Intermittent Hemodialysis Sessions Research Articles

Early renal replacement therapy in coronavirus disease 2019-infected patients with acute kidney injury

Background Acute kidney injury (AKI) is developing as a frequent and significant coronavirus illness [coronavirus disease 2019 (COVID-19)] sequela owing to the spread of the virus in 2019. A few trials, meanwhile, have focused on AKI managed with renal replacement therapy (AKI-RRT). Aim To evaluate the effectiveness of early renal replacement treatment in COVID-19 AKI cases. Patients and methods A total of 100 individuals with AKI and confirmed COVID-19 infection participated in this case–control research. All participants were split into two groups: group A included 50 COVID-19-confirmed diagnosis patients with AKI and group B included 50 COVID-19-confirmed diagnosis patients without AKI. Following ICU admission, we collected laboratory results, physiological parameters, drugs, therapies, and organ support (including RRT), as well as clinical events like mortality. Results Use of invasive ventilation, vasopressor, deep sedation, and RRT was significantly higher in group A. When compared with patients with AKI who did not get RRT, 14 (28%) patients who had RRT were younger, had greater creatinine and blood urea nitrogen levels, and experienced oliguria more often. Five patients had at least one session of intermittent hemodialysis, and all patients experienced continuous venovenous hemofiltration. Considering mortality, hospital mortality and 60-day mortality rate were significantly higher in group A. However, there was no substantial variation between the two groups regarding ICU mortality, 28-day mortality, and RRT mortality. Age, baseline creatinine, and effective RRT were the independent predictors linked to 60-day mortality in the multiple logistic regression analysis. Conclusion Patients with AKI who need RRT had a nonsignificantly higher death rate than COVID-19-infected patients without AKI. Age, initial creatinine, and RRT effectiveness were all independent variables linked to 60-day mortality.

Syndecan-1 predicts hemodynamic instability in critically ill patients under intermittent hemodialysis.

Up to 70% of intermittent hemodialysis (IHD) sessions in critically ill patients are complicated by hemodynamic instability. Although several clinical characteristics have been associated with hemodynamic instability during IHD, the discriminatory capacity of predicting such events during IHD sessions is less defined. In the present study, we aimed to analyse endothelium-related biomarkers collected before IHD sessions and their capacity to predict hemodynamic instability related to IHD in critically ill patients. In this prospective observational study, we enrolled adult critically ill patients with acute kidney injury who required fluid removal with IHD. We screened each included patient daily for IHD sessions. Thirty minutes before each IHD session, each patient had a 5-mL blood collection for measurement of endothelial biomarkers-vascular cell adhesion molecule-1 (VCAM-1), angiopoietin-1 and -2 (AGPT1 and AGPT2) and syndecan-1. Hemodynamic instability during IHD was the main outcome. Analyses were adjusted for variables already known to be associated with hemodynamic instability during IHD. Plasma syndecan-1 was the only endothelium-related biomarker independently associated with hemodynamic instability. The accuracy of syndecan-1 for predicting hemodynamic instability during IHD was moderate [area under the receiver operating characteristic curve 0.78 (95% confidence interval 0.68-0.89)]. The addition of syndecan-1 improved the discrimination capacity of a clinical model from 0.67 to 0.82 (P<.001) and improved risk prediction, as measured by net reclassification improvement. Syndecan-1 is associated with hemodynamic instability during IHD in critically ill patients. It may be useful to identify patients who are at increased risk for such events and suggests that endothelial glycocalyx derangement is involved in the pathophysiology of IHD-related hemodynamic instability.

Neurological Impairment in Critically Ill Patients on Dialysis: Research Letter for the INCOGNITO-AKI Feasibility Study.

Acute kidney injury (AKI) resulting in kidney replacement therapy is rising among critically ill adults. Long-term kidney replacement therapy and critical illness are independently linked to acute and prolonged cognitive impairment, and structural brain pathology. Poor regional cerebral oxygenation (rSO2) may be a contributing factor. To assess the feasibility of testing the association between intradialytic rSO2 and acute and long-term neurological outcomes. Longitudinal observational study. We enrolled patients initiating continuous kidney replacement therapy or intermittent hemodialysis in the Kingston Health Sciences Centre (KHSC) Intensive Care Unit (ICU). rSO2 was monitored during the first 72 hours of continuous kidney replacement therapy or throughout each intermittent hemodialysis session. We measured acute neurological impairment by daily delirium screening and long-term neurocognitive outcomes using the Kinarm robot, Repeatable Battery for the Assessment of Neuropsychological Status, and brain magnetic resonance imaging. Of 484 ICU patients, 26 met the screening criteria. Two declined, and 13 met at least one exclusion criteria. Eleven patients were enrolled. Eight died in ICU, one died 2 months after discharge, and one declined follow-up. Data capture rates were high: rSO2/vitals (91.3%), and delirium screening and demographics (100%). Longitudinal testing was completed in 50% (1 of 2) of survivors. Enrollment was low due to a variety of factors, limiting our ability to evaluate long-term outcomes. rSO2 and delirium data collection is feasible in critically ill patients undergoing kidney replacement therapy; high mortality limits follow-up.

The Plasma Concentration Profiles and Pharmacokinetics of Levetiracetam among Thai Adult Patients Undergoing Intermittent Hemodialysis

Background: Levetiracetam is a second-generation antiepileptic drug that is primarily eliminated in urine via glomerular filtration and requires dose adjustment in patients with renal insufficiency. However, there are still a lack of evidence on pharmacokinetics including dialysis clearance of levetiracetam among patients undergoing intermittent hemodialysis. Objective: To assess the plasma concentrations and pharmacokinetic parameters of levetiracetam in patients undergoing intermittent hemodialysis. Materials and Methods: A pharmacokinetic study was conducted on six Thai adult patients receiving intermittent hemodialysis. The patients received levetiracetam 1,000 to 1,500 mg administered by intravenous injection once daily. Blood samples were obtained prior to hemodialysis, during the hemodialysis session, and post-hemodialysis to investigate levetiracetam pharmacokinetic parameters in each phase of treatments. Results: Five of six patients had residual urine volume of more than 50 mL/day. The Pharmacokinetic parameters derived from the present study were as followed, the median dialysis clearance was 9.07 L/hour (IQR 7.13, 12.17), the median elimination rate constant (Ke) was 0.30 hour⁻¹ (IQR 0.24, 0.56), and the median elimination halflife (t½) during hemodialysis session was 2.34 hours (IQR 1.25, 2.91). The present study found the median percentage of levetiracetam plasma concentration reduction after four hours of hemodialysis was 76.89% (IQR 69.02, 85.43). Overall, plasma concentration of levetiracetam was decreased during intermittent hemodialysis sessions. Conclusion: The findings of the present study support the use of LEV dosing of 1,000 to 1,500 mg/day and a supplemental dose after each hemodialysis session should be considered. Levetiracetam dose reduction in patients undergoing intermittent hemodialysis will lead to subtherapeutic plasma concentrations. Levetiracetam plasma concentration should be monitored in patients receiving intermittent hemodialysis. Keywords: Levetiracetam; Hemodialysis; Pharmacokinetics; Antiepileptic drug

Short-term Outcomes Of Intermittent Hemodialysis In Patients With Ventricular Assist Devices

<h3>Introduction</h3> There is little evidence about the short-term outcomes of patients undergoing implantation of ventricular assist devices (VADs) who require initiation of chronic intermittent hemodialysis (IHD). Filling this knowledge gap may help anticipate potential complications and improve outcomes. <h3>Methods</h3> This is a chart review, retrospective study that included all patients who underwent VAD implantation followed by initiation of IHD at our center. Intermittent hemodialysis was defined as ≤6-hour sessions, 3-4 times weekly. Continuous renal replacement therapy (CRRT) did not meet this inclusion criteria. Continuous and categorical variables were expressed in means (standard deviation) and numbers (%), respectively. <h3>Results</h3> Among the 11 patients that met inclusion criteria, 6 (54.6%) were female, 6 (54.6%) were African American, 6 (54.6%) had non-ischemic cardiomyopathy, 6 were being bridged to HT, and 9 (81.8%) had chronic kidney disease. Home regimen was available for 10 patients, all of whom were taking loop diuretics, but only 7 (70%) and 3 (30%) of them had medical regimens with ACEIs or ARBs, and spironolactone, respectively. All patients received tunneled catheters, and in 2 of them AV fistulas were performed afterwards. At least 3 patients experienced asymptomatic hypotension (<60 mm Hg) during the first 10 IHD sessions, leading to finishing the session early in one of the cases. Another patient had catheter thrombosis leading to catheter exchange. No other major event was documented during the 10 initial IHD sessions. One patient started IHD outpatient without complications. Among the 10 (90.9%) patients who started IHD during index hospitalization, the length of hospital stay was 81.5 (±40.7) days, and their most relevant complications were death (1), stroke (1), infections (5), gastrointestinal bleeding (4), right ventricular failure (2), and tracheostomy (1). For those who started IHD during index hospitalization, time to first readmission was 44.6 (±36.3) days, with 4 (44.4%) patients being readmitted within 30 days, and 1 of them dying during the first readmission. Additional information is found in Table 1. <h3>Conclusions</h3> This study confirms feasibility of IHD initiation after VAD implantation, even as outpatient, but also proves a high burden of morbidity during index hospitalization and short-term follow up. Larger studies prospective studies with the newest VADs could provide valuable insight into this strategy for left ventricular and renal replacement therapies.

Dialysis circuit clotting in critically ill patients with COVID-19 infection

BackgroundCoronavirus Disease 2019 (COVID-19) infection has been associated with a hypercoagulable state with increased reports of thrombotic events. Acute kidney injury requiring dialysis is common in critically ill patients and circuit clotting compromises efficacy of treatment. This study aims to analyze the circuit life and circuit clotting during continuous kidney replacement therapy (CKRT) and intermittent hemodialysis in patients with and without COVID-19.MethodsThis is a single-center, retrospective cohort study in critically ill patients undergoing CKRT or intermittent hemodialysis between 1 February 2020 to 22 May 2020. Patients in the intensive care unit (ICU) with COVID-19 infection and contemporary controls who tested negative were included. Co-primary outcomes were functional circuit life for patients on CKRT and all circuit clotting events for patients on CKRT and/or intermittent hemodialysis.ResultsSeventy CKRT circuits and 32 intermittent hemodialysis sessions for 12 COVID-19 cases and 22 CKRT circuits and 18 intermittent hemodialysis sessions for 15 controls were analyzed. CKRT circuit clotting was more common in the COVID-19 group compared to the control group (64% vs 36%, p = 0.02), despite higher anticoagulation use in the COVID-19 group (41% vs 14%, p = 0.02). Functional CKRT circuit life was similar in COVID-19 patients and controls (median 11 vs 12 h, p = 0.69). On Cox regression analysis, circuit clotting was similar with hazard ratio (HR) 1.90 [95% confidence interval (CI): 0.89–4.04]; however, clotting was increased in COVID-19 patients after adjustment for anticoagulation use (HR: 3.31 [95% CI 1.49–7.33]). In patients with COVID-19, CKRT circuits with anticoagulation had a longer circuit life compared to CKRT circuits without anticoagulation (median 22 versus 7 h respectively, p < 0.001). Circuit clotting was similar in both groups undergoing intermittent hemodialysis.ConclusionDialysis clotting amongst COVID-19 patients is increased despite more anticoagulation use and the hazard for clotting is greater especially after adjusting for anticoagulation use. Circuit life was suboptimal in COVID-19 patients on circuits without anticoagulation and therefore routine use of anticoagulation amongst COVID-19 patients should be considered whenever possible.

Comparison between regional citrate anticoagulation and heparin for intermittent hemodialysis in ICU patients: a propensity score-matched cohort study

BackgroundRegional citrate anticoagulation (RCA) is the gold standard of anticoagulation for continuous renal replacement therapy but is rarely used for intermittent hemodialysis (IHD) in ICU. Few studies assessed the safety and efficacy of RCA during IHD in ICU; however, no data are available comparing RCA to heparin anticoagulation, which are commonly used for IHD. The aim of this study was to assess the efficacy and safety of RCA compared to heparin anticoagulation during IHD.MethodsThis retrospective single-center cohort study included consecutive ICU patients treated with either heparin anticoagulation (unfractionated or low-molecular-weight heparin) or RCA for IHD from July to September in 2015 and 2017. RCA was performed with citrate infusion according to blood flow and calcium infusion by diffusive influx from dialysate. Using a propensity score analysis, as the primary endpoint we assessed whether RCA improved efficacy, quantified with Kt/V from the ionic dialysance, compared to heparin anticoagulation. The secondary endpoint was safety. Exploratory analyses were performed on the changes in efficacy and safety between the implementation period (2015) and at long term (2017).ResultsIn total, 208 IHD sessions were performed in 56 patients and were compared (124 RCA and 84 heparin coagulation). There was no difference in Kt/V between RCA and heparin (0.95 ± 0.38 vs. 0.89 ± 0.32; p = 0.98). A higher number of circuit clotting (12.9% vs. 2.4%; p = 0.02) and premature interruption resulting from acute high transmembrane pressure (21% vs. 7%; p = 0.02) occurred in the RCA sessions compared to the heparin sessions. In the propensity score-matching analysis, RCA was associated with an increased risk of circuit clotting (absolute differences = 0.10, 95% CI [0.03–0.18]; p = 0.008). There was no difference in efficacy and safety between the two time periods (2015 and 2017).ConclusionRCA with calcium infusion by diffusive influx from dialysate for IHD was easy to implement with stable long-term efficacy and safety but did not improve efficacy and could be associated with an increased risk of circuit clotting compared to heparin anticoagulation in non-selected ICU patients. Randomized trials to determine the best anticoagulation for IHD in ICU patients should be conducted in a variety of settings.

Pharmacokinetics of Tobramycin Administered at the Beginning of Intermittent Hemodialysis Session (ESRD Study).

Background and Objectives:There is a renewed interest in the successful use of aminoglycosides due to increasing resistance in gram-negative infections. Few studies to date have examined the pharmacokinetics (PK) of intradialytic infusions of tobramycin. This study sought to characterize the pharmacokinetic profile of intradialytically administered tobramycin in infected patients receiving chronic intermittent hemodialysis and to determine whether it is possible to achieve favorable PK targets.Design, Setting, Participants, and Measurements:In this prospective pharmacokinetic study, a single dose (5 mg/kg) of tobramycin was administered intradialytically to 11 noncritically ill patients undergoing chronic intermittent hemodialysis. Blood samples were collected at selected time to determine tobramycin serum concentrations. The PK analysis was performed using Phoenix™ NLME. The efficacy exposure outcome for nonsevere gram-negative infections sensitive to tobramycin with a minimum inhibitory concentration ≤1 were maximum concentration (Cmax ≥ 10 mg/L) and area under the curve (AUC24 h > 30 mg⋅h/L). For toxicity, the goal was to identify plasma trough concentrations <2 mg/L.Results:Tobramycin disposition was best described by a one-compartment model using a total clearance composed of the systemic clearance and a transitory hemodialysis clearance. Tobramycin mean (SD) Cmax, trough levels, and AUC24h were 13.1 (1.3) mg/L, 1.32 (0.47) mg/L, and 61 (23) mg⋅h/L, respectively. Monte Carlo simulation run with 1000 virtual patients showed that a 5 mg/kg dose of tobramycin administered intradialytically can outperformed the usual low-dose postdialysis dosing (80% meeting all targets versus <1%, respectively).Conclusions:A single high dose of tobramycin can achieve favorable PK outcome when administered using intradialytic infusions in hemodialysis patients. This practical dosing regimen may represent an effective and safer alternative to the usual dosing in the treatment of nonsevere gram-negative infections.

Serum Urate Levels of Hemodialyzed Renal Patients Revisited.

The need of maintaining serum urate (SU)-lowering agents in hemodialysis (HD) patients is an understudied area that requires a review, as it is a common practice. The aims were to assess the SU reduction achieved under HD and to analyze the kinetics of SU in a week of intermittent HD. The serum urate levels were determined before and after HD sessions in 96 consecutive patients with end-stage renal disease, and the average SU reduction was assessed. Variables related to HD were analyzed whether they were associated with SU reductions of 80% greater. In addition, a kinetics study was performed on 10 selected patients with hyperuricemia (SU before HD >6.8 mg/dL) throughout intermittent HD sessions in a 1-week period. The mean ± SD age of the patients was 66.5 ± 13.8 years, and 62 of them were male (64.6%). The mean ± SD time on HD replacement was 7.1 ± 7.2 years, and 16 (16.4%) continued with urate-lowering agents. The mean SU reduction immediately after HD was 80.2% (95% confidence interval, 78.4-82.0); 51 patients (56.7%) showed SU reduction of 80% or greater. In the SU kinetics study, SU levels significantly reduced all over the period and persisted below hyperuricemia threshold (p = 0.015). Noteworthy, 6 patients (60%) were hyperuricemic before session 1, but only 1 (10%) before session 2 and none before session 3. Under HD replacement therapy, the SU levels effectively reduced and persisted below saturation point, suggesting that the SU-lowering therapy would be unnecessary for patients on HD, but necessary in selected cases. The definition of hyperuricemia under HD needs to be revised.

Plasma exchange and hemodialysis for severe manifestations of multiple wasp stings in a child

Wasp stings occur frequently in developing countries and often lead to fatal outcomes due to the effects of wasp venom. Hemolysis and rhabdomyolysis often complicate wasp stings and result in acute kidney injury (AKI). We report a case of multiple wasp stings leading to AKI and multiple organ dysfunction syndrome (MODS) in a 9-year-old Indonesian girl. Kidney biopsy revealed acute tubular necrosis and acute interstitial nephritis. Despite delayed admission, she recovered in 33 days after 3 days of intravenous steroid administration, eight sessions of intermittent hemodialysis, and two sessions of plasma exchange (PE). Complete recovery of kidney function, indicated by normal diuresis, normal estimated glomerular filtration rate, and negative albuminuria, was reached within 12 weeks. This case showed that immediate admission following multiple wasp stings (particularly &gt;10 stings) to initiate early dialysis is important to promptly remove toxins and preserve kidney function. The case also showed that PE can be beneficial in cases of hemolysis and rhabdomyolysis complicated by MODS.

Bedside prediction of intradialytic hemodynamic instability in critically ill patients: the SOCRATE study

BackgroundDespite improvements in intermittent hemodialysis management, intradialytic hemodynamic instability (IHI) remains a common issue that could account for increased mortality and delayed renal recovery. However, predictive factors of IHI remain poorly explored. The objective of this study was to evaluate the relationship between baseline macrohemodynamic, tissue hypoperfusion parameters and IHI occurrence.MethodsProspective observational study conducted in a 18-bed medical ICU of a tertiary teaching hospital. Cardiovascular SOFA score, index capillary refill time (CRT) and lactate level were measured just before (T0) consecutive intermittent hemodialysis sessions performed for AKI. The occurrence of IHI requiring a therapeutic intervention was recorded.ResultsTwo hundred eleven sessions, corresponding to 72 (34%) first sessions and 139 (66%) later sessions, were included. As IHI mostly occurred during first sessions (43% vs 12%, P < 0.0001), following analyses were performed on the 72 first sessions. At T0, cardiovascular SOFA score ≥1 (87% vs 51%, P = 0.0021) was more frequent before IHI sessions, as well as index CRT ≥ 3 s (55% vs 15%, P = 0.0004), and hyperlactatemia > 2 mmol/L (68% vs 29%, P = 0.0018). Moreover, the occurrence of IHI increased with the number of macrohemodynamic and tissue perfusion impaired parameters, named SOCRATE score (cardiovascular SOFA, index CRT and lactATE): 10% (95% CI [3%, 30%]), 33% (95% CI [15%, 58%]), 55% (95% CI [35%, 73%]) and 80% (95% CI [55%, 93%]) for 0, 1, 2 and 3 parameters, respectively (AUC = 0.79 [0.69–0.89], P < 0.0001). These results were confirmed by analyzing the 139 later sessions included in the study.ConclusionsThe SOCRATE score based on 3 easy-to-use bedside parameters correlates with the risk of IHI. By improving risk stratification of IHI, this score could help clinicians to manage intermittent hemodialysis initiation in critically ill AKI patients.

Evaluation of peripheral perfusion index and heart rate variability as early predictors for intradialytic hypotension in critically ill patients

BackgroundIntradialytic hypotension is a serious complication during renal replacement therapy in critically ill patients. Early prediction of intradialytic hypotension could allow adequate prophylactic measures. In this study we evaluated the ability of peripheral perfusion index (PPI) and heart rate variability (HRV) to predict intradialytic hypotension.MethodsA prospective observational study included 36 critically ill patients with acute kidney injury during their first session of intermittent hemodialysis. In addition to basic vital signs, PPI was measured using Radical-7 (Masimo) device. Electrical cardiometry (ICON) device was used for measuring cardiac output, systemic vascular resistance, and HRV. All hemodynamic values were recorded at the following time points: 30 min before the hemodialysis session, 15 min before the start of hemodialysis session, every 5 min during the session, and 15 min after the conclusion of the session. The ability of all variables to predict intradialytic hypotension was assessed through area under receiver operating characteristic (AUROC) curve calculation.ResultsTwenty-three patients (64%) had intradialytic hypotension. Patients with pulmonary oedema showed higher risk for development of intradialytic hypotension {Odds ratio (95% CI): 13.75(1.4–136)}. Each of baseline HRV, and baseline PPI showed good predictive properties for intradialytic hypotension {AUROC (95% CI): 0.761(0.59–0.88)}, and 0.721(0.547–0.857)} respectively.ConclusionsEach of low PPI, low HRV, and the presence of pulmonary oedema are good predictors of intradialytic hypotension.

Intermittent Hemodialysis for Managing Metabolic Acidosis During Resuscitation of Septic Shock: A Descriptive Study.

Objectives:Septic shock is often complicated by severe metabolic acidosis, for which renal replacement therapy may be considered. However, little is known about the use of intermittent hemodialysis to manage this condition. The aim of this study was to compare physiologic and biochemical variables and vasopressor requirements before and after intermittent hemodialysis among patients who received intermittent hemodialysis to manage metabolic acidosis during resuscitation of septic shock.Design:This retrospective, cross-sectional study was conducted between April 2014 and September 2015.Settings:The ICU of a non-university-affiliated teaching hospital.Patients:Patients who were admitted to the ICU with septic shock and underwent intermittent hemodialysis to manage metabolic acidosis within 48 hours after the diagnosis of septic shock.Measurements and Main Results:The main outcomes were mean arterial pressure, minute ventilator volume, norepinephrine requirement, bicarbonate and pH before and after intermittent hemodialysis. Of 1,190 patients screened, 34 were included, and 33 accomplished a planned session of intermittent hemodialysis. After intermittent hemodialysis, an increased mean arterial pressure (+9.0 mm Hg; 95% CI, 6–13; p < 0.001), decreased minute ventilatory volume (–2.0 L/min; 95% CI, –3.3 to 0.8; p = 0.002), decreased norepinephrine requirement (–0.07 µg/kg/min; 95% CI, –0.12 to –0.02; p = 0.009), increased bicarbonate level (+7.2 mmol/L; 95% CI, 6.1–8.3; p < 0.001), and increased pH (+0.17; 95% CI, 0.13–0.21; p < 0.001) were observed in comparison to those before intermittent hemodialysis.Conclusions:In conclusion, intermittent hemodialysis appeared to be feasible and to stabilize hemodynamic and respiratory conditions in patients with septic shock complicated by metabolic acidosis during resuscitation.

Validation of a Weight Threshold–Based Vancomycin Dosing Protocol for Patients Undergoing Intermittent Hemodialysis

Patients receiving intermittent hemodialysis (IHD) are at high risk of acquiring gram-positive infections, which are often treated with IV vancomycin. Despite frequent use of vancomycin in the IHD setting, there is variability in dosing and monitoring practices among clinicians at the study institution. There is also a paucity of evidence regarding optimal vancomycin dosing to achieve target pre-IHD serum concentration. The primary objective was to compare the percentage of treatment courses with a serum vancomycin concentration between 15 and 20 mg/L, measured before the third IHD session, before and after implementation of a weight threshold-based dosing protocol. The secondary objectives were to compare the percentage of treatment courses with a pre-third IHD vancomycin concentration between 10 and 22 mg/L and the number of vancomycin measurements per treatment day, before and after protocol implementation. This quasi-experimental, single-centre study included inpatients and outpatients who underwent IHD and received at least 2 IV doses of vancomycin, with vancomycin being measured in an appropriately drawn sample before the third IHD session. Before protocol implementation, vancomycin dosing was at the clinician's discretion (usual care). After protocol implementation, each patient received a loading dose of 1000, 1500, or 2000 mg and a maintenance dose of 500, 750, or 1000 mg, depending on body weight. The percentage of treatment courses with a pre-third IHD vancomycin concentration between 15 and 20 mg/L was greater after implementation of the protocol than with usual care, but the difference was nonsignificant (44% [8/18] versus 20% [3/15], p = 0.27). However, the percentage of treatment courses with a pre-third IHD vancomycin concentration between 10 and 22 mg/L was significantly higher after protocol implementation (94% [17/18] versus 53% [8/15], p = 0.012). There was no difference in the median number of vancomycin measurements per treatment day before and after protocol implementation (0.133 versus 0.125, p = 0.99). At the study institution, the likelihood of achieving recommended vancomycin concentration increased (relative to previous practice) after implementation of a simplified vancomycin dosing protocol for patients undergoing IHD.

Mortality and Recovery of Renal Function in Acute Kidney Injury Patients Treated with Prolonged Intermittent Hemodialysis Sessions Lasting 10 versus 6 Hours: Results of a Randomized Clinical Trial.

Purpose This trial aimed to compare mortality and recovery of renal function in acute kidney injury (AKI) patients treated with different durations of prolonged hemodialysis (PHD) sessions (6 h versus 10 h). Methodology We included patients with sepsis-associated AKI, >18 years, who are in use of a norepinephrine (lower than 0.7 ucg/kg/min). Results One hundred and ninety-four patients were treated with 531 sessions of PHD (G1=104 and G2=90 patients). The two groups were similar in age and SOFA. There was no significant difference in hypotension, hypokalemia, and anticoagulation during PHD sessions. The two groups showed differences in filter clotting, hypophosphatemia, and treatment discontinuation (12.3 versus 23.1%, p=0.002; 15.5 versus 25.8%, p=0.005; and 7.9 versus 15.6%, p=0.008, respectively). There was no difference in fluid balance (FB) before and after PHD sessions. Death and complete recovery of renal function were similar (81.3 versus 82.2%, p=0.87 and 21 versus 31.2%, p=0.7, respectively). At logistic regression, the positive FB before and after dialysis was identified as risk factor for death, while volume overload after three PHD sessions and predialysis creatinine were negatively associated with recovery of renal function in 28 days. Conclusion There was no difference in the mortality and recovery of renal function of AKI patients submitted to different durations of PHD and sessions lasting 10 h presented higher filter clotting, hypophosphatemia, and treatment discontinuation. ISRCTN Registry number is ISRCTN33774458.

A Case of Linezolid Induced Toxicity

Adverse effects of linezolid are typically limited to diarrhea, nausea, and headache when shorter durations are used; however, as extended durations of linezolid therapy are increasingly more common, additional monitoring parameters should be considered in these patients. We describe a unique case of hypoglycemia, lactic acidosis, and pancreatitis related to an extended duration of linezolid therapy. A 52-year-old woman presented with altered mental status, abdominal pain, and hypotension following six weeks of linezolid and ertapenem therapy. Laboratory data revealed an initial blood glucose of 40 mg/dL and metabolic acidosis secondary to lactic acidosis. Finally, her abdominal pain on admission was likely related to an enlarged pancreas noted on computed tomography of her abdomen. Due to suspected linezolid toxicity, the patient received two intermittent hemodialysis sessions to remove linezolid and correct the metabolic acidosis. Given limited data on long-term monitoring of patients receiving extended durations of linezolid therapy, we suggest periodic monitoring of lactate, arterial blood gas, and blood glucose. If patients present with this triad of symptoms secondary to linezolid therapy, adverse effects should be treated with dextrose and intravenous thiamine while reserving hemodialysis for those with metabolic acidosis refractory to thiamine.

119 CORRECTION OF EXTREME HYPERNATREMIA IN ACUTE KIDNEY INJURY WITH CONTINUOUS RENAL REPLACEMENT THERAPY: A CASE REPORT

Category: RRT Technique Characteristics Presenter: Dr SU HOOI TEO Keywords: Acute Kidney Injury, Hypernatremia Management of extreme hypernatremia in patients with acute kidney injury (AKI) with hemodialysis poses a therapeutic challenge with risk of inadvertent over-rapid hypernatremia correction. An 84 year-old 49kg man with history of hypertension and cerebrovascular accident presented with a three-day history of reduced oral intake and cough. On examination, he was severely dehydrated and confused, with blood pressure of 115/67 mmHg and heart rate of 107/min. Initial laboratory investigations showed serum sodium of 173 mmol/L, serum creatinine of 291 umol/L and urea of 56.3 mmol/L. His baseline creatinine was 120 umol/L. He was diagnosed to have AKI secondary to severe dehydration and pneumonia, and started on intravenous hydration with estimated total water deficit of 4.7 L. He however did not respond and decision was made to initiate continuous venovenous hemodiafiltration (CVVHDF) with Qb (blood flow rate) of 150ml/min, Qd (dialysate flow rate) of 0.5L/hour, Qr (replacement flow rate) of 1L/hour. Customization of dialysate and replacement fluid by modifying sodium concentration was performed with addition of calculated amount of 3% Hypertonic Sodium Chloride solution. The mean achieved sodium correction was a reduction of 6 mmol/L every 24 hours from 168 mmol/L to 150 mmol/L over 72 hours, followed by 2 sessions of intermittent hemodialysis with sodium modeling with subsequent complete normalization of serum sodium level. Hypernatremia is an important risk factor for mortality in critically ill patient. Continuous renal replacement therapy (CRRT) may be useful in extreme hypernatremia to allow gradual, stepwise and controlled correction of hypernatremia with the aim of preventing cerebral oedema and related neurological complications. Current recommendation suggests that a daily maximal reduction in serum concentration of 8 to 10 mmol/L is considered safe especially in setting of chronic hypernatremia.

Prevalence and risk factors of hypotension associated with preload-dependence during intermittent hemodialysis in critically ill patients.

BackgroundHypotension is a frequent complication of intermittent hemodialysis (IHD) performed in intensive care units (ICUs). Passive leg raising (PLR) combined with continuous measurement of cardiac output is highly reliable to identify preload dependence, and may provide new insights into the mechanisms involved in IHD-related hypotension. The aim of this study was to assess prevalence and risk factors of preload dependence-related hypotension during IHD in the ICU.MethodsA single-center prospective observational study performed on ICU patients undergoing IHD for acute kidney injury and monitored with a PiCCO® device. Primary end points were the prevalence of hypotension (defined as a mean arterial pressure below 65 mm Hg) and hypotension associated with preload dependence. Preload dependence was assessed by the passive leg raising test, and considered present if the systolic ejection volume increased by at least 10 % during the test, as assessed continuously by the PiCCO® device.ResultsForty-seven patients totaling 107 IHD sessions were included. Hypotension was observed in 61 IHD sessions (57 %, CI95%: 47–66 %) and was independently associated with inotrope administration, higher SOFA score, lower time lag between ICU admission and IHD session, and lower MAP at IHD session onset. Hypotension associated with preload dependence was observed in 19 % (CI95%: 10–31 %) of sessions with hypotension, and was associated with mechanical ventilation, lower SAPS II, higher pulmonary vascular permeability index (PVPI) and dialysate sodium concentration at IHD session onset. ROC curve analysis identified PVPI and mechanical ventilation as the only variables with significant diagnostic performance to predict hypotension associated with preload dependence (respective AUC: 0.68 (CI95%: 0.53–0.83) and 0.69 (CI95%: 0.54–0.85). A PVPI ≥ 1.6 at IHD session onset predicted occurrence of hypotension associated with preload dependence during IHD with a sensitivity of 91 % (CI95%: 59–100 %), and a specificity of 53 % (CI95%: 42–63 %).ConclusionsThe majority of hypotensive episodes occurring during intermittent hemodialysis are unrelated to preload dependence and should not necessarily lead to reduction of fluid removal by hemodialysis. However, high PVPI at IHD session onset and mechanical ventilation are risk factors of preload dependence-related hypotension, and should prompt reduction of planned fluid removal during the session, and/or an increase in session duration.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1227-3) contains supplementary material, which is available to authorized users.

Solute and Volume Dosing during Kidney Replacement Therapy in Critically Ill Patients with Acute Kidney Injury.

ABSTRACTAmong critically ill patients with severe acute kidney injury either continuous kidney replacement therapy (CKRT) or intermittent hemodialysis (IHD) can be performed to provide optimal solute and volume control. The modality of KRT should be chosen based on the needs of the patient, hemodynamic status, clinician expertise, and resource available under a particular setting and consideration of costs. Evidence from high-quality randomized trials suggests that an effluent flow rate of 25 mL/kg/hour per day using CKRT and Kt/V of 1.3 per session of IHD provide optimal solute control. For volume dosing, the net ultrafiltration (UFNET) rate should be prescribed based on patient body weight in milliliters per kilogram per hour, with close monitoring of patient hemodynamics and fluid balance. Emerging evidence from observational studies suggests a “J”-shaped association between UFNET rate and outcomes with both faster and slower UFNET rates being associated with increased mortality compared with moderate UFNET rates. Thus, randomized trials are required to determine optimal UFNET rates in critically ill patients.How to cite this articleMurugan R. Solute and Volume Dosing during Kidney Replacement Therapy in Critically Ill Patients with Acute Kidney Injury. Indian J Crit Care Med 2020;24(Suppl 3):S107–S111.

Clinical experience with nadroparin in patients undergoing dialysis for renal impairment

Dialysis procedures are life-sustaining renal replacement therapies indicated for patients with limited or no kidney function. The formation of clots in the extracorporeal circuit during dialysis is an undesirable event. Anticoagulation is therefore routinely practiced in this context. Unfractionated heparin (UFH) is largely used in dialysis patients. However, except in patients with an elevated risk of bleeding, the 2002 European Best Practice Guidelines Expert Group on Hemodialysis recommended the use of low-molecular-weight heparins over UFH, in view of their equal efficacy, improved safety, and easy handling. Low-molecular-weight heparins comprise several drugs, differing in a number of pharmacological and clinical properties. This manuscript reviews the data obtained with nadroparin, a low-molecular-weight heparin studied extensively in dialysis patients. Thus, several studies investigated the benefit of nadroparin vs. UFH, other low-molecular-weight heparins, or citrate in patients undergoing intermittent hemodialysis. Overall, they showed that a single intravenous bolus dose of nadroparin, adjusted according to body weight, was effective and safe for maintaining the patency of the extracorporeal circuit during intermittent hemodialysis sessions lasting up to 6 hours, in both adults and children with end-stage renal failure. In contrast to UFH, nadroparin required no laboratory monitoring of anticoagulant activity owing to the reliable anticoagulant response following its administration. Compared with UFH, nadroparin was beneficial in terms of lipid and possibly bone parameters. Nadroparin administered by a bolus dose, followed by a continuous infusion was also shown to be effective and safe in patients undergoing continuous renal replacement therapy for acute renal failure.