Continuous Renal Replacement Therapy Treatment Research Articles

Early initiation of continuous renal replacement therapy improves patient survival in severe progressive septic acute kidney injury

PurposeThe definition of “early” in terms of continuous renal replacement therapy (CRRT) initiation has not been uniformly used. Therefore, we tried to elucidate whether the timing of CRRT application, based on the interval between the start time of vasopressors infusion and CRRT initiation, was an independent predictor of mortality in the patients with septic acute kidney injury (AKI). Materials and MethodsProgressive septic AKI patients, in whom the infusion doses of vasopressors were increased compared with the initial dose during the first 6 hours of vasopressor treatment and CRRT was performed, between 2009 and 2011, were collected and divided into 2 groups based on the median interval between the 2 points. ResultsA total of 210 patients were included. The mean age was 62.4 years, and 126 patients (60.0%) were male. The most common comorbid disease was malignancy (53.8%), followed by hypertension (35.7%) and diabetes mellitus (29.0%). The median interval between the start time of vasopressor infusion and CRRT commencement was 2.0 days. During the study period, 156 patients (74.3%) died within 28 days of CRRT application. The interval between 2 points was significantly shorter in the survivor compared with the death group (P < .001). Moreover, 28-day overall mortality rates in the early CRRT group were significantly lower than those in the late CRRT group (P = .034). Furthermore, early CRRT treatment was independently associated with a lower mortality rate even after adjustment for age, sex, causative organisms, and infection sites (P = .032). ConclusionsThis retrospective cohort study suggests that early initiation of CRRT may be of benefit. Given the complex nature of this intervention, the ongoing controversies regarding early vs late initiation of therapy in acute and chronic situation, there is an urgent need to develop well-designed clinical trials to answer the question definitely.

Application and nursing of high replacement rate continuous renal replacement therapy (CRRT) in severe acute pancreatitis (SAP) complicated by acute respiratory distress syndrome ( ARDS )

Objective To study the application and nursing of high replacement rate continuous renal replacement therapy (CRRT) in severe acute pancreatitis ( SAP), complicated by acute respiratory distress syndrome ( ARDS) .Methods Twenty four cases of severe acute pancreatitis ( SAP) concurrent ARDS patients were treated with high replacement rate CRRT treatment by ventilator support.Dynamically observing life signs,oxygenation index,APACHE - Ⅱ score,positive end expiratory pressure ( PEEP) level were compared before and after treatment.Results Fifteen cases of patients were treated successfully on high replacement ratio CRRT therapy.the level of A PACHE - II score,body temperature,breathing,heart rate,mean arterial pressure,and positive end expiratory pressure ( PEEP) were significantly decreased (P < 0.05).oxygenation index was increased significantly (P < 0.05) .Conclusions Early application of high replacement rate CRRT treatment,can alleviate clinical symptoms,improve disease,improve the success rate of treatment. Moreover it plays an important role to improve therapeutic effect of severe acute pancreatitis concurrent acute respiratory distress syndrome by clirucal closely monitoring and scientificly nursing. Key words: High replacement rate CRRT; Severe acute pancreatitis (SAP); Acute respiratory distress syndrome (ARDS); Nursing

Red blood cell distribution width is an independent predictor of mortality in acute kidney injury patients treated with continuous renal replacement therapy

A potential independent association was recently demonstrated between high red blood cell distribution width (RDW) and the risk of all-cause mortality in patients with cardiovascular disease, although the mechanism remains unclear. However, there have been no reports on the relationship between RDW and mortality in acute kidney injury (AKI) patients treated with continuous renal replacement therapy (CRRT). In this study, we assessed whether RDW was associated with mortality in AKI patients on CRRT treatment in the intensive care unit (ICU). We enrolled 470 patients with AKI who were treated with CRRT at the Yonsei University Medical Center ICU from August 2007 to September 2009 in this study. We performed a retrospective analysis of demographic, biochemical parameters and patient outcomes. Following CRRT treatment, 28-day all-cause mortality was evaluated. At the initiation of CRRT treatment, RDW level was significantly correlated with white blood cell count, hemoglobin (Hb) and total cholesterol. Patients with high RDW levels exhibited significantly higher 28-day mortality rates than patients with low RDW levels (P < 0.01). Baseline RDW level, Sequential Organ Failure Assessment (SOFA) score, low mean arterial pressure (MAP) and low cholesterol levels were independent risk factors for mortality. In multivariate Cox proportional hazard analyses, RDW at CRRT initiation was an independent predictor for 28-day all-cause mortality after adjusting for age, gender, MAP, Hb, albumin, total cholesterol, C-reactive protein and SOFA score. Our study demonstrates that RDW could be an additive predictor for all-cause mortality in AKI patients on CRRT treatment in the ICU.

Clinical research of severe burn patients with chemical poisoning treatment by continuous renal replacement therapy

Objective To investigate the influence of biochemical indices and coagulation function in severe burn patients with chemical poisoning by continuous renal replacement therapy(CRRT)treatment.Methods 60 patients were randomly divided into CRRT treatment group(n=30)and basic therapy(n=30).The control group received conventional treatment,based therapies in the treatment group based on the use CRRT treatment,the average course of 2 or 3 times to observe the biochemical indicators coagulation,and cytokine before treatment compared with that after treatment.Results In treatment group,the index of heart rate,arterial partial pressure of oxygen,blood urea nitrogen,serum creatinine after treatment[(110.0±26.0)times/min,(93.3±11.0)mm Hg,(6.1 ±1.3)mmol/L,(106.4±24.8)μmol/L],compared with before treatment[(148.0±38.0)times/min、(84.5 9.1)mm Hg,(8.6±1.9)mmol/L,(172.6 ±29.8)μmol/L]were significantly different(t=2.154,2.345、2.458,2.544,all P＜0.05),and compared with control group[(133.0±37.0)times/min,(86.5 ±9.9)mm Hg,(8.3 ±2.0)mmol/L,(134.6±26.8)μmol/L]were statistically significant(t=2.174,2.245,2.558,2.444,all P＜0.05);The index of IL-1,IL-6,IL-8,TNF-α after treatment in treatment group[(260.7 ±25.9)ng/L,(327.6±129.2)ng/L,(300.3±146.6)ng/L,(97.1±22.3)ng/L)compared with control group after treatment[(368 .2±24.8)ng/L,(400.2±198.3)ng/L,(482.9±198.5)ng/L,(225.0 ±22.3)ng/L]had significant differences(t=2.314、2.371、2.278、2.316,all P＜0.05).Conclusion The treatment group of patients with severe burns could remove the inflammatory mediators and cywkines,to improve their inflammatory state and maintain stability in the environment. Key words: Renal replacement therapy; Burn,inhalation; Cytokines

Phosphate-containing dialysis solution prevents hypophosphatemia during continuous renal replacement therapy

BackgroundHypophosphatemia occurs in up to 80% of the patients during continuous renal replacement therapy (CRRT). Phosphate supplementation is time-consuming and the phosphate level might be dangerously low before normophosphatemia is re-established. This study evaluated the possibility to prevent hypophosphatemia during CRRT treatment by using a new commercially available phosphate-containing dialysis fluid.MethodsForty-two heterogeneous intensive care unit patients, admitted between January 2007 and July 2008, undergoing hemodiafiltration, were treated with a new Gambro dialysis solution with 1.2 mM phosphate (Phoxilium) or with standard medical treatment (Hemosol B0). The patients were divided into three groups: group 1 (n=14) receiving standard medical treatment and intravenous phosphate supplementation as required, group 2 (n=14) receiving the phosphate solution as dialysate solution and Hemosol B0 as replacement solution and group 3 (n=14) receiving the phosphate-containing solution as both dialysate and replacement solutions.ResultsStandard medical treatment resulted in hypophosphatemia in 11 of 14 of the patients (group 1) compared with five of 14 in the patients receiving phosphate solution as the dialysate solution and Hemosol B0 as the replacement solution (group 2). Patients treated with the phosphate-containing dialysis solution (group 3) experienced stable serum phosphate levels throughout the study. Potassium, ionized calcium, magnesium, pH, pCO2 and bicarbonate remained unchanged throughout the study.ConclusionThe new phosphate-containing replacement and dialysis solution reduces the variability of serum phosphate levels during CRRT and eliminates the incidence of hypophosphatemia.

Continuous renal replacement therapy for patients with acute kidney injury caused by melamine-related urolithiasis

In 2008 there was an epidemic of renal disease affecting infants after consumption of melamine-tainted milk products. Most of the infected children were asymptomatic or with mild symptoms, and a few suffered from acute obstructive kidney injury secondary to melamine-contained renal stones (8 of 15,577 children screened at our hospital for urolithiasis). This study was intended to retrospectively review the management of acute kidney injury using continuous renal replacement therapy (CRRT) in the 8 children with acute kidney injury. The 8 infants with acute kidney injury caused by melamine-related urolithiasis were referred to the pediatric intensive care unit at the hospital in late 2008. CRRT was given to treat their kidney injuries. Medical records of the infants were reviewed for demographic features, diagnosis, CRRT treatment, and outcomes. Before CRRT, hypertension was found in 6 of the 8 children. Varying degrees of oliguria, anuria, elevated levels of blood urea nitrogen (BUN) (13.11-35.6 mmol/L) and creatinine (Cr) (238.8-773.7 mumol/L) were observed in these patients. After CRRT, the levels of BUN, Cr and electrolytes decreased. Urine output and edema were improved clinically. CRRT can rapidly improve renal function, avoiding such surgical interventions as lithotripsy, percutaneous nephrolithotomy, and ureteroscopy. It is an efficient modality to treat acute kidney injury caused by melamine-related urolithiasis.

Serum proteome alteration of severe sepsis in the treatment of continuous renal replacement therapy

Continuous renal replacement therapy (CRRT) techniques have occupied an important position in the intensive care units (ICU). Serum proteome alteration and protein removal in this process are not clear. Since it has a poor understanding of mechanism of the treatment, there is a specific need of proteomics research for CRRT. The aim of this research was to study the serum proteome alterations of severe sepsis patients in the treatment of CRRT. Improved knowledge of proteome alteration could lead to the development of more efficient treatment strategies. In this study, 20 severe sepsis patients were enrolled. A proteomic approach with two-dimensional gel electrophoresis (2-DE) coupled with mass spectrometry and bioinformatics methods was utilized to identify proteins with altered expression at different times in the treatment of continuous veno-venous haemofiltration (CVVH). All proteins were identified on the appearance of the 2-DE gel at the appropriate molecular size and pI and score from peptide mass fingerprinting. Protein identifications were confirmed by sequencing of the tryptic peptides and an independent database search based on the sequence. A further validation study was performed by western blot. Thirty-four protein spots expressed differentially were separated. Ten proteins were identified to be the commonly differentially expressed proteins in the treatment. Seven proteins decreased in the serum and three increased. This study gives a novel overview of serum proteome alteration of severe sepsis patient in the treatment of CVVH. Potentially interesting proteins have been revealed that are different from those identified by method of traditional biology.

Protein and calorie prescription for children and young adults receiving continuous renal replacement therapy: A report from the Prospective Pediatric Continuous Renal Replacement Therapy Registry Group

Few published reports describe nutrition provision for critically ill children and young adults with acute kidney injury receiving continuous renal replacement therapy. The goals of this study were to describe feeding practices in pediatric continuous renal replacement therapy and to evaluate factors associated with over- and under-prescription of protein and calories. Retrospective database study. Multicenter study in pediatric critical care units. Patients with acute kidney injury (estimated glomerular filtration rate < 75 mL/min/1.73 m at continuous renal replacement therapy initiation) enrolled in the Prospective Pediatric Continuous Renal Replacement Therapy Registry. None. Nutrition variables: initial and maximal protein (g/kg/day) and caloric (kcal/kg/day) prescription and predicted resting energy expenditure (kcal/kg/day). We determined factors predicting initial and maximal protein and caloric prescription by multivariate analysis. One hundred ninety-five patients (median [interquartile range] age = 8.1 [12.8] yrs, 56.9% men) were studied. Mean protein and caloric prescriptions at continuous renal replacement therapy initiation were 1.3 +/- 1.5 g/kg/day (median, 1.0; range, 0-10) and 37 +/- 27 kcal/kg/day (median, 32; range, 0-107). Mean maximal protein and caloric prescriptions during continuous renal replacement therapy were 2.0 +/- 1.5 g/kg/day (median, 1.7; range, 0-12) and 48 +/- 32 kcal/kg/day (median, 43; range, 0-117). Thirty-four percent of patients were initially prescribed < 1 g/kg/day protein; 23% never attained > 1 g/kg/day protein prescription. By continuous renal replacement therapy day 5, median protein prescribed was > 2 g/kg/day. Protein prescription practices differed substantially between medical centers with 5 of 10 centers achieving maximal protein prescription of > 2 g/kg/day in > or = 40% of patients. Caloric prescription exceeded predicted resting energy expenditure by 30%-100%. Factors independently associated with maximal protein and caloric prescription while on continuous renal replacement therapy were younger age, initial protein and caloric prescription and number of continuous renal replacement therapy treatment days (p < 0.05). Protein prescription in pediatric continuous renal replacement therapy may be inadequate. Inter-center variation exists with respect to nutrition prescription. Feeding practice standardization and research in pediatric acute kidney injury nutrition are essential to begin providing evidence-based feeding recommendations.

Metabolic disturbances following the use of inadequate solutions for hemofiltration in acute renal failure

Continuous renal replacement therapy (CRRT) has become an important supportive therapy for critically ill children with acute renal failure. In Turkey, commercially available diafiltration and replacement fluids cannot be found on the market. Instead, peritoneal dialysis fluids for dialysis and normal saline as replacement fluid are used. The first objective of this study was to examine metabolic complications due to CRRT treatments. The second objective was to determine demographic characteristics and outcomes of patients who receive CRRT. We did a retrospective chart review of all pediatric patients treated with CRRT between February and December 2004. Thirteen patients received CRRT; seven survived (53.8%). All patients were treated with continuous venovenous hemodiafiltration. Median patient age was 71.8 +/- 78.8 (1.5-180) months. Hyperglycemia occurred in 76.9% (n=10), and metabolic acidosis occurred in 53.8% (n=7) of patients. Median age was younger (48.8 vs.106.2 months), median urea level (106.2 vs. 71 mg/dl) and percent fluid overload (FO) (17.2% vs. 7.6%, respectively) were higher, and CRRT initiation time was longer (8.6 vs 5.6 days) in nonsurvivors vs. survivors for all patients, although these were not statistically significant. CRRT was stopped in all survivors, and four nonsurvivors (67%) were on renal replacement therapy at the time of death. Hyperglycemia and metabolic acidosis were frequently seen in CRRT patients when commercially available diafiltration fluids were not available. Using peritoneal dialysis fluid as dialysate is not a preferable solution. Early initiation of CRRT offered survival benefits to critically ill pediatric patients. Mortality was associated with the primary disease diagnosis.

Torsemide Versus Furosemide After Continuous Renal Replacement Therapy Due to Acute Renal Failure in Cardiac Surgery Patients

Diuretic therapy in ARF (acute renal failure) is mainly done with loop diuretics, first of all furosemide. Torsemide has a longer duration of action and does not accumulate in renal failure. In chronic and acute renal failure, both diuretics have been effectively applied, with a more pronounced diuretic effect for torsemide. In this study, the effects of torsemide versus furosemide on renal function in cardiac surgery patients recovering from ARF after continuous renal replacement therapy (CRRT) were studied. Twenty-nine critically ill patients admitted to an intensive care unit at a university teaching hospital after cardiac surgery recovering from ARF after CRRT were included in this prospective, controlled, single-center, open-labeled, randomized clinical trial. Inclusion criteria were urine output > 0.5 mL/kg/h over 6 h under CRRT. Torsemide and furosemide dosages were adjusted with the target urine output being 0.8–1.5 mL/kg/h. Hemodynamic data, urine output, volume balance, serum creatinine clearance, electrolytes, blood urea nitrogen, serum creatinine, renin, and aldosterone concentrations were measured. Fourteen patients were included in the furosemide group and 15 patients in the torsemide group. Dosages of 29 (0–160) mg torsemide and a dosage of 60 (0–240) mg furosemide were given every 6 h in each group, respectively. The dosage given at the end of the study decreased significantly in furosemide and torsemide treated patients. Urine output, 24 h balance, and serum creatinine clearance did not differ significantly between groups. Urine output decreased in both groups, mostly dose-dependent in the torsemide group. The intragroup comparison of the first time-interval after inclusion with the last time-interval showed a significant increase in serum creatinine and blood urea nitrogen in the furosemide group. Renin and aldosterone concentrations did not show significant differences. In conclusion, torsemide and furosemide were effective in increasing urine output. Torsemide might show a better dose-dependent diuretic effect in ARF patients after CRRT treatment. Serum creatinine and blood urea nitrogen elimination were less pronounced in the furosemide group.

CONTINUOUS RENAL REPLACEMENT THERAPY: OUR EXPERIENCE IN INTENSIVE CARE UNIT

Continuous Renal Replacement Therapy (CRRT) indication is still discussed. We report our experience on 98 patients affected with Multiple Organ System Failure (MOSF) and renal failure (acute or chronic) requiring dialysis and timely treated by CRRT. Mortality after 5 days of ICU permanence was 60.2%; the remaining 39 patients were discharged within 21 days and received CRRT treatment for 6.36 ± 5.59 days. APACHE II score was not able to predict the outcome of patients suffering from acute renal failure (ARF). On the contrary, Systemic Inflammatory Response Syndrome (SIRS) incidence was significantly higher in deceased patients compared to recovered patients.In conclusion, it is important to start dialytic treatment immediately when patients affected with MOSF show renal function damage, even if at an initial stage, in order to improve patients' survival. Moreover a multidisciplinary approach is preferable in ICU patients treatment for not underestimating the management of metabolic and infective complications, the nursing care, and nutritional support.

Continuous venovenous hemodialysis treatment in critically ill patients after liver transplantation

Continuous venovenous hemodialysis treatment in critically ill patients after liver transplantation.BackgroundAcute renal failure (ARF) in critically ill patients is associated with a high mortality rate. Continuous renal replacement therapy (CRRT) is now widely used for the treatment of ARF in these critically ill patients. We retrospectively analyzed the role of CRRT as a prognostic parameter in patients receiving a cadaveric liver graft in 1998.MethodsWe reviewed the patient records of all adult recipients of a cadaveric liver graft (N = 54) in 1998 and compared those who underwent CRRT treatment (N = 19) to those without CRRT treatment (N = 35).ResultsMortality was high in the continuous venovenous hemodialysis (CVVHD) group (58%). At the time of transplantation, creatinine (1.7 ± 0.4 vs. 1.0 ± 0.1 mg/dl), blood urea nitrogen (40 ± 13 vs. 22 ± 3 mg/dl), aspartate aminotransferase (ASAT; 585 ± 420 vs. 242 ± 97 U/liter), and bilirubin (11.6 ± 4.1 vs. 6.5 ± 1.9 mg/dl) were higher in the CVVHD group than in controls, whereas hemoglobin (10.3 ± 0.6 vs. 10.8 ± 0.4 g/dl), white blood cells (6.3 ± 0.6 vs. 7.0 ± 0.8/nl), and thrombocytes (110 ± 18 vs. 90 ± 10/nl) were similar. After transplantation, liver graft function was impaired in the CVVHD group as compared with controls.ConclusionsThe necessity for CRRT in patients after liver transplantation correlates with a high risk of death. Thus, more efforts have to be made to prevent renal failure in patients after liver transplantation. Continuous venovenous hemodialysis treatment in critically ill patients after liver transplantation. Acute renal failure (ARF) in critically ill patients is associated with a high mortality rate. Continuous renal replacement therapy (CRRT) is now widely used for the treatment of ARF in these critically ill patients. We retrospectively analyzed the role of CRRT as a prognostic parameter in patients receiving a cadaveric liver graft in 1998. We reviewed the patient records of all adult recipients of a cadaveric liver graft (N = 54) in 1998 and compared those who underwent CRRT treatment (N = 19) to those without CRRT treatment (N = 35). Mortality was high in the continuous venovenous hemodialysis (CVVHD) group (58%). At the time of transplantation, creatinine (1.7 ± 0.4 vs. 1.0 ± 0.1 mg/dl), blood urea nitrogen (40 ± 13 vs. 22 ± 3 mg/dl), aspartate aminotransferase (ASAT; 585 ± 420 vs. 242 ± 97 U/liter), and bilirubin (11.6 ± 4.1 vs. 6.5 ± 1.9 mg/dl) were higher in the CVVHD group than in controls, whereas hemoglobin (10.3 ± 0.6 vs. 10.8 ± 0.4 g/dl), white blood cells (6.3 ± 0.6 vs. 7.0 ± 0.8/nl), and thrombocytes (110 ± 18 vs. 90 ± 10/nl) were similar. After transplantation, liver graft function was impaired in the CVVHD group as compared with controls. The necessity for CRRT in patients after liver transplantation correlates with a high risk of death. Thus, more efforts have to be made to prevent renal failure in patients after liver transplantation.

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

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

Protein losses in continuous renal replacement therapies.

Continuous renal replacement therapy (CRRT) has become a popular treatment modality but may have the disadvantage of producing substantial protein losses. With use of the Biuret method, a relatively insensitive assay, dialysate/ultrafiltrate protein losses have been reported to be as high as 1.3 g/L. With CRRT outputs of up to 50 L/day, these values would amount to protein losses of up to 65 g/day. In this study, dialysate/ultrafiltrate protein losses were reanalyzed by using a highly sensitive microprotein reagent (pyrogallol red) considered to be more accurate than previously available methods. Twenty-two dialysate/ultrafiltrate samples were obtained from Amicon-20 Diafilters or Fresenius F-80 dialyzers during continuous venovenous hemofiltration (CVVH) or continuous venovenous hemodialysis/hemodiafiltration (CVVHD/F). Mean hourly output for all treatments was 1637 +/- 694 mL/h. Mean protein concentration for all 22 dialysate/ultrafiltrate samples was 4.2 +/- 4.0 mg/dL. Mean dialysate/ultrafiltrate protein concentrations were similar for the Amicon 20 (3.4 +/- 4.4 mg/dL, N = 9) and the Fresenius F-80 (4.7 +/- 3.9 mg/dL, N = 13) (P = not significant). Protein losses were higher during convection-based CVVH (6.0 +/- 5.1 mg/dL, N = 10; range, 1 to 15 mg/dL) than during the mixed convection and diffusion-based CVVHD/F (2.7 +/- 1.9 mg/dL, N = 12; range, 0 to 6 mg/dL) (P = 0.049). Mean serum protein concentration at the time of dialysate/ultrafiltrate sampling was 4.7 +/- 1.8 g/dL. There was a weak, but statistically significant correlation between the dialysate/ultrafiltrate samples and the corresponding value for serum protein (r = 0.468, P < 0.03). It was concluded that protein losses during CRRT treatments are substantially lower than previously reported, are dependent on the serum protein concentration and the predominant nature of solute removal (convection versus diffusion), and can vary between 1.2 and 7.5 g/day.