Intermittent Hemodialysis Group Research Articles

#226 Outcome of intermittent hemodialysis vs. continuous kidney replacement therapy for acute kidney injury: observational prospective multi-center study

Abstract Background and Aims Continuous hemodialysis in hemodynamically stable acute kidney injury (AKI) patients may impact outcome differently compared to intermittent hemodialysis, although this issue is controversial. We look at differences in AKI outcomes between patients treated with intermittent hemodialysis (IHD) and patients treated with continuous kidney replacement therapy (CKRT) modalities in in Kuwait. Method Clinically and hemodynamically stable adult inpatients with native kidneys (i.e., did not need inotropic support or mechanical ventilation) who received IHD or CKRT for AKI, in seven public hospitals in Kuwait between 1/January to 31/December 2021 were recruited. CKRT was selected due to lack of access to water treatment in patients wards in some of the participating hospitals. Demographics, comorbidities, dialytic and non-dialytic management data, and 30-day kidney and patient outcome data for, were prospectively collected and analyzed. Results Total number of AKI patients not on inotropic support and not mechanically ventilated who received dialysis during study period was 229 (age: 59.9 years; males: 60.3%; baseline eGFR: 56 ml/min). IHD (group 1) was performed in 27.1% of the cohort whereas CKRT (group 2) was performed in 72.9%. There was no statistically significant difference between the two groups in age (58.4 for IHD and 59.9 for CKRT, p=0.6), baseline eGFR (55 ml/min for IHD and 56.4 for CKRT, p=0.8), sex ratio, incidence of diabetes, hypertension or cardiovascular disease, or cause of AKI. However, renin angiotensin aldosterone system inhibitors (RAASi) were precipitating factors for AKI more significantly in the IHD group (25.8% vs. 6% for CKRT, P ≤ 0.001). Intensive care unit (ICU) contributed 21% of cases (14.5% for IHD and 23.4% for CKRT, insignificant p value of 0.1). Also, there was no statistically significant difference in receiving intravenous fluids between the two groups (71% for IHD vs. 71.5% for CKRT, p=0.8), however, more patients in the IHD group received diuretics (62.9% vs 43.1% for CKRT, p=0.008). Dialysis vascular access was right internal jugular vein in 59% (75.8% FOR IHD vs. 52.7% for CKRT) followed by femoral vein in 35% of cases (19.4%). Extracorporeal membrane oxygenation (ECMO) was used in only two cases in the CKRT group. Of the total cohort, 21.8% died, with no difference between the two groups (16.1% for IHD vs 24% for CKRT, p=0.2). Partial recovery was higher in IHD group (30.8% vs.17.3%, p=0.046) and complete recovery higher in CKRT group 33.1% vs 13.5%, p=0.009). eGFR at 30 days was 53.2 ml/min with no statistically significant difference between the two groups (44.6 for IHD vs 56.1 for CKRT, p=0.15). Conclusion The IHD group and the CKRT group were statistically similar in basic characteristics and received similar lines of management, except for the diuretics. At 30 days, they had similar death rates but CKRT group had higher rates of complete recovery than the IHD group. This is in line with published literature that suggest CKRT may not improve mortality but may improve kidney recovery.

C-reactive protein concentrations are higher in dogs with stage IV chronic kidney disease treated with intermittent hemodialysis.

In chronic kidney disease dogs, the inflammatory process increases C-reactive protein concentrations. This study aimed to determine C-reactive protein serum concentrations in stage IV chronic kidney disease dogs treated with intermittent hemodialysis. A prospective cohort study was conducted with 23 dogs allocated into three groups: control group (CG, n = 7), intermittent hemodialysis group (IHG, n = 8) and clinical treatment group (CTG, n = 8), both comprised of stage IV chronic kidney disease dogs. One blood sample from CG (initial evaluation) and two samples from IHG and CTG (first- and last-moment) were obtained to determine C-reactive protein concentration, total leukocytes, platelets, erythrocytes, total plasma protein, serum albumin, urea, creatinine, and phosphorus. C-reactive protein was higher in IHG compared to CG in the first- and last-moments (p <0.001) and compared to CTG in the first-moment (p = 0.0406). C-reactive protein presented moderate positive correlation with leukocytes (r = 0.5479; p = 0.01), and moderate negative correlation with albumin (r = - 0.5974; p = 0.006) and red blood cells (r = - 0.5878, p = 0.01). A high correlation coefficient was observed in the tests’ evaluation (CI = 0.59–0.78; r = 0.70; P<0.0001). In conclusion, both assays used in this study to measure C-reactive protein have provided safe and reliable quantification of the results. Additionally, despite IHG dogs presented an active inflammatory profile, intermittent hemodialysis has proven to be beneficial, leading to a clinical improvement in life quality of patients, and thus being recommended for stage IV CKD dogs when performed by trained professionals.

Comparison of the Treatment Efficacy of Continuous Renal Replacement Therapy and Intermittent Hemodialysis in Patients With Acute Kidney İnjury Admitted to the Intensive Care Unit.

Introduction and aimAcute kidney injury (AKI) is part of the multiple organ dysfunction syndrome in critically ill patients and is a common condition in intensive care units (ICUs). Renal replacement therapy (RRT) is the cornerstone of treatment for AKI in critically ill patients. This patient population has a high mortality rate despite RRT. There are two methods of RRT for patients in ICUs: intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT). Both CRRT and IHD similarly provide adequate metabolic control. We aimed to compare these two RRT modalities in terms of ICU stay, mortality, and laboratory recovery in these patients with high mortality.Materials and methodsA total of 120 patients with AKI who needed RRT in the ICU were included in the study (CRRT, n:40; IHD, n:80). Acute Physiology and Chronic Health Evaluation (APACHE) II, Sepsis-related Organ Failure Assessment (SOFA), and Simplified Acute Physiology Score (SAPS)-II scores at the time of admission to the ICU were calculated. Mean arterial pressure, urea, creatinine, sodium, potassium, calcium, pH, lactate, and bicarbonate levels were measured before and after dialysis. Patients were classified as living and deceased. Factors affecting the length of stay in the intensive care unit and 30-day mortality were evaluated. The variability in laboratory parameters between groups before and after dialysis was examined. The groups were compared with these parameters.ResultsSixty-one point seven percent (61.7%, n:74) of the patients were female. The mean age was 62.90±13.64 years. At the time of admission to the ICU, the patients' SAPS II score was 45.05±12.76, APACHE II score was 22.05±6.32, and SOFA score was 8.26±2.48. 66.7% (n:80) of the patients included in the study died, and the length of stay of these patients in the ICU was 12.85±10.23 days. When the groups were compared, SAPS II, APACHE II scores, and SOFA scores were significantly higher in the CRRT group than in the IHD group (p:0.038, p:0.015, p:0.027, respectively). Although the length of stay in the ICU was shorter in the CRRT group, it was not statistically significant (p:0.075). There was no statistically significant difference between the groups in terms of mortality (p: 0.891). SAPS-II, APACHE II, and SOFA score affected 30-day mortality while age, gender, and RRT modalities were not associated with mortality. The improvement in laboratory parameters between the pre and post-RRT groups was statistically more significant in the IHD group (p<0.001). It was determined that there was a statistically greater decrease in mean arterial pressure in the IHD group (p<0.001).ConclusionsIt was determined that there was no difference between the CRRT and IHD modalities applied in patients with AKI admitted to the ICU in terms of mortality and length of stay in the ICU. It was observed that both modalities improved on laboratory parameters, but the improvement was greater in the IHD group. However, it was determined that there was a statistically greater decrease in mean arterial pressure in the IHD group.

Symmetric dimethylarginine concentrations in dogs with International Renal Interest Society stage 4 chronic kidney disease undergoing intermittent hemodialysis.

BackgroundSymmetric dimethylarginine (SDMA) is a methylated arginine derived from intranuclear methylation of l‐arginine by protein‐arginine methyltransferase and released into circulation after proteolysis. It is primarily eliminated by renal excretion, and its concentration is highly correlated with glomerular filtration rate (GFR) in animals and humans and is an earlier indicator of kidney dysfunction than serum creatinine concentration (sCr).ObjectivesTo evaluate and quantify the effects of IV fluid therapy (IF) or intermittent hemodialysis (IH) on renal function in a randomized group of dogs previously diagnosed with International Renal Interest Society (IRIS) stage 4 chronic kidney disease (CKD).AnimalsTwenty‐four client‐owned dogs with naturally occurring CKD.MethodsSerum from 14 dogs treated by IH and 10 dogs treated with IF was submitted for measurement of sCr and SDMA. Dogs in each treatment group received up to 5 treatment sessions, administered 48 hours apart.ResultsSignificant differences (P ≤ .05) were seen between treatment groups, but dogs from the IH group were the most affected based on SDMA (P < .001), sCr (P < .001), and blood urea (P < .001) concentrations. Furthermore, for each 10% increase in urea reduction ratio, there was a 6.2 μg/dL decrease in SDMA (P = .002).Conclusions and Clinical ImportanceAlthough SDMA is dialyzable biomarker and despite its removal by IH, SDMA correlates better with renal function than does sCr in dogs with CKD undergoing IF and IH.

The impact of continuous renal replacement therapy on renal outcomes in dialysis-requiring acute kidney injury may be related to the baseline kidney function

BackgroundMany controversies exist regarding the management of dialysis-requiring acute kidney injury (D-AKI). No clear evidence has shown that the choice of dialysis modality can change the survival rate or kidney function recovery of critically ill patients with D-AKI.MethodsWe conducted a retrospective study investigating patients (≥16 years old) admitted to an intensive care unit with D-AKI from 1999 to 2012. We analyzed D-AKI incidence, and outcomes, as well as the most commonly used dialysis modality over time. Outcomes were based on hospital mortality, renal function recovery (estimated glomerular filtration rate-eGFR), and the need for dialysis treatment at hospital discharge.ResultsIn 1,493 patients with D-AKI, sepsis was the main cause of kidney injury (56.2%). The comparison between the three study periods, (1999–2003, 2004–2008, and 2009–2012) showed an increased in incidence of D-AKI (from 2.56 to 5.17%; p = 0.001), in the APACHE II score (from 20 to 26; p < 0.001), and in the use of continuous renal replacement therapy (CRRT) as initial dialysis modality choice (from 64.2 to 72.2%; p < 0.001). The mortality rate (53.9%) and dialysis dependence at hospital discharge (12.3%) remained unchanged over time. Individuals who recovered renal function (33.8%) showed that those who had initially undergone CRRT had a higher eGFR than those in the intermittent hemodialysis group (54.0 × 46.0 ml/min/1.73 m2, respectively; p = 0.014). In multivariate analysis, type of patient, sepsis-associated AKI and APACHE II score were associated to death. For each additional unit of the APACHE II score, the odds of death increased by 52%. The odds ratio of death for medical patients with sepsis-associated AKI was estimated to be 2.93 (1.81–4.75; p < 0.001).ConclusionOur study showed that the incidence of D-AKI increased with illness severity, and the use of CRRT also increased over time. The improvement in renal outcomes observed in the CRRT group may be related to the better baseline kidney function, especially in the dialysis dependence patients at hospital discharge.

Efficiency of acidemia correction on intermittent versus continuous hemodialysis in acute methanol poisoning

Context: Acidemia is a marker of prognosis in methanol poisoning, as well as compounding formate-induced cytotoxicity. Prompt correction of acidemia is a key treatment of methanol toxicity and methods to optimize this are poorly defined.Objective: We studied the efficiency of acidemia correction by intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) in a mass outbreak of methanol poisoning.Methods: The study was designed as observational cohort study. The mean time for an increase of 1 mmol/L HCO3–, 0.01 unit arterial blood pH, and the total time for correction of HCO3– were determined in IHD- and CRRT-treated patients.Results: Data were obtained from 18 patients treated with IHD and 13 patients treated with CRRT. At baseline, CRRT group was more acidemic than IHD group (mean arterial pH 6.79 ± 0.10 versus 7.05 ± 0.10; p = 0.001). No association was found between the rate of acidemia correction and age, weight, serum methanol, lactate, formate, and glucose on admission. The time to HCO3– correction correlated with arterial blood pH (r= −0.511; p = 0.003) and creatinine (r = 0.415; p = 0.020). There was association between the time to HCO3– correction and dialysate/effluent and blood flow rates (r= −0.738; p < 0.001 and r= −0.602; p < 0.001, correspondingly).The mean time for HCO3– to increase by 1 mmol/L was 12 ± 2 min for IHD versus 34 ± 8 min for CRRT (p < 0.001), and the mean time for arterial blood pH to increase 0.01 was 7 ± 1 mins for IHD versus 11 ± 4 min for CRRT (p = 0.024). The mean increase in HCO3– was 5.67 ± 0.90 mmol/L/h for IHD versus 2.17 ± 0.74 mmol/L/h for CRRT (p < 0.001).Conclusions: Our study supports the superiority of IHD over CRRT in terms of the rate of acidemia correction.

Clinical Evaluation of High-Volume Hemofiltration with Hemoperfusion Followed by Intermittent Hemodialysis in the Treatment of Acute Wasp Stings Complicated by Multiple Organ Dysfunction Syndrome.

Multiple organ dysfunction syndrome (MODS) is a rare complication of wasp stings. Currently, there is no standardized treatment for MODS secondary to multiple wasp stings, although blood purification techniques are often used. This study aimed to analyze our experiences of using intermittent hemodialysis (IHD) with or without high-volume hemofiltration (HVHF) for treating acute wasp stings complicated by MODS. In this retrospective study, 36 patients with wasp stings complicated by MODS received either IHD combined with hemoperfusion, or HVHF (ultrafiltration flow rate, 70 mL/kg/h) combined with hemoperfusion for 5 days followed by IHD. Clinical symptoms, blood biochemical parameters, duration of mechanical ventilation, use of vasoactive agents, duration of hospital stay and survival rate were recorded, and Acute Physiology and Chronic Health Evaluation II (APACHE II) and multiple organ dysfunction (MOD) scores estimated. Patients treated with HVHF followed by IHD appeared to exhibit a faster recovery than those receiving IHD alone, as evidenced by superior improvements in MOD (4.29±1.08 vs. 2.27±1.07) and APACHE II (7.09±2.62 vs. 4.20±1.69) scores (P < 0.05). Patients treated with HVHF had significantly lower myoglobin, creatine kinase-MB, lactate dehydrogenase, bilirubin and creatinine levels than patients treated with IHD alone. In addition, the durations of hospital stay (13.15±2.77 vs. 27.92±3.18 days), vasopressor use (1.76±0.24 vs. 3.43 ± 1.01 days), mechanical ventilation (3.02±1.63 vs. 5.94 ± 2.11 days) and oliguria (6.57±2.45 vs. 15.29 ± 3.51 days) were reduced, and renal function more often recovered (85.1% vs. 53.1%), in the HVHF group compared with the IHD group (P < 0.05). These results raise the possibility that HVHF plus IHD may be superior to IHD alone for the treatment of acute wasp stings complicated by MODS; additional prospective studies are merited to explore this further.

The clearing effects and safety research of various blood purification modes on β2-microglulin in acute kidney injury children

Objective To investigate the clearing effects and safety of various blood purification modes on β2-microglulin (β2-MG)in acute kidney injury(acute kidney injury, AKI)children. Methods We collected 38 acute kidney injury children including 98 cases by blood purification treatment in department of nephrology and immunology and PICU in Children's Hospital of Guiyang from March 2011 to March 2013, of which males 20 and females 18, aged from 5 months to 14.Sixty-six cases underwent continuous renal replacement therapy(CRRT)including continuous veno-venous hemofiltration(CVVH) and continuous veno-venous hemodiafiltration(CVVHDF), while 32 cases underwent intermittent hemodialysis(IHD). The primary disease of children: 7 cases of circulatory disturbance, 10 cases of nephrotoxic drugs and toxic poisoning, 9 cases of sepsis with multiple organ failure and 12 cases of renal parenchymal disease, such as nephrotic syndrome, poststreptococcal glomerulonephritis, lupus nephritis, rapidly progressive glomerulonephritis.The CRRT group were treated for 8 h to 16 h and the IHD group for 2.5 h to 3 h. Then we investigated blood urea nitrogen(BUN), serum creatinine(SCr), and disturbance of acid-base balance and β2-MG, etc. Results There were 98 cases treated by AKI of blood purification therapy(IHD, CVVH, CVVHDF). Sixty-six of them were CRRT group(CVVH or CVVHDF), others were IHD group.Two cases progressed to ESRD(accounted for 5%). They needed a long term dialysis in treatment.The mortality rates were 0.(1)Before and afert treastment of CRRT group, the difference of serum BUN[(22.34±2.08)mmol/L, (12.24±0.98)mmol/L] and Scr[(310.23±85.34)μmol/L, (178.15±34.12)μmol/L]had statistical significane(t=12.39, t=5.906, P all<0.05). Before and after trentment of IHD group, the difference of serum BUN[(23.80±2.14)mmol/L, (7.39±0.88)mmol/L] and Scr[(350.11±78.42)μmol/L, (108.20±28.20)μmol/L]had statistical significance(t=29.04, t=13.83, P all<0.05); (2)The clearing effects of β2-MG in CRRT group(40.50±7.20)% were better than IHD group(1.50±0.05)%.The difference had statistical significance(P<0.05). (3)The adverse reactions of CRRT group were mild.Its safety was higher than IHD group.In patients hemodynamics and vital signs were maintained stable after CRRT. Conclusion CRRT is good for the clearing effects of β2-MG and hemodynamics in acute kidney injury children.It is a quickly effective and safe method for treating acute kidney injury children. Key words: Acute kidney injury; Children; Continuous renal replacement therapy; Intermittent hemodialysis; β2-microglulin

Recovery from AKI Following Multiple Wasp Stings

To observe the outcomes of AKI following multiple wasp stings. Eighty-one patients (mean age ± SD, 45.5 ± 14.7 years; 55 men and 26 women; mean Acute Physiology and Chronic Health Evaluation II score, 16.85 ± 2.78) with AKI following multiple wasp stings between 1997 and 2011 were retrospectively analyzed. Data on their demographic characteristics, initial modalities of renal replacement therapy (RRT), urine output, serum creatinine, bilirubin, myoglobin, and other variables were collected. Renal outcomes included complete recovery of kidney function, CKD, and death. Subgroup analysis was performed according to initial modality of RRT in the first 48 hours, including continuous veno-venous hemofiltration (CVVH), intermittent hemodialysis (IHD), and CVVH plus plasma exchange (PE). Of the 75 patients available for follow-up, 7 (9.3%) died, and 8 (10.7%, all in the IHD group) developed CKD. The average RRT time was 18.2 ± 8.4 days, and the average kidney function recovery time was 36.0 (29.0, 41.0) days. Subgroup analysis showed no difference in the mortality rates between the CVVH, CVVH + PE, and IHD groups (8.0%, 7.1%, and 11.1%, respectively; P>0.99). The recovery time for kidney function was significantly shorter in the CVVH and CVVH + PE groups than in the IHD group (31.9 ± 8.5 days, 28.6 ± 9.4 days, and 41.6 ± 8.1 days, respectively; P<0.001). This is a large case series report on the outcomes of patients with AKI following multiple wasp stings. Most patients survived with complete recovery of their kidney function. Despite the lack of difference in mortality rates, the patients who began RRT with CVVH and CVVH + PE experienced a better and more rapid recovery of kidney function than those initiated with IHD.

Continuous Renal Replacement Therapy May Increase the Risk of Catheter Infection

Little is known about the risks of catheter-related infections in patients undergoing intermittent hemodialysis (IHD) as compared with continuous renal replacement therapy (CRRT) techniques. We compared the two modalities among critically ill adults requiring acute renal replacement therapy (RRT). We used the multicenter Cathedia study cohort of 736 critically ill adults requiring RRT. Cox marginal structural models were used to compare time to catheter-tip colonization at removal (intent-to-treat, primary endpoint) among patients who started IHD (n = 470) versus CRRT (n = 266). On-treatment analysis was also conducted to take into account changes in prescription of RRT modality. Hazard rate of catheter-tip colonization did not increase within the first 10 days of catheter use. Predictors of catheter-tip colonization were higher lactate levels and hypertension, while systemic antibiotics, antiseptics-impregnated catheters, and mechanical ventilation were associated with decreased risk. The incidence of catheter-tip colonization per 1000 catheter-days was 42.7 in the IHD group and 27.7 in the CRRT group (P < 0.01). This association was no longer significant after correction for channeling bias (weighted HR, 0.96; 95% CI: 0.77 to 1.20, P = 0.73). On-treatment analysis revealed an increased risk of primary endpoint during CRRT exposure as compared with IHD exposure (weighted HR, 0.71; 95% CI: 0.56 to 0.92, P < 0.009). Our results do not support the use of CRRT when IHD could be an alternative to reduce the risk of catheter-related infection.

Acute Effects of Intermittent Hemodialysis and Sustained Low-Efficiency Hemodialysis (SLED) on the Pulmonary Function of Patients under Mechanical Ventilation

The effects of hemodialysis (HD) on pulmonary function are still controversial. The objective of this study was to evaluate the effect of intermittent hemodialysis (IHD) and sustained low-efficiency dialysis (SLED) on the respiratory mechanics of ICU patients under invasive mechanical ventilation. We prospectively studied 31 patients. Laboratory and respiratory evaluation (static and dynamic compliance and resistance) was performed pre- and post-HD. Forty HD sessions were studied and grouped in: SLED (n = 17; Qa = 200–250 mL/min, Qd = 300 mL/min) and IHD (n = 23; Qa = 250–300 mL/min, Qd = 500 mL/min). There was no difference between the groups according to age, gender, comorbidities, APACHE II, and cause of mechanical ventilation, but pre-HD, patients in the IHD group had higher levels of plasma creatinine (5.4 ± 2.0 vs. 4.2 ± 1.3 mg/dL, p = 0.048) and platelets (286 ± 186 vs. 174 ± 95 103/mm2, p = 0.032) and lower arterial pH (7.37 ± 0.07 vs. 7.42 ± 0.05, p = 0.02). The efficiency of the treatment was similar (p > 0.05) with both types of HD regarding fluid removal, urea reduction rate, and decrease in plasma creatinine. Pre-HD, the ventilatory conditions of both groups were similar (p > 0.05) except for pressure support ventilation and airflow resistance. There were no changes (pre- versus post-HD p > 0.05) induced either by IHD or SLED in the ratio PaO2/FiO2 or in any measured ventilatory parameter. In conclusion, neither IHD nor SLED modifies the pulmonary function of patients under mechanical ventilation.

A randomized controlled trial comparing intermittent with continuous dialysis in patients with ARF

Despite the widespread use of continuous renal replacement therapy in critically ill patients with acute renal failure (ARF), there are few data supporting its benefits over conventional intermittent hemodialysis (IHD). We sought to analyze differences in survival between modalities in a study that compared continuous venovenous hemodialysis (CVVHD) with IHD. Eighty critically ill patients with ARF requiring dialysis were randomized after stratification by severity of illness to treatment with CVVHD or IHD. There were no differences in survival or renal recovery between groups. In patients who died, mean survival time was 10.7 +/- 11.2 days for the IHD group versus 14.3 +/- 16.1 days for the CVVHD group (P = not significant). There was greater net volume removal in the CVVHD group during 72 hours. Declines in urine output during 72 hours were similar between groups. Mean arterial pressure off and on dialysis therapy was analyzed retrospectively. There was a significant decrease in mean arterial pressure for patients on IHD therapy not seen in those on CVVHD therapy, but this did not lead to a survival advantage. Despite greater volume control, CVVHD did not lead to an improvement in survival, preservation of urine output, or renal recovery compared with IHD in patients with ARF.