Continuous Renal Replacement Therapy Research Articles

Complex presentation of atypical hemolytic uremic syndrome: A case study

This case study discusses atypical hemolytic uremic syndrome (aHUS) in a 67-year-old female who presented with hypertension and hyperlipidemia 8 days after a suspected foodborne illness. Her initial presentation included acute respiratory and renal failure in which her condition required extensive re-warming, intubation, pressor or vasopressor therapy, continuous renal replacement therapy or hemodialysis, broad-spectrum antibiotic therapy, and blood and culture workups. Kidney function also showed signs of renal failure, metabolic acidosis, thrombocytopenia, and an elevated level of lactate dehydrogenase in the laboratory results. Radiological investigations demonstrated enteritis, colitis, and an ischemic infarct without hemorrhage. Multidisciplinary consultations achieved the importance and urgency of early diagnosis and treatment of aHUS to prevent irreversible organ damage. This case highlights the role of a timely diagnosis and interprofessional patient care in the treatment of severe aHUS.

Deciphering simplified regional anticoagulation with citrate in intermittent hemodialysis: a clinical and computational study

Regional citrate anticoagulation use in intermittent hemodialysis is limited by the increased risk of metabolic complications due to faster solute exchanges than with continuous renal replacement therapies. Several simplifications have been proposed. The objective of this study was to validate a mathematical model of hemodialysis anticoagulated with citrate that was then used to evaluate different prescription scenarios on anticoagulant effectiveness (free calcium concentration in dialysis filter) and calcium balance. A study was conducted in hemodialyzed patients with a citrate infusion into the arterial line and a 1.25 mmol/L calcium dialysate. Calcium and citrate concentrations were measured upstream and downstream of the citrate infusion site and in the venous line. The values measured in the venous lines were compared with those predicted by the model using Bland and Altman diagrams. The model was then used with 22 patients to make simulations. The model can predict the concentration of free calcium, bound to citrate or albumin, accurately. Irrespective of the prescription scenario a decrease in free calcium below 0.4 mmol/L was obtained only in a fraction of the dialysis filter. A zero or slightly negative calcium balance was observed, and should be taken into account in case of prolonged use.

Regional citrate anticoagulation with continuous renal replacement therapy as a cause of hypercalcemia.

Awareness of the causes of hypercalcemia is essential for timely diagnosis of calcium disorders and optimal treatment. Citrate is commonly used as an anticoagulant during continuous renal replacement therapy (CRRT). Accumulation of citrate in the systemic circulation during CRRT may induce several metabolic disturbances, including total hypercalcemia and ionized hypocalcemia. The aim of the present study is to increase awareness of citrate accumulation and toxicity as a cause of hypercalcemia by relating three cases and reviewing the pathophysiology and clinical implications. We utilized electronic health records to examine the clinical cases and outlined key studies to review the consequences of citrate toxicity and general approaches to management. Citrate toxicity is associated with high mortality. A safe threshold for tolerating hypercalcemia during citrate anticoagulation is not clearly defined, and whether citrate toxicity independently increases mortality has not been resolved. Greater attention to citrate toxicity as a cause of hypercalcemia may lead to earlier detection, help to optimize the management of systemic calcium levels, and foster interest in future clinical studies.

Regional citrate anticoagulation versus LMWH anticoagulation for CRRT in liver failure patients without increased bleeding risk.

The optimal anticoagulation regimen for continuous renal replacement therapy (CRRT) in liver failure (LF) patients without increased bleeding risk remains controversial. Therefore, we conducted a monocentric retrospective study to evaluate the efficacy and safety of the regional citrate anticoagulation (RCA) versus low molecular weight heparin (LMWH) anticoagulation for CRRT in LF without increased bleeding risk. According to the anticoagulation strategy for CRRT, patients were divided into the RCA and LMWH-anticoagulation groups. The evaluated endpoints were patient survival, filter lifespan, bleeding, citrate accumulation, and totCa/ionCa ratio. Totally 167 and 164 filters were used in the RCA and LMWH group, respectively. The median filter lifespan was significantly longer in the RCA group (34 h (IQR = 24-54) versus 24 h (IQR = 18-45.5) [95%CI, 24.5-33]; p < 0.001). The 4-week mortality rate was significantly higher in the LMWH-anticoagulation group (71 (57.72%) vs 53 (40.46%); p = 0.006). After adjusted the important parameters in the multivariate COX regression model, the mortality risk was significantly reduced in the RCA group (HR = 0.668 [95%CI, 0.468-0.955]; p = 0.027). In the LMWH group, 30 bleeding episodes (24,19%) were observed, whereas only 7 (5.34%) occurred in the RCA group (p < 0.001). Two patients (1.5%) in the RCA group occurred citrate accumulation. In LF patients without increased bleeding risk who underwent CRRT, RCA significantly extended the filter lifespan and improved patient survival rate. There was no significant difference in the rate of adverse events between the two groups.

Fulminant myocarditis caused by influenza B virus in a male child: a case report and literature review

BackgroundInfluenza B virus induced myocarditis is a rare complication with potentially wide variations in severity and clinical presentation, and the pathogenesis is unclear.Case presentationWe describe a rare case of a 7-year-old boy who developed fulminant myocarditis (FM) due to influenza B virus infection. Treatment measures included mechanical ventilation, vasoactive agents, Extracorporeal membrane oxygenation (ECMO), Continuous Renal Replacement Therapy (CRRT), anti-inflammatory, antiviral, anti-infection, and enteral nutrition support. After 10 days of treatment, the patient succumbed to multiorgan failure.ConclusionsAfter a systematic review of the literature, we found that this disease predominantly affects females, with pediatric cases exceedingly rare. Fulminant myocarditis (FM) progresses rapidly, poses significant treatment challenges sporadic, and carries a poor prognosis. Interestingly, literature reports suggest that anti-thymocyte globulin therapy may have a positive impact in treating FM, potentially offering new insights into its pathogenesis and clinical management.

How to Accurately Detect Renal Replacement Therapy Weaning in Intensive Care: Data Quality and Standardization Considerations for the OMOP Common Data Model.

This study assesses the effectiveness of the Observational Medical Outcomes Partnership common data model (OMOP CDM) in standardising Continuous Renal Replacement Therapy (CRRT) data from intensive care units (ICU) of two French university hospitals. Our objective was to extract and standardise data from various sources, enabling the development of predictive models for CRRT weaning that are agnostic to the data's origin. Data for 1,696 ICU stays from the two data sources were extracted, transformed, and loaded into the OMOP format after semantic alignment of 46 CRRT standard concepts. Although the OMOP CDM demonstrated potential in harmonising CRRT data, we encountered challenges related to data variability and the lack of standard concepts. Despite these challenges, our study supports the promise of the OMOP CDM for ICU data standardization, suggesting that further refinement and adaptation could significantly improve clinical decision making and patient outcomes in critical care settings.

Dialoxygenation: A Preclinical Trial for Transforming the Artificial Kidney Into an Oxygenator.

Critically ill patients sometimes require tandem application of extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) which is easier and cheaper. We aimed to transform the kidney membrane into a lung membrane by adding hydrogen peroxide (H 2 O 2 ) to the dialysate as the oxygen source. A solution containing H 2 O 2 and a dialysate fluid mixture was used as the final dialysate. Starting with 100% H 2 O 2 solution and gradually reducing the volume of H 2 O 2 , respectively: 50%, 10%, 5%, 4%, 3%, 2%, and 1%. PRISMAFLEX system, Prismaflex M60 set and a bag of packed red blood cells (pRBCs) were the prototype. blood flow rate was about 40 ml/minute and the dialysis rate was about 200 ml/m 2 /minute/1.73 m 2 . blood sampling times were; at the beginning ( T0 ), at 15th ( T1 ), 30th ( T2 ), 60th ( T3 ) minutes. Amongst eight attempts H 2 O 2 concentration that increased the partial oxygen pressure (pO 2 ) level significantly in a reasonable period, without any bubbles, was 3%. Methemoglobinemia was not observed in any trial. After the test with 3%, H 2 O 2 in the dialysate fluid decreased progressively without any H 2 O 2 detection at post-membrane blood. Three percent H 2 O 2 solution is sufficient and safe for oxygenation in CRRT systems. With this new oxy-dialysate solution, both pulmonary and renal replacement can be possible viaa single membrane in a simpler manner.

Multifaceted approach to successful management of pediatric acute liver failure: High-volume plasma exchange as a pivotal intervention

Abstract: Pediatric acute liver failure (pALF) poses a formidable clinical challenge characterized by rapid hepatocyte necrosis and pro-inflammatory events. The urgency of pALF necessitates advanced therapeutic modalities, prompting the exploration of high-volume plasma exchange (HVPE) as a sophisticated intervention. This case report delves into the intricate management of a 16-year-old female with hyperacute liver failure secondary to hepatitis A, highlighting the critical need for nuanced and multidisciplinary approaches. The case unfolds through a detailed description of symptoms, clinical decision-making, and the therapeutic journey. The management includes a calculated deferral of liver transplantation in favor of HVPE, with a focus on the rationale for choosing HVPE over continuous renal replacement therapy. Technical aspects of the procedure, such as blood volume calculations and procedural details, are meticulously outlined. Laboratory investigations track the patient’s progress, showcasing the profound impact of HVPE on clinical and laboratory recovery. The patient’s response to HVPE is evident in the comprehensive clinical and laboratory recovery observed after the intervention. The resolution of encephalopathy, successful extubation, and eventual discharge highlight the positive outcomes achieved through the judicious application of HVPE. However, the procedure is not without challenges, as the emergence of hypertension during the second and third cycles and a lone episode of seizure require swift and careful management. The management of pALF demands a sophisticated and multidimensional approach, especially when liver transplantation is not immediately feasible. This case report underscores the nuanced decision-making involved in selecting extracorporeal therapies, with a focus on the successful application of HVPE. HVPE, as recommended by the American Society for Apheresis, emerges as a promising intervention in the context of pALF, offering a viable option when liver transplantation is deferred due to advanced encephalopathy. The favorable outcomes and considerations of cost-effectiveness and procedural simplicity further accentuate the potential of HVPE as a cornerstone in the critical care of pediatric patients with acute liver failure.

Comparison of Anticoagulant Effect of Low-Molecular-Weight Heparin Sodium and Sodium Citrate on Patients with Severe Acute Kidney Injury Treated by Continuous Renal Replacement Therapy.

Continuous renal replacement therapy (CRRT) is effective in treating acute kidney injury (AKI), but it requires anticoagulants. The study was conducted to compare the anticoagulant effect of low-molecular-weight heparin (LMWH) sodium and sodium citrate on AKI patients treated by CRRT. The medical records of 150 severe AKI patients treated by CRRT in the Second Affiliated Hospital of Hainan Medical College (China, Hainan) from January 2020 to January 2023 were analyzed retrospectively. LMWH sodium was administered as an anticoagulant for 72 patients in the control group, and the remaining 78 receiving sodium citrate were enrolled into the observation group. Outcomes compared between groups included coagulation indices, inflammatory factors and renal function indices prior and post therapy, filter lifespan and adverse reactions. Post therapy, in contrast to the control group, the observation group showed notably lower prothrombin time (PT) and activated partial thromboplastin time (APTT) levels and a notably higher platelet (PLT) level (P < .05) and presented notably lower C-reactive protein (CRP) and interleukin-6 (IL-6) levels (P < .05). In contrast to the control group, the observation group experienced a notably longer filter service life and a notably lower total incidence of adverse reactions (P < .05). Sodium citrate had a better anticoagulant effect than LMWH for severe AKI patients treated by CRRT, improving renal function and filter longevity with fewer adverse effects.

Construction and evaluation of a mortality prediction model for patients with acute kidney injury undergoing continuous renal replacement therapy based on machine learning algorithms

Background To construct and evaluate a predictive model for in-hospital mortality among critically ill patients with acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT), based on nine machine learning (ML) algorithm. Methods The study retrospectively included patients with AKI who underwent CRRT during their initial hospitalization in the United States using the medical information mart for intensive care (MIMIC) database IV (version 2.0), as well as in the intensive care unit (ICU) of Huzhou Central Hospital. Patients from the MIMIC database were used as the training cohort to construct the models (from 2008 to 2019, n = 1068). Patients from Huzhou Central Hospital were utilized as the external validation cohort to evaluate the models (from June 2019 to December 2022, n = 327). In the training cohort, least absolute shrinkage and selection operator (LASSO) regression with cross-validation was employed to select features for constructing the model and subsequently established nine ML predictive models. The performance of these nine models on the external validation cohort dataset was comprehensively evaluated based on the area under the receiver operating characteristic curve (AUROC) and the optimal model was selected. A static nomogram and a web-based dynamic nomogram were presented, with a comprehensive evaluation from the perspectives of discrimination (AUROC), calibration (calibration curve) and clinical practicability (DCA curves). Results Finally, 1395 eligible patients were enrolled, including 1068 patients in the training cohort and 327 patients in the external validation cohort. In the training cohort, LASSO regression with cross-validation was employed to select features and nine models were individually constructed. Compared to the other eight models, the Lasso regularized logistic regression (Lasso-LR) model exhibited the highest AUROC (0.756) and the optimal calibration curve. The DCA curve suggested a certain clinical utility in predicting in-hospital mortality among critically ill patients with AKI undergoing CRRT. Consequently, the Lasso-LR model was the optimal model and it was visualized as a common nomogram (static nomogram) and a web-based dynamic nomogram (https://chsyh2006.shinyapps.io/dynnomapp/). Discrimination, calibration and DCA curves were employed to assess the performance of the nomogram. The AUROC for the training and external validation cohorts in the nomogram model was 0.771 (95%CI: 0.743, 0.799) and 0.756 (95%CI: 0.702, 0.809), respectively. The calibration slope and Brier score for the training cohort were 1.000 and 0.195, while for the external validation cohort, they were 0.849 and 0.197, respectively. The DCA indicated that the model had a certain clinical application value. Conclusions Our study selected the optimal model and visualized it as a static and dynamic nomogram integrating clinical predictors, so that clinicians can personalized predict the in-hospital outcome of critically ill patients with AKI undergoing CRRT upon ICU admission.

A comparative study on the haemostatic changes in kidney failure patients: Pre- and post- haemodialysis and haemodiafiltration

BackgroundIndividuals with kidney failure have a compromised haemostatic system making them susceptible to both thrombosis and bleeding. ObjectivesAssessment of primary haemostasis in patients treated with either haemodialysis (HD) or haemodiafiltration (HDF) was performed through the measurement of several coagulation-based tests, both pre- and post-dialysis. Patients/methods41 renal failure patients and 40 controls were recruited. Platelet aggregometry, Factor XIII (FXIII), Fibrinogen, Von Willebrand Factor (VWF) and Soluble P-Selectin (sP-Sel) levels were measured. ResultsMaximum platelet aggregation was diminished in renal patients irrespective of aspirin intake. Post-dialysis, platelet function was exacerbated. Pre-dialysis FXIII levels were similar to the healthy cohort and became elevated post-dialysis. This elevation could not be explained by the relative decrease of water by dialysis. Fibrinogen levels were already elevated pre-dialysis and further increased post-dialysis. This elevation was associated with the relative decrease of water by dialysis. VWF levels in males were similar to the healthy cohort and became elevated post-dialysis. This elevation was associated with dialysis-related water loss. VWF antigen and activity in female patients were already elevated pre-dialysis and further increased post-dialysis with the exception of VWF activity in HDF treated female patients. sP-Sel levels were lower than those of the healthy cohort and became similar to the healthy cohort post-dialysis. This elevation could not be explained by the relative decrease of water by dialysis. ConclusionsWhilst platelet aggregometry was diminished, we noted elevated clotting factors such as fibrinogen, FXIII and VWF with no significant differences between HD and HDF-treated patients.

CRRT experience in a patient diagnosed with anthracofibrosis in intensive care : a case report

Bronchial anthracofibrosis is a condition characterized by dark pigmentation (anthracosis) in the bronchial mucosa, often accompanied by bronchial stenosis or obstruction due to fibrosis in the same area. Diagnosis is frequently established by bronchoscopy in patients who do not fully respond to treatment, show radiological abnormalities, and have obstructive lung disease. When looking at the literature on anthracofibrosis, it is mostly seen in conjunction with tuberculosis, but it can also frequently accompany pneumonia, therefore necessitating close monitoring. In intensive care unit (ICU), continuous renal replacement therapy (CRRT) is one of the frequently used treatment methods in critically ill patients with acute kidney injury (AKI) due to sepsis. It is particularly preferred in patients with acute renal failure (ARF) who have hemodynamic instability and are using inotropic agents. Our case is a 78-year-old male patient who was admitted to ICU due to pneumonia secondary to sepsis, septic shock, and AKI. During his follow-ups in ICU, due to frequent airway obstructions, a bronchoscopy was performed, and a diagnosis of anthracofibrosis was made. CRRT was planned as he was hypotensive and anuric under the support of inotropic agents. However, both the Disseminated Intravascular Coagulation picture due to sepsis that occurred in the patient and intrabronchial hemorrhages-clot plugs, as well as obstruction in the airway and increase in airway pressure due to anthracofibrosis were observed. The increase in airway pressure could not be performed for a long time as it increased the hemodynamic instability for CRRT. With this case report, it is intended to emphasize the effects of an increase in airway pressure on CRRT. In cases of obstructive lung diseases that do not respond to bronchodilators, such as anthracofibrosis, it should be kept in mind that the increase in airway pressure can cause more hemodynamic instability, especially in critically ill patients, and measures should be taken to reduce airway pressure

Population Pharmacokinetics of Trimethoprim/Sulfamethoxazole: Dosage Optimization for Patients with Renal Insufficiency or Receiving Continuous Renal Replacement Therapy.

The goal of the study was to describe the population pharmacokinetics of trimethoprim, sulfamethoxazole, and N-acetyl sulfamethoxazole in hospitalized patients. Furthermore, this study used the model to optimize dosing regimens of cotrimoxazole for Pneumocystis jirovecii pneumonia and in patients with renal insufficiency or with continuous renal replacement therapy (CRRT). This was a retrospective multicenter observational cohort study based on therapeutic drug monitoring (TDM) data from hospitalized patients treated with cotrimoxazole. We developed two population pharmacokinetic (POPPK) models: a model of trimethoprim and an integrated model with both sulfamethoxazole and N-acetyl sulfamethoxazole concentrations. Monte Carlo simulations were performed to determine the optimal dosing regimen. A total of 348 measurements from 168 patients were available. The estimated glomerular filtration rate (eGFR) and CRRT were included as covariates on the clearance of all three compounds. Cotrimoxazole TID 1,920 mg and b.i.d. 2,400 mg led to sufficient exposure for infections with P. jirovecii in patients without renal insufficiency. To reach equivalent exposure, a dose reduction of 33.3% is needed in patients with an eGFR of 10 mL/minute/1.73 m2 and of 16.7% for an eGFR of 30 mL/minute/1.73 m2. N-acetyl sulfamethoxazole accumulates in patients with a reduced eGFR. CRRT increased the clearance of sulfamethoxazole, but not trimethoprim or N-acetyl sulfamethoxazole, compared with the median clearance in the population. Doubling the sulfamethoxazole dose is needed for patients on CRRT to reach equivalent exposure.

COMPARISON OF OXIRIS AND CONVENTIONAL CONTINUOUS RENAL REPLACEMENT THERAPY IN MANAGING SEVERE ABDOMINAL INFECTIONS: IMPACT ON SEPTIC SHOCK MORTALITY.

Objective: The objective of this study is to assess and compare the efficacy of oXiris with conventional continuous renal replacement therapy (CRRT) in managing severe abdominal infections. Methods: A retrospective analysis encompassing cases from 2017 to 2023 was conducted at the Department of Critical Care Medicine within the First Affiliated Hospital of Fujian Medical University. Parameters including heart rate (HR), mean arterial pressure (MAP), oxygenation index, lactate (Lac), platelet count, neutrophil ratio, procalcitonin, C-reactive protein (CRP), interleukin 6 (IL-6), norepinephrine dosage, Acute Physiology and Chronic Health Evaluation II (APACHE II), and Sequential Organ Failure Assessment (SOFA) were recorded prior to treatment initiation, at 24 h, and 72 h after treatment for both the oXiris and conventional CRRT groups. In addition, the duration of respiratory support, CRRT treatment, length of stay in the intensive care unit (ICU), total hospitalization period, and mortality rates at 14 and 28 days for both groups were recorded. Results: 1) Within the conventional CRRT group, notable enhancement was observed solely in Lac levels at 24 h after treatment compared with pretreatment levels. In addition, at 72 h after treatment, improvements were evident in HR, Lac, CRP, and IL-6 levels. 2) Conversely, the oXiris group exhibited improvements in HR, MAP, Lac, oxygenation index, neutrophil ratio, and IL-6 at 24 h after treatment when compared with baseline values. In addition, reductions were observed in APACHE II and SOFA scores. At 72 h after treatment, all parameters demonstrated enhancement except for platelet count. 3) Analysis of the changes in the indexes (Δ) between the two groups at 24 h after treatment revealed variances in HR, MAP, Lac, norepinephrine dosage, CRP levels, IL-6 levels, APACHE II scores, and SOFA scores. 4) The Δ indexes at 72 h after treatment indicated more significant improvements following oXiris treatment for both groups, except for procalcitonin. 5) The 14-day mortality rate (24.4%) exhibited a significant reduction in the oXiris group when compared with the conventional group (43.6%). However, no significant difference was observed in the 28-day mortality rate between the two groups. 6) Subsequent to multifactorial logistic regression analysis, the results indicated that oXiris treatment correlated with a noteworthy decrease in the 14-day and 28-day mortality rates associated with severe abdominal infections, by 71.3% and 67.6%, respectively. Conclusion: oXiris demonstrates clear advantages over conventional CRRT in the management of severe abdominal infections. Notably, it reduces the fatality rates, thereby establishing itself as a promising and potent therapeutic option.

Clinical Outcomes and Risk Factors of Heart Transplantation Patients Experiencing Gastrointestinal Bleeding.

Gastrointestinal bleeding (GIB) after heart transplantation (HT) remains a significant clinical issue. This study aimed to explore the incidence, trends, outcomes, and clinical predictors of GIB in HT patients. Adult patients who underwent HT between 2015 and 2021 at Union Hospital were recruited and divided into two groups based on the presence or absence of postoperative GIB. The primary outcomes were evaluated at follow-up. Independent predictors of GIB after HT were identified using a logistic regression analysis. A nomogram prediction model was constructed according to these independent variables, and the accuracy of the model was assessed using the receiver operating characteristic (ROC) curve and the calibration curve. Among the 461 patients, 40 (8.7%) developed GIB post-HT. HT patients with postoperative GIB exhibited higher in-hospital, 30-day, 90-day, and 1-year mortality (all p < 0.05). A multivariate analysis was used to identify age, preoperative warfarin, postoperative continuous renal replacement therapy, and postoperative nasogastric tubes as independent risk factors for GIB following HT. A nomogram prediction model was applied using the four variables. The area under the curve (AUC) of this model was 0.852 (95% CI: 0.787-0.917, p < 0.001), and the calibration curve was close to the ideal diagonal line. GIB following HT is associated with a poor clinical prognosis. The constructed nomogram demonstrated a favorable predictive value for GIB.

Relative Blood Volume Monitoring during Continuous Renal Replacement Therapy: A Prospective Observational Study.

Hematocrit monitoring during continuous renal replacement therapy (CRRT) allows the continuous estimation of relative blood volume (RBV). This may enable early detection of intravascular volume depletion prior to clinical sequelae. We aimed to investigate the feasibility of extended RBV monitoring and its epidemiology during usual CRRT management by clinicians unaware of RBV. Moreover, we studied the association between changes in RBV and net ultrafiltration (NUF) rates. In a cohort of adult intensive care unit patients receiving CRRT, we continuously monitored hematocrit and RBV using a pre-filter noninvasive optical sensor. We analyzed temporal changes in RBV and investigated the association between RBV change and NUF rates, using the classification of NUF rates into low, moderate, or high based on predefined cut-offs. We obtained &gt;60,000 minute-by-minute measurements in &gt;1,000 CRRT hours in 36 patients. The median RBV change was negative (decrease) in 69% of patients and the median peak change in RBV was -9.3% (interquartile range: -3.9% to -14.3%). Moreover, the median RBV decreased from baseline by &gt;5% in 40.2% of measurements and by &gt;10% in 20.6% of measurements. Finally, RBV decreased significantly more when patients received a high NUF rate (&gt;1.75 mL/kg/h) compared to low or moderate NUF rates (5.32% vs. 1.93% or 1.97%, p &lt; 0.001). Continuous hematocrit and RBV monitoring during CRRT was feasible. RBV decreased significantly during CRRT, and decreases were greater with higher NUF rates. RBV monitoring may help optimize NUF management and prevent the occurrence of intravascular volume depletion.

Incidence and impact of near-miss events during continuous renal replacement therapy in critically ill patients

Incidence and impact of near-miss events during continuous renal replacement therapy in critically ill patients

Incidence of hypothermia in critically ill patients receiving continuous renal replacement therapy in Siriraj Hospital, Thailand.

Hypothermia is a relatively common complication in patients receiving continuous renal replacement therapy (CRRT). However, few studies have reported the factors associated with hypothermia. A retrospective cohort study was performed in five intensive care units (ICUs) to evaluate the incidence of hypothermia and the predictive factors for developing hypothermia during CRRT, with hypothermia defined as a time-weighted average temperature <36 °C. From January 2020 to December 2021, 300 patients were enrolled. Hypothermia developed in 23.7% of them within the first 24 hours after CRRT initiation. Compared to non-hypothermic patients, hypothermic patients were older and had lower body weight, more frequent acidemia, and higher ICU and 30-day mortality rates. In the multivariate analysis, age >70 years (odds ratio [OR], 2.59; 95% CI, 1.38-4.98; P=0.004), higher positive fluid balance on the day before CRRT (OR, 1.11; 95% CI, 1.02-1.22; P=0.02), and CRRT dose (OR, 1.003; 95% CI, 1.00-1.01; P=0.04) were significantly associated with hypothermia. Conversely, a higher body weight was independently associated with mitigated risk of hypothermia (OR, 0.89; 95% CI, 0.81-0.97; P=0.01). Moreover, a higher coefficient of variance of temperature was associated with greater ICU mortality (OR, 1.41; 95% CI, 1.13-1.78; P=0.003). Hypothermia during CRRT is a relatively common occurrence, and factors associated with hypothermia onset in the first 24 hours include older age, lower body weight, higher positive fluid balance on the day before CRRT, and higher CRRT dose. Greater temperature variability was associated with increased ICU mortality.

Coagulation Risk Predicting in Anticoagulant-Free Continuous Renal Replacement Therapy.

Continuous renal replacement therapy (CRRT) is a prolonged continuous extracorporeal blood purification therapy to replace impaired renal function. Typically, CRRT therapy requires routine anticoagulation, but for patients at risk of bleeding and with contraindications to sodium citrate, anticoagulant-free dialysis therapy is necessary. However, this approach increases the risk of CRRT circuit coagulation, leading to treatment interruption and increased resource consumption. In this study, we utilized artificial intelligence machine learning methods to predict the risk of CRRT circuit coagulation based on pre-CRRT treatment metrics. We retrospectively analyzed 212 patients who underwent anticoagulant-free CRRT from October 2022 to October 2023. Patients were categorized into high-risk and low-risk groups based on CRRT circuit coagulation within 24 h. We employed eight machine learning methods to predict the risk of circuit coagulation. The performance of the model was evaluated using the area under the curve (AUC) of the receiver operating characteristic. 5-fold cross-validation was used to validate the machine learning models. Feature importance and SHAP plots were used to interpret the model's performance and key drivers. We identified 88 patients (41.51%) at high risk of circuit coagulation within 24 h of CRRT. Our machine learning models showed excellent predictive performance, with ensemble learning achieving an AUC of 0.863 (95% CI: 0.860-0.868), outperforming individual algorithms. Random forest was the best single-algorithm model, with an AUC of 0.819 (95% CI: 0.814-0.823). The top three features identified as most important by the SHAP summary plot and feature importance graph are platelet, filtration fraction (FF), and triglycerides. We created a model using machine learning to predict the risk of circuit coagulation during anticoagulant-free CRRT therapy. Our model performs well (AUC 0.863) and identifies key factors like platelets, FF, and triglycerides. This facilitates the development of personalized treatment strategies by clinicians aimed at reducing circuit coagulation risk, thereby enhancing patient outcomes and reducing healthcare expenses.

Anticoagulation methods used and role of antithrombin III level monitoring in children on continuous renal replacement therapy: an observational cross-sectional study

BackgroundIn critically ill cases, CRRT is a renal replacement intervention. The most common reason why CRRT terminates prematurely (non-electively) is clotting in the extracorporeal circuit, more especially in the filter.Aim of workTo determine the frequency of thrombotic and hemorrhage complications throughout CRRT, the role of antithrombin III level monitoring, the type of anticoagulation, and the dose and laboratory tests utilized to monitor it.MethodThe study was carried out on 58 children who were undergoing CRRT. The children underwent a comprehensive history-taking, assessment, CRRT prescription parameters and alterations, vascular access data, anticoagulation type, dose, and adjustment, as well as monitoring of antithrombin III levels. Furthermore, any extracorporeal circuit clotting or bleeding was documented.ResultsOf the 58 sessions that were examined, 25 (43.1%) resulted in filter clotting. The indication was cured in 16 cases (27.6%), 8 cases (13.8%) resulted in the patient’s mortality, and 9 cases (15.5%) had life-threatening bleeding. The remaining 33 cases (56.9%) were not terminated with filter clotting. Forty-one (70.7%) of studied sessions used unfractionated heparin as anticoagulation, 22.4% used heparin-protamine, 5.2% was not anticoagulated, and one circuit (1.7%) was anticoagulated using regional citrate.Filter clotting incidence was significantly related to activated partial thromboplastin time (a PTT) value at the end of sessions (P value = 0.000), and platelets count after 4 h of session initiation (P value = 0.048). Antithrombin III levels pre-heparin infusion less than 80 were found in patients who received higher doses of a heparin bolus dose, median dose 35 (IQR 20–35), this relation is statistically significant (P value = 0.042).ConclusionIn the 58 cases that were examined, the incidence of bleeding was 32.8%; however, 19% of the cases were not severe. The incidence of filter clotting was 43.1% in the study group. a PTT value at the end of sessions, and platelets count after 4 h could be predictors of thrombotic complications during CRRT, antithrombin III deficiency before sessions is a predictor of filter clotting.