Rate Of Fluid Removal Research Articles

Incidence and associated factors for hypotension during continuous renal replacement therapy in critically ill patients.

This work aimed to analyse retrospective data on hypotension incidence and associated factors among patients requiring continuous renal replacement therapy. The incidence and risk factors of continuous renal replacement therapy-related hypotension have not been adequately explored. The study was designed as a retrospective analysis. Patients who required continuous renal replacement therapy in the ICU between January 2017 and June 2021 were reviewed. The multivariate logistic regression model was used to determine the associated factors of hypotension. Hypotension occurred in 242 out of 885 circuits (27.3%) among 140 patients. The logistic regression analysis identified seven factors associated with the occurrence of hypotension during CRRT: serum albumin (OR = 0.969, 95%CI: 0.934-0.999), serum calcium (OR = 0.514, 95%CI: 0.345-0.905), CO2CP (OR = 0.933, 95%CI: 0.897-0.971), use of vasopressors (OR = 5.731, 95%CI: 4.023-8.165), hypotension before CRRT initiation (OR = 2.779, 95%CI:1.238-6.242), age (OR = 1.016, 95%CI: 1.005-1.027), and fluid removal rate (OR = 1.002, 95%CI: 1.001-1.003). Hypotension frequently occurs in patients receiving continuous renal replacement therapy, especially in the early stages. Multiple factors can be associated with cardiac output or peripheral resistance changes, including excessive ultrafiltration, vasopressors, serum albumin and serum calcium levels, and carbon dioxide combining power.

Myocardial markers are highly altered by higher rates of fluid removal during hemodialysis.

Although hemodialysis is lifesaving in patients with kidney failure extensive interdialytic weight gain (IDWG) between dialyses worsens the prognosis. We recently showed a strong correlation between IDWG and predialytic values of cardiac markers. The aim of the present study was to evaluate if the cardiac markers N-terminal pro-B-type natriuretic peptide (proBNP) and troponin T were influenced by IDWG and speed of fluid removal (ultrafiltration-rate). Twenty hemodialysis patients performed in total 60 hemodialysis (three each). Predialytic values of proBNP and troponin T and changes from predialysis to 180 min hemodialysis (180-0 min) were compared with the IDWG calculated in percent of body weight. The ultrafiltration-rate was adjusted (UF-rateadj ) to IDWG: (100 × weight gain between dialysis [kg])/(estimated body dry weight [kg] × length of hemodialysis session [hours]). UF-rateadj correlated (Spearman) with (1) predialytic values of IDWG (r = 0.983, p < 0.001), proBNP (r = 0.443, p < 0.001), and troponin T (r = 0.296, p = 0.025); and (2) differences in proBNP180-0min (r = 0.572, p < 0.001) and troponin T180-0min (r = 0.400, p = 0.002). UF-ratesadj above a breakpoint of 0.60 caused more release of proBNP180-0min (p = 0.027). Remaining variables in multiple regression analysis with ProBNP180-0min as dependent factor were predialytic proBNP (p < 0.001) and the ultrafiltration-rate (p < 0.001). Higher UF-rateadj during dialysis was correlated to increased levels of cardiac markers. Data support a UF-rateadj lower than 0.6 to limit such increase. Further studies may confirm if limited fluid intake and a lower UF-rateadj should be recommended to prevent cardiac injury during dialysis.

Toward microfluidic integration of respiratory and renal organ support in a single cartridge.

Extracorporeal organ assist devices provide lifesaving functions for acutely and chronically ill patients suffering from respiratory and renal failure, but their availability and use is severely limited by an extremely high level of operational complexity. While current hollow fiber-based devices provide high-efficiency blood gas transfer and waste removal in extracorporeal membrane oxygenation (ECMO) and hemodialysis, respectively, their impact on blood health is often highly deleterious and difficult to control. Further challenges are encountered when integrating multiple organ support functions, as is often required when ECMO and ultrafiltration (UF) are combined to deal with fluid overload in critically ill patients, necessitating an unwieldy circuit containing two separate cartridges. We report the first laboratory demonstration of simultaneous blood gas oxygenation and fluid removal in single microfluidic circuit, an achievement enabled by the microchannel-based blood flow configuration of the device. Porcine blood is flowed through a stack of two microfluidic layers, one with a non-porous, gas-permeable silicone membrane separating blood and oxygen chambers, and the other containing a porous dialysis membrane separating blood and filtrate compartments. High levels of oxygen transfer are measured across the oxygenator, while tunable rates of fluid removal, governed by the transmembrane pressure (TMP), are achieved across the UF layer. Key parameters including the blood flow rate, TMP and hematocrit are monitored and compared with computationally predicted performance metrics. These results represent a model demonstration of a potential future clinical therapy where respiratory support and fluid removal are both realized through a single monolithic cartridge.

Ultrafiltration during intermittent hemodialysis in dogs with acute kidney injury.

Ultrafiltration is performed to alleviate fluid overload in dogs with acute kidney injury (AKI) undergoing intermittent hemodialysis (IHD). To describe prescription patterns for ultrafiltration in dogs receiving IHD for AKI and risk factors for ultrafiltration-related complications. Seventy-seven dogs undergoing 144 IHD treatments between 2009 and 2019. Medical records of dogs receiving IHD for AKI were reviewed. The initial 3 IHD treatments in which ultrafiltration was prescribed were included. Ultrafiltration-related complications were defined as those requiring an intervention such as transient or permanent discontinuation of ultrafiltration. Mean fluid removal rate per treatment was 8.1 ± 4.5mL/kg/h. Ultrafiltration-related complications occurred in 37/144 (25.7%) of treatments. Hypotension was rare (6/144, 4.2% of treatments). No ultrafiltration-related complications resulted in deaths. The mean prescribed fluid removal rate per treatment was higher in dogs with ultrafiltration-related complications than without (10.8 ± 4.9mL/kg/h vs 8.8 ± 5.1mL/kg/h, respectively; P=.03). The mean delivered fluid removal rate per treatment was significantly lower in dogs with UF-related complications compared to those without complications (6.8 ± 4.0mL/kg/h vs 8.6 ± 4.6mL/kg/h, respectively; P=.04). Variables associated with ultrafiltration-related complications (P < .05) included central venous oxygen saturation, body temperature before IHD treatment, total extracorporeal circuit volume and BUN at the end of IHD treatment. Ultrafiltration during IHD in dogs with AKI is overall safe. Higher prescribed ultrafiltration rates were associated with increased risk of complications. Decrease in central venous oxygen saturation is associated with ultrafiltration-related complications, emphasizing the utility of in-line blood monitoring.

A novel pump-free ultrafiltration rate modulation system for continuous renal replacement therapy applications

PurposeExtracorporeal ultrafiltration is an attractive alternative to diuretics for removing excess plasma water in critically ill patients suffering from fluid overload. In continuous renal replacement therapy (CRRT), ultrafiltration occurs in isolated form (SCUF) or supplemented by replacement fluid infusion (CVVH) and the net fluid removal rate is controlled by peristaltic pumps. In this work, a pump-free solution for regulating the ultrafiltration rate in CRRT applications is presented.MethodsThe system consists of a motorized clamp on the ultrafiltration line, whose intermittent opening is modulated with a closed-loop control system based on monitoring of ultrafiltrate collected and any replacement fluid infused. The system was tested on two platforms for SCUF and CVVH, with “low-flux” and “high-flux” hemofilter, with various ultrafiltration setpoints and patient net weight loss targets.ResultsIn all configurations the set ultrafiltration rate was achieved with a maximum error of 5% and the values recorded were kept within ± 100 ml/h with respect to the setpoint, as recommended by international standard IEC 60601-2-16. The net fluid removal trend was highly correlated with that expected (95%<R2<99%) and the weight loss target was reached in the expected time. For low ultrafiltration rates (60-150 ml/h) the system accuracy was better with the “low-flux” hemofilter.ConclusionThe developed clamp system represents a valid alternative to state-of-the-art solutions with peristaltic pumps in terms of performance, with potential usability advantages. The compliance with safety requirements given by international standard IEC 60601-2-16 is a prerequisite for clinical use.

Evaluation of Continuous Renal Replacement Therapy Results Applied in the Intensive Care Unit

Purpose: Acute kidney injury diagnosed patients are in need of renal replacement therapy (RRT). Continuous RRT is believed to be safer because the rates of fluid and solute removal are slower than with intermittent hemodialysis. In many centers, CRRT is preferred in special conditions such as increased cranial pressure, sepsis, burns, heart and liver failure. In our study, we present one year data of CRRT usage in our ICU.&#x0D; Materials and methods: This study included the patients who admitted to the Internal Medicine Intensive Care Unit of our university between January 2019 and June 2020. Among these patients, those over 18 years of age and those who had acute renal failure during their hospitalization and received continuous renal replacement therapy were included in the study.&#x0D; Results: Mean SOFA scores at admission were 2.7 which is an indication for severe disease. Lengths of ICU stay were long and approximately 77 percent of these patients died in ICU. When the comorbid conditions of the patients were examined, it was seen that oncological diseases were the most common. It was followed by hypertension, diabetes mellitus and heart diseases. Considering the KDIGO scores of the patients diagnosed with AKI, it was seen that 60 percent of them were grade 5. Treatment could be applied for an average of 25 hours. &#x0D; Conclusion: Indications, timing and benefits of CRRT are the questions that need to be research and yet remained unsolved. With evolving of technology, CRRT will be our most useful helper in ICUs.

How to Determine Fluid Management Goals during Continuous Kidney Replacement Therapy in Patients with AKI: Focus on POCUS.

The utilization of kidney replacement therapies (KRT) for fluid management of patients who are critically ill has significantly increased over the last years. Clinical studies have suggested that both fluid accumulation and high fluid removal rates are associated with adverse outcomes in the critically ill population receiving KRT. Importantly, the ideal indications and/or fluid management strategies that could favorably affect these patients are unknown; however, differentiating clinical scenarios in which effective fluid removal may provide benefit to the patient by avoiding congestive organ injury, compared with other settings in which this intervention may result in harm, is direly needed in the critical care nephrology field. In this review, we describe observational data related to fluid management with KRT, and examine the role of point-of-care ultrasonography as a potential tool that could provide physiologic insights to better individualize decisions related to fluid management through KRT.

MO641: Hemodiafiltration with Intermittent Infusion Reduces the Incidence of Dialysis Disequilibrium Syndrome in Hemodialysis Patients in the Initiation Phase

Abstract BACKGROUND AND AIMS The dialysis disequilibrium syndrome (DDS) is a major complication in hemodialysis patients in the initiation phase. Since urea removal restriction is an effective method to prevent DDS, a reduced dialysis dose is used in the initiation phase in hemodialysis patients. However, despite this, some patients still develop DDS in the initiation phase. Hemodiafiltration with intermittent infusion (I-HDF) provides intermittent infusion during dialysis, which can reduce the imbalance between the intravascular and interstitial concentrations, thus maintaining a high plasma osmolarity and potentially high plasma osmolarity, lowering the incidence of DDS. The aim of the present study was to clarify whether starting the treatment with I-HDF is useful for preventing DDS in hemodialysis patients in the initiation phase. METHOD Since January 2021, we have used I-HDF at the start of the treatment in patients being initiated on hemodialysis at our hospital. We conducted a retrospective review to examine if there were any changes in the incidence of clinical symptoms such as DDS or the mean blood pressure during dialysis with this mode change. The participants in this study included 11 patients who were started on treatment with conventional low-dose hemodialysis (HD group) (10 males/1 female; 5 diabetic, 6 non-diabetic; mean age, 73.7 years; SD 8.3) and 14 patients who were started on treatment with I-HDF (I-HDF group) (12 males/2 females; 12 diabetic, 2 non-diabetic; mean age, 66.8 years; SD 16.1). We compared the prevalence of symptoms of DDS (headache, nausea, vomiting, leg cramps, fatigue and hypotension), the normalized dialysis dose (spKt/V), the urea nitrogen (UN), serum albumin (Alb), fluid removal rate and mean blood pressure in the HD and I-HDF groups at first treatment. The treatment conditions were FA-150F membrane for the HD group and FIX-170E membrane for the I-HDF group, with a blood flow rate of 150 mL/min, dialysate flow rate of 500 mL/min and treatment time of 3-h in both groups. I-HDF was carried out with five infusions of 150–200 mL/min for one minute by back filtration of the dialysate every 30 minutes. RESULTS A significantly lower incidence of DDS was noted in the I-HDF group, with 3 events in the I-HDF group as compared with 17 events in the HD group (P &amp;lt; .01, chi-squared test). There was no significant difference in the spKt/V, UN, Alb, or fluid removal rate between the two groups (P = .80, P = .28, P = .96 and P = .20, respectively). The mean blood pressure was significantly lower in the HD group than in the I-HDF group (P &amp;lt; .05, t-test). These results indicated that the incidence of DDS could be reduced by starting treatment with I-HDF in patients being initiated on hemodialysis, because the intentional loading of fluid by intermittent infusion may enhance plasma refilling and have a positive effect on suppressing any rapid changes in the plasma osmolality. CONCLUSION I-HDF was useful for maintaining the blood pressure and reducing the incidence of dialysis disequilibrium syndrome in the initiation phase in hemodialysis patients.

Investigation on the relationship between apparent viscosity of Fe3O4@SiO2 abrasive-based magneto-rheological fluid and material removal rate of sapphire in magneto-rheological polishing

The Fe3O4@SiO2 core-shell abrasive-based magneto-rheological (MR) fluid shows promising prospect for magneto-rheological polishing (MRP) of sapphire, so it is essential to investigate the influence of its rheological properties on polishing performance of sapphire. This paper proposed an original self-assembled apparatus to measure normal force, shear force and interface area between MR ribbon and sapphire wafers during polishing, then evaluated systematically the separation rate and dynamic viscosity of Fe3O4/SiO2 abrasive-based MR fluid under various working parameters. Furthermore, the correlation between apparent dynamic viscosity of MR ribbon and the material removal rate (MRR) of sapphire was investigated. The results showed that both normal force and shear force generated on sapphire surface increase with abrasives concentration and shear velocity, while decrease with excitation distance and working distance. Both apparent dynamic viscosity and separation rate of MR ribbon decrease with working distance. The dynamic viscosity of MR ribbon increases significantly with magnetic field strength, and the larger the fraction of abrasive volume, the higher its increasing slope. The MRR of sapphire wafer increases with dynamic viscosity of MR ribbon, which shows a notably linear correlation, while the Ra value of wafer surface decreases with dynamic viscosity of MR ribbon. The largest MRR (0.323 mg/h) and the lowest Ra (2.21 nm) were achieved when the dynamic viscosity of MR ribbon was 15.33 Pa·s.

Intensive Volume Removal in Patients with Advanced Heart Failure and Chronic Kidney Disease: Pitfalls and Pearls

Congestive heart failure (CHF) and chronic kidney disease (CKD) represent concurrent chronic diseases. The presence of one condition appears to accelerate the presentation and progression of the other[1], having both conditions increase the risk of hospitalization, rehospitalization, need for intensive care or kidney replacement therapy, and death[2]. Intensive volume removal has been the core management to relieve pressure and volume overload in CHF and CKD. However, fluid removal in both concurrent conditions is very challenging. Many strategies have been used, including diuretics, vasopressin V2 receptor antagonist, ultrafiltration, and renal replacement therapy. There are many considerations in patients with advanced heart failure, including diuretic resistance, worsening kidney function, rate of fluid removal, electrolyte abnormalities, and the option of renal replacement therapy[3]. Congestive heart failure (CHF) and chronic kidney disease (CKD) represent concurrent chronic diseases. The presence of one condition appears to accelerate the presentation and progression of the other[1], having both conditions increase the risk of hospitalization, rehospitalization, need for intensive care or kidney replacement therapy, and death[2]. Intensive volume removal has been the core management to relieve pressure and volume overload in CHF and CKD. However, fluid removal in both concurrent conditions is very challenging. Many strategies have been used, including diuretics, vasopressin V2 receptor antagonist, ultrafiltration, and renal replacement therapy. There are many considerations in patients with advanced heart failure, including diuretic resistance, worsening kidney function, rate of fluid removal, electrolyte abnormalities, and the option of renal replacement therapy[3].

An overview of the machinability of alloy steel

Machinability is an important aspect for the machining of any materials. In general, it is controlled by means of tool life, surface roughness, power consumption, chip morphology, cutting forces, cutting fluid and material removal rate. Furthermore, it is also affected the microstructure, grain size, hardness, yield, tensile strength and chemical composition of the work piece material and tool materials. Advanced materials such as alloy steel, structural ceramics, and hardened steel are difficult to machine using conventional tool materials. The machining parameters such as depth of cut, cutting velocity and feed rate play a very important role to achieve high quality of surface finish on the machined surface. High interface temperatures at the tool tip and work piece material resulted poor surface finish and increases cutting forces and tool wear. A high cutting speeds with high feed and depth of cut causes high heat generation which reduces the tool substrates bonding strength resulting in accelerated tool wear and reducing tool life. In this article influence of heat treatment to enhance machinability alloy steel reviewed in terms of tool life, surface roughness, cutting forces and chip morphology. This article will be very useful for the students, research scholar and industrialist working in the area of machining.

Sustained low efficiency dialysis is non-inferior to continuous renal replacement therapy in critically ill patients with acute kidney injury: A comparative meta-analysis.

Background:Critically ill adults with acute kidney injury (AKI) experience considerable morbidity and mortality. This systematic review aimed to compare the effectiveness of continuous renal replacement therapy (CCRT) versus sustained low efficiency dialysis (SLED) for individuals with AKI.Methods:We carried out a systematic search of existing databases according to standard methods and random effects models were used to generate the overall estimate. Heterogeneity coefficient was also calculated for each outcome measure.Results:Eleven studies having 1160 patients with AKI were included in the analyses. Meta-analysis results indicated that there was no statistically significant difference between SLED versus continuous renal replacement therapy (CRRT) in our primary outcomes, like mortality rate (rate ratio [RR] 0.67, 95% confidence interval [CI] 0.44–1.00; P = .05), renal recovery (RR 1.08, 95% CI 0.83–1.42; P = .56), and dialysis dependence (RR = 1.03, 95% CI 0.69–1.53; P = .89). Also, no statistically significant difference was observed for between SLED versus CRRT in the secondary outcomes: that is, length of intensive care unit stay (mean difference –0.16, 95% CI –0.56–0.22; P = .41) and fluid removal rate (mean difference –0.24, 95% CI –0.72–0.24; P = .32). The summary mean difference indicated that there was a significant difference in the serum phosphate clearance among patients treated with SLED and CRRT (mean difference –1.17, 95% CI –1.90 to –0.44, P = .002).Conclusions:The analysis indicate that there was no major advantage of using continuous renal replacement compared with sustained low efficiency dialysis in hemodynamically unstable AKI patients. Both modalities are equally safe and effective in treating AKI among critically ill patients.

Ultrafiltration for patients with acute decompensated heart failure: A systematic review and meta-analysis.

Background:Ultrafiltration plays an indispensable role in relieving congestion and fluid retention in patients with acute decompensated heart failure (ADHF) in recent years. So far, there is no consistent agreement about whether early ultrafiltration (UF) is a first-line treatment for patients with ADHF. We, therefore, conducted a meta-analysis to assess the efficacy and safety of UF.Methods:PubMed, Embase, and Cochrane Library databases were searched for randomized controlled trials (RCTs) that compared UF with diuretics in patients with ADHF and included our interested outcomes. The primary outcomes are heart failure rehospitalization, all-cause rehospitalization, and mortality. The second outcomes are fluid loss, weight loss, and adverse events. RevMan Version 5.4.1 was used to analyze the data of included studies.Results:A total of 12 studies with 1197 patients were included. Our results showed a reduction in heart failure rehospitalization (risk ratio [RR] 0.67, 95% confidence interval [CI]: 0.52–0.87, P = .003) and all-cause rehospitalization (RR 0.62, 95% CI: 0.42–0.92; P = .02), an increase in fluid loss (1.47 L, 95% CI: 0.95–1.99 L, P < .001) and weight loss (1.65 kg, 95% CI: 0.90–2.41 kg; P < .001). There was no difference in mortality (RR 1.09, 95% CI: 0.78–1.51; P = .62). There were inconsistent agreements about which group have more total adverse events. Subgroup analysis showed that UF with larger mean fluid-remove rate (≥200 mL/h) could significantly remove more fluid, lose more weight, and decrease heart failure rehospitalization. Less weight loss for patients with ADHF may correlated to higher percent of ischemic etiology (ischemic etiology ≥50%).Conclusion:Although UF is more effective in removing fluid than diuretics and decrease rehospitalization of heart failure and all causes, there is not enough evidence to prove that UF is superior because of adverse events and mortality in the UF group. The mean fluid-removal rates should be set to ≥200 mL/h. Patient with different etiology may have different effects when treated with UF and it is a weak conclusion.Trial registration: The systematic review was registered with the International Prospective Registry of Systematic Reviews. (https://www.crd.york.ac.uk/prospero/, registration number CRD42021245049).

A Comparison of the Biomechanical Performance of 3 Negative Pressure Wound Therapy Foams.

PURPOSE:The purpose of this study was to compare 3 foam dressings to (1) determine the biomechanical performance of existing negative pressure wound therapy (NPWT) foams and (2) to determine if a test foam is possibly suitable as an antimicrobial “white” foam alternative for use in NPWT.DESIGN:A comparison of mechanical performance of 3 foams used for vacuum-assisted NPWT.SUBJECTS AND SETTING:Preclinical laboratory study using an in vitro model.METHODS:The performance of a “white” foam (polyvinyl alcohol [PVA]), an antimicrobial “black” foam (polyurethane [PU]), and an antimicrobial white foam alternative (test PVA) were tested and compared using 3 mechanically relevant criteria. First, the fluid removal rate was measured for 72 hours. Next, the pressure input was compared to the pressure directly beneath the center of the foam. Finally, the spread of negative pressure beneath the foam was measured and compared.RESULTS:Significant differences were found in fluid removal rates; specifically, the PU foam removed fluids faster than the PVA and test PVA foams, and the currently available PVA foams performed similarly. Both the PU and test PVA foams were able to transmit the negative pressure through the center of the dressing, while the typical PVA foam began failing at 140 mm Hg, with 50% of the samples failing at 200 mm Hg. All PU replicate foams evenly distributed the pressure, while 47% to 60% of the test PVA foams and 7% of the typical PVA foams distributed pressures evenly.CONCLUSIONS:Study findings suggest that the test PVA foam does not mechanically interfere with NPWT and performs equivalently to currently used foams. These results suggest that the test PVA may be modified and incorporated into a vacuum-assisted NPWT device. In addition, the methods employed in these experiments provide a reproducible means to compare biomechanical compatibility of various NPWT foams, dressings, and subdrape devices.

Control system for glucose level regulation in peritoneal dialysis

Kidney failure leads to the serious health issues associated with abnormal water-salt balance. In this case, peritoneal dialysis therapy is often prescribed: 1-2 liters of dialysis solution is administered in peritoneal cavity for 3-4 hours. During this time, due to diffusion and osmosis, toxins and excess water are transferred from blood to solution. One of the method’s downsides is the transition of glucose (osmotic agent) into the bloodstream, which leads to a gradual decrease in the fluid removal rate. To mitigate this problem, one must use the system, which will measure current glucose concentration and inject glucose into solution to compensate absorption. The paper proposes such a control system for automatic regulation of the glucose concentration in peritoneal dialysate solution. Its structure, elements, their functions and characteristics are discussed. Proposed system is capable to work autonomously or can be incorporated into wearable “artificial kidney” device.

Changes in practice patterns in Japan from before to after JSDT 2013 guidelines on hemodialysis prescriptions: results from the JDOPPS

BackgroundThe Japanese Society for Dialysis Therapy (JSDT) published in 2013 inaugural hemodialysis (HD) guidelines. Specific targets include 1.4 for single-pool Kt/V (spKt/V) with a minimum dose of 1.2, minimum dialysis session length of 4 hours, minimum blood flow rate (BFR) of 200 mL/min, fluid removal rate no more than 15 mL/kg/hr, and hemodiafiltration (HDF) therapy for certain identified symptoms. We evaluated the effect of these guidelines on actual practice in the years spanning 2005 – 2018.MethodsAnalyses were carried out to describe trends in the above HD prescription practices from December 2005 to April 2013 (before guideline publication) to August 2018 based on prevalent patient cross-sections from approximately 60 randomly selected HD facilities participating in the Japan Dialysis Outcomes and Practice Patterns Study.ResultsFrom April 2006 to August 2017 continual rises occurred in mean spKt/V (from 1.35 to 1.49), and percent of patients having spKt/V>1.2 (71% to 85%). Mean BFR increased with time from 198.3 mL/min (April 2006) to 218.4 mL/min (August 2017) , along with percent of patients with BFR >200 ml/min (65% to 85%). HDF use increased slightly from 6% (April 2006 and August 2009) to 8% by April 2013, but increased greatly thereafter to 23% by August 2017. In contrast, mean HD treatment time showed little change from 2006-2017, whereas mean UFR declined from 11.3 in 2006 to 8.4 mL/Kg/hour in 2017.ConclusionsFrom 2006 – 2018 Japanese HD patients experienced marked improvement in reaching the spKt/V target specified by the 2013 JSDT guidelines. This may have been due to moderate increase in mean BFR even though mean HD session length did not change much. In addition, HDF use increased dramatically in this time period. Other HD delivery changes during this time, such as increased use of super high flux dialyzers, also merit study. While we cannot definitively conclude a causal relationship between the publication of the guidelines and the subsequent practice changes in Japan, those changes moved practice closer to the recommendations of the guidelines.

Monitoring skin blood flow to rapidly identify alterations in tissue perfusion during fluid removal using continuous veno-venous hemofiltration in patients with circulatory shock

BackgroundContinuous veno-venous hemofiltration (CVVH) can be used to reduce fluid overload and tissue edema, but excessive fluid removal may impair tissue perfusion. Skin blood flow (SBF) alters rapidly in shock, so its measurement may be useful to help monitor tissue perfusion.MethodsIn a prospective, observational study in a 35-bed department of intensive care, all patients with shock who required fluid removal with CVVH were considered for inclusion. SBF was measured on the index finger using skin laser Doppler (Periflux 5000, Perimed, Järfälla, Sweden) for 3 min at baseline (before starting fluid removal, T0), and 1, 3 and 6 h after starting fluid removal. The same fluid removal rate was maintained throughout the study period. Patients were grouped according to absence (Group A) or presence (Group B) of altered tissue perfusion, defined as a 10% increase in blood lactate from T0 to T6 with the T6 lactate ≥ 1.5 mmol/l. Receiver operating characteristic curves were constructed and areas under the curve (AUROC) calculated to identify variables predictive of altered tissue perfusion. Data are reported as medians [25th–75th percentiles].ResultsWe studied 42 patients (31 septic shock, 11 cardiogenic shock); median SOFA score at inclusion was 9 [8–12]. At T0, there were no significant differences in hemodynamic variables, norepinephrine dose, lactate concentration, ScvO2 or ultrafiltration rate between groups A and B. Cardiac index and MAP did not change over time, but SBF decreased in both groups (p < 0.05) throughout the study period. The baseline SBF was lower (58[35–118] vs 119[57–178] perfusion units [PU], p = 0.03) and the decrease in SBF from T0 to T1 (ΔSBF%) higher (53[39–63] vs 21[12–24]%, p = 0.01) in group B than in group A. Baseline SBF and ΔSBF% predicted altered tissue perfusion with AUROCs of 0.83 and 0.96, respectively, with cut-offs for SBF of ≤ 57 PU (sensitivity 78%, specificity 87%) and ∆SBF% of ≥ 45% (sensitivity 92%, specificity 99%).ConclusionBaseline SBF and its early reduction after initiation of fluid removal using CVVH can predict worsened tissue perfusion, reflected by an increase in blood lactate levels.

Continuous renal replacement therapy principles.

Continuous renal replacement therapy (CRRT) is an extracorporeal blood purification therapy that aims to support kidney function over an extended period of time. One of the main objectives of CRRT is the removal of excess fluid and solutes retained as a consequence of acute kidney injury. Because prescription of CRRT requires goals to be set with regard to the rate and extent of solute and fluid removal, a comprehensive understanding of the mechanism by which solute and fluid removal occurs during CRRT is essential. Basic mechanisms of fluid transport and solute removal (ultrafiltration, diffusion, convection, and adsorption) and the factors influencing these processes in CRRT are described. From the combination of the different transport mechanisms, a number of CRRT modalities are identified and described. Finally, these principles are applied to provide a brief overview of the concept of effluent-based CRRT dose.

A227 UMBILICAL HERNIA INCARCERATION IN LIVER CIRRHOSIS: A RARE COMPLICATION OF PARACENTESIS

Abstract Background Patients with decompensated liver cirrhosis with ascites frequently have umbilical hernias with a prevalence of 20% and are managed with large volume paracentesis (LVP). Common complications of LVP include hemorrhage, infection, and bowel perforation that occur infrequently with a frequency of less than 1%. However, incarceration of umbilical hernias has been reported as a rare complication of LVP and is speculated to be from ascitic fluid decompression that reduces the umbilical hernia ring diameter resulting in entrapment of the hernia sac. It is unclear whether the quantity or the fluid removal rate increases the herniation risk. Based on case series, this rare complication occurs within 48 hours of the LVP and requires emergent surgical repair and involves a high risk of morbidity and mortality due to potential infection, bleeding, and poor wound healing. Aims We describe a case report of an incarcerated umbilical hernia following a bedside large-volume paracentesis. Methods Case report Results A 59-year-old Caucasian male presented to the emergency department with a 24-hour history of acute abdominal pain following his outpatient LVP. His medical history included Child-Pugh class C alcoholic liver cirrhosis with refractory ascites managed with biweekly outpatient LVP and a reducible umbilical hernia. He reported the onset of his abdominal pain 2-hours after his LVP with an inability to reduce his umbilical hernia. Seven liters of clear, straw-coloured asitic fluid was drained. Laboratory values at presentation revealed a hemoglobin of 139 g/L, leukocyte count of 4.9 x109 /L, platelet count of 110 xo 109 /L, and a lactate of 2.7 mmol/L His physical exam demonstrated an irreducible 4 cm umbilical hernia and bulging flanks with a positive fluid wave test. Abdominal computed tomography showed a small bowel obstruction due to herniation of a proximal ileal loop into the anterior abdominal wall hernia, with afferent loop dilation measuring up to 3.4 cm. He was evaluated by the General Surgery consultation service and underwent an emergent laparoscopic hernia repair. There was 5 cm of small bowel noted to be ecchymotic but viable, with no devitalized tissue. He tolerated the surgical intervention with no post-operative complications and was discharged home. Conclusions Ultrasound-guided bedside paracentesis is a common procedure used in the management of refractory ascites and abdominal wall hernia incarceration should be recognized as a potential rare complication. To prevent hernia incarceration, patients with liver cirrhosis should be examined closely for hernias and an attempt should be made for external reduction prior to LVP. A high index of suspicion for this potential life-threatening condition should be had in patients who present with symptoms of bowel obstruction following a LVP. Funding Agencies None

Precision medicine approach to dialysis including incremental and decremental dialysis regimens.

Conventional standardization of haemodialysis for treatment of end-stage kidney disease (ESKD) is predicated upon the fixed construct of one disease stage and one patient category. Increasingly recognized are subgroups of patients for whom less-intensive haemodialysis, such as incremental or decremental haemodialysis, could be employed. Almost 30% of patients with incident ESKD have clinical and residual kidney function (RFK) parameters that could accommodate less-intensive haemodialysis. In one study, patients with incident ESKD and substantial RKF treated with low-dose haemodialysis had similar mortality rate as those treated with standard-dose haemodialysis, adding to the evidence that endogenous kidney function -- when present -- can complement less-intensive haemodialysis schedules. Hazards related to incremental haemodialysis include insidious development of fluid overload and higher rates of fluid removal. Finally, deintensification of haemodialysis treatment could be employed in patients with ESKD who seek conservative care. A shift in approach to ESKD from a dichotomous frame -- disease presence versus absence -- to stages of dialysis-dependent kidney disease, each stage associated with attuned haemodialysis intensity, has been proposed. Haemodialysis standardization and personalization -- often considered mutually exclusive -- can be combined in incremental haemodialysis. Data from ongoing and future randomized clinical trials, comparing less-intensive with standard haemodialysis schedules, are required to change practice.