Discontinuation Of Continuous Renal Replacement Therapy Research Articles

Selective Cytopheretic Device Use in Continuous Kidney Replacement Therapy in Children: A Cohort Study With a Historical Comparator

Rationale & ObjectiveCritically ill children with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) are at increased risk of death. The selective cytopheretic device (SCD) promotes an immunomodulatory effect at circuit ionized calcium <0.40 mmol/L. In an adult CRRT patient study, SCD-treated patients had improved survival/dialysis independence. We report safety data from children who received CRRT-SCD therapy and compared outcomes to a historical pediatric CRRT cohort. Study DesignWe conducted two prospective multicenter studies to evaluate safety and feasibility of SCD in critically ill children. Setting& Participants: Four pediatric institutions enrolled children >10 kg with AKI and multiorgan dysfunction receiving CRRT as standard of care with the SCD integrated post-CRRT membrane. ExposurePatients received CRRT-SCD with regional citrate anticoagulation for up to 7-10 days, or CRRT discontinuation, whichever came first. Analytical ApproachWe report serious adverse events, patient and CRRT-SCD related process and outcome variables. We compared survival to ICU discharge rates between the CRRT-SCD cohort and a matched cohort from the Prospective Pediatric CRRT (ppCRRT) registry, using odds ratios in multivariable analysis for factors associated with ppCRRT patient ICU mortality. To validate these crude analyses, Bayesian logistic regression was performed to assess for attributable benefit-risk assessment of the SCD. ResultsTwenty-two patients received CRRT-SCD treatments. Fifteen serious adverse events were recorded; none were SCD related. Seventeen patients survived to ICU discharge/Day 60. Both multivariable and Bayesian analyses revealed probable benefit of addition of SCD. Fourteen of the 16 patients surviving ICU discharge had normal eGFR and no patient was dialysis dependent at 60 days. Limitations1) Small sample size in SCD-PED cohort 2) Historical control group 3) Adverse events not recorded in control group. ConclusionsSCD therapy is feasible, safe, and demonstrates probable benefit for critically ill children who require CRRT for AKI.

Real-Time Acute Kidney Injury Risk Stratification–Biomarker Directed Fluid Management Improves Outcomes in Critically Ill Children and Young Adults

Critically ill admitted patients are at high risk of acute kidney injury (AKI). The renal angina index (RAI) and urinary biomarker neutrophil gelatinase-associated lipocalin (uNGAL) can aid in AKI risk assessment. We implemented the Trial in AKI using NGAL and Fluid Overload to optimize CRRT Use (TAKING FOCUS 2; TF2) to personalize fluid management and continuous renal replacement therapy (CRRT) initiation based on AKI risk and patient fluid accumulation. We compared outcomes pre-TF2 and post-TF2 initiation. Patients admitted from July 2017 were followed-up prospectively with the following: (i) an automated RAI result at 12 hours of admission, (ii) a conditional uNGAL order for RAI≥8, and (iii) a CRRT initiation goal at 10% to 15% weight-based fluid accumulation. A total of 286 patients comprised 304 intensive care unit (ICU) RAI+ admissions; 178 patients received CRRT over the observation period (2014-2021). Median time from ICU admission to CRRT initiation was 2 days shorter (P< 0.002), and≥15% pre-CRRT fluid accumulation rate was lower in the TF2 era (P< 0.02). TF2 ICU length of stay (LOS) after CRRT discontinuation and total ICU LOS were 6 and 11 days shorter for CRRT survivors (both P< 0.02). Survival rates to ICU discharge after CRRT discontinuation were higher in the TF2 era (P= 0.001). These associations persisted in each TF2 year; we estimate a conservative $12,500 health care cost savings per CRRT patient treated after TF2 implementation. We suggest that automated clinical decision support (CDS) combining risk stratification and AKI biomarker assessment can produce durable reductions in pediatric CRRT patient morbidity.

Evaluation of Proenkephalin A 119–159 for liberation from renal replacement therapy: an external, multicenter pilot study in critically ill patients with acute kidney injury

IntroductionRecent evidence suggests an association of plasma Proenkephalin A 119–159 (penKid) with early and successful liberation from continuous renal replacement therapy (CRRT) in critically ill patients with acute kidney injury. However, these exploratory results are derived from a monocentric trial and therefore require external validation in a multicenter cohort.MethodsData and plasma samples from the “Effect of Regional Citrate Anticoagulation versus Systemic Heparin Anticoagulation During Continuous Kidney Replacement Therapy on Dialysis Filter Life Span and Mortality Among Critically Ill Patients With Acute Kidney Injury—A Randomized Clinical Trial” (RICH Trial) were used for this validation study. PenKid was measured in all plasma samples available at CRRT initiation and at day 3 of CRRT. Patients were categorized into low and high penKid groups with a cutoff at 100 pmol/l. Competing-risk time-to-event analyses were performed. Competing risk endpoints were successful and unsuccessful liberation from CRRT, the latter meaning death or initiation of a new RRT within one week of discontinuation of primary CRRT. Then penKid was compared to urinary output.ResultsLow pre-CRRT penKid levels at CRRT initiation were not associated with early and successful liberation from CRRT compared to patients with high pre-CRRT penKid levels [subdistribution hazard ratio (sHR) 1.01, 95% CI 0.73–1.40, p = 0.945]. However, the landmark analysis on day 3 of ongoing CRRT demonstrated an association between low penKid levels and successful liberation from CRRT (sHR 2.35, 95% CI 1.45–3.81, p < 0.001) and an association between high penKid levels and unsuccessful liberation (sHR 0.46, 95% CI 0.26–0.80, p = 0.007). High daily urinary output (> 436 ml/d) was even stronger associated with successful liberation (sHR 2.91, 95% CI 1.80–4.73, p < 0.001) compared to penKid.DiscussionThis study suggests that penKid may be a competent biomarker to monitor the recovery of kidney function during CRRT. This is in line with previous findings and investigated this concept in a multicenter cohort. Again, low penKid was associated with early and successful CRRT liberation, but was outperformed by high daily urinary output. The findings of this study now warrant further evaluation in prospective studies or a randomized controlled trial.Trial registration The RICH Trial was registered at clinicaltrials.gov: NCT02669589. Registered 01 February 2016.

#4641 RISK FACTORS FOR RRT RESTART AFTER CESSATION OF CRRT: A MULTICENTER STUDY

Abstract Background and Aims Acute Kidney Injury occurs frequently in patients admitted to the Intensive Care Unit (ICU) and continuous renal replacement therapy (CRRT) is a commonly used treatment modality in these patients. Restart of renal replacement therapy (RRT) after initial discontinuation of CRRT is also frequently needed. The purpose of this study is to identify clinical characteristics and biomarkers influencing the restart of RRT after the cessation of CRRT, and to build a predictive model using these parameters. Method This multicenter retrospective study includes 891 patients who were treated using CRRT from July 2012 to December 2020 in the ICU of 3 academic hospitals. The primary end point observed was the restart of RRT during hospitalization. Baseline characteristics were compared between the no restart and restart RRT groups. Using univariate analysis and logistic regression, a prospective index was developed, and receiver operator characteristic (ROC) curve analysis was performed to confirm the predictivity of the prognostic index. Results Restart of RRT was needed in 632 (71.2%) patients. Compared to patients that did not restarting, patients in the restart RRT group demonstrated higher age, higher BMI, higher baseline serum creatinine (Cr), lower urine output, longer ICU admission, and more comorbid conditions (HTN, DM, HF, ischemic heart disease). In the multivariate analysis, five parameters demonstrated independent influence on restart of RRT: HTN, Cr, ICU admission duration, BMI, and mean blood pressure. The prognostic index, which was calculated from these variables, showed a satisfactory potential to predict the restart of RRT after discontinuation of CRRT. ROC analysis revealed an area under the curve of 0.738 (95% CI, 0.703-0.773, p&amp;lt;0.001). Conclusion We found that 5 of the 40 parameters observed in our study were independent risk factors for the restart of RRT during admission and we successfully developed a prognostic index based on these variables to predict the restart of RRT after discontinuation of CRRT.

Factors affecting continuous renal replacement therapy duration in critically ill patients: A retrospective study.

This study aimed to analyze the factors affecting continuous renal replacement therapy (CRRT) duration in critically ill patients and provide a reference for clinical treatment. We divided patients into regional citrate anti-coagulation (RCA) and low-molecular-weight-heparin (LMWH) groups according to the anti-coagulation method and collected the relevant data, to analyze the factors associated with CRRT time. Compared with the LMWH group, the RCA group had a longer mean treatment time (55.36 ± 22.57 vs. 37.65 ± 27.09 h, p < 0.001), lower transmembrane pressure, and lower filter pressure, regardless of vascular access site. Multivariable linear regression analysis showed a significant correlation between anti-coagulation patterns, filter pressure at CRRT discontinuation, nurses' level of intensive care unit experience, pre-machine fibrinogen level, and CRRT time. Anti-coagulation is the most important factor affecting CRRT duration. Filter pressure, nurses' level of intensive care unit experience, and fibrinogen level also affecting CRRT duration.

Safety and Effectiveness of Veno-Venous Extracorporeal Membrane Oxygenation Combined With Continuous Renal Replacement Therapy.

Patients receiving extracorporeal membrane oxygenation (ECMO) often suffer from acute kidney injury (AKI), requiring continuous renal replacement therapy (CRRT). In our clinical practice, we connected the inlet line of a CRRT machine to the postoxygenator Luer port and the outlet line to the inlet Luer port of the oxygenator. In this case series, we analyzed the interaction between the two machines. Between December 31, 2017, and December 31, 2019, we enrolled 15 patients from the ICU of the San Matteo Hospital, Pavia, Italy. All of them suffered from severe acute respiratory distress syndrome and AKI stage 3. We analyzed 570 hours of CRRT combined with venovenous ECMO and collected 261,751 CRRT data. No discontinuation of CRRT occurred before 48 hours. Most of the alarms occurred within 24 hours of the connection: 22/10,831 (0.2%) showed an outranged inlet pressure, 11/10831 (0.11%) showed an outranged transmembrane pressure, 14/10,831 (0.13%) showed an outranged inlet pressure, and 138/10,831 (1.27%) an outranged effluent pressure. The rate per minute set for the ECMO circuit was correlated with the inlet (β = 5.38; CI, 95% 1.42-9.35; p = 0.008), transmembrane (β = 4.6; CI, 95% 1.97-7.24; p = 0.001), effluent (β = 3.02; CI, 95% 1.15-4.90; p = 0.002), and outlet pressures (β = 597; CI, 95% 2.31-9.63; p = 0.001) of the CRRT circuit. We reported that our configuration could be safe and effective, however well-designed studies would be beneficial for determining the potential risks and benefits.

Applying bio-impedance vector analysis (BIVA) to adjust ultrafiltration rate in critically ill patients on continuous renal replacement therapy: A randomized controlled trial

BackgroundBioimpedance vector analysis (BIVA) has been suggested as a valuable tool in assessing volume status in critically ill patients. However, its effectiveness in guiding fluid removal by continuous renal replacement therapy (CRRT) has not been evaluated. MethodsIn this randomized controlled trial, 65 critically ill patients receiving CRRT were allocated on a 1:1 ratio to have UF prescribed and adjusted using BIVA fluid assessment in the intervention group (32 patients) or conventional clinical parameters (33 patients). The primary outcome was the lean body mass (LBM) water content at CRRT discontinuation, and the secondary outcomes included the mortality rate, urinary output, the duration of ventilation support, and ICU stay. ResultsThe study group was associated with a lower water content of LBM (80.7 ± 9.4 vs. 85.9 ± 10.4%; p < 0.05), and a higher mean UF-rate and urinary output (1.5 ± 0.8 vs. 1.2 ± 0.5 ml/kg/h and 0.9 ± 0.9 vs 0.5 ± 0.6 ml/kg/h, both: p < 0.05). The mortality rate, the length of ICU stay, and ventilation support duration were similar. ConclusionBIVA guided UF prescription may be associated with a lower rate of fluid overload. Larger studies are required to evaluate its impact on patients' outcomes.

The importance of anticoagulation in COVID-19-related acute kidney injury requiring continuous renal replacement therapy

Introduction/Objective. In Serbia, the coronavirus disease 2019 (COVID-19) pandemic began in early March 2020. The aim of this study is to summarize clinical experience in the treatment of COVID-19-associated acute kidney injury by methods of continuous renal replacement therapy (CRRT) with the focus on the amount of the administered dose of unfractionated heparin. Methods. The study covers 12 patients treated with CRRT at the Clinic for Infectious Diseases at the Clinical Center of Vojvodina from March 6 to May 20, 2020. Antithrombotic prophylaxis, risk of venous thromboembolism (VTE), applied therapy, biochemical parameters before and after CRRT, anticoagulation and other CRRT parameters were analyzed. Results. The mean age of the patients was 61.54 ? 10.37 years and seven (58.3%) were men. All the patients received standard thromboprophylaxis. Nine (75%) patients had Padua Prediction Score for Risk of VTE ? 4, but none developed a thrombotic event. Seven critically ill patients with multi-organic dysfunction developed acute kidney injury dependent on CRRT. The mean CRRT dose was 36.6 ml/kg/h, the mean bolus dose of unfractionated heparin was 3250 ? 1138.18 IU, and the continuous dose was 1112.5 ? 334.48 IU/kg/h. Discontinuation of CRRT due to the clotting circuit was necessary in only one patient. The values of leukocytes, AST, ALT, GGT, aPTT, PT were significantly higher after CRRT compared to urea, creatinine, potassium, chlorine and magnesium, whose values were significantly lower. Conclusion. In our COVID-19 patients who had high inflammatory parameters and D-dimer and an estimated risk of developing deep vein thrombosis, the implementation pre-dilution continuous venovenous hemodiafiltration with antithrombotic membrane and 1/? to 1/? higher unfractionated heparin doses than the recommended one, the filter life lasted longer with no complications.

Prolonged exposure to continuous renal replacement therapy in patients with acute kidney injury.

Little is known about the process of deciding to discontinue continuous renal replacement therapy (CRRT) in patients with acute kidney injury (AKI) and the impact of CRRT duration on outcomes. We report the clinical parameters of prolonged CRRT exposure and predictors of doubling of serum creatinine or need for dialysis at 90days after CRRT with propensity score matching, including covariates that were likely to influence patients in the prolonged CRRT group. Among 104 survey responders, most use urine output (87%) to guide CRRT discontinuation, 24% use improvement in clinical or hemodynamic status. In the cohort study, of 854 included patients, 465 participated in the assessment of kidney recovery. Patients with prolonged CRRT had higher SOFA scores (11.9 vs. 11.2) and were more likely to be mechanically ventilated (99% vs. 84%) at CRRT initiation compared to patients without prolonged CRRT, p-value < 0.05. In multivariable logistic regression, daily urine output and cumulative fluid balance leading to CRRT discontinuation or day seven were independently associated with lower [OR 0.87 per 200ml/day increase] and higher odds [OR 1.03 per 1-L increase] of requiring prolonged CRRT, respectively. After propensity score matching, prolonged exposure to CRRT was independently associated with increased risk of doubling serum creatinine or dialysis at 90days, OR 3.1 (95% CI 1.23-8.3 p = 0.017). Resolution of critical illness and signs of kidney recovery are important factors when considering CRRT discontinuation. Prolonged CRRT exposure may be associated with less chance of kidney recovery among survivors.

Intra-dialytic hypotension following the transition from continuous to intermittent renal replacement therapy

BackgroundTransition from continuous renal replacement therapy (CRRT) to intermittent renal replacement therapy (IRRT) can be associated with intra-dialytic hypotension (IDH) although data to inform the definition of IDH, its incidence and clinical implications, are lacking. We aimed to describe the incidence and factors associated with IDH during the first IRRT session following transition from CRRT and its association with hospital mortality. This was a retrospective single-center cohort study in patients with acute kidney injury for whom at least one CRRT-to-IRRT transition occurred while in intensive care. We assessed associations between multiple candidate definitions of IDH and hospital mortality. We then evaluated the factors associated with IDH.ResultsWe evaluated 231 CRRT-to-IRRT transitions in 213 critically ill patients with AKI. Hospital mortality was 43.7% (n = 93). We defined IDH during the first IRRT session as 1) discontinuation of IRRT for hemodynamic instability; 2) any initiation or increase in vasopressor/inotropic agents or 3) a nadir systolic blood pressure of < 90 mmHg. IDH during the first IRRT session occurred in 50.2% of CRRT-to-IRRT transitions and was independently associated with hospital mortality (adjusted odds ratio [OR]: 2.71; CI 1.51–4.84, p < 0.001). Clinical variables at the time of CRRT discontinuation associated with IDH included vasopressor use, higher cumulative fluid balance, and lower urine output.ConclusionsIDH events during CRRT-to-IRRT transition occurred in nearly half of patients and were independently associated with hospital mortality. We identified several characteristics that anticipate the development of IDH following the initiation of IRRT.

A Scoring Model with Simple Clinical Parameters to Predict Successful Discontinuation of Continuous Renal Replacement Therapy

Background: Continuous renal replacement therapy (CRRT) is the standard treatment for severe acute kidney injury in critically ill patients. However, a practical consensus for discontinuing CRRT is lacking. We aimed to develop a prediction model with simple clinical parameters for successful discontinuation of CRRT. Methods: Adult patients who received CRRT at Samsung Medical Center from 2007 to 2017 were included. Patients with preexisting ESRD and patients who progressed to ESRD within 1 year or died within 7 days after CRRT were excluded. Successful discontinuation of CRRT was defined as no requirement for renal replacement therapy for 7 days after discontinuing CRRT. Patients were assigned to either a success group or failure group according to whether discontinuation of CRRT was successful or not. Results: A total of 1,158 patients were included in the final analyses. The success group showed greater urine output on the day before CRRT discontinuation (D-1) and the discontinuation day (D0). Multivariable analysis identified that urine output ≥300 mL on D-1, and mean arterial pressure 50∼78 mm Hg, serum potassium <4.1 mmol/L, and BUN <35 mg/dL (12.5 mmol/L) on D0 were predictive factors for successful discontinuation of CRRT. A scoring system using the 4 variables above (area under the receiver operating curve: 0.731) was developed. Conclusions: Scoring system composed of urine output ≥300 mL/day on D-1, and adequate blood pressure, serum potassium <4.1 mmol/L, and BUN <35 mg/dL (12.5 mmol/L) on D0 was developed to predict successful discontinuation of CRRT.

A meta-analysis of clinical predictors for renal recovery and overall mortality in acute kidney injury requiring continuous renal replacement therapy.

To determine clinical predictors for continuous renal replacement therapy (CRRT) discontinuation in patients with acute kidney injury (AKI). Ovid MEDLINE, EMBASE, and Cochrane Library were searched. The protocol is registered on researchregistry.com (reviewregistry909). Our criteria included non-end-stage kidney disease adults who required CRRT for AKI. Renal recovery was defined by CRRT discontinuation. Risk of bias was assessed using ROBINS-I tool. We classified our analyses into renal recovery cohort and overall mortality cohort. All studies were observational. For renal recovery cohort, increasing urine output at time of CRRT discontinuation, elevated initial SOFA score and serum creatinine at CRRT initiation were predictive of renal recovery with OR 1.021 (95%CI=1.011-1.031), 0.869 (95%CI=0.811-0.932) and 0.995 (95%CI=0.996-0.999), respectively. For overall mortality cohort, age and presence of sepsis were significantly associated with overall mortality with OR of 1.028 (95%CI=1.008-1.048) and 2.160 (95%CI=0.973-1.932), respectively. Urine output at CRRT discontinuation, lower initial SOFA score, and lower serum creatinine levels at CRRT initiation were associated with higher likelihood of renal recovery. Increasing age and the presence of sepsis were associated with increased overall mortality from AKI on CRRT. However, there were limited data on co-morbidities which might preclude their inclusion in our analysis.

Severe Hyponatremia and Continuous Renal Replacement Therapy: Safety and Effectiveness of Low-Sodium Dialysate

Rationale & ObjectiveIn patients with severe hyponatremia in the setting of acute kidney injury or end-stage kidney disease, continuous renal replacement therapy (CRRT) using standard-sodium (140 mEq/L) fluids may lead to excessively rapid correction of plasma sodium concentration. Use of dialysate and replacement fluids with reduced sodium concentrations can provide a controlled rate of correction of plasma sodium concentration.Study DesignWe performed a single-center retrospective analysis of the safety and effectiveness of this approach in patients with plasma sodium concentrations ≤ 126 mEq/L who underwent CRRT for 24 or more hours using low-sodium (119 or 126 mEq/L) dialysate and replacement fluids. Change in plasma sodium level was assessed at 24 and 48 hours after initiation of low-sodium CRRT and at the end of treatment.Setting & ParticipantsBetween January 2016 and June 2018, a total of 23 hyponatremic patients underwent continuous venovenous hemodiafiltration using low-sodium dialysate and replacement fluids; 4 patients were excluded from analysis because of CRRT duration less than <24 hours.ResultsThe 19 patients included in the study had a mean age of 56 years, 11 (58%) were men, and 15 (79%) were white. The initial mean plasma sodium level was 121 mEq/L and the initial CRRT effluent dose was 27 mL/kg/h. Only 2 (11%) patients had an increase in plasma sodium concentration > 6 mEq/L at 24 hours. Mean changes in plasma sodium levels at 24 and 48 hours and at the time of CRRT discontinuation were 3, 3, and 6 mEq/L, respectively. None of the patients developed osmotic demyelination syndrome.LimitationsKey limitations were small sample size and lack of a control group.ConclusionsUse of low-sodium dialysate and replacement fluids is a safe strategy for the prevention of overly rapid correction of plasma sodium levels in hyponatremic patients undergoing CRRT.

1340. The Effect of Continuous Renal Replacement Therapy on Body Temperature in Patients with and without Infection

BackgroundSepsis frequently leads to acute kidney injury. In severe cases, patients may require continuous renal replacement therapy (CRRT) which involves placement of a dialysis catheter and an extracorporeal blood filtration circuit. CRRT is commonly considered to “mask” fever, though this phenomenon has not been investigated.MethodsWe queried an institutional database of all patients on CRRT from 2007 to 2015 for inpatient temperature data and antibiotic administration records. Receipts of piperacillin–tazobactam, a carbapenem, or a third or fourth-generation cephalosporin, indicating a serious infection, were considered intervention arm. We analyzed temperatures recorded in the intensive care unit before, during, and after CRRT. Patients were divided into groups that did not receive antibiotics as well as those who did. Temperature data were Winsorized to correct for outliers. We also performed descriptive statistics for each group.ResultsThere were 237,988 temperature readings for 1,568 ICU patients on CRRT. 1,153 patients received broad-spectrum antibiotics in ICU. In patients who received antibiotics in ICU and were presumed to have an infection, the mean temperature was 37.2°C prior to initiation of CRRT, 36.8°C while on CRRT, and 37.2°C following discontinuation of CRRT. In the 415 patients who did not receive IV antibiotics, the mean temperature was 36.9°C prior to initiation of CRRT, 36.6°C while on CRRT, and 37.0°C following discontinuation of CRRT. During each of the periods before, during, and after CRRT, patients who received antibiotics had significantly higher temperatures than those who did not (P < 0.001). Patients receiving antibiotics were generally younger (mean 60 years vs. 64 years, P < 0.001), had longer ICU stays (mean 29 days vs. 12 days, P < 0.001) and spent more time being ventilated (mean 23 days vs. 7 days, P < 0.001). The mean SOFA score on day one was similar (mean 11.1 in the antibiotic group and 10.5 in the other group).ConclusionThis investigation suggests that patients have slightly lower temperatures while on CRRT, by on average less than half a degree. A similar effect is seen in both patients with infections as well as those without. Further work will be needed to determine what constitutes a true febrile response in this population.Disclosures All authors: No reported disclosures.

Feasibility of a protocol to wean patients from continuous renal replacement therapy: A retrospective pilot observation

PurposeTo evaluate the feasibility of a protocol-based algorithm to wean acute kidney injury (AKI) patients from continuous renal replacement therapy (CRRT). MethodsThe protocol was introduced on one of two similarly equipped ICUs, while on the other (reference) ICU, CRRT discontinuation was based on clinical judgement. Patients were allocated to either ICU and were subjected to physician- or protocol-directed weaning, respectively. According to the algorithm, periodical withdrawal trials (WTs) were mandatory. Interventions were recommended (administration of diuretics, fluid, vasopressors, inotropes, or human albumin) to achieve specific goals (sufficient urine output, balanced fluid status, adequate renal perfusion pressure, optimal oxygen delivery, normoalbuminemia). Clearly stated criteria defined when to abort a WT and to resume RRT for one cycle, followed by another WT. ResultsUrine output and ScvO2 during WTs were higher with protocol-directed weaning, as well as the amount of administered fluids. WT abort ratio was 48% with a tendency to prolonged WT duration, compared to 64% in the reference patients. No relevant adverse side effects were observed. ConclusionOur data show the feasibility of a structured approach to wean AKI patients from RRT that bundles established interventions and brings the weaning into the physician's focus.

Predictors of short-term successful discontinuation of continuous renal replacement therapy: results from a prospective multicentre study

BackgroundPrediction of successful discontinuation of continuous renal replacement therapy (CRRT) might reduce complications of over- and under-treatment. The aim of this study was to identify renal and non-renal predictors of short-term successful discontinuation of CRRT in patients in whom CRRT was stopped because renal recovery was expected and who were still in the Intensive Care Unit (ICU) at day 2 after stop CRRT.MethodsProspective multicentre observational study in 92 patients alive after discontinuation of CRRT for acute kidney injury (AKI), still in the ICU and free from renal replacement therapy (RRT) at day 2 after discontinuation. Successful discontinuation was defined as alive and free from RRT at day 7 after stop CRRT. Urinary neutrophil gelatinase-associated lipocalin (NGAL) and clinical variables were collected. Logistic regression and Receiver Operator Characteristic (ROC) curve analysis were performed to determine the best predictive and discriminative variables.ResultsDiscontinuation of CRRT was successful in 61/92 patients (66%). Patients with successful discontinuation of CRRT had higher day 2 urine output, better renal function indicated by higher creatinine clearance (6-h) or lower creatinine ratio (day 2/day 0), less often vasopressors, lower urinary NGAL, shorter duration of CRRT and lower cumulative fluid balance (day 0–2). In multivariate analysis renal function determined by creatinine clearance (Odds Ratio (OR) 1.066, 95% confidence interval (CI) 1.022–1.111, p = 0.003) or by creatinine ratio (day 2/day 0) (OR 0.149, 95% CI 0.037–0.583, p = 0.006) and non-renal sequential organ failure assessment (SOFA) score (OR 0.822, 95% CI 0.678–0.996, p = 0.045) were independently associated with successful discontinuation of CRRT. The area under the curve of creatinine clearance to predict successful discontinuation was 0.791, optimal cut-off of 11 ml/min (95% CI 6–16 ml/min) and of creatinine ratio 0.819 (95% CI 0.732–0.907) optimal cut-off of 1.41 (95% CI 1.27–1.59).ConclusionIn this prospective multicentre study we found higher creatinine clearance or lower creatinine ratio as best predictors of short-term successful discontinuation of CRRT, with a creatinine ratio of 1.41 (95% CI 1.27–1.59) as optimal cut-off. This study provides a practical bedside tool for clinical decision making.

The Effect of Serum Neutrophil Gelatinase-Associated Lipocalin on the Discontinuation of Continuous Renal Replacement Therapy in Critically Ill Patients with Acute Kidney Injury

Background: To determine the optimal time for discontinuing continuous renal replacement therapy (CRRT) by evaluating serum neutrophil gelatinase-associated lipocalin (NGAL) in critically ill patients with acute kidney injury (AKI). Methods: A prospective observational study was conducted from September 2015 to March 2018. AKI patients treated with CRRT for at least 24 h were divided into “success” and “failure” groups according to their RRT requirement within 7 days after the initial discontinuation of CRRT. The prefilter and effluent NGAL concentrations were measured to calculate the sieving coefficient (SC) of NGAL in all included subjects from 0 to 72 h. Results: In total, 110 patients were divided into success (n = 78) and failure groups (n = 32). The mean SC of NGAL during CRRT was less than 0.05. The patients in the failure group were associated with higher mortality compared with patients in the success group (37.5 vs. 12.8%, respectively, p = 0.013). There were significant differences in serum NGAL, creatinine, and urine output at discontinuation. In patients without sepsis (n = 70), serum NGAL and urine output were significant predictors of successful cessation. The area under the receiver operating characteristic to predict the successful discontinuation of CRRT was 0.88 for NGAL and 0.86 for urine output. An NGAL level of 403 ng/mL had the highest sensitivity (81%) and specificity (89%) and a urine output of 695 mL/day had the highest sensitivity (83%) and specificity (88%). However, in septic patients (n = 40), urine output but not serum NGAL (OR 0.999, p = 0.69) was a significant variable (OR 1.002, p = 0.005), with a cutoff of 796 mL/day (sensitivity 83%, specificity 88%). Conclusions: Serum NGAL was a significant factor for predicting successful CRRT discontinuation in nonseptic AKI patients. However, urine output, rather than serum NGAL, was a significant predictor in septic AKI patients.

Kinetic estimated glomerular filtration rate as a predictor of successful continuous renal replacement therapy discontinuation.

No standardized criteria for continuous renal replacement therapy (CRRT) discontinuation have been established. Kinetic estimated glomerular filtration rate (eGFR) is a newly developed estimation method based on dynamic changes of serum creatinine expected to reflect the true GFR. This study aimed to evaluate the predictive role of kinetic eGFR for CRRT discontinuation. A retrospective single-centre cohort study was conducted. Acute kidney injury (AKI) patients who received CRRT between May 2015 and April 2016 were enrolled. Successful CRRT discontinuation was defined as neither resuming CRRT for the next 48 h nor receiving intermittent haemodialysis 7 days from the CRRT discontinuation. Clinical factors associated with CRRT discontinuation were evaluated by receiver operating characteristic (ROC) curve analysis. Of 52 AKI patients treated with CRRT, 38 could discontinue CRRT while 14 could not. Urine volume, regular and kinetic eGFR of days 0 (day of CRRT discontinuation) and 1 were all good predictive parameters (area under the ROC curve (AUC) > 0.7). Kinetic eGFR of day 1 showed the AUC of 0.87 [95% confidence interval 0.73-0.94]). Combining kinetic eGFR of day 1 and urine volume of day 0 gave a high AUC of 0.93 [95% confidence interval 0.82-0.97]. The combination was significantly greater than urine volume of day 0 (P = 0.008). Kinetic eGFR combined with urine volume was a better predictor for CRRT discontinuation. Evaluation of kinetic eGFR utility in other clinical settings will be necessary.

Continuous Veno-Venous Hemodialysis Using the Cardio-Renal Pediatric Dialysis Emergency MachineTM: First Clinical Experiences

We report the first worldwide experience with continuous veno-venous hemodialysis (CVVHD) in children using the last generation Cardio-Renal Pediatric Dialysis Emergency Machine (CARPEDIEM)^TM device. Thirteen children received 1,008 h of CVVHD during 95 sessions, using a 0.15 (n = 7) or a 0.25 m² (n = 6) hemofilter. The median weight was 3 kg (interquartile range [IQR] 2.5–6.2). In 10 patients, CVVHD was conducted using a 5 Fr double-lumen central vascular access, whereas in 3 children, bigger sizes were used (6.5 and 8 Ch). The median prescribed Qb was 17 mL/min (IQR 10–29.5), with a median Qd of 10 mL/min. Circuits were primed with 5% albumin in 12 out of 13 patients, using anticoagulation with heparin in all 13 cases. The median delivered/prescribed time ratio yielded a 100% result (95–100%). The most common cause for “downtime” was clotting that however occurred in only 3% of all treatments. Survivals at continuous renal replacement therapy discontinuation and ICU discharge were 100 and 69% respectively. The CARPEDIEM^TM machine allowed successful delivery of diffusive blood purification modality to very small patients, using small catheters, no blood primes, and excellent concordance between delivered and prescribed treatment duration.

Association between diuretics and successful discontinuation of continuous renal replacement therapy in critically ill patients with acute kidney injury

BackgroundDespite aggressive application of continuous renal replacement therapy (CRRT) in critically ill patients with acute kidney injury (AKI), there is no consensus on diuretic therapy when discontinuation of CRRT is attempted. The effect of diuretics on discontinuation of CRRT in critically ill patients was evaluated.MethodsThis retrospective cohort study enrolled 1176 adult patients who survived for more than 3 days after discontinuing CRRT between 2009 and 2014. Patients were categorized depending on the re-initiation of renal replacement therapy within 3 days after discontinuing CRRT or use of diuretics. Changes in urine output (UO) and renal function after discontinuing CRRT were outcomes. Predictive factors for successful discontinuation of CRRT were also analyzed.ResultsThe CRRT discontinuation group had a shorter duration of CRRT, more frequent use of diuretics after discontinuing CRRT, and greater UO on the day before CRRT discontinuation [day minus 1 (day − 1)]. The diuretics group had greater increases in UO and serum creatinine elevation after discontinuing CRRT. In the CRRT discontinuation group, continuous infusion of furosemide tended to increase UO more effectively. Multivariable regression analysis identified high day − 1 UO and use of diuretics as significant predictors of successful discontinuation of CRRT. Day − 1 UO of 125 mL/day was the cutoff value for predicting successful discontinuation of CRRT in oliguric patients treated with diuretics following CRRT.ConclusionsDay − 1 UO and aggressive diuretic therapy were associated with successful CRRT discontinuation. Diuretic therapy may be helpful when attempting CRRT discontinuation in critically ill patients with AKI, by inducing a favorable fluid balance, especially in oliguric patients.