Prolonged Intermittent Renal Replacement Therapy Research Articles

Successful prolonged intermittent renal replacement therapy in managing isolated coronary artery bypass graft surgery-associated acute kidney injury: A case report

Successful prolonged intermittent renal replacement therapy in managing isolated coronary artery bypass graft surgery-associated acute kidney injury: A case report

Vancomycin removal and pharmacokinetics during accelerated venovenous hemofiltration.

Vancomycin pharmacokinetics are affected by renal replacement therapy and physiologic changes in critically ill patients. Literature regarding vancomycin removal and pharmacokinetics during accelerated venovenous hemofiltration (AVVH), a form of prolonged intermittent renal replacement therapy, is limited. To describe the removal and pharmacokinetics of vancomycin during AVVH. Eighteen critically ill adults receiving vancomycin and AVVH were included. Vancomycin serum concentrations were obtained within 4 h before and 2-6 h after the AVVH session. Patients' serum concentrations were plotted against time, and individual pharmacokinetic parameters were determined by a one-compartmental analysis. Continuous data are reported as a median (interquartile range [IQR]) and categorical data as a percentage. The median AVVH effluent rate was 39.3 mL/kg/h (IQR 35.5-48 mL/kg/h) for a duration of 9 h (IQR 8-9.75 h). AVVH decreased vancomycin concentrations by 29.8% (IQR 24.9%-35.9%), at a rate of 3.4% per hour (IQR 3.1%-4.3% per hour) of AVVH. The vancomycin elimination rate constant and half-life were 0.039 h-1 (IQR 0.036-0.053 h-1 ) and 17.6 h (IQR 13.1-18.8 h), respectively. The area under the curve during AVVH was 171.7 mg*h/L (IQR 149.1-190 mg*h/L). The volume of distribution in 10 patients was 1 L/kg (IQR 0.73-1.1 L/kg). After AVVH, vancomycin 1000 mg (IQR 750-1000 mg) was needed to maintain a serum trough concentration ≥15 mg/L. Vancomycin is significantly removed by AVVH, which requires supplemental dosing after completion of the AVVH session to maintain desired serum concentrations. Therapeutic drug monitoring of vancomycin serum concentrations is recommended for patients undergoing AVVH.

Antimicrobial Pharmacokinetics and Dosing in Critically Ill Adults Receiving Prolonged Intermittent Renal Replacement Therapy: A Systematic Review.

Prolonged intermittent renal replacement therapy (PIRRT) is gaining popularity as a renal replacement modality in intensive care units, but there is a relative lack of guidance regarding antimicrobial clearance and dosing when compared with other modalities. The objectives of this systematic review were to: 1) identify and describe the pharmacokinetics (PK) of relevant antimicrobials used in critically ill adults receiving PIRRT, 2) evaluate the quality of evidence supporting this data, and 3) propose dosing recommendations based on the synthesis of this data. A search strategy for multiple databases was designed and executed to identify relevant published evidence describing the PK of antimicrobials used in critically ill adults receiving PIRRT. Quality assessment, evaluation of reporting, and relevant data extraction was conducted in duplicate. Synthesis of PK/pharmacodynamic (PD) outcomes, dosing recommendations from study authors, and physicochemical properties of included antibiotics were assessed by investigators in addition to the quality of evidence to develop dosing recommendations. Thirty-nine studies enrolling 452 patients met criteria for inclusion and provided PK and/or PD data for 20 antimicrobials in critically ill adults receiving PIRRT. Nineteen studies describe both PK and PD outcomes. Vancomycin (12 studies, 171 patients), meropenem (7 studies, 84 patients), and piperacillin/tazobactam (5 studies, 56 patients) were the most frequent antimicrobials encountered. The quality of evidence was deemed strong for 7/20 antimicrobials, and strong dosing recomendations were determined for 9/20 antimicrobials. This systematic review updates and addresses issues of quality in previous systematic reviews on this topic. Despite an overall low quality of evidence, strong recommendations were able to be made for almost half of the identified antimicrobials. Knowledge gaps persist for many antimicrobials and higher quality studies (i.e., population PK studies with assessment of PD target attainment) are needed to address these gaps.

Short-term prognostic models for severe acute kidney injury patients receiving prolonged intermittent renal replacement therapy based on machine learning

BackgroundAs an effective measurement for severe acute kidney injury (AKI), the prolonged intermittent renal replacement therapy (PIRRT) received attention. Also, machine learning has advanced and been applied to medicine. This study aimed to establish short-term prognosis prediction models for severe AKI patients who received PIRRT by machine learning.MethodsThe hospitalized AKI patients who received PIRRT were assigned to this retrospective case-control study. They were grouped based on survival situation and renal recovery status. To screen the correlation, Pearson’s correlation coefficient, partial ETA square, and chi-square test were applied, eight machine learning models were used for training.ResultsAmong 493 subjects, the mortality rate was 51.93% and the kidney recovery rate was 30.43% at 30 days post-discharge, respectively. The indices related to survival were Sodium, Total protein, Lactate dehydrogenase (LDH), Phosphorus, Thrombin time, Liver cirrhosis, chronic kidney disease stage, number of vital organ injuries, and AKI stage, while Sodium, Total protein, LDH, Phosphorus, Thrombin time, Diabetes, peripherally inserted central catheter and AKI stage were selected to predict the 30-day renal recovery. Naive Bayes has a good performance in the prediction model for survival, Random Forest has a good performance in 30-day renal recovery prediction model, while for 90-day renal recovery prediction model, it’s K-Nearest Neighbor.ConclusionsMachine learning can not only screen out indicators influencing prognosis of AKI patients receiving PIRRT, but also establish prediction models to optimize the risk assessment of these people. Moreover, attention should be paid to serum electrolytes to improve prognosis.

Long-term arteriovenous fistula prognosis for maintenance hemodialysis patients who accepted PIRRT by using arteriovenous fistula.

Maintenance hemodialysis (MHD) patients are often admitted to the hospital for severe morbidities. Prolonged intermittent renal replacement therapy (PIRRT) is required during the hospital staying. There are controversial opinions on the use of arteriovenous fistula (AVF) as vascular access for PIRRT in MHD patients. Patients with AVF who accepted PIRRT in our center between January 2014 and June 2021 were retrospectively screened. AVF dysfunction and patient mortality were assessed as endpoints. Univariate and multivariate regression models were employed to identify the risk factors of AVF dysfunction. About 162 patients were included in our present study. Twenty-six experienced AVF dysfunction, of whom 53.8%, 19.2%, and 27.0% had percutaneous transluminal balloon angioplasty, surgical revision, and AVF reconstruction, respectively. The accumulated AVF dysfunction rates were 11.8%, 16.2%, and 21.0% in 1, 2, and 3 years, respectively. Multivariate analysis revealed that smoking (HR 2.750, 95% CI 1.181-6.402, p = 0.019), higher platelet (PLT, HR 1.009, 95% CI 1.000-1.017, p = 0.047), higher prothrombin activity (PTA, HR 1.039, 95% CI 1.012-1.066, p = 0.004), and lower diastolic blood pressure (DBP, HR 0.963, 95% CI 0.932-0.996, p = 0.026) were independent risk factors for AVF dysfunction. During the follow-up period, 37 patients died. Overall, the use of AVF for PIRRT might not dramatically increase the incidence of AVF dysfunction. And, Smoking, lower DBP, higher PLT, and higher PTA were associated with increased AVF dysfunction.

Global Perspectives in Acute Kidney Injury: Spain.

Global Perspectives in Acute Kidney Injury: Spain.

Outcomes of Prolonged Intermittent Renal Replacement Therapy Combined with Hemoperfusion among Patients Aged <18 Years Old with Severe Dengue

Context: Fluid overload is inevitable in severe dengue shock syndrome despite intensive fluid management. Aims: To compare the outcomes of prolonged intermittent renal replacement therapy (PIRRT) with or without hemoperfusion (HP) in treating severe dengue among patients ≤18 years old. Settings and Design: Retrospective cohort study in the hemodialysis unit of a tertiary hospital in the Philippines. Methods: Demographic and clinical data, kidney replacement therapy prescription variables, hemodynamic status, and outcomes were analyzed retrospectively for pediatric patients who underwent PIRRT with or without HP for severe dengue. The primary outcome was 28-day all-cause mortality, whereas secondary outcomes were changes in percent fluid overload, vasopressor index (VI), mean arterial pressure, and vasopressor dependency. Statistical Analysis Used: Mann–Whitney U, Chi-square, Fisher exact, and Student’s t test. Results: Among 357 severe dengue patients, 27 underwent PIRRT with (n = 18) or without (n = 9) HP. Baseline demographic and clinical characteristics differed significantly only with respect to the degree of fluid overload, time to therapy initiation, proportion with obesity and overweight, and duration of treatment during the first session. There were no significant differences between the two groups in 28-day mortality (PIRRT, n = 7 of 9, vs. PIRRT + HP, n = 10; P = 0.40) or secondary outcomes except an increased VI in PIRRT group (mean 38.2 vs. 12.4; P = 0.04). Conclusions: PIRRT combined with HP is feasible in hemodynamically unstable children with severe dengue in a resource-limited setting, but the outcomes of the combination are similar to those with PIRRT alone. Larger prospective studies should examine the efficacy of the combination of PIRRT with HP in terms of the dialysis dose and changes in cytokine levels or other inflammatory markers.

The Role of Sustained Low-Efficiency Dialysis (SLED) in the Intensive Care Unit

Renal replacement therapies are frequently used in the intensive care unit, most often in patients with severe acute kidney injury, a common complication in this setting. The choice of a prolonged intermittent renal replacement therapy (PIRRT) has grown in its popularity. Nevertheless, not all clinicians are familiar with it. The most frequently performed PIRRT is sustained low-efficiency dialysis. The aim of this article is to review the sustained low-efficiency dialysis technique, namely the necessary machinery, the prescription specificities, its complications and the particularities related to intoxications and drug dosing. Lastly, when to start sustained low-efficiency dialysis and its advantages and disadvantages over intermittent hemodialysis and continuous renal replacement therapies is discussed.

Prolonged Intermittent Renal Replacement Therapy Combined with Hemoperfusion Can Improve Early Recovery of Moderate and Severe Acute Pancreatitis, Especially in Patients with Acute Kidney Injury

Introduction: The aim of this study was to investigate the efficacy of prolonged intermittent renal replacement therapy (PIRRT) plus hemoperfusion (HP) in treating moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP). Methods: A total of 105 MSAP and SAP patients were enrolled. Sixty of them received routine internal medical therapy (control group), and 45 received PIRRT and HP in addition to routine internal medical therapy (PIRRT + HP group). The vital signs, laboratory results, and the Acute Physiology and Chronic Health Evaluation II (APACHE II) score were compared between the two groups before treatment and on the 3rd and 7th days of treatment. Results: No deaths or treatment-related serious adverse reactions occurred in both groups. After 3 and 7 days of treatment, the APACHE II score decreased more significantly in the PIRRT + HP group than in the control group (3 days: 5.47 [±3.30] vs. 7.53 [±3.89], p = 0.005. 7 days: 4.82 [±3.49] vs. 6.87 [±3.54], p = 0.004). After 3 days of treatment, the inflammatory combination parameters systemic immune-inflammation index (SII) and neutrophil-to-lymphocyte ratio (NLR) in the PIRRT + HP group decreased more significantly than those in the control group (SII: 1,239.00 [737.80–1,769.00] vs. 2,013.00 [1,260.00–3,167.00], p = 0.001. NLR: 8.78 [±4.52] vs. 11.88 [±7.30], p = 0.009). After 7 days of treatment, SII, NLR, and hypersensitive C-reactive protein decreased significantly compared with baseline, but no statistical differences between the two groups were observed. AST in both groups remained stable with treatment. There was no significant difference in baseline creatinine between the two groups of AKI patients, but after 3 and 7 days of treatment, the proportion of acute kidney injury (AKI) patients in the PIRRT + HP group whose creatinine decreased by 50% from baseline or fell to the normal range was significantly higher than that in the control group (p < 0.05). Conclusion: PIRRT + HP therapy could not only improve the general conditions, as measured by APACHE II score, but also reduce the inflammatory cascade of patients with acute pancreatitis. For MSAP and SAP patients complicated with AKI, this therapy may accelerate the recovery of renal function.

Fosfomycin single- and multiple-dose pharmacokinetics in patients undergoing prolonged intermittent renal replacement therapy.

Fosfomycin is used increasingly in the treatment of MDR bacteria. It is eliminated by renal excretion, but data regarding dosing recommendations for patients undergoing modern means of renal replacement therapies are scarce. Evaluation of the pharmacokinetics (PK) of fosfomycin in patients undergoing prolonged intermittent renal replacement therapy (PIRRT) to guide dosing recommendations. Fosfomycin was given in 11 (7 female) patients with severe infections undergoing PIRRT. Plasma levels were measured at several timepoints on the first day of fosfomycin therapy, as well as 5-6 days into therapy, before and after the dialyser, to calculate its clearance. Fosfomycin was measured in the collected spent dialysate. The median (IQR) plasma dialyser clearance for fosfomycin was 183.4 (156.9-214.9) mL/min, eliminating a total amount of 8834 (4556-10 440) mg of fosfomycin, i.e. 73.9% (45.3%-93.5%) of the initial dose. During PIRRT, the fosfomycin half-life was 2.5 (2.2-3.4) h. Data from multiple-dose PK showed an increase in fosfomycin Cmax from 266.8 (166.3-438.1) to 926.1 (446.8-1168.0) mg/L and AUC0-14 from 2540.5 (1815.2-3644.3) to 6714 (4060.6-10612.6) mg·h/L. Dialysis intensity during the study was 1.5 L/h. T>MIC was 100% in all patients. Patients undergoing PIRRT experience significant fosfomycin elimination, requiring a dose of 5 g/8 h to reach adequate plasma levels. However, drug accumulation may occur, depending on dialysis frequency and intensity.

Antimicrobial dosing in prolonged intermittent renal replacement therapy: a systematic review

AbstractAimThe research aim was to conduct a systematic review of the literature regarding the pharmacokinetics (PK) and dosing of antimicrobials in prolonged intermittent renal replacement therapy (PIRRT), a hybrid form of dialysis becoming increasingly utilised in critical care.MethodsA literature review was performed using PubMed from database inception to October 2020 according to the PRISMA guidelines. All papers published in English language were included in the review. Two researchers independently conducted literature searches, screened abstracts and full text and came to agreement as to which articles were suitable for inclusion before compiling the relevant data into a spreadsheet. The types of papers retrieved varied between case reports, single and multiple dose pharmacokinetic studies and Monte Carlo simulations.ResultsA total of 149 articles were found in the initial literature review and via other sources. Of these papers, 50 articles were deemed eligible for inclusion. These studies included one to 34 patients. PIRRT settings varied between institutions, including filter surface area, duration of PIRRT and type of dialyser used. With the exception of vancomycin and meropenem, few antimicrobials had sufficient data available from which reasonable empiric dosing regimens can be recommended.ConclusionThere is limited data to guide dosing of antimicrobials during PIRRT. More studies are required to understand how dosing can be optimised in this population of critically ill patients.

Short-term prognosis and influencing factors of patients with acute kidney injury treated with prolonged intermittent renal replacement therapy.

Studies assessing prognosis after prolonged intermittent renal replacement therapy (PIRRT) for acute kidney injury (AKI) are scarce. To assess the impact of PIRRT on AKI and factors associated with short-term prognosis. In this retrospective nested case-control study, AKI patients administered PIRRT in Shanghai General Hospital from 01/2012 to 10/2018 were assigned to the 30-day survivor and death groups. Surviving patients were further divided into the kidney recovery and non-recovery groups at 30 and 90days post-discharge, respectively. Propensity score matching was performed. Totally 576 patients were included in the non-matched study population, mortality and kidney recovery rates were 51.7% and 33.4%, respectively. After propensity score matching, there were 250 patients in each of the death and survival groups. Low PIRRT frequency (OR=2.165, 95% CI=1.178-3.978), infection (OR=0.447, 95% CI=0.251-0.795), number of damaged vital organs (OR=0.478, 95% CI=0.346-0.661), sodium (OR=0.958, 95% CI=0.928-0.988), total protein (OR=1.047, 95% CI=1.022-1.072), pre-dialysis thrombin time (TT; OR=0.959, 95% CI=0.936-0.983), pre-discharge glomerular filtration rate (GFR; OR=1.024, 95% CI=1.017-1.031) and admission ward [reference: renal ward; intensive care unit (OR=0.042, 95% CI=0.008-0.211); surgery (OR=0.092, 95% CI=0.018-0.465); medical (OR=0.049, 95% C% CI=0.009-0.259); other (OR=0.097, 95% CI=0.016-0.572)] independently predicted 30-day mortality. Peripherally inserted central catheter (OR=13.970, 95% CI=1.439-135.589), urea nitrogen (OR=0.961, 95% CI=0.933-0.990) and pre-discharge GFR (OR=1.102, 95% CI=1.067-1.137) independently predicted 30-day kidney recovery. Pre-dialysis Scr (OR=0.997, 95% CI=0.995-0.999), urea nitrogen (OR=0.948, 95% CI=0.912-0.986) and pre-discharge GFR (OR=1.137 95% CI=1.088-1.189) independently predicted 90-day kidney recovery. PIRRT improves survival and kidney function recovery in AKI patients. In patients with previous GFR≥30mL/(min-1.73m2 ) and no prior maintenance dialysis, PIRRT at 3-5 sessions/week might be appropriate.

Association between Prolonged Intermittent Renal Replacement Therapy and All-Cause Mortality in COVID-19 Patients Undergoing Invasive Mechanical Ventilation: A Retrospective Cohort Study

Background: The mortality rate of critically ill patients with coronavirus disease 2019 (COVID-19) was high. We aimed to assess the association between prolonged intermittent renal replacement therapy (PIRRT) and mortality in patients with COVID-19 undergoing invasive mechanical ventilation. Methods: This retrospective cohort study included all COVID-19 patients receiving invasive mechanical ventilation between February 12 and March 2, 2020. All patients were followed until death or March 28, and all survivors were followed for at least 30 days. Results: For 36 hospitalized COVID-19 patients receiving invasive mechanical ventilation, the mean age was 69.4 (±10.8) years, and 30 patients (83.3%) were men. Twenty-two (61.1%) patients received PIRRT (PIRRT group), and 14 cases (38.9%) were managed with conventional strategy (non-PIRRT group). There were no differences in age, sex, comorbidities, complications, treatments, and most of the laboratory findings. During the median follow-up period of 9.5 (interquartile range 4.3–33.5) days, 13 of 22 (59.1%) patients in the PIRRT group and 11 of 14 (78.6%) patients in the non-PIRRT group died. Kaplan-Meier analysis demonstrated prolonged survival in patients in the PIRRT group compared with that in the non-PIRRT group (p = 0.042). The association between PIRRT and a reduced risk of mortality remained significant in 3 different models, with adjusted hazard ratios varying from 0.332 to 0.398. Increased IL-2 receptor, TNF-α, procalcitonin, prothrombin time, and NT-proBNP levels were significantly associated with an increased risk of mortality in patients with PIRRT. Conclusion: PIRRT may be beneficial for the treatment of COVID-19 patients with invasive mechanical ventilation. Further prospective multicenter studies with larger sample sizes are required.

Hemoperfusión con dispositivo CytoSorb en paciente con COVID-19

La enfermedad COVID-19 es una enfermedad infecciosa ocasionada por el virus SARS-CoV 2 cuya presentación clínica es muy heterogénea: puede ir desde personas asintomáticas hasta pacientes críticamente enfermos, con tormenta de citoquinas, distrés respiratorio agudo, disfunción de órganos e incluso la muerte. Las terapias actuales para su tratamiento van encaminadas a reducir el impacto de la cascada inflamatoria, y dentro de estas encontramos las tecnologías de hemoadsorción como la membrana CytoSorb. A continuación, presentamos un paciente masculino de 31 años de edad, quien consultó por sintomatología severa de COVID-19 y mostró una evidente mejoría clínica y bioquímica posterior al uso del dispositivo CytoSorb. Este es el único paciente documentado en Colombia al que se le haya realizado terapia de hemoperfusión con este dispositivo en conjunto con terapia de reemplazo renal intermitente prolongada y se hayanregistrado desenlaces clínicos favorables.

Prolonged Intermittent Renal Replacement Therapy for Acute Kidney Injury in COVID-19 Patients with Acute Respiratory Distress Syndrome

Introduction: Patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 frequently develop severe acute kidney injury (AKI). Although continuous renal replacement therapy is the standard of care for critically ill patients, prolonged intermittent renal replacement therapy (PIRRT) may be a feasible option. We aimed to describe the tolerability and security of PIRRT treatments in COVID-19 patients with ARDS who required mechanical ventilation and developed severe AKI. Methods: We prospectively analyzed patients who underwent PIRRT treatments at a COVID-19 reference hospital in Mexico City. Intradialytic hypotension was defined as a systolic blood pressure decrease of ≥20 mm Hg or an increase of 100% in vasopressor dose. Results: We identified 136 AKI cases (60.7%) in 224 patients admitted to the intensive care unit. Among them, 21 (15%) underwent PIRRT (130 sessions) due to stage 3 AKI. The median age of the cohort was 49 (range 36–73) years, 17 (81%) were male, 7 (33%) had diabetes, and the median time between symptoms onset and PIRRT initiation was 12 (interquartile range [IQR] 7–14) days. The median of PIRRT procedures for each patient was 5 (IQR 4–9) sessions. In 108 (83%) PIRRT sessions, the total ultrafiltration goal was achieved. In 84 (65%) PIRRT procedures, there was a median increase in norepinephrine dose of +0.031 mcg/kg/min during PIRRT (IQR 0.00 to +0.07). Intradialytic hypotensive events occurred in 56 (43%) procedures. Fifteen (12%) PIRRT treatments were discontinued due to severe hypotension. Vasopressor treatment at PIRRT session onset (OR 6.2, 95% CI 1.4–28.0, p: 0.02) and a pre-PIRRT lactate ≥3.0 mmol/L (OR 4.63, 95% CI 1.3–12.8, p: 0.003) were independently and significantly associated with the risk of hypotension during PIRRT. During follow-up, 11 patients (52%) recovered from AKI and respiratory failure and 9 (43%) died. Several adaptations to our PIRRT protocol during the COVID-19 outbreak are presented. Conclusions: PIRRT was feasible in the majority of COVID-19 patients with ARDS and severe AKI, despite frequent transitory intradialytic hypotensive episodes. PIRRT may represent an acceptable alternative of renal replacement therapy during the COVID-19 outbreak.

Prolonged Intermittent Renal Replacement Therapy for AKI in COVID-19 Patients with Acute Respiratory Distress Syndrome

Prolonged Intermittent Renal Replacement Therapy for AKI in COVID-19 Patients with Acute Respiratory Distress Syndrome

Pharmacokinetics of Amoxicillin and Cefepime During Prolonged Intermittent Renal Replacement Therapy: A Case Report

Prolonged intermittent renal replacement therapy (PIRRT) is an emerging form of renal replacement therapy in critically ill patients, but dosing data for antibiotics such as amoxicillin and cefepime are scarce and limited. This case report describes the effect of PIRRT on the plasma pharmacokinetics of amoxicillin and cefepime in a 69-year-old, critically ill patient with a polymicrobial intra-abdominal infection. Blood samples taken over 2 days, including a 7-hour PIRRT session, were analysed and a two-compartment model was used to describe cefepime and amoxicillin clearance and dosing requirements during PIRRT and off-PIRRT in this patient. Based on these data, an off-PIRRT dose of 1 g amoxicillin 12-hourly and cefepime 2 g daily with an on-PIRRT dose of 1 g amoxicillin 8-hourly and cefepime 2 g 12-hourly was deemed appropriate.

Providing Care to Patients with AKI and COVID-19 Infection: Experience of Front Line Nephrologists in New York.

Governor Cuomo recently stated, “We will lose people, the virus takes the most vulnerable. The challenge is to make sure we don’t lose anyone else we could have saved.” Severe acute respiratory syndrome coronavirus 2, known as COVID-19, was first described in China in December 2019 (1). A global pandemic followed in the months to come, leading to devastating consequences. By April 26, 2020, COVID-19 had spread to >200 countries, infecting >2.9 million people, and resulting in >200,000 deaths globally (2). The suspected index case of COVID-19 infection leading to the New York City/Westchester outbreak was described in a man who became ill on February 22. By the third week of March, New York City had become an epicenter of the COVID-19 outbreak in the United States. Nearly 1 million Americans have been infected with the virus and New York accounts for 29% of these infections. Never in our lifetime have so many people fallen ill simultaneously. The rapid increase in hospitalizations has challenged the delivery of health care in unprecedented ways. AKI has been reported in up to 25% of patients with severe COVID-19 infection (3,4). The volume of patients with severe AKI in a single hospital poses unique challenges for the nephrologist including ( 1 ) infection prevention ( 2 ) workforce ( 3 ) dialysis resources, and ( 4 ) communication. We report our experience of providing care to hospitalized patients with AKI in the Bronx during the first month of the outbreak. Montefiore Medical Center (MMC), located in the North Bronx in close proximity to Westchester County, has been one of the main urban tertiary care centers for patients in New York City with COVID-19 infection. MMC’s two main campuses are the Moses and Weiler Hospitals. Moses Hospital is a 726-bed hospital with five intensive care units (ICUs) (47 beds) and Weiler …

Usefulness of prolonged renal replacement therapy in patients with acute kidney injury requiring dialysis

Acute kidney injury (AKI) requiring dialysis is becoming more common. Several types of renal replacement therapies have been used, including continuous, intermittent, and prolonged intermittent renal replacement therapy (PIRRT). There is no clear difference between those therapies in terms of patient survival. The aim of this study was to describe a form of PIRRT (shift continuous veno-venous hemodialysis [CVVHD]) and the results of this technique in a population of patients with AKI requiring dialysis in a tertiary care center. We studied 302 patients with AKI requiring dialysis over a 3-year period. All patients were treated in the intensive care unit. There were 1709 treatments in the study. Shift CVVHD was done for 8 h daily using NxStage machines, with a bicarbonate base dialysate at a rate of 5 L/h. Demographics and laboratory data were obtained from the electronic medical record. Dialysis data were obtained from the dialysis run sheets. Patient mortality was 51.3%.The dialysis time was close to 8 h and the blood flow was 310 (± 43) mL/min. The mean arterial pressure was stable before and after the dialysis. The total ultrafiltration averaged 2934 mL per treatment; the ultrafiltration rate was 4.1 (± 3.1) mL/kg/h, and the ultrafiltration per hour was 359 (± 257.8) mL/h. The average dialysate potassium used was 2.9 mEq/L. The dose of dialysis was 57 (± 19) mL/kg/h. The urea reduction ratio was 48% (± 15%), the standardized KT/V (a measure of dialysis dose obtained by urea kinetic modeling) was 3.5 (± 0.9), and the equivalent renal urea clearance (EKR) was 9.8 (± 4.1) mL/min. The method produced a consistent reduction in the levels of blood urea nitrogen, creatinine, potassium, and phosphorous. The delivered dose of dialysis was stable during the observation period. In conclusion, shift CVVHD is effective in treating patients with AKI requiring dialysis and has a survival similar to that of continuous therapies with less intensive use of resources.

Pediatric Continuous Renal Replacement Therapy (PCRRT) expert committee recommendation on prescribing prolonged intermittent renal replacement therapy (PIRRT) in critically ill children.

Recently, prolonged intermittent renal replacement therapies (PIRRT) have emerged as cost-effective alternatives to conventional CRRT and their use in the pediatric population has started to become more prominent. However, there is a lack of consensus guidelines on the use of PIRRT in pediatric patients in an intensive care setting. A literature search was performed on PubMed/Medline, Embase, and Google Scholar in conjunction with medical librarians from both India and the Cleveland Clinic hospital system to find relevant articles. The Pediatric Continuous Renal Replacement Therapy workgroup analyzed all articles for relevancy, proposed recommendations, and graded each recommendation for their strength of evidence. Of the 60 studies eligible for review, the workgroup considered data from 37 studies to formulate guidelines for the use of PIRRT in children. The guidelines focused on the definition, indications, machines, and prescription of PIRRT. Although the literature on the use of PIRRT in children is limited, the current studies give credence to their benefits and these expert recommendations are a valuable first step in the continued study of PIRRT in the pediatric population.