Continuous Venovenous Hemodialysis Research Articles

Analysis of Inflammatory Mediator Profiles in Sepsis Patients Reveals That Extracellular Histones Are Strongly Elevated in Nonsurvivors

The timely recognition of sepsis and the prediction of its clinical course are challenging due to the complex molecular mechanisms leading to organ failure and to the heterogeneity of sepsis patients. Treatment strategies relying on a “one-fits-all” approach have failed to reduce mortality, suggesting that therapeutic targets differ between patient subgroups and highlighting the need for accurate analysis of the molecular cascades to assess the highly variable host response. Here, we characterized a panel of 44 inflammatory mediators, including cytokines, chemokines, damage-associated molecular patterns, and coagulation-related factors, as well as markers of endothelial activation in 30 patients suffering from renal failure in the course of sepsis. All patients received continuous veno-venous hemodialysis with either high cut-off filters or with standard filters, and mediators were quantified for all patients at the initiation of dialysis and after 24 h and 48 h. Mediator concentrations in individual patients ranged widely, demonstrating the heterogeneity of sepsis patients. None of the mediators correlated with SAPS III or TISS scores. The overall in-hospital mortality of the study population was 56.7% (57.1% vs. 56.3% for high cut-off vs. standard filter). The two filter groups differed regarding most of the mediator levels at baseline, prohibiting conclusions regarding the effect of standard filters versus high cut-off filters on mediator depletion. The elevation and correlation of damage-associated molecular patterns and markers of endothelial activation gave evidence of severe tissue damage. In particular, extracellular histones were strongly increased and were almost 30-fold higher in nonsurvivors as compared to survivors, indicating their diagnostic and prognostic potential.

The Production, Efficacy, and Safety of Machine-Generated Bicarbonate Solution for Continuous Venovenous Hemodialysis (CVVHD): The Cleveland Clinic Method

Rationale & ObjectiveSince 1994, the Nephrology and Hypertension Department at the Cleveland Clinic has prepared and used bicarbonate-based solution for continuous venovenous hemodialysis (CVVHD) using a standard volumetric hemodialysis machine rather than purchasing from a commercial vendor. This report describes the process of producing Cleveland Clinic UltraPure Solution (CCUPS), quality and safety monitoring, economic costs, and clinical outcomes.Study DesignRetrospective study.Setting & ParticipantsCVVHD experience at Cleveland Clinic, focusing on dialysate production, institutional factors, and patients requiring continuous kidney replacement therapy. Production is shown at www.youtube.com/watch?v=WGQgephMEwA.OutcomesFeasibility, safety , and cost.ResultsOf 6,426 patients treated between 2011 and 2019 with continuous kidney replacement therapy, 59% were men, 71% were White, 40% had diabetes mellitus, and 74% presented with acute kidney injury. 98% of patients were treated with CVVHD using CCUPS, while the remaining 2% were treated with either continuous venovenous hemofiltration or continuous venovenous hemodiafiltration using commercial solution. The prescribed and delivered effluent doses were 24.8 (IQR) versus 20.7 mL/kg/h (IQR), respectively. CCUPS was as effective in restoring electrolyte and serum bicarbonate levels and reducing phosphate, creatinine, and serum urea nitrogen levels as compared with packaged commercial solution over a 3-day period following initiation of dialysis, with a comparable effluent dose. Among those with acute kidney injury, mortality was similar to that predicted with the 60-day acute kidney injury predicted mortality score (r = 0.997; CI: 0.989-0.999). At our institution, the cost of production for 1 L of CCUPS is $0.67, which is considerably less than the cost of commercially purchased fluid.LimitationsObservational design without a rigorous control group.ConclusionsCVVHD using locally generated dialysate is safe and cost-effective.

Continuous hemodialysis with citrate anticoagulation and standard dialysate for managing acute kidney injury in patients with moderate to severe hyponatremia-A retrospective study.

The safety of continuous veno-venous hemodialysis (CVVHD) with citrate-calcium anticoagulation for acute kidney injury (AKI) with coincident hyponatremia remains unclear. We aimed to explore the feasibility of CVVHD with standard dialysate and citrate-calcium anticoagulation in hyponatremic critically ill AKI patients. Thirty-seven of the 493 critically ill AKI patients requiring CVVHD and admitted to our intensive care unit during a 10-year period had hyponatremia (<130mmol/L) and were included in this retrospective study. All patients received CVVHD with citrate-calcium anticoagulation and standard commercial dialysate and plasma sodium concentrations were frequently controlled until death or CVVHD discontinuation. Clinical data, mortalities and cases of central pontine myelinolysis within one-year follow-up were recorded. Median plasma sodium concentration was 127 (IQR 124-129)mmol/L at CVVHD initiation. CVVHD duration was median 3 (IQR 1.5-5.5)days and the mean daily sodium load of the trisodium citrate solution during the first 3days of CVVHD was 1754 (SD 730)mmol. The plasma sodium concentration increased a median 8 (IQR 5-10)mmol/L during the first 24hours of CVVHD and excessively high plasma sodium correction (>8mmol/L/24h) was observed in 18 (48.6%) patients. However, increased mortality in association to rapid plasma sodium correction was not observed in this study. CVVHD using standard citrate-calcium anticoagulation effectively increased plasma sodium concentration in this study. However, excessively high plasma sodium correction was observed in half of the patients and the sodium load provided by the standard citrate anticoagulation solutions was substantial.

P0103 / #697: CONTINUOUS RENAL REPLACEMENT THERAPIES (CRRT) IN IMMUNOCOMPROMISED CHILDREN ADMITTED IN PEDIATRIC INTENSIVE CARE UNIT (PICU)

Aims & Objectives: BACKGROUND Acute Kidney Injury (AKI) appears in 26.9% of pediatric patients admitted to PICU and has a significant impact on morbidity and mortality. Of those 50% will require CRRT. These techniques offer an alternative for dialysis treatment in the management of hemodynamically unstable patients OBJECTIVE: Describe the epidemiology and outcome of immunocompromised patients (IMP) who required CRRT. Methods: Retrospective, observational and descriptive study. Medical records of patients admitted to the PICU of an academic children’s hospital in Argentina from January 2012 to December 2018 were reviewed. Patients requiring CRRT were included. Patients who needed intermittent dialysis techniques were excluded. Results: Of 1506 patients were admitted, 6.7% required CRRT (n: 102), the median age was 66 months (Q12-144), median days of hospitalization was 16 days (Q7-29). The most frequent diagnoses were 34% solid organ transplantation followed by 27% hematopoietic progenitor cell transplantation (HPCT). The prevalent secondary diagnoses were septic shock 44% and acute respiratory distress syndrome 20%. Median CRRT duration was 5 days (Q 3-9). The most commonly used dialytic mode was Continuous Venovenous Hemodialysis in 87% of patients. Overall survival was 25%. Conclusions: In our study mortality in IMP with AKI remains high, especially in those undergoing HPTC. CRRT is still a good therapeutic approach for its treatment. Early recognition of the patients who need nephroprotection strategies is crucial to reduce AKI incidence.

Early Laboratory Predictors for Necessity of Renal Replacement Therapy in Patients With Spontaneous Deep-Seated Intracerebral Hemorrhage

Objective: The need for continuous renal replacement therapy (CRRT) in patients with deep-seated intracerebral hemorrhage (ICH) requires sustained intensive care and often postpones further rehabilitation therapy. Therefore, an early identification of patients at risk is essential.Methods: From 2014 to 2019, all patients with deep-seated ICH who were admitted to intensive care for >3 days were included in the further analysis and retrospectively reviewed for the need for CRRT. All patients underwent CRRT with regional citrate anticoagulation for continuous veno-venous hemodialysis (CVVHD). Outcome was evaluated after 3 months using the modified Rankin scale. A multivariate analysis was performed to identify potential predictors for CRRT in patients with deep-seated ICH.Results: After applying the inclusion criteria, a total of 87 patients with deep-seated spontaneous ICH were identified and further analyzed. During the first 48 h after admission, 21 of these patients developed early acute kidney injury (AKI; 24%). During treatment course, CRRT became necessary in nine patients suffering from deep-seated ICH (10%). The multivariate analysis revealed “development of AKI during the first 48 h” [p = 0.025, odds ratio (OR) 6.1, 95% confidence interval (CI) 1.3–29.8] and “admission procalcitonin (PCT) value >0.5 μg/l” (p = 0.02, OR 7.7, 95% CI 1.4–43.3) as independent and significant predictors for CRRT in patients with deep-seated ICH.Conclusions: Elevated serum levels of procalcitonin on admission as well as early development of acute renal injury are independent predictors of the need for renal replacement therapy in patients with deep-seated intracerebral bleeding. Therefore, further research is warranted to identify these vulnerable patients as early as possible to enable adequate treatment.

Pharmacokinetics and dialytic clearance of apixaban during in vitro continuous renal replacement therapy

BackgroundTo evaluate the transmembrane clearance (CLTM) of apixaban during modeled in vitro continuous renal replacement therapy (CRRT), assess protein binding and circuit adsorption, and provide initial dosing recommendations.MethodsApixaban was added to the CRRT circuit and serial pre-filter bovine blood samples were collected along with post-filter blood and effluent samples. All experiments were performed in duplicate using continuous veno-venous hemofiltration (CVVH) and hemodialysis (CVVHD) modes, with varying filter types, flow rates, and point of CVVH replacement fluid dilution. Concentrations of apixaban and urea were quantified via liquid chromatography-tandem mass spectrometry. Plasma pharmacokinetic parameters for apixaban were estimated via noncompartmental analysis. CLTM was calculated via the estimated area under the curve (AUC) and by the product of the sieving/saturation coefficient (SC/SA) and flow rate. Two and three-way analysis of variance (ANOVA) models were built to assess the effects of mode, filter type, flow rate, and point of dilution on CLTM by each method. Optimal doses were suggested by matching the AUC observed in vitro to the systemic exposure demonstrated in Phase 2/3 studies of apixaban. Linear regression was utilized to provide dosing estimations for flow rates from 0.5–5 L/h.ResultsMean adsorption to the HF1400 and M150 filters differed significantly at 38 and 13%, respectively, while mean (± standard deviation, SD) percent protein binding was 70.81 ± 0.01%. Effect of CVVH point of dilution did not differ across filter types, although CLTM was consistently significantly higher during CRRT with the HF1400 filter compared to the M150. The three-way ANOVA demonstrated improved fit when CLTM values calculated by AUC were used (adjusted R2 0.87 vs. 0.52), and therefore, these values were used to generate optimal dosing recommendations. Linear regression revealed significant effects of filter type and flow rate on CLTM by AUC, suggesting doses of 2.5–7.5 mg twice daily (BID) may be needed for flow rates ranging from 0.5–5 L/h, respectively.ConclusionFor CRRT flow rates most commonly employed in clinical practice, the standard labeled 5 mg BID dose of apixaban is predicted to achieve target systemic exposure thresholds. The safety and efficacy of these proposed dosing regimens warrants further investigation in clinical studies.

Clearance of inflammatory cytokines in patients with septic acute kidney injury during renal replacement therapy using the EMiC2 filter (Clic-AKI study)

BackgroundThe EMiC2 membrane is a medium cut-off haemofilter (45 kiloDalton). Little is known regarding its efficacy in eliminating medium-sized cytokines in sepsis. This study aimed to explore the effects of continuous veno-venous haemodialysis (CVVHD) using the EMiC2 filter on cytokine clearance.MethodsThis was a prospective observational study conducted in critically ill patients with sepsis and acute kidney injury requiring kidney replacement therapy. We measured concentrations of 12 cytokines [Interleukin (IL) IL-1β, IL-1α, IL-2, IL-4, IL-6, IL-8, IL-10, interferon (IFN)-γ, tumour necrosis factor (TNF)-α, vascular endothelial growth factor, monocyte chemoattractant protein (MCP)-1, epidermal growth factor (EGF)] in plasma at baseline (T0) and pre- and post-dialyzer at 1, 6, 24, and 48 h after CVVHD initiation and in the effluent fluid at corresponding time points. Outcomes were the effluent and adsorptive clearance rates, mass balances, and changes in serial serum concentrations.ResultsTwelve patients were included in the final analysis. All cytokines except EGF concentrations declined over 48 h (p < 0.001). The effluent clearance rates were variable and ranged from negligible values for IL-2, IFN-γ, IL-1α, IL-1β, and EGF, to 19.0 ml/min for TNF-α. Negative or minimal adsorption was observed. The effluent and adsorptive clearance rates remained steady over time. The percentage of cytokine removal was low for most cytokines throughout the 48-h period.ConclusionEMiC2-CVVHD achieved modest removal of most cytokines and demonstrated small to no adsorptive capacity despite a decline in plasma cytokine concentrations. This suggests that changes in plasma cytokine concentrations may not be solely influenced by extracorporeal removal.Trial registration: NCT03231748, registered on 27th July 2017.

Use of CytoSorb hemoadsorption in a patient with sepsis and acute kidney injury: A case report

Introduction. Continuous renal replacement therapy is one of the methods that proved to be successful in the treatment of sepsis and its complications such as acute kidney injury. One of the adsorbers tested is CytoSorb, which contains polystyrene-divinylbenzene pores with a biocompatible polyvinylpyrrolidone coating and that is also a highly adsorptive and biocompatible filter that facilitates selective removal of medium molecular weight molecules (10 - 15 kDa). Case Report. A 51-year-old male patient was hospitalized at the Department of Anesthesia, Resuscitation and Intensive Care due to multiple traumas caused by a fall from the third floor. After admission, laboratory and diagnostic methods were performed, the injuries were surgically treated and the patient received infusion, antibiotic and preventive anti-ulcer therapy along with measures of intensive treatment and monitoring of vital parameters. Progression of the pulmonary lesions, prolonged refractory hypotension unresponsive to therapeutic protocols, predisposed the onset of acute renal impairment and continuous venovenous hemodialysis with CytoSorb was applied. The procedure lasted 21 hours and 39 minutes, during which the urine output increased, and the need for vasoactive support was significantly reduced, while the lactate levels declined. Upon completion of the procedure, hemodynamic stability was achieved, with gradual improvement of consciousness, regression of pulmonary changes and reduction of inflammatory parameters and parameters of renal function. Conclusion. We can say that control of the patient?s hyperinflammatory response was the key factor in achieving stabilization of the patient, as well as organ recovery and survival. Future research should provide additional information on the contribution of CytoSorb in the treatment of patients with sepsis.

COVID-19-related acute kidney injury and dialysis: What are the outcomes in South Africa?

Introduction: Acute kidney injury (AKI) in hospitalized patients infected with COVID-19 is associated with an elevated mortality rate compared to non-infected patients (39% versus 24%). This is despite a lower prevalence of AKI in COVID-19-infected patients (17 vs 22%). The reasons are multifactorial and have been well documented in developed countries, whereas in developing countries there are scant data. Methods: This study aimed to document the mortality in COVID-19-infected South African patients who required dialysis for AKI. Exclusion criteria included any chronic kidney replacement therapy (transplantation or dialysis). A REDCap survey of South African nephrologists and nephrology fellows registered with the South African Nephrology Society was conducted. The primary outcome was all-cause in-hospital mortality, while additional points of interest included comorbidities, dialysis modality and intervention required. Univariate analysis of mortality predictors was performed. Results: The COVID-19-related AKI mortality rate was 58.9%. Significant predictors included continuous veno-venous haemodialysis therapy, invasive ventilation, use of inotropes and the presence of shock. Ischaemic heart disease, heart failure and admission to a private healthcare facility were associated with lower mortality. No significant associations were found with ethnicity, sex, hypertension, diabetes, HIV infection or the use of other modes of dialysis. Conclusions: In South African patients, we report similar outcomes in critically ill patients requiring dialysis for AKI, relative to international data. The predictors of mortality most likely reflect the severity of the illness in our patients. The data suggest that continuous veno-venous haemodiafiltration or slow low efficiency dialysis may be the preferred dialysis modalities in these patients.

Continuous Renal Replacement Therapy: A Review

ABSTRACT&#x0D; Kidney is an important organ to maintain hemodynamic stability inside the human body. In patient with acute kidney injury (AKI) there was a decreased kidney function that could interfere hemodynamic stability which can lead to multi organ failure even death. Around 5-10% patients with AKI required renal replacement therapy (RRT) to support their decreased renal function. Continuous renal replacement therapy (CRRT) is one of RRT modality that commonly used for patients with AKI who are hemodynamically unstable or in critically ill conditions.&#x0D; CRRT could divided into 4 mode, slow continuous ultrafiltration (SCUF), continuous veno-venous hemofiltration (CVVH), continuous veno-venous hemodialysis (CVVHD) and continuous veno-venous hemodialfiltration (CVVHDF). CRRT used based on renal and nonrenal indication. Several studies are still trying to prove nonrenal indication of RRT, to ascertain whether CRRT could be used as therapy effectively. Therefore the indication, the mechanism and the comparison of renal replacement therapy are very important to be understood.

Gender-related differences in treatment and outcome of extracorporeal cardiopulmonary resuscitation-patients.

Extracorporeal cardiopulmonary resuscitation (eCPR) is a rapidly growing treatment strategy due to significant improvement in selected patients' survival rates. Gender-related differences might impact the outcome of therapeutic measures. Therefore, we sought to investigate patients with eCPR at our interdisciplinary extracorporeal membrane oxygenation center regarding sex-related differences with the view to potentially adjusting current selection criteria. From January 2016 to December 2019, 71 patients underwent eCPR at our institution. Data before eCPR and early outcome parameters were analyzed comparing male and female patients. The cohort analyzed consisted of 60 male (84%) and 11 female (15%) patients. Comparing both groups, male patients significantly more frequently suffered out-of-hospital cardiac arrest (68% male vs. 36% female, P=.04), whereas female patients were associated with more in-hospital cardiac arrest (32% male vs. 64% female, P=.04). Creatinine levels differed significantly (1.5 (1.1;2.1) mg/dL in male vs. 1.0 (0.7;1.5) mg/dL in female patients, P=.03). Also, several hepatic parameters showed a significant difference between the groups: aspartate aminotransferase 423 (249;804) U/L in male vs. 115 (61;408) U/L in female patients, P=.01; alanine aminotransferase 174 (102;446) U/L in male vs. 86 (36;118) U/L in female patients, P=.01). Renal failure requiring hemodialysis occurred more frequently in men than in women (P<.01). There is a significant effect of male sex regarding renal failure with subsequent continuous venovenous hemodialysis (CVVH) (R2 =0.11, ANOVA P=.01, 95% CI=-0.79--0.079). However, in-hospital mortality was comparable between the groups (78% in male vs. 72% in female patients, P=.68). Our retrospective study showed several gender-related differences associated with different cardiac arrest scenarios. Male sex was associated with a significantly higher risk for renal failure requiring CVVH. Survival rates were comparable between the groups. Further investigations should include gender in the evaluation of risk stratification for eCPR-related complications to further improve selection criteria for this demanding therapy.

Comparison of different anticoagulation strategies for renal replacement therapy in critically ill patients with COVID-19: a cohort study

BackgroundCritically ill coronavirus disease 2019 (COVID-19) patients have a high risk of acute kidney injury (AKI) that requires renal replacement therapy (RRT). A state of hypercoagulability reduces circuit life spans. To maintain circuit patency and therapeutic efficiency, an optimized anticoagulation strategy is needed. This study investigates whether alternative anticoagulation strategies for RRT during COVID-19 are superior to administration of unfractionated heparin (UFH).MethodsRetrospective cohort study on 71 critically ill COVID-19 patients (≥18 years), admitted to intensive care units at a tertiary health care facility in the southwestern part of Germany between February 26 and May 21, 2020. We collected data on the disease course, AKI, RRT, and thromboembolic events. Four different anticoagulatory regimens were administered. Anticoagulation during continuous veno-venous hemodialysis (CVVHD) was performed with UFH or citrate. Anticoagulation during sustained low-efficiency daily dialysis (SLEDD) was performed with UFH, argatroban, or low molecular weight heparin (LMWH). Primary outcome is the effect of the anticoagulation regimen on mean treatment times of RRT.ResultsIn patients receiving CVVHD, mean treatment time in the UFH group was 21.3 h (SEM: ±5.6 h), in the citrate group 45.6 h (SEM: ±2.7 h). Citrate anticoagulation significantly prolonged treatment times by 24.4 h (P = .001). In patients receiving SLEDD, mean treatment time with UFH was 8.1 h (SEM: ±1.3 h), with argatroban 8.0 h (SEM: ±0.9 h), and with LMWH 11.8 h (SEM: ±0.5 h). LMWH significantly prolonged treatment times by 3.7 h (P = .008) and 3.8 h (P = .002), respectively.ConclusionsUFH fails to prevent early clotting events in the dialysis circuit during COVID-19. For patients, who do not require effective systemic anticoagulation, regional citrate dialysis is the most effective strategy. For patients, who require effective systemic anticoagulation, the usage of LMWH results in the longest circuit life spans. The proposed anticoagulatory strategies are safe, can easily be monitored, and allow an individualized treatment.Graphical abstract

Myoglobin clearance with continuous veno-venous hemodialysis using high cutoff dialyzer versus continuous veno-venous hemodiafiltration using high-flux dialyzer: a prospective randomized controlled trial

BackgroundMyoglobin clearance in acute kidney injury requiring renal replacement therapy is important because myoglobin has direct renal toxic effects. Clinical data comparing different modalities of renal replacement therapy addressing myoglobin clearance are limited. This study aimed to compare two renal replacement modalities regarding myoglobin clearance.MethodsIn this prospective, randomized, single-blinded, single-center trial, 70 critically ill patients requiring renal replacement therapy were randomized 1:1 into an intervention arm using continuous veno-venous hemodialysis with high cutoff dialyzer and a control arm using continuous veno-venous hemodiafiltration postdilution with high-flux dialyzer. Regional citrate anticoagulation was used in both groups to maintain the extracorporeal circuit. The concentrations of myoglobin, urea, creatinine, β2-microglobulin, interleukin-6 and albumin were measured before and after the dialyzer at 1 h, 6 h, 12 h, 24 h and 48 h after initiating continuous renal replacement therapy.ResultsThirty-three patients were allocated to the control arm (CVVHDF with high-flux dialyzer) and 35 patients to the intervention arm (CVVHD with high cutoff dialyzer). Myoglobin clearance, as a primary endpoint, was significantly better in the intervention arm than in the control arm throughout the whole study period. The clearance values for urea and creatinine were higher in the control arm. There was no measurable albumin clearance in both arms. The clearance data for β2-microglobulin and interleukin-6 were non-inferior in the intervention arm compared to those for the control arm. Dialyzer lifespan was 57.0 [38.0, 72.0] hours in the control arm and 70.0 [56.75, 72.0] hours in the intervention arm (p = 0.029).ConclusionsMyoglobin clearance using continuous veno-venous hemodialysis with high cutoff dialyzer and regional citrate anticoagulation is better than that with continuous veno-venous hemodiafiltration with regional citrate anticoagulation.Trial registrationGerman Clinical Trials Registry (DRKS00012407); date of registration 23/05/2017. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00012407.

In-House Production of Dialysis Solutions to Overcome Challenges During the Coronavirus Disease 2019 Pandemic

In-House Production of Dialysis Solutions to Overcome Challenges During the Coronavirus Disease 2019 Pandemic

Cost analysis of two modalities of continuous renal replacement therapy.

Continuous veno-venous hemofiltration (CVVH) and continuous veno-venous hemodialysis (CVVHD) are costly therapies reserved for use in critically ill patients with kidney failure. Quality improvement study at St. Elizabeth's Medical Center, Boston, MA, USA. Members of nephrology and pharmacy department, working alongside intensive care unit nursing staff and hospital administration, undertook an initiative to transition from CVVH to CVVHD, to simplify therapy administration, lessen need for electrolyte repletion, and reduce total treatment-related costs. We postulated that conversion from CVVH to CVVHD would result in fewer filter clotting events, longer filter use (up to 72 hours), lower resource utilization, and confer overall cost benefit. Over 12 months, patients initiated on CVVH were identified. Following conversion to CVVHD, patients initiated on CVVHD over 9 months were identified. Patient characteristics, comorbidities, and hospital-related outcomes, as well as CRRT-related information including treatment modality, treatment duration, and treatment-related costs were obtained. Daily treatment-related costs, intensive care unit and hospital length of stay (LOS), and in-hospital mortality. During the baseline period, 77 patients were initiated on CVVH, and during the intervention period, 60 patients were initiated on CVVHD. Following conversion from CVVH to CVVHD, mean (±SD) daily total treatment cost decreased from $1813 ± $2143 to $775 ± $766 (P < 0.001). Conversion from CVVH to CVVHD had no impact on intensive care unit LOS (11.8 ± 9.7 vs. 12.4 ± 9.5 days; P = 0.53), hospital LOS (15.0 ± 11.1 vs. 16.4 ± 14.0 days; P = 0.89), or in-hospital mortality (58% vs. 60%; P = 0.85). Nursing costs, costs of dialysis machine utilization, phosphate repletion, and systemic anti-coagulation were not studied. Transition from CVVH to CVVHD resulted in a significant cost benefit and reduced resource utilization. There was no difference in LOS and in-hospital mortality between the two treatment modalities.

GROUP B STREPTOCOCCUS AGALACTIAE INFECTIVE ENDOCARDITIS COMPLICATED BY AORTO-CAVITARY FISTULA IN A POSTPARTUM FEMALE

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Infective Endocarditis (IE) can have many devastating complications and it is prudent to keep in mind even the rarest of sequela, including aorto-cavitary fistula (ACF). The following case describes an ACF, masked as tricuspid regurgitation, in the setting of native valve IE. The pathogen was Group B streptococcus (GBS) agalactiae, an uncommon culprit, but noteworthy given recent pregnancy. CASE PRESENTATION: A 34-year-old female, postpartum 10 months, was evaluated for 3 weeks of intermittent fevers, chills and dyspnea. Labs were unremarkable, but examination revealed a murmur. A transthoracic echocardiogram (TTE) showed severe aortic regurgitation (AR) with vegetation. At the cardiologist’s office, she endorsed presyncope and had a wide pulse pressure with a loud systolic murmur throughout the precordium and right upper sternum diastolic murmur. Bedside TTE in the ED showed additional severe tricuspid regurgitation. Cardiothoracic surgery was immediately consulted and she was quickly triaged to the ICU. Initial labs showed elevated lactate (19) with acute liver and renal failure. Continuous veno-venous hemodialysis and broad-spectrum antibiotics were started. She developed bradycardia with new left bundle branch block requiring pressors. Swan ganz catheter showed cardiac output of 7-8 L/min with an oxygenation step up in right atrium (68%) to pulmonary artery (90%), suggestive of ACF. Intraoperative transesophageal echo exposed a large aortic to right atria fistula, severe AR with vegetation and a normal tricuspid valve. She underwent aortic valve replacement, ACF repair, coronary artery bypass and intra-aortic balloon pump placement. Central venoarterial extracorporeal membrane oxygenation was initiated, however it was complicated by persistent thrombosis of the arterial cannula and the patient expired. Blood cultures, aortic and tricuspid valve tissue samples grew GBS agalactiae. DISCUSSION: ACF in IE occurs more readily in prosthetic valves IE versus native with an in-hospital mortality of roughly 40%. The primary culprit is classically coagulase negative staphylococcus and staphylococcus aureus. GBS is much less common, but can be a normal part of vaginal and rectal flora with colonization in 10-30% of pregnancies. GBS bacteremia is highly prevalent during pregnancy and can remain present in up to one third of patients 6 weeks postpartum. It is unclear if bacterial translocation during the birthing process may have resulted in bacteremia and sub-acute IE. CONCLUSIONS: Streptococcus agalactiae is an uncommon pathogen in infective endocarditis associated with high mortality and morbidity and even more ominous when coupled with an aorto-right atrial fistula. The result of this combination was an extremely critical and complex patient presentation that demanded emergent multidisciplinary attention. Reference #1: Ignasi Anguera et al, Aorto-cavitary Fistula in Endocarditis Working Group, Aorto-cavitary fistulous tract formation in infective endocarditis: European Heart Journal, Volume 26, Issue 3, February 2005, Pages 288–297. Reference #2: Patras, Kathryn A, and Victor Nizet. “Group B Streptococcal Maternal Colonization and Neonatal Disease: Molecular Mechanisms and Preventative Approaches.” Frontiers in pediatrics vol. 6 27. 22 Feb. 2018. Reference #3: Muller AE, Oostvogel PM, Steegers EA, Dorr PJ. Morbidity related to maternal group B streptococcal infections. Acta Obstet Gynecol Scand (2006) 85(9):1027–37. DISCLOSURES: No relevant relationships by Fastina Khan, source=Web Response No relevant relationships by Michaela Murphy, source=Web Response No relevant relationships by Sarah Upson, source=Web Response

A Case of Severe Thrombocytopenia in a Patient with COVID-19 Receiving Continuous Venovenous Hemodialysis

A Case of Severe Thrombocytopenia in a Patient with COVID-19 Receiving Continuous Venovenous Hemodialysis

Lower Continuous Venovenous Hemodialysis Replacement Rate and Its Effect on Patient Outcome in the COVID Crisis Time

Lower Continuous Venovenous Hemodialysis Replacement Rate and Its Effect on Patient Outcome in the COVID Crisis Time

Novel Prescription of Continuous Venovenous Hemodialysis Dialysate Na+ in a Patient with Cerebral Edema and Severe Hypernatremia

Novel Prescription of Continuous Venovenous Hemodialysis Dialysate Na+ in a Patient with Cerebral Edema and Severe Hypernatremia

Clinical effect and safety of continuous renal replacement therapy in the treatment of neonatal sepsis-related acute kidney injury

BackgroundSepsis is the leading cause of acute kidney injury (AKI) in the neonatal intensive care unit (NICU). The aim of the study is to explore the efficacy and security of continuous renal replacement therapy (CRRT) in the treatment of neonatal sepsis-related AKI.MethodTotally12 sepsis-related AKI neonates treated with CRRT were hospitalized in the NICU of Shanghai Children’s Hospital between November 2012 and November 2019, and the clinical data of these 12 cases were retrospectively analyzed. Renal function, acid-base balance, electrolytes, blood pressure and hemodynamics indexes were recorded before CRRT initiation, 12/24/48 h after CRRT initiation and at the end of CRRT respectively. The efficacy of CRRT was evaluated and the clinical outcome was observed in these 12 sepsis-related AKI neonates. Repeated measurement analysis of variance was used for statistical analysis of the data.Result(1) Continuous veno-venous hemodialysis filtration (CVVHDF) was used in 12 cases of sepsis-related AKI neonates. There were 6 cases with oliguria, 3 cases with fluid overload (FO), 3 cases with septic shock. The duration of CRRT was 49 ~ 110 h, average (76.2 ± 23.5) h. (2) The blood pressure (BP) of 12 sepsis -related AKI neonates could reach the normal level (40–60 mmHg) 12 h after CRRT initiation, and the normal BP level could be maintained during the CRRT treatment. After 12 h CRRT, the blood pH value increased to the normal range (7.35 ~ 7.45). After 12 h CRRT treatment, the oxygenation index of 12sepsis-related AKI neonates could reach 200 mmHg. After 24 h CRRT treatment, it could rise to more than 300 mmHg. Serum potassium, serum urea nitrogen and serum creatinine levels decreased significantly 12 h after CRRT initiation, and reached the normal range 24 h after CRRT initiation. The urine volume significantly increased 24 h after CRRT initiation. (3) Venous catheterization was performed successfully in all sepsis-related AKI neonates. We observed 2 cases of thrombocytopenia, 1 case of obstruction and 1 case of hypotension in the course of CRRT. There were no complications such as hypothermia, hemorrhage, thrombosis and infection.11 neonates were cured and discharged. One neonate was treated with CRRT and passed through the oliguria stage of AKI, but died after the parents gave up the treatment.ConclusionsIt is safe and effective to treat neonatal sepsis-related AKI with CRRT, which should be an effective measure for the treatment of sepsis-related AKI neonates.