blood loss [mL: 370 (220-800) vs. 310 (200-400)] in CRRT group were significantly higher than those in non-CRRT group. CRRT group had significantly higher incidence of postoperative complication [unplanned operation: 8 cases (44.4%) vs. 14 cases (8.2%), primary nonfunction: 1 case (5.6%) vs. 0 case (0%), retransplantation: 3 cases (16.7%) vs. 0 case (0%), hepatic artery thrombosis: 3 cases (16.7%) vs. 4 cases (2.3%), intestinal fistula: 2 cases (11.1%) vs. 2 cases (1.2%)] than non-CRRT group (all P < 0.05). (3) The average start time of CRRT was 10 (1-240) days. The per capita frequency of CRRT treatment was 3.3 (1.0-14.0) times. The average duration of each CRRT treatment was 10.1 (6.0-19.3) hours, the average reduction rate of serum creatinine (SCr) was 25.6% (13.5%-45.0%) after CRRT. (4) In CRRT group, 5 patients died, the 1-year and 2-year survival rates were both 72.22%. In non-CRRT group, 6 patients died, the 1-year and 2-year survival rates were 97.1% and 96.5%, respectively. There were significant differences in 1-year and 2-year survival rates between the two groups (both P < 0.01). The incidence of AKI after pediatric liver transplantation was high, and most infants treated with CRRT were associated with serious surgical complications. CRRT was a powerful means to remove inflammatory factors and maintain the stability of circulation and internal environment, which could improve the multi-organ dysfunction effectively.

Management for Electrolytes Disturbances during Continuous Renal Replacement Therapy.

Despite the lack of proven superiority in mortality compared to intermittent hemodialysis, continuous renal replacement therapy (CRRT) is the preferred renal replacement therapy modality for critically ill patients with acute kidney injury (AKI) due to better hemodynamic stability and steady correction of electrolytes disturbances and volume overload. Multiple and complex electrolyte disorders in patients with AKI can be managed effectively with CRRT because controlled and predictable correction is feasible. Thus, CRRT has an advantage with safety over conventional hemodialysis, especially in patients with both renal dysfunction and electrolyte disorder that require a sophisticated treatment with avoidance of rapid correction. On the contrary, CRRT can potentially lead to paradoxical disturbance of electrolytes such as hypokalemia or hypophosphatemia, especially in patients under high dose or prolonged duration of CRRT treatment. These electrolytes related complications can be prevented with close monitoring followed by the appropriate use of CRRT fluids. Although there is a lack of solid evidence and standardized guideline for CRRT prescriptions, optimal management of various electrolyte disturbances can be achieved with individualized and tailored dialysate and replacement fluid prescriptions. Several commercially available CRRT solutions with varying compositions provide flexibility to manage electrolyte disorders and maintain the stability of electrolyte. In this review, we discuss various prescription methods to manage common electrolyte imbalances as well as preventative strategies to maintain electrolyte homeostasis during CRRT providing detailed protocols used in our center. This review may contribute to future research that can lead to the development of clinical practice guidelines.

Risk factors of continuous renal replacement therapy following total aortic arch replacement under moderate hypothermia.

BackgroundStanford type A aortic dissection (TAAD) has a sudden onset and high mortality, and emergency total aortic arch replacement (TAAR) is the main treatment option for TAAD. The mortality rate of patients with postoperative acute kidney injury (AKI) combined with continuous renal replacement therapy (CRRT) is remarkable higher than that of patients without AKI. However, incidence of AKI and risk factors for CRRT following TAAR isn’t entirely understood.MethodsFrom October 2018 to March 2021, all patients with Stanford type A dissection who underwent total arch replacement surgery under MHCA were enrolled. According to whether CRRT treatment was performed, participants were divided into a CRRT group (n=49) and control group (n=72). Both groups incorporated the brain protection strategy of moderate hypothermia, and the left common carotid artery and the innominate artery were perfused anteriorly. Relevant medical data was collected.ResultsAge, gender, and a history of smoking and drinking were not significantly different between the 2 groups (P>0.1). There were statistical differences between the 2 groups in aortic sinus diameter and Bentall procedure (P≤0.05). Univariate analysis revealed that fresh frozen plasma was a protective factor (P<0.05) and the intraoperative transfusion volume of red blood cells, platelets, fresh frozen plasma, autologous blood used for intraoperative bleeding, aortic sinus diameter, and Bentall procedure were risk factors (P<0.1). Multivariate analysis showed that the Bentall procedure and intraoperative bleeding were risk factors for CRRT (P<0.05), and the aortic sinus diameter and intraoperative transfusion score were also risk factors for CRRT (P<0.05). Receiver operating characteristic (ROC) analysis demonstrated that the model of aortic sinus diameter and intraoperative transfusion score had more significantly different discriminatory powers.ConclusionsThe Bentall procedure, intraoperative bleeding, aortic sinus diameter, and intraoperative transfusion score were risk factors for postoperative CRRT. The model of aortic sinus diameter and intraoperative transfusion score had more significantly different discriminatory powers.

Effects of CRRT on renal function and toxin clearance in patients with sepsis: a case-control study.

ObjectiveTo explore the effects of continuous renal replacement therapy (CRRT) on renal function and toxin clearance in patients with sepsis and concurrent acute kidney injury (AKI).MethodA retrospective analysis was performed using the medical records of 115 patients with sepsis and AKI. Among them, 60 patients received routine treatment (group A) and 55 patients received CRRT plus routine treatment (group B).ResultAfter treatment, the clearance rates of serum creatinine, lactic acid, and urea nitrogen were significantly lower in group A than in group B. The decrease in high-sensitivity C-reactive protein and tumor necrosis factor-α levels after treatment was significantly higher in group B than in group A. For the Acute Physiology Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores from the two groups, the scores were significantly lower in group B than in group A. The mortality rate within 28 days was significantly higher in group A than in group B.ConclusionCRRT can effectively improve the condition of patients with sepsis and AKI, promote elimination of toxins (serum creatinine, lactic acid, and urea nitrogen) from the body, and reduce the mortality rate.