Continuous Replacement Research Articles

Continuous Kidney Replacement Therapy and Survival in Children and Young Adults: Findings From the Multinational WE-ROCK Collaborative

Rationale & ObjectiveThere are limited studies describing the epidemiology and outcomes of children and young adults receiving continuous kidney replacement therapy (CKRT). We aimed to describe associations between patient characteristics, CKRT prescription, and survival. Study DesignRetrospective multicenter cohort study. Setting& Participants: 980 patients aged birth-25 years old who received CKRT between 2015 and 2021 at 1 of 32 centers in 7 countries participating in the Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Diseases (WE-ROCK). ExposureCKRT for acute kidney injury or volume overload. OutcomesDeath before ICU discharge. Analytical ApproachDescriptive statistics. ResultsMedian age was 8.8 years (IQR 1.6, 15.0) with a median weight of 26.8 kg (IQR 11.6, 55.0). CKRT was initiated a median of 2 days (IQR 1, 6) after ICU admission and lasted a median of 6 days (IQR 3, 14). The most common CKRT modality was continuous veno-venous hemodiafiltration. Citrate anticoagulation was used in 62%, and the internal jugular vein was the most common catheter placement location (66%). 629 participants (64.1%) survived at least until ICU discharge. The CKRT dose, filter type, and anticoagulation were similar in those who did and did not survive to ICU discharge. There were apparent practice variations by institutional ICU size. LimitationsRetrospective design; limited representation from centers outside United States. ConclusionsIn this study of children and young adults receiving CKRT approximately two-thirds survived at least until ICU discharge. While variations in dialysis mode, dose, catheter size and location, and anticoagulation were observed, survival was not detected to be associated with these parameters.

Oral electrolyte supplementation and prevention of dehydration in horses

Dehydration is common in equine disciplines and can be avoided by effective oral rehydration strategies. Thermoregulatory loss of heat in horses requires sweating which, in turn, can result in considerable loss of water and electrolytes. Maintenance of hydration and prevention of dehydration requires the continuous replacement of lost electrolytes and water. The stomach and small intestine can function as reservoirs to facilitate the uptake of water and electrolytes consumed 1–2 hours prior to competitions, training and transport. Ions and water are rapidly absorbed in the small intestine and taken up by muscles and the skin, where they serve to replace losses resulting from muscle contraction and sweating. An effective electrolyte supplement replaces electrolytes in the proportion that they are lost through sweating; failure to do this results in an electrolyte imbalance. Electrolyte solution osmolality must be maintained at less than that of bodily fluids to promote gastric emptying and intestinal absorption. Palatability of the electrolyte supplement should be high, and horses should be trained to drink the solution voluntarily before any dehydrating event to try to prevent dehydration from occurring.

Impact of Early Continuous Kidney Replacement Therapy in Patients With Sepsis-Associated Acute Kidney Injury: An Analysis of the MIMIC-IV Database

Impact of Early Continuous Kidney Replacement Therapy in Patients With Sepsis-Associated Acute Kidney Injury: An Analysis of the MIMIC-IV Database

Factors Affecting the Discrepancy Between Coagulation Times on Extracorporeal Circulation Using Unfractionated Heparin in Children and Young Adults.

In unfractionated heparin (UFH) monitoring during extracorporeal circulation, the traditional measures of activated clotting time (ACT) or activated partial thromboplastin time (APTT) may diverge, confounding anticoagulant adjustments. We aimed to explore the factors explaining this discrepancy in children and young adults. This retrospective observational study, conducted at an urban regional tertiary hospital, included consecutive pediatric patients who received UFH during extracorporeal circulation (continuous kidney replacement therapy or extracorporeal membrane oxygenation) between April 2017 and March 2021. After patients whose ACT and APTT were not measured simultaneously or who were also taking other anticoagulants were excluded, we analyzed 94 samples from 23 patients. To explain the discrepancy between ACT and APTT, regression equations were created using a generalized linear model (family = gamma, link = logarithmic) with ACT as the response variable. Other explanatory variables included age, platelet count, and antithrombin. Compared to APTT alone as an explanatory variable, the Akaike information criterion and pseudo-coefficient of determination improved from 855 to 625 and from 0.01 to 0.42, respectively, when these explanatory variables were used. In conclusion, we identified several factors that may explain some of the discrepancy between ACT and APTT in the routinely measured tests. Evaluation of these factors may aid in appropriate adjustments in anticoagulation therapy.

Cretaceous Fore‐Arc Basin and Its Provenance in Sakhalin, Far East Russia: U‐Pb Ages of Detrital Zircons From the Yezo Group

ABSTRACTIn order to reconstruct the pre‐Japan Sea configuration of the Cretaceous arc‐trench system, we measured U‐Pb ages of detrital zircons in the five sandstone samples from the Yezo Group in Sakhalin using LA‐ICP‐MS. A sandstone sample from the lowermost horizon (Ai Formation) contains abundant Early Cretaceous (110–100 Ma) zircons with minor amounts of pre‐Jurassic ones. Four sandstones from the uppermost (Krasnoyarka Formation) are enriched dominantly in Late Cretaceous (100–66 Ma) grains. The YC1σ ages of these samples are generally consistent with the previous fossil ages; nonetheless, a possible age extension of the Ai Fm up possibly into the Cenomanian was newly suggested. The stepwise younging in peak age of zircons according to the stratigraphy suggests the continuous replacement of arc granitoid exposures in the Cretaceous magmatic arc in the provenance likely developed on the continent side. This secular trend in zircon age spectra of the Yezo Group in Sakhalin is properly correlated with that in Hokkaido and also with that of coeval sandstones in southwest Japan, suggesting a monotonous sedimentation in the fore‐arc basin of the Late Cretaceous arc‐trench system developed along the Pacific margin, from Sakhalin to southwest Japan for ca. 2500 km in length. Its spatial dimension corresponds to that of the modern representative fore‐arc basin in the Java‐Sumatra region.

Continuous tooth replacement: what can teleost fish teach us?

Most tooth-bearing non-mammalian vertebrates have the capacity to replace their teeth throughout life. This capacity was lost in mammals, which replace their teeth only once at most. Not surprisingly, continuous tooth replacement has attracted much attention. Classical morphological studies (e.g. to analyse patterns of replacement) are now being complemented by molecular studies that investigate the expression of genes involved in tooth formation. This review focuses on ray-finned fish (actinopterygians), which have teeth often distributed throughout the mouth and pharynx, and more specifically on teleost fish, the largest group of extant vertebrates. First we highlight the diversity in tooth distribution and in tooth replacement patterns. Replacement tooth formation can start from a distinct (usually discontinuous and transient) dental lamina, but also in the absence of a successional lamina, e.g. from the surface epithelium of the oropharynx or from the outer dental epithelium of a predecessor tooth. The relationship of a replacement tooth to its predecessor is closely related to whether replacement is the result of a prepattern or occurs on demand. As replacement teeth do not necessarily have the same molecular signature as first-generation teeth, the question of the actual trigger for tooth replacement is discussed. Much emphasis has been laid in the past on the potential role of epithelial stem cells in initiating tooth replacement. The outcome of such studies has been equivocal, possibly related to the taxa investigated, and the permanent or transient nature of the dental lamina. Alternatively, replacement may result from local proliferation of undifferentiated progenitors, stimulated by hitherto unknown, perhaps mesenchymal, factors. So far, the role of the neurovascular link in continuous tooth replacement has been poorly investigated, despite the presence of a rich vascularisation surrounding actinopterygian (as well as chondrichthyan) teeth and despite a complete arrest of tooth replacement after nerve resection. Lastly, tooth replacement is possibly co-opted as a process to expand the number of teeth in a dentition ontogenetically whilst conserving features of the primary dentition. That neither a dental lamina, nor stem cells appear to be required for tooth replacement places teleosts in an advantageous position as models for tooth regeneration in humans, where the dental lamina regresses and epithelial stem cells are considered lost.

Hybrid Therapies for Supporting Critically Ill Patients with Acute Kidney Injury: When, how, and for Whom?

Acute kidney injury (AKI) is common in critically ill patients. There is no specific pharmacological treatment for established severe AKI. Therefore, the conventional therapeutic strategy is limited to the use of kidney replacement therapy (KRT) to maintain homeostasis. Hybrid therapies optimize the advantages of intermittent and continuous modalities of KRT, combining lower hourly efficiency, longer application time, at lesser cost, but also adding different physicochemical principles of extracorporeal clearance. The sum of convection and diffusion, with or without adsorption or apheresis, and in different time combinations gives hybrid techniques great flexibility in prescribing a personalized treatment adapted to the needs of each patient at any given time. Hybrid therapies are increasingly being used due to their flexibility, which is determined by the combination of equipment, membranes, and available resources (machines and health-care personnel experience). The required technology is widely available in most intensive care units and uses low-cost consumables compared to other types of AKI treatment modalities, favoring its widespread use. Hybrid therapies are feasible and provide a viable form of KRT, either alone or as a transition therapy from continuous kidney replacement therapy to intermittent hemodialysis. (Rev Invest Clin. 2023;75(6):337-47).

Utilization of aquapheresis among hospitalized patients with end-stage liver disease: A case series and literature review.

Third-spacing of fluid is a common complication in hospitalized patients with decompensated cirrhosis. In addition to ascites, patients with advanced cirrhosis may develop significant peripheral edema, which may limit mobility and exacerbate debility and muscle wasting. Concomitant kidney failure and cardiac dysfunction may lead to worsening hypervolemia, which may ultimately result in pulmonary edema and respiratory compromise. Diuretic use in such patients may be limited by kidney dysfunction and electrolyte abnormalities, including hyponatremia and hypokalemia. A slow, continuous form of ultrafiltration known as aquapheresis is a method of extracorporeal fluid removal whereby a pump generates a transmembrane pressure that forces an isotonic ultrafiltrate across a semipermeable membrane. This leads to removal of an ultrafiltrate that is isotonic to blood without the need for dialysate or replacement fluid as is necessary in other forms of continuous kidney replacement therapy. This technique has been utilized in other conditions including acute decompensated heart failure, with trials showing mixed, but generally favorable results. Herein, we present a series of our own experience using aquapheresis among patients with cirrhosis, review the literature regarding its use in other hypervolemic states, and discuss how we may apply lessons learned from use of aquapheresis in heart failure to patients with end-stage liver disease.

Medication patterns and dosing guidance in pediatric patients supported with intermittent hemodialysis or continuous kidney replacement therapy.

Hemodialysis is a life-saving technology used during periods of acute or chronic kidney failure to remove toxins, and maintain fluid, electrolyte and metabolic balance. While this technology plays an important role for pediatric patients with kidney dysfunction, it can alter the pharmacokinetic behavior of medications placing patients at risk for suboptimal dosing and drug toxicity. The ability to directly translate pharmacokinetic alterations into dosing recommendations has thus far been limited and dosing guidance specific to pediatric hemodialysis patients is rare. Despite differences in dialysis prescription and patient populations, intermittent (iHD) and continuous kidney replacement therapy (CKRT) patients are often pooled together. In order to develop evidence-based dosing guidelines, it is important to first prioritize drugs for study in each modality. Here we aim to identify priority drugs in two hemodialysis modalities, through: 1) Identification of hospitalized, pediatric patients who received CKRT or intermittent hemodialysis (iHD) using a machine learning-based predictive model based on medications; 2) Identification of medication administration patterns in these patient cohorts; and 3) Identification of the most commonly prescribed drugs that lack published dosing guidance. Notable differences were found in the pattern of medications and drug dosing guidance between iHD and CKRT patients. Antibiotics, diuretics and sedatives were more common in CKRT patients. Out of the 50 most commonly administered medications in the two modalities, only 34% and 28% had dosing guidance present for iHD and CKRT, respectively. Our results add to the understanding of the differences between iHD and CKRT patient populations by identifying commonly used medications that lack dosing guidance for each hemodialysis modality, helping to pinpoint priority medications for further study. Overall, this study provides an overview of the current limitations in medication use in this at-risk population, and provides a framework for future studies by identifying commonly used medications in pediatric CKRT and iHD patients.

From teeth to pad: tooth loss and development of keratinous structures in sirenians.

Sirenians are a well-known example of morphological adaptation to a shallow-water grazing diet characterized by a modified feeding apparatus and orofacial morphology. Such adaptations were accompanied by an anterior tooth reduction associated with the development of keratinized pads, the evolution of which remains elusive. Among sirenians, the recently extinct Steller's sea cow represents a special case for being completely toothless. Here, we used μ-CT scans of sirenian crania to understand how motor-sensor systems associated with tooth innervation responded to innovations such as keratinized pads and continuous dental replacement. In addition, we surveyed nine genes associated with dental reduction for signatures of loss of function. Our results reveal how patterns of innervation changed with modifications of the dental formula, especially continuous replacement in manatees. Both our morphological and genomic data show that dental development was not completely lost in the edentulous Steller's sea cows. By tracing the phylogenetic history of tooth innervation, we illustrate the role of development in promoting the innervation of keratinized pads, similar to the secondary use of dental canals for innervating neomorphic keratinized structures in other tetrapod groups.

Precision net ultrafiltration dosing in continuous kidney replacement therapy: a practical approach

Precision net ultrafiltration dosing in continuous kidney replacement therapy: a practical approach

Extracorporeal adsorption of protective and toxic bile acids and bilirubin in patients with cholestatic liver dysfunction: a prospective study

BackgroundThe release of toxic bile acids (BAs) in the blood of critically ill patients with cholestatic liver dysfunction might lead to the damage of various organs. Their extracorporeal elimination using the cytokine adsorber Cytosorb® (CS) (adsorption of especially hydrophobic molecules < 60 kDa) might be promising, but data proving a potential adsorption are missing so far.MethodsThe prospective Cyto-SOVLE study (NCT04913298) included 20 intensive care patients with cholestatic liver dysfunction, continuous kidney replacement therapy, total bilirubin concentration > 10 mg/dl and the application of CS into the dialysis circuit. Bilirubin and different BAs were measured pre- and post-CS at defined timepoints (10 min, 1, 3, 6, and 12 h after initiation). Relative reduction (RR, %) was calculated with: 1-left(frac{mathrm{concentration} (mathrm{pre}-mathrm{post})}{mathrm{concentration} (mathrm{pre})}right)*100.ResultsThe median RR for total and conjugated bilirubin after initiation was − 31.8% and − 30.3%, respectively, and decreased to − 4.5% and − 4.8% after 6 h. A high initial RR was observed for the toxic BAs GCA (− 97.4%), TCA (− 94.9%), GCDCA (− 82.5%), and TCDCA (− 86.0%), decreasing after 6 h to − 32.9%, − 32.7%, − 12.8%, and − 14.3%, respectively. The protective hydrophilic BAs showed a comparable RR after initiation (UDCA: − 77.7%, GUDCA: − 83.0%, TUDCA: − 91.3%) dropping after 6 h to − 7.4%, − 8.5%, and − 12.5%, respectively.ConclusionsCytosorb® can adsorb bilirubin and toxic as well as protective BAs. However, a fast saturation of the adsorber resulting in a rapid decrease of the RR was observed. Furthermore, no relevant difference between hydrophobic toxic and hydrophilic protective BAs was detected regarding the adsorption amount. The clinical benefit or harm of the BA adsorption needs to be evaluated in the future.

Association between volume status assessed by bioelectrical impedance analysis, lung ultrasound, or weight change and mortality in patients with sepsisassociated acute kidney injury receiving continuous kidney replacement therapy.

Fluid overload is an independent risk factor of mortality in patients with acute kidney injury (AKI) receiving continuous kidney replacement therapy (CKRT). However, the association between fluid status, as assessed by bioelectrical impedance analysis (BIA) or lung ultrasound, and survival in patients with AKI requiring CKRT has not been established. We analyzed 36 participants with sepsis-associated AKI who received CKRT at a tertiary hospital. The main exposures were volume surrogates: 1) overhydration normalized by extracellular water (OH/ECW, L/L) assessed by BIA, 2) the number of B-lines measured by lung ultrasound, and 3) weight change ([body weight at CKRT initiation - body weight at admission] × 100/body weight at admission). The primary outcome was the 28-day mortality. Seventeen participants (47.2%) died within 28 days. There were no significant correlations between OH/ECW and weight change (R2 = 0.040, p = 0.24), number of B-lines and OH/ECW (R2 = 0.056, p = 0.16), or weight change and number of B-lines (R2 = 0.014, p = 0.49). Kaplan-Meier analyses revealed that patients in the highest tertile of OH/ECW showed a significantly lower cumulative 28-day survival probability than the others (the lowest + middle tertiles). The survival probability of participants in the highest tertile of the number of B-lines or weight change did not differ from that of their counterparts. In a multivariate Cox proportional hazard model, the hazard ratio for the highest tertile of OH/ECW was 3.83 (95% confidence interval, 1.04-14.03). Volume overload assessed using BIA (OH/ECW) was associated with the 28-day survival rate in patients with sepsis-associated AKI who received CKRT.

Nutrition in critically ill children with acute kidney injury on continuous kidney replacement therapy: a 2023 executive summary

ObjectivesNutrition plays a vital role in the outcome of critical illness in children, particularly those with acute kidney injury. Currently, there are no established guidelines for children with acute kidney injury treated with continuous kidney replacement therapy. Our objective was to create clinical practice points for nutritional assessment and management in critically ill children with acute kidney injury receiving continuous kidney replacement therapy. MethodsAn electronic search using PubMed and an inclusive academic library search (including MEDLINE, Cochrane, and Embase databases) was conducted to find relevant English-language articles on nutrition therapy for children (<18 y of age) receiving continuous kidney replacement therapy. ResultsThe existing literature was reviewed by our work group, comprising pediatric nephrologists and experts in nutrition. The modified Delphi method was then used to develop a total of 45 clinical practice points. The best methods for nutritional assessment are discussed. Indirect calorimetry is the most reliable method of predicting resting energy expenditure in children on continuous kidney replacement therapy. Schofield equations can be used when indirect calorimetry is not available. The non-intentional calories contributed by continuous kidney replacement therapy should also be accounted for during caloric dosing. Protein supplementation should be increased to account for the proteins, peptides, and amino acids lost with continuous kidney replacement therapy. ConclusionsClinical practice points are provided on nutrition assessment, determining energy needs, and nutrient intake in children with acute kidney injury and on continuous kidney replacement therapy based on the existing literature and expert opinions of a multidisciplinary panel.

Hypotensive Episodes During Continuous Kidney Replacement Therapy and Mortality

Hypotensive Episodes During Continuous Kidney Replacement Therapy and Mortality

Magnesium Supplementation Is Associated with Reduced Mortality in AKI Requiring Continuous Kidney Replacement Therapy (CKRT)

Magnesium Supplementation Is Associated with Reduced Mortality in AKI Requiring Continuous Kidney Replacement Therapy (CKRT)

Impact of Using Blood Warmer During Continuous Kidney Replacement Therapy on Hemodynamic Instability

Impact of Using Blood Warmer During Continuous Kidney Replacement Therapy on Hemodynamic Instability

Plasma Cystatin C Predicts Kidney Function Recovery in Patients Requiring Continuous Kidney Replacement Therapy (CKRT) for AKI

Plasma Cystatin C Predicts Kidney Function Recovery in Patients Requiring Continuous Kidney Replacement Therapy (CKRT) for AKI

Hypomagnesemia in Critically Ill Patients Undergoing Continuous and Prolonged Intermittent Kidney Replacement Therapies: Still a Matter of Debate?

Hypomagnesemia in Critically Ill Patients Undergoing Continuous and Prolonged Intermittent Kidney Replacement Therapies: Still a Matter of Debate?

Impact of Using Blood Warmer During Continuous Kidney Replacement Therapy on Adverse Kidney Events and Mortality

Impact of Using Blood Warmer During Continuous Kidney Replacement Therapy on Adverse Kidney Events and Mortality