Continuous Renal Replacement Therapy Treatment Research Articles

079 OUTCOMES EVALUATION OF PATIENTS ON EXTRACORPOREAL MEMBRANE OXYGENATION WITH CONCOMITANT CONTINUOUS RENAL REPLACEMENT THERAPY

Category: RRT Applications and Targeted Interventions Presenter: Mr PETER CHI KEUNG LAI Keywords: Extracorporeal Membrane Oxygenation, Concomitant Continuous Renal Replacement Therapy Patients on Extracorporeal Membrane Oxygenation (ECMO) often have acute kidney injury or fluid overload requiring Continuous Renal Replacement Therapy (CRRT). There was evidence that ECMO patient requiring CRRT had higher mortality due to increased severity of illness, but it is uncertain how CRRT affects outcomes of ECMO patients. To explore the characteristics of ECMO survivors who underwent concomitant CRRT. Retrospective chart review of 27 adult ECMO patients with CRRT in a university-affiliated hospital in 2015 - 2016. 12 patients had veno-venous ECMO and 15 had veno-arterial ECMO. Indications for ECMO were hypoxemic respiratory failure refractory to conventional therapy, cardiogenic shock associated with myocardial infarction, myocarditis and cardiac arrest. Mean age was 49.4±14.8 years. 9 ECMO-CRRT patients survived and 18 died. There were more patients with primary respiratory diseases in survivor group (77.8% vs 17.8%, p=0.01). Similar findings were observed between survivors and non-survivors for ECMO blood flow rate (3.96±0.56 vs 3.5±0.6, p=0.06), ECMO duration (16.7±14.1 vs 13.8±16.1, p=0.64) and length of stay in intensive care unit (ICU) (29.3±25.6 vs 15.0±17.0, p=0.16). CRRT-ECMO configuration was the same for all cases, except for one case in which CRRT was conducted with non-tunneled dialysis catheter. Indications for CRRT treatment included acute kidney injury, fluid overload and metabolic disturbance. 23 patients received systemic ECMO anticoagulation with unfractionated heparin infusion at 12-18unit/kg/hour while 4 patients in non-survivor group received regional citrate anticoagulation for CRRT. Baseline creatinine before CRRT was 327.7±233.9umol/L and percentage creatinine change was 41.4±21.2%. CRRT treatment hours (151.6±191.1 hours), total fluid removal with CRRT (12.9±18.1 liters) and number of hemofilter change (5.0±4.6) were not associated to increase in mortality. In this series of 27 patients managed with ECMO and concomitant CRRT in an adult ICU, survival to ICU discharge was 33.3%. Mortality risk was increased in patients with circulatory failure but not it was not associated with CRRT treatment modality.

The impact of continuous renal replacement therapy for metabolic disorders in infants

While Continuous Renal Replacement Therapy (CRRT) is a well established treatment modality for patients with acute kidney insufficiency (AKI), it is now also being used for the management of various illnesses such as acute metabolic disorders presenting with hyperammonemia and elevated leucine levels. Herein, we aimed to describe our experience with CRRT in treatment of acute decompensation of 14 patients with a diagnosis of metabolic disorder who has been admitted to our pediatric intensive care unit (PICU) in the last year. Patients who have had life threatening acute metabolic crisis due to various metabolic disorders and were treated with continuous renal replacement therapy (CRRT) were evaluated retrospectively. Between November 2014 and December 2015, 14 patients were found to have received CRRT for various metabolic disorders in the PICU. Ten patients had hyperammonemia and four patients had elevated leucine levels. Nine patients were male and five were female. The age interval was between 2 days and 18 months, with a mean of 5.5±7.4 months. The weight distribution was between 2.5 and 18kg, with a mean of 7.3±5.6kg. Eleven patients received continuous veno-venous hemodiafiltration (CVVHDF), and 3 patients with MSUD received continuous veno-venous hemodialysis (CVVHD). All patients have received high throughput hemodialysis and hemofiltration. The dialyzate rate was set to be minimum 4042ml/h/1.73m2, and maximum 12,900ml/h/1.73m2. Hemofiltration was performed with a replacement rate of 40-76ml/kg/h. The average CRRT duration was 16.6±15.6h. We suggest that CRRT is an efficient method that can be used in hyperammonemia and elevated leucine levels which are metabolic emergencies.

Effects of hemoperfusion and continuous renal replacement therapy on patient survival following paraquat poisoning.

Mortality in patients with paraquat (PQ) poisoning is related to plasma PQ levels. Concentrations lower than 5,000 ng/mL are considered critical but curable. This study assessed the effects of hemoperfusion (HP) and continuous renal replacement therapy (CRRT) on the survival of PQ-poisoned patients with plasma PQ levels below 5,000ng/mL. We analyzed the records of 164 patients with PQ poisoning who were treated at the First Affiliated Hospital of Wenzhou Medical University in China between January 2011 and May 2015. We divided these patients into six sub-groups based on baseline plasma PQ levels and treatment, compared their clinical characteristics, and analyzed their survival rates. Patient sub-groups did not differ in terms of age, sex, time between poisoning and hospital admission, or time to first gavage. Biochemical indicators improved over time in all sub-groups following treatment, and the combined HP and CRRT treatment yielded better results than HP or CRRT alone. Fatality rates in the three treatment sub-groups did not differ among patients with baseline plasma PQ levels of 50–1,000 ng/mL, but in patients with 1,000–5,000 ng/mL levels, the mortality rate was 59.2% (HP treatment group), 48% (CRRT treatment group), and 37.9% (combined treatment group). Mortality rates were higher 10–30 days after hospitalization than in the first 10 days after admission. In the early stages of PQ poisoning, CRRT is effective in reducing patient fatality rates, particularly when combined with HP. Our data could be useful in increasing survival in acute PQ poisoning patients.

The relation between positive fluid balance and the prognosis in severe sepsis patients with acute kidney injury

Objective To investigate the relation between positive fluid balance and the prognosis in severe sepsis patients with acute kidney injury (AKI). Methods A retrospective analysis of clinical data of 90 patients in our department was carried out. According to the final outcome, patients were divided into survival group (n=26) and non-survival group (n=64), in which the relation between patients’positive fluid balance and the prognosis was evaluated. Results (1)There was no statistically significant difference in the age and severity between survival group and non-survival group of patients with severe sepsis and consequent AKI, but the patients in non-survival group had greater volume overload. Compared with the survival group, higher mean fluid balance [(1 112.12±546.85) mLvs.(644.69±474.93)mL, P=0.00], and less urine output [(1 224.07±708.79)mL vs.(2 032.36±723.53)mL, P=0.00) in non-survival group.(2)There was no significant difference in mortality between early and late continuous renal replacement therapy (CRRT) during ICU care. However, the average daily fluid load in late CRRT patients was significantly greater than that in early CRRT patients [(1178.81±397.03)mLvs.(287.22±433.53)mL, P=0.00]and the lung oxygenation index in late CRRT patients was significantly worse than that in early CRRT patients [(211.22±42.56)vs.(169.46±57.40), P=0.04](3)The relevant variables to 28-day mortality in AKI patients with severe sepsis included CRRT treatment, oxygenation index and the average daily fluid balance>500 mL.Among them, fluid balance>500mL was an independent risk factor for AKI patients with severe sepsis. Their prognosis was worse if they had greater positive fluid balance. CRRT was the protective factor which could affect the prognosis of patients with severe sepsis complicated by AKI. Conclusions Patients with severe sepsis complicated by AKI has a high mortality. Persistent fluid overload can lead to increased mortality in patients with severe sepsis complicated by AKI. Early CRRT can reduce fluid retention in patients with renal failure and improve oxygenation index. Key words: Acute kidney injury; Severe sepsis; Positive fluid balance

Continuous renal replacement therapy of acute renal failure in neonate

Acute renal failure (ARF) is the common critical disease caused by various factors in neonates, its clinical manifestation is the sharp decline in renal function, in a short period of time, the serum creatinine is increased and urine volume decreases.However, recently, with the progress of blood purification technology, continuous renal replacement therapy (CRRT) has been used from ARF in elderly children to the newborn.In this paper, the risk factors of neonatal ARF, diagnostic criteria, the relevant questions of CRRT treatment were reviewed. Key words: Renal failure; Infant, newborn; Continuous renal replacement therapy

Data analytics for continuous renal replacement therapy: historical limitations and recent technology advances.

Dialysis is a highly quantitative therapy involving large volumes of both clinical and technical data. While automated data collection has been implemented for chronic dialysis, this has not been done for acute kidney injury patients treated with continuous renal replacement therapy (CRRT). After a brief review of the fundamental aspects of electronic medical records (EMRs), a new tool designed to provide clinicians with individualized CRRT treatment data is analyzed, with emphasis on its quality assurance capabilities. The first platform addressing the problem of data collection and management with current CRRT machines (Sharesource system; Baxter Healthcare) is described. The system provides connectivity for the Prismaflex CRRT machine and enables both EMR connectivity and therapy analytics with 2 basic components: the connect module and the report module. The enormous amount of data in CRRT should be collected and analyzed to enable adequate clinical decisions. Current CRRT technology presents significant limitations with consequent lack of rigorous analysis of technical data and relevant feedback. From a quality assurance perspective, these limitations preclude any systematic assessment of prescription and delivery trends that may be adversely affecting clinical outcomes. A detailed assessment of current practice limitations is provided together with several possible ways to address such limitations by a new technical tool.

D-dimer Is a Predictor of 28-Day Mortality in Critically Ill Patients Receiving Continuous Renal Replacement Therapy

Continuous renal replacement therapy (CRRT) is an important treatment in the intensive care unit (ICU). Nevertheless, the outcome of CRRT remains unclear. It is important to find a useful and easy indicator to predict the prognosis in patients on CRRT treatment. We undertook this study to observe the association between serum D-dimer level and mortality of ICU patients in the treatment of CRRT. A total of 149 patients who received CRRT were enrolled in our study. We observed the correlation of D-dimer with the information of biochemical parameters, acute physiology and chronic health evaluation II (APACHE II) score. We analyzed the association between serum D-dimer level before CRRT and 28-d mortality retrospectively. Furthermore, we used Cox regression analysis to assess whether D-dimer could be the independent risk factor for mortality. There were significant correlations between D-dimer and C-reaction protein (r2=0.033, p=0.026), creatinine (r2=0.066, p=0.002) and APACHE II (r2=0.036, p=0.021). The difference in 28-d mortality risk between elevated D-dimer group and normal D-dimer group was significant (HR 2.872, 95% CI 1.563-5.278, p=0.001), and the elevated D-dimer level was an independent risk factor for 28-d mortality (HR 2.067, 95% CI 1.104-3.872, p=0.023). The difference in 28-d mortality was significant between groups (p <0.001). ROC curves showed that the area under the curve (AUC) of D-dimer was 0.763. The present study demonstrates that serum D-dimer could be a useful and easy prognostic variable of 28-d mortality in critically ill patients who received CRRT.

The clinical study of continuous renal replacement therapy in the treatment of severe sepsis complicated with acute kidney injury

Objectives To observe the clinical effect of continuous renal replacement therapy(CRRT) in the treatment of severe sepsis complicated with acute kidney injury, so as to provide reference for clinical treatment. Methods We selected 76 cases of severe sepsis complicated with acute kidney injury patients from our Hospital from July 2013 to April 2015, then randomly divided into two groups, CRRT treatment group and conventional treatment group respectively, 38 cases in each group. to compare the vital signs (Body temperature, heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure), Biochemical parameters (PH, hemoglobin, serum creatinine, urea nitrogen, white blood cell count, platelet count, albumin and C reactive protein) before and after treatment between the two groups, and to compare the APACHE II score and survival rate between the two groups before and after treatment. Results After treatment, the body temperature and heart rate in the CRRT group were lower than the conventional treatment group, the body temperature, heart rate in the two groups before and after treatment had statistically significant differences, the systolic blood pressure in continuous renal replacement therapy group after treatment was higher than before treatment, it had statistical significance(P<0.05); after treatment, the differences in PH, SCr, bun, WBC and PLT in patients between the two groups had statistical significance(P<0.05), PH, SCr, bun, WBC, PLT, ALB and hsCRP in CRRT treatment group before and after treatment had statisticallyl sig–nificant differences(P<0.05); after treatment, the APACHE of CRRT group was lower than the conventional treatment group, and the survival rate of CRRT treated group was higher than the conventional treatment group, the difference was statistically significant(P<0.05). Conclusions CRRT can remove metabolic waste, and can maintain the interior environment, and improve short term survival rate for severe sepsis complicated with acute kidney injury patients, therefore it can be recommended in clinical application. Key words: Kidney Diseases; Toxemia; Renal Replacement Therapy

Can early initiation of continuous renal replacement therapy improve patient survival with septic acute kidney injury when enrolled in early goal-directed therapy?

PurposeThe purpose of our study was to investigate the timing of continuous renal replacement therapy (CRRT) application, based on the interval between the start of early goal-directed therapy (EGDT) and CRRT initiation, to ascertain whether the timing was an independent predictor of mortality in patients with septic acute kidney injury (AKI). Materials and methodsAn observational retrospective cohort study was conducted of 60 patients (>18 years old) who had been admitted to the emergency department and received resuscitation according to the standard EGDT algorithm for severe sepsis and septic shock, and who were treated with CRRT due to septic AKI, between June 2008 and February 2013 at a tertiary hospital in Seoul, Korea. The patients were divided into 2 groups based on the median interval between the start of EGDT and the commencement of CRRT. The main outcome was 28-day all-cause mortality, and a multivariate Cox analysis for mortality was used to evaluate the independent impact of the early CRRT treatment. ResultsThe mean patient age was 66.3 years, and 52 (86.7%) were male. The most common comorbid disease was diabetes mellitus (35.0%) followed by malignancy (26.7%). The median interval between the start of EGDT and commencement of CRRT was 26.4 hours. During the study period, 28-day mortality was 43.3% (26 of 60 patients). The 28-day all-cause mortality rate was significantly higher in the late CRRT group than in the early CRRT group (56.7 vs 30.0%, P= .037). Furthermore, the higher mortality risk in the late group remained significant even after adjusting for diabetes mellitus, liver failure, and Acute Physiology and Chronic Health Evaluation II scores (hazard ratio, 2.461; 95% confidence interval, 1.044-5.800; P= .026). ConclusionEarly initiation of CRRT may be of benefit. Given the complex nature of this intervention and the ongoing controversy regarding early vs late initiation of therapy in acute and chronic situations, it is vital to develop accurate clinical trials to find definitive answers.

Experience of Circuit Survival in Extracorporeal Continuous Renal Replacement Therapy Using Small-Calibre Venous Cannulae.

To describe an experience of circuit survival in extracorporeal continuous renal replacement therapy using small-calibre (< 7 French gauge [F]) venous cannulae. An observational study. A multidisciplinary, university-affiliated PICU. Case note review of all continuous renal replacement therapy episodes (1998-2010), which used vascular access cannulae of an external diameter less than 7F, was performed. Forty-nine patients underwent continuous renal replacement therapy treatment during which circuit blood flow was delivered using either 5F or 6.5F double-lumen cannulae. One hundred thirty-nine circuits were employed (median per patient, 2; interquartile range, 1-3) in providing 4,903 hours of therapy (median duration of therapy, 43 hr; interquartile range, 22-86 hr); allowing for censoring, the median circuit survival time was 40 hours (95% CI, 28-66). Eighty-one circuits (58%) failed because of clotting/technical problems, equating to a circuit failure rate of 16.5 (95% CI, 13.3-20.5) per 1,000 hours of continuous renal replacement therapy. The probability of a circuit surviving 40 hours or greater was 50% with 43% (95% CI, 34-53%) expected to survive 60 hours or more. No significant relationship between circuit survival and the calibre of the cannula deployed was identified; however, placement of venous access in an internal jugular vein was associated with improved circuit survival. Contrary to previous reports, vascular access cannulae of a caliber less than 7F can support sufficiently prolonged continuous renal replacement therapy to make them a useful means of delivering renal support in neonates and small infants.

Effects of parenteral nutrition in different administration methods on the treatment of CRRT

Objectives To explore the effect of different parenteral nutrition (TPN) dosing time on critical surgical patients of continuous renal replacement therapy (CRRT) influence the nutritional status of patients. Methods 80 cases of renal failure induced by severe surgical trauma or sepsis were collected from January 2014 to January 2015 in our SICU.All patients with APACH II type >10 were performed CRRT, and , randomly divided into early and late group. According to plasma specimens after renal replacement therapy, the amino acid filtration rate and creatinine clearance rate were compared between two groups. Results There was no difference in creatinine clearance rate between the two groups(P>0.05). The amino acid filtration rate in group of patients with early filtration rate was significantly higher than the control group(P<0.05). Conclusions Although the nutrients in CRRT by combination of TPN therapy for AKI patients was filtered out, the rest of nutrients in plasma of patients was still high. CRRT by combination of TPN therapy for AKI patients can be used in nutrition support. So we think using early PN to CRRT patients is the preferred way of filtration. Key words: Kidney Failure; Renal Replacement Therapy; Parenteral Nutrition

Prophylaxis and management of early acute renal failure after orthotopic liver transplantation

To summarize the experiences of prophylaxis and management of early period acute renal failure (ARF) after orthotopic liver transplantation (OLTx). The clinical data of 516 patients from January 2004 to December 2006 at our hospital undergoing allograft orthotopic liver transplantation, 418 males and 98 females, aged 43 (8-76) years old, were collected to analyze the incidence of early ARF. Of these patients, 106 (20.5%)experienced early ARF, including 21 mild, 40 moderate and 45 severe cases. The integrated control treatment including retrieving prerenal factors, adjusting immunosuppressive schedule, drug therapy and blood purification were taken to cure ARF and 21 patients of severe ARF needed continuous renal replacement therapy (CRRT). Of 106 patients, 37 (34.9%) died within 1 month post-OLT. The one month post-OLT survival rate of patients with MELD (model for end-stage liver disease) score less than 20 fared better than those whose MELD score between 20 to 30 and MELD score over 30. The prophylaxis and management of early post-OLT ARF is a systemic procedure from preoperative assessment to postoperative management. The significant steps of preventing and curing ARF within perioperative procedure of OLTx include preoperative evaluation of patient renal function, various intra-operative measures for protecting renal function, reducing renal function impairment due to drug toxicity after OLT and CRRT treatment if needed.

The effect of AN69 ST membrane on filter lifetime in continuous renal replacement therapy without anticoagulation in patients with high risk of bleeding

To evaluate whether AN69 ST membrane would prolong filter lifetime in continuous renal replacement therapy (CRRT) without anticoagulation in patients with high risk of bleeding. A single-center, prospective, randomized, double-blind control trial with crossover design was conducted. From March 1st to December 31st in 2013, patients who were admitted to Department of Critical Care Medicine of the Fourth Hospital of Hebei Medical University meeting CRRT treatment indications, but could not receive systemic anticoagulation because of high risk of bleeding were studied. The selected patients were randomly divided into two groups according to a random number table, and four filters consisting of two AN69 ST100 membrane filters (A) and two traditional AN69 M100 membrane filters (B) were used for them. Group I with the filter order of A-B-A-B, and group II with the order of B-A-B-A. The clinical data of patients was recorded in detail, and conventional AN69 ST and AN69 membrane filter lifetime, their influence on coagulability, and the incidence of bleeding complications were compared. Seventeen patients were enrolled, with 10 in groupI, and 7 in group II. The basic medical characteristics including gender, age, acute physiology and chronic health evaluation II ( APAECH II) score, sequential organ failure score (SOFA), Acute Renal Injury Network (AKIN) stage, activated partial thromboplastin time (APTT), prothrombin time (PT), international normalized ratio (INR), platelet count (PLT), and use of mechanical ventilation were not significantly different between two groups. But the use of vasoactive drug was more frequent in group IIcompared with that of group I[ 100.0% (7/7) vs. 30.0% (3/10), χ² = 8.330, P = 0.010]. AN69 ST filter lifetime (n = 34) was (15.92±2.10) hours, there was no statistically significant difference compared with that of AN69 membrane (t = 0.088, P = 0.942), filter lifetime of which (n = 34) was (16.12±1.38) hours. It was also found by Kaplan-Meier survival analysis that there was no significant difference between the two membrane filter lifetime (χ² =1.589, P = 0.208). Logistic regression analysis showed that the life of the first filter was not correlated with coagulation indicators, including APTT, PT, INR, and PLT [ APTT: odds ratio (OR) = 0.977, 95% confidence interval (95%CI) = 0.892-1.071, P = 0.623; PT: OR = 1.001, 95%CI = 0.901-1.109, P = 0.988; INR: OR = 1.078, 95%CI = 0.348-3.340, P = 0.896; PLT: OR = 0.996, 95%CI = 0.974-1.019, P = 0.735]. The application rate of vasoactive drugs, which was different between two groups for basic medical indications showed no effect on filter life time (OR = 2.541, 95%CI = 0.239-26.955, P = 0.439). Reasons of clotting in filters were also analyzed, and it was found that blood coagulation in the filter ranked the top (88.2%), and the other reasons were catheter-related problems, death, and unscheduled transport. No difference in blood coagulation function was found in both groups after treatment for 12 hours, and there was no bleeding complication. During the CRRT without systemic anticoagulant, both surface-treatment with polyethyleneimine AN69 and AN69 ST membrane cannot prolong filter lifetime.

Anidulafungin dosing during CRRT: do not underestimate adsorption!

Two recent papers in Critical Care discuss the use of echinocandins in general [1], and anidulafungin in particular [2], during continuous renal replacement therapy (CRRT). Being highly protein bound and predominantly nonrenally eliminated drugs, echinocandins are barely removed by convection and thus require no dose adjustment during CRRT. Based on scarce literature data, Gonzalez de Molina and colleagues additionally state that echinocandin removal by adsorption to the synthetic surface of hemofilters is unlikely to have clinical relevance [1]. This conclusion is largely driven by the study from Leitner and colleagues, who found similar pharmacokinetics of anidulafungin during continuous venovenous hemofiltration in healthy adults and in adults with fungal infections [3]. However, Leitner and colleagues also observed a 20 to 25% loss of initial anidulafungin dose by filter adsorption [3]. This loss resulted in lower maximal concentrations of anidulafungin, yet necessitated no dose adaptation. Importantly, CRRT in this study was performed using polysulfone membranes, which are known to be the least adsorptive. At present, highly adsorptive membranes (for example, AN69 surface-treated and polymethylmethacrylate filters) are increasingly introduced for CRRT treatment in critically ill patients. As shown for other antimicrobial agents [4], highly adsorptive membranes may adsorb a significantly higher amount of anidulafungin, thereby lowering maximal concentrations to a point at which dose adjustment becomes inevitable. Recent studies also suggest slower saturation (and thus enhanced adsorption capacity) within the bulk of highly adsorptive membranes [5]. Therefore, before recommending unadjusted anidulafungin dosing during CRRT, more information about the handling of this drug by highly adsorptive membranes is urgently needed.

The benefit of specialized team approaches in patients with acute kidney injury undergoing continuous renal replacement therapy: propensity score matched analysis.

IntroductionContinuous renal replacement therapy (CRRT) has been widely used in critically ill acute kidney injury (AKI) patients. Moreover, some centers operate a specialized CRRT team (SCT) composed of physicians and nurses, but few studies have yet determined the superiority of SCT control.MethodsA total of 334 among 534 patients in the original cohort, who started CRRT for severe AKI between August 2007 and September 2009 in Yonsei University Health System and were matched with a propensity score (PS), were divided into two groups based on SCT application. Moreover, we compared CRRT-related outcomes including down-time per day and lost time per filter-exchange between the two groups. The primary outcomes were 28- and 90-day all-cause mortality, and the secondary outcomes were the rates of renal function recovery at 28- and 90-day.ResultsThe down-time per day, lost time per filter-exchange, and red blood cell-transfused numbers during CRRT treatment were significantly lower after SCT approach compared with the group before SCT, while net ultrafiltration rate in the after SCT group was significantly higher compared to the before SCT group. During the study period, the 28- and 90-day all-cause mortality rates were significantly decreased after SCT application. Cox regression analysis revealed that 28- and 90-day all-cause mortality rates were significantly lower under SCT control, after adjusting for primary diagnosis, emergent surgical cases, Charlson Comorbidity Index and biochemical parameters. However, there were no significant differences in the rate of renal function recovery before and after SCT approach in CRRT.ConclusionsA well-organized CRRT team could be beneficial for clinical outcomes through improving quality of care in AKI patients requiring CRRT treatment in the ICU.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0454-8) contains supplementary material, which is available to authorized users.

Testify patient's blood electrolyte concentration a tendency to approach that of replacement-fluid in continuous renal replacement therapy

To prove with mathematical formula that the patient's blood electrolyte concentration shows a tendency to approach that of replacement-fluid after continuous renal replacement therapy (CRRT). Electrolyte concentration of plasma, replacement-fluid and returning fluid were compared, and they were labeled as C(blood), C(norm), and C(return) respectively. The "C(return)" was calculated, and the relationship among them was demonstrated with comparison by mathematical formula. At last, according to their relationship, plasma change towards to the replacement fluid was analyzed. It was showed that "C(blood)<C(return)<C(norm)" or "C(blood)>C(return)>C(norm)", and according the relationship, it was derive that the trend of change in "C(blood)" after circulation for m unit time was "C(blood)1>C(blood)2>C(blood)3> ... >C(blood)m>C(norm)" or "C(blood)1 < C(blood)2 < C(blood)3 < ... < C(blood)m < C(norm)". The plasma electrolyte concentration would close to that of replacement fluid infinitely with the continue of CRRT. With mathematical model, it is proved that the replacement fluid electrolyte concentration is the final target of the plasma. We must make up the replacement fluid correctly. And this results provide the basis for CRRT treatment of electrolyte disorder.

Management of acute kidney injury with continuous venovenous haemodiafiltration in a cat.

Continuous renal replacement therapy is an emerging technique for the treatment of acute kidney injury (AKI). Data regarding its use in cats are limited. This report describes the use of a novel continuous renal replacement therapy (CRRT) system for the treatment of AKI in a cat. A 1.3-year-old cat developed uraemic signs following the administration of a non-steroidal anti-inflammatory agent for the treatment of a suspect traumatic episode. CRRT was provided with a Prismaflex Gambro machine used in continuous venovenous haemodiafiltration mode, with an AN-69 surface-treated membrane, synthetic colloid priming and heparin anticoagulation. Two treatment cycles were performed, totalling 51 h of CRRT. The treatment was effective in controlling uraemic signs, and no major complications were noted. Owing to financial constraints the owners declined further CRRT treatments, and on day 8 of hospitalisation, owing to the lack of significant clinical improvement, humane euthanasia was performed. The set-up detailed in this report provides a viable option for the initial treatment of cats with AKI.

A biphasic dialytic strategy for the treatment of neonatal hyperammonemia

Neonates with inborn errors of metabolism (IEM) often develop hyperammonemia which, if not corrected quickly, may result in poor neurologic outcomes. As pharmacologic therapy cannot rapidly lower ammonia levels, dialysis is frequently required. Both hemodialysis (HD) and standard-dose continuous renal replacement therapy (CRRT) are effective; however, HD may be followed by post-dialytic ammonia rebound, and standard-dose CRRT may not effect a rapid enough decrease in ammonia levels. We present two cases of IEM-associated neonatal hyperammonemia in which we employed a biphasic, high-dose CRRT treatment strategy, initially using dialysate flow rates of 5,000 mL/h (approximately 40,000 mL/h/1.73 m(2)) in order to rapidly decrease ammonia levels, then decreasing the dialysate flow rates to 500 mL/h (approximately 4,000 mL/h/1.73 m(2)) in order to prevent ammonia rebound. This biphasic dialytic treatment strategy for neonatal hyperammonemia effected rapid ammonia reduction without rebound and accomplished during a single dialysis run without equipment changes.

High-dose continuous renal replacement therapy for neonatal hyperammonemia

Infants with hyperammonemia can present with nonspecific findings so ordering an ammonia level requires a high index of suspicion. Renal replacement therapy (RRT) should be considered for ammonia concentrations of >400 μmol/L since medical therapy will not rapidly clear ammonia. However, the optimal RRT prescription for neonatal hyperammonemia remains unknown. Hemodialysis and continuous renal replacement therapy (CRRT) are both effective, with differing risks and benefits. We present the cases of two neonates with hyperammonemia who were later diagnosed with ornithine transcarbamylase deficiency and received high-dose CRRT. Using dialysis/replacement flow rates of 8,000 mL/h/1.73 m(2) (1,000 mL/h or fourfold higher than the typical rate used for acute kidney injury) the ammonia decreased to <400 μmol/L within 3 h of initiating CRRT and to <100 μmol/L within 10 h. We propose a CRRT treatment algorithm to rapidly decrease the ammonia level using collaboration between the emergency department and departments of genetics, critical care, surgery/interventional radiology, and nephrology.

The effect of continuous renal replacement therapy on the outcome of severe pneumonia in patients receiving long-term immunosuppressants

To investigate the effect of continuous renal replacement therapy (CRRT) on the outcome of severe pneumonia in patients receiving long-term immunosuppressants. Thirty-four patients, who had been treated with long-term immunosuppressants, were admitted for severe pneumonia. After admission, the dose of immunosuppressants including glucocorticoids was decreased, and the patients were divided into 2 groups: antibiotic treatment group (n = 16) and antibiotic + CRRT treatment group (n = 18). Before and after treatment, the changes of the patients' condition, chest CT and blood gas analysis were monitored. Biomarkers including C-reactive protein (CRP), interferon-γ (IFN-γ), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-8(IL-8), white blood cell and neutrophil counts were determined. After treatment, the levels of CRP[(109 ± 24) vs (40 ± 13) mg/L], IFN-γ [(151 ± 28) vs (42 ± 12) ng/L], TNF-α [(301 ± 45) vs (118 ± 28) pg/L], IL-6 [(214 ± 45) vs (76 ± 23) pg/L], IL-8[(590 ± 121) vs (159 ± 60) pg/L], white blood cell count [(14.3 ± 5.7)×10⁹/L vs (8.5 ± 2.7)×10⁹/L], and neutrophil percentage [(91.3 ± 3.1)% vs (75.3 ± 2.6)%] decreased significantly in the antibiotic + CRRT group (P < 0.05) as compared to the antibiotic treatment group. In the antibiotic + CRRT group, blood gas showed significant improvement in pH [(7.30 ± 0.12) to (7.37 ± 0.18)], SaO₂ [(80.6 ± 7.6)% to (91.9 ± 7.3)%] and PaO₂ (41 ± 6) mm Hg (1 mm Hg = 0.133 kPa) to (71 ± 9) mm Hg. The patients' condition and chest CT abnormalities also improved more rapidly in the antibiotic + CRRT group. The 6-month survival was increased by 12.9% in the antibiotic + CRRT group as compared to the antibiotic group (P < 0.05). CRRT is effective in clearance of inflammatory mediators and may increase survival of severe pneumonia patients receiving long-term treatment of immunosuppressants.