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Purpose: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is beneficial for uncontrollable torso bleeding; however, prolonged REBOA causes ischemia-reperfusion injury. The purpose of this study is to examine the hypothesis that continuous renal replacement therapy (CRRT) with a cytokine-adsorbing hemofilter would improve mortality due to hemorrhagic shock with REBOA-reperfusion injury by controlling metabolic acidosis, hyperkalemia, and hypercytokinemia. Methods: Hemorrhagic shock with 40% blood loss was induced by phlebotomy in eight female swine. CRRT was performed on four swine after 90 min of REBOA, and the remaining four swine (control group) underwent the same procedures except for CRRT. We evaluated the survival time and trends of pH, HCO3−, potassium, lactate, circulatory inflammatory cytokines, and histopathology of the intestine for 180 min after REBOA deflation. Results: Two swine in the CRRT group and one in the control group survived; no significant difference were observed in survival rates between the groups (p = 0.45). Furthermore, no significant differences in the transition of biomarkers and histopathological grades were observed between the groups. The CRRT group showed a tendency of increasing pH and HCO3−, decreasing lactate, lower elevation of potassium and cytokine levels (interleukin 6, CRRT: 1008.5 [770.4–1246.6], control; 1636.7 [1636.7–1636.7] pg/mL at t = 270), and lower intestine histopathological grade (jejunum, CRRT; 1.5 [1.3–1.8], control; 4.0 [4.0–4.0], ileum, CRRT; 1.5 [1.3–1.8], control; 4.0 [4.0–4.0] at t = 270) than the control group. Conclusions: CRRT may mitigate acute-REBOA-related ischemia-reperfusion injury by controlling biomarkers. Further research is required to evaluate the impact on long-term mortality. [ABSTRACT FROM AUTHOR]

Introduction: Biological invasions may promote the onset of systemic inflammatory response syndrome in patients eligible for continuous renal replacement therapy (CRRT), leading to poor prognosis. Hence, we aimed to examine the inflammatory reactions in circulation using vitamin E‐coated polysulfone hollow fiber membrane (ViLIFE). Methods: Lipopolysaccharides were intravenously administered to pigs (2 μg/kg/30 min) to establish an acute inflammation model. Extracorporeal circulation was performed for 6 h in continuous venovenous hemodiafiltration mode using a hemofilter for CRRT filled with a polysulfone hollow fiber membrane or ViLIFE, and the differences in inflammatory reactions were evaluated. Results: The ViLIFE group exhibited low platelet and cytokine levels (p < 0.05 vs. sham‐CRRT group). Additionally, the ViLIFE group had lower lactate and high mobility group box 1 levels than the other groups. Conclusion: ViLIFE represents a promising CRRT modality that can inhibit the inflammatory response in circulation and inhibit further biological invasions. [ABSTRACT FROM AUTHOR]

Background: Continuous veno-venous hemodiafiltration (CVVHDF) is used in critically ill patients, but its impact on O₂ and CO₂ removal, as well as the accuracy of resting energy expenditure (REE) measurement using indirect calorimetry (IC) remains unclear. This study aims to evaluate the effects of CVVHDF on O₂ and CO₂ removal and the accuracy of REE measurement using IC in patients undergoing continuous renal replacement therapy. Design: Prospective, observational, single-center study. Methodology: Patients with sepsis undergoing CVVHDF had CO₂ flow (QCO₂) and O₂ flow (QO₂) measured at multiple sampling points before and after the filter. REE was calculated using the Weir equation based on V̇CO₂ and V̇O₂ measured by IC, using true V̇CO₂ accounting for the CRRT balance, and estimated using the Harris-Benedict equation. The respiratory quotient (RQ), the ratio of V̇CO₂ to V̇O₂, was evaluated by comparing measured and true values. Results: The mean QCO₂ levels measured upstream of the filter were 76.26 ± 17.33 ml/min and significantly decreased to 62.12 ± 13.64 ml/min downstream of the filter (p < 0.0001). The mean QO₂ levels remained relatively unchanged. The mean true REE was 1774.28 ± 438.20 kcal/day, significantly different from both the measured REE of 1758.59 ± 434.06 kcal/day (p = 0.0029) and the estimated REE of 1619.36 ± 295.46 kcal/day (p = 0.0475). The mean measured RQ value was 0.693 ± 0.118, while the mean true RQ value was 0.731 ± 0.121, with a significant difference (p < 0.0001). Conclusions: CVVHDF may significantly alter QCO₂ levels without affecting QO₂, influencing the REE and RQ results measured by IC. However, the impact on REE is not clinically significant, and the REE value obtained via IC is closer to the true REE than that estimated using the Harris-Benedict equation. Further studies are recommended to confirm these findings. [ABSTRACT FROM AUTHOR]

Background: Renal replacement therapy (RRT) may affect coagulation and platelet function in critically ill patients. However, the mechanism and the difference in the impact on coagulation between intermittent hemodialysis (iHD) and continuous renal replacement therapy (CRRT) remains unclear. This study aimed to investigate and compare the impact of iHD and CRRT on coagulation and platelet function. Methods: Critically ill patients undergoing RRT were classified into the iHD group or the CRRT group. After the first blood sampling, patients underwent either a single session of hemodialysis or 48 h of CRRT, then a second blood sample was taken. Rotational thromboelastometry (ROTEM), platelet aggregometry and conventional coagulation tests were performed. The primary outcome was a change in extrinsically activated ROTEM (EXTEM) clotting time (CT). Results: 60 dialysis sessions from 56 patients were finally included, with 30 dialysis sessions per group. EXTEM CT was prolonged significantly after dialysis in the iHD group (90 [74, 128] vs. 74 [61, 91], p < 0.001), but did not change in the CRRT group (94.4 ± 29.4 vs. 91.6 ± 22.9, p = 0.986). The platelet aggregation did not change after both iHD and CRRT. A change in EXTEM CT was significantly greater in the iHD group compared to the CRRT group (p = 0.006). The difference in the incidence of bleeding events was insignificant between the two groups (p = 0.301). Conclusions: EXTEM CT was significantly prolonged after iHD, but this change was not shown after CRRT. Platelet function was not affected by both dialysis modalities. [ABSTRACT FROM AUTHOR]

Introduction: Intermittent hemodialysis (IHD) is a preferable renal replacement therapy (RRT) option in metformin-associated lactic acidosis (MALA) due to rapid correct metabolic acidosis. However, IHD might not be started immediately. Immediate urgent-start peritoneal dialysis (iUSPD) is used as a life-saving dialysis option and then followed by IHD. The outcomes of iUSPD were compared with other extracorporeal dialysis in MALA. Methods: In two tertiary hospitals in Thailand, the outcomes of patients with MALA who had received three different RRT modalities (iUSPD followed by IHD, IHD, and continuous renal replacement therapy [CRRT]) from January 2015 to December 2019 were compared. The primary outcome was 30-day mortality. The secondary outcomes were door-to-dialysis time and 90-day RRT dependence. Results: A total of 180 MALA cases that required dialysis were included (20 iUSPD, 120 IHD, and 40 CRRT). Their mean age was 64 years. Most of the patients had severe metabolic acidosis (mean pH 6.91, HCO3 6 mmol/L, and anion gap 40 mmol/L) and were critically ill. The 30-day mortality was 30% in iUSPD, 9.2% in IHD, and 32.5% in CRRT (p = 0.001). The mortality risk in the iUSPD group was not significantly different from those of the IHD and CRRT groups (adjusted HR 2.5, 95% CI: 0.65–9.6, and adjusted HR 0.75, 95% CI: 0.2–2.78, respectively). All dialysis modalities had comparable 90-day dialysis dependence. iUSPD exhibited the shortest door-to-dialysis time. Conclusion: In MALA, iUSPD followed by IHD might be a viable RRT option to save patient lives if no other dialysis options are available. [ABSTRACT FROM AUTHOR]

Background: Patient care informatics are becoming more advanced with digital capacity and server functionality. The intensive care unit (ICU) is becoming paperless for prescribing, charting, and monitoring care. A further challenge is to include all life sustaining therapies in this digital space. Digital modules and options may be available; however, continuous renal replacement therapies (CRRTs) often require custom design for many nuances. Associated with the COVID pandemic and a surge in the paperless and "green" ICU bedside, we gathered a team to design, develop, and implement a CRRT orders, charting-documentation, and monitoring functionality into our existing Cerner (ORACLE Corp., Austin, Texas, USA) software. Key Messages: This included new approaches to the two-dimensional paper documents used prior and a live dashboard with new metrics and data. The design linked to other relevant CRRT pages such as the master patient fluid balance, pathology results, and medication prescribing. The primary views and function are role-related for medical, nursing, and pharmacy with specific and sensitive input. Following the build and implementation, initial evaluation was positive and led to an audit trail or e-history for prescribers use and provision for concurrent therapies. Clinicians use this digital ordering differently with live data available for "handover" and case discussion. There is scope for research and further links to devices such as personal phones and via an app. Summary: This experience may assist CRRT users design and develop similar prescribing, charting, and monitoring bedside computer opportunities in the desire for digital and green nephrology in the ICU. [ABSTRACT FROM AUTHOR]

Background and objective: Critical bedside ultrasound is widely used in clinical practice, and it can monitor renal perfusion. The reduction of renal perfusion and inflammatory injury are two contributing factors to sepsis-associated acute kidney injury (SA-AKI).The aim of this study was to examine whether the oXiris filter was useful in the continuous renal replacement therapy(CRRT) treatment of SA-AKI patients. Design, setting, participants, and measurements: We performed a retrospective single-center observational study and enrolled two hundred and forty-three SA-AKI patients from January 2022 to December 2023, who were divided into the oXiris group (n = 88) and the control group (n = 155). The primary endpoints were the 28-day recovery of renal function and 28-day all-cause mortality. The secondary endpoints included renal Doppler markers (RRI, RVSI, and PDU), SOFA, vasoactive-inotropic score (VIS), inflammatory markers (PCT, CRP, IL-10 and TNFα), lactate level, and length of stay in ICU and hospital. Results: For the primary endpoint, the rates of complete recovery, partial recovery, and dialysis dependence were observed to be 60.3%, 13.6%, and 26.1% in the oXiris group, respectively, compared to 63.9%, 15.5%, and 20.6% in the control group. The 28-day all-cause mortality was not different in the two groups (22.7% vs. 27.1%). For the secondary endpoint, the oXiris group exhibited greater reductions in VIS scores compared to the control group within the first 24 h (p = 0.001) and 48 h (p < 0.001) of CRRT. Following 48-h of CRRT, lactate levels in the oXiris group were significantly lower than those in the control group (p = 0.014). Prior to CRRT, levels of IL-6 were higher in the oXiris group (p = 0.036), but these differences were not significant after CRRT (p > 0.05). The levels of RRI at T1 (p = 0.002) and T2 (p = 0.001) were lower in the oXiris group than in the control group. Even after adjusting for AKI stage, multivariable Cox regression analysis showed that SOFA and inflammatory factors (TNFα, IL-10, and IL-6), oXiris were significantly associated with a lower 28-day mortality among SA-AKI patients when compared to M150 [HR = 0.466, 95%CI 0.233–0.934, p = 0.031]. Conclusion: Our findings suggest that the use of the oXiris filter in CRRT is associated with reduced inflammatory injury and improvement in renal perfusion. However, it is not associated with improved 28-day recovery of renal function and 28-day all-cause mortality. [ABSTRACT FROM AUTHOR]

Background Aims Study Design Results Conclusion Relevance to Clinical Practice Continuous renal replacement therapy (CRRT) is a method of blood purification, which is widely used in the treatment of critical diseases as a means of multiple organ function protection and life support therapy. However, because of the serious condition of ICU (intensive care unit) patients, CRRT needs to be carried out continuously, but the treatment is interrupted ahead of time as a result of various conditions, which not only affects the treatment effect but also increases the patient cost.To evaluate intervention measures to improve the filter life of CRRT in critically ill patients, and also to identify which interventions are considered ‘promising interventions’.This is a systematic review. Seven databases were searched using terms related to the concepts of ‘continuous renal replacement therapy’ and ‘filter life’, from the establishment of the database to 31 December 2023. The quality of the methodology included in the study was assessed using standard evaluation tools developed by the Effective Public Health Practice Project (EPHPP), and pre‐established criteria were used to identify ‘promising interventions’.A total of 28 studies were included, of which 7 were rated ‘strong’ in terms of design and methodological quality, and the others were ‘medium’. The most commonly identified interventions to extend the life of CRRT filters include the use of sodium citrate anticoagulation, the choice of CVVHD or CVVHDF or pre‐diluted CVVH for CRRT and the use of personalized sodium citrate anticoagulant regimens to reduce the incidence of filter clotting. The intervention measures of 14 studies were statistically significant, while the other 14 studies were not statistically significant. Interventions in nine studies were identified as ‘promising interventions’ because they were published within 10 years, with a medium or strong methodological quality rating, significant positive results and a strong evidence base.In the promising interventions study, citrate anticoagulation and CVVHD or CVVHDF models were recommended to significantly prolong filter life. However, more high‐quality studies are needed to identify interventions that can prolong the life of CRRT filters in critically ill patients, thereby supplementing the literature in this field. The existing studies lack blinding and have limited quality. Future studies should be carried out with the goal of ‘best evidence’, and the interventions should be more universal and clinically practical.This study uses the method of systematic review to scientifically and rigorously provide some suggestions for extending the life of CRRT filters in critically ill patients, such as ‘By implementing personalized citrate anticoagulation protocols, the incidence of CRRT filter life shortening due to coagulation can be reduced’, which can reduce the cost of patients and improve the quality of treatment to a certain extent in clinical practice. [ABSTRACT FROM AUTHOR]

This study aimed to identify risk factors for mortality in septic patients undergoing extracorporeal membrane oxygenation (ECMO) and/or continuous renal replacement therapy (CRRT). Data from the MIMIC-IV database were retrospectively reviewed for 24,502 septic patients treated with ECMO or CRRT between 2008 and 2019. After applying inclusion and exclusion criteria, 70 patients receiving ECMO, 513 receiving CRRT, and 22 receiving both were included in the final analysis. Univariate and multivariate stepwise Cox regression analyses were performed to identify independent risk factors for mortality. Model performance was assessed using receiver operating characteristic (ROC) curve analysis. We also provided model-agnostic explanations for each Cox regression model. For septic patients on ECMO, prothrombin time (per 1-s increase, HR 1.037, 95% CI 1.007–1.068, p =.015) was the key independent risk factor. For septic patients undergoing CRRT, SOFA score (per one-point increase, HR 1.100, 95% CI 1.055–1.147, p <.001) was the most significant factor. For septic patients requiring both ECMO and CRRT, prior history of hypertension (HR 4.342, 95% CI 1.332–14.153, p =.015) was the sole independent risk factor. ROC analysis showed satisfactory model performance (AUC > 0.75). For septic patients requiring ECMO, prothrombin time was the key independent risk factor. For those needing CRRT, SOFA score was the most significant independent risk factor. Prior history of hypertension was the primary independent risk factor for septic patients needing both CRRT and ECMO. [ABSTRACT FROM AUTHOR]

The prognosis-predicting factors for non-surgical patients receiving continuous renal replacement therapy (CRRT) and extracorporeal membrane oxygenation (ECMO) remains limited. In this study, we aim to analyze prognosis-predicting factors in the non-surgical patients receiving these two therapies. We retrospectively analyzed data from non-surgical patients with ECMO treatment from December 2013 until April 2023. Hospital mortality was primary endpoint of this study. The area under the curve and receiver operating characteristic curves were used to assess the sensitivity and specificity of mortality. The independent risk factors were identified by multivariate logistic regression. The prediction model was a nomogram, and decision curve analysis and the calibration plot were used to assess it. Using restricted cubic spline curves and Spearman correlation, the correlation analysis was performed. The model that incorporated CRRT duration and age surpassed the two variables alone in predicting hospital mortality in non-surgical patients with ECMO therapy (AUC value = 0.868, 95% CI = 0.779–0.956). Older age, CRRT implantation, and duration were independent risk factors for hospital mortality (all p < 0.05). The nomogram predicting outcomes model containing on CRRT implantation and duration was developed, and the consistency between the predicted probability and observed probability and clinical utility of the models were good. CRRT duration was negatively associated with hemoglobin concentration and positively associated with urea nitrogen and serum creatinine levels. Hospital mortality in non-surgical ECMO patients was found to be independently associated with older age, longer CRRT duration, and CRRT implantation. [ABSTRACT FROM AUTHOR]

Patients on extracorporeal membrane oxygenation (ECMO) are often complex and have a high mortality rate. Currently, risk assessment and treatment decisions for patients receiving ECMO are controversial. Therefore, we sought to identify risk factors for mortality in patients receiving ECMO and provide a reference for patient management. We retrospectively analyzed the clinical data of 199 patients who received ECMO support from December 2013 to April 2023. Univariate and multivariable logistic regression analyses were used to identify risk factors. The cutoff value was determined by receiver operating characteristic (ROC) curve analysis. A total of 199 patients were selected for this study, and the mortality rate was 76.38%. More than half of the patients underwent surgery during hospitalization. Multivariable logistic regression analysis revealed that continuous renal replacement therapy (CRRT) implantation (OR = 2.994; 95% CI, 1.405–6.167; p = 0.004) and age (OR = 1.021; 95% CI, 1.002–1.040; p = 0.032) were the independent risk factors for mortality. In the ROC curve analysis, age had the best predictive effect (AUC 0.646, 95% CI 0.559–0.732, p = 0.003) for death when the cutoff value was 48.5 years. Furthermore, in patients receiving combined CRRT and ECMO, lack of congenital heart disease and previous surgical history were the independent risk factors for mortality. CRRT implantation and age were independent risk factors for patients with ECMO implantation in a predominantly surgical cohort. In patients receiving a combination of CRRT and ECMO, lack of congenital heart disease and previous surgical history were independent risk factors for mortality. [ABSTRACT FROM AUTHOR]

To systematically review the risk factors for unplanned weaning during continuous renal replacement therapy in ICU patients. A combination of subject words + free words was used to search the relevant literature published in CNKI, Wanfang, VIP, CBM, PubMed, EMbase, Web of Science, Cochrane Library, Mediline and other databases. The search period was from the establishment of the databases to June 25, 2024. Revman 5.4 software and Stata15.0 software was used to meta-analyze the risk factors for unplanned weaning during continuous renal replacement therapy in ICU patients. A total of 23 studies were included in this meta-analysis, describing 15 variables, 3793 patients, and using 7197 filters. Meta-analysis results showed that risk factors for unplanned weaning during continuous renal replacement therapy in ICU patients were as follows: Low mean arterial pressure [OR = 1.02, 95%CI (1.00, 1.03), p < 0.05], hypothermia [OR = 3.40, 95%CI (1.78, 6.47), p < 0.05], age (≥60 years) [OR = 4.45, 95%CI (3.18, 6.22), p < 0.05], comorbid underlying disease [OR = 3.63, 95%CI (2.70, 4.88), p < 0.05], agitation [OR = 4.97, 95%CI (3.20, 7.74), p < 0.05], no anticoagulant use [OR = 1.65, 95%CI (1.25, 2.17), p < 0.05], short activated partial prothrombin time [OR = 1.23, 95%CI (1.13, 1.34), p < 0.05], hyper-hematocrit [OR = 1.73, 95%CI (1.13, 2.66), p = 0.01], low ionized calcium concentration [OR = 1.48, 95% CI (1.08, 2.02), p = 0.01], CRRT that was treated at a high dose [OR = 1.42, 95%CI (1.14, 1.76), p < 0.05], mechanical ventilation [OR = 4.25, 95%CI (2.67, 6.77), p < 0.05], and lack of dedicated care [OR = 5.08, 95%CI (2.51, 10.28), p < 0.05]. However, it is unclear whether platelet count, prothrombin activity, and blood flow velocity are risk factors for unplanned weaning during CRRT in ICU patients, and more studies are needed for further validation. Available evidence suggests that a variety of factors contribute to unplanned weaning of CRRT in ICU patients. Early detection of these risk factors is essential for healthcare professionals to develop preventive and curative strategies. This study is registered on the PROSERO website under registration number CRD42024543554. [ABSTRACT FROM AUTHOR]

The primary objective was to examine the association between the lactate/albumin ratio (LAR) and the prognosis of patients with acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT). Utilizing the Medical Information Mart for Intensive Care IV (MIMIC-IV, v2.0) database, we categorized 703 adult AKI patients undergoing CRRT into survival and non-survival groups based on 28-day mortality. Patients were further grouped by LAR tertiles: low (< 0.692), moderate (0.692-1.641), and high (> 1.641). Restricted cubic splines (RCS), Least Absolute Shrinkage and Selection Operator (LASSO) regression, inverse probability treatment weighting (IPTW), and Kaplan-Meier curves were employed. In our study, the patients had a mortality rate of 50.07% within 28 days and 62.87% within 360 days. RCS analysis revealed a non-linear correlation between LAR and the risk of mortality at both 28 and 360 days. Cox regression analysis, which was adjusted for nine variables identified by LASSO, confirmed that a high LAR (>1.641) served as an independent predictor of mortality at these specific time points (p < 0.05) in AKI patients who were receiving CRRT. These findings remained consistent even after IPTW adjustment, thereby ensuring a reliable and robust outcome. Kaplan-Meier survival curves exhibited a gradual decline in cumulative survival rates at both 28 and 360 days as the LAR values increased (log-rank test, χ2 = 48.630, p < 0.001; χ2 = 33.530, p < 0.001). A high LAR (>1.641) was found to be an autonomous predictor of mortality at both 28 and 360 days in critically ill patients with AKI undergoing CRRT. [ABSTRACT FROM AUTHOR]

Geriatric Nutritional Risk Index (GNRI) is a new and simple index recently introduced to assess nutritional status, and its predictive value for clinical outcomes has been demonstrated in patients with chronic kidney disease. However, the association between the GNRI and prognosis has not been evaluated so far in patients with acute kidney injury (AKI), especially in those receiving continuous renal replacement therapy (CRRT). A total of 1096 patients with severe AKI initiating CRRT were identified for inclusion in this retrospective observational study. Patients were divided into three groups according to GNRI tertiles, with tertile 1 as the reference. The outcomes of interest were the 28- and 90-days of all-cause mortality. The associations between GNRI and clinical outcomes were estimated using multivariate Cox proportional hazards model analysis. The overall mortality rates at 28- and 90-days were 61.6% (675/1096) and 71.5% (784/1096), respectively. After adjusting for multiple confounding factors, GNRI was identified as an independent prognostic factor for 28-days all-cause mortality (HR, 0.582; 95% CI, 0.467–0.727; p <.001 for tertile 3 vs. tertile 1) as well as 90-days all-cause mortality (HR, 0.540; 95% CI, 0.440–0.661; p <.001 for tertile 3 vs. tertile 1). The observed inverse associations were robust across subgroup analysis, and were more pronounced in elderly patients over 65 years of age. Finally, incorporating GNRI in a model with established risk factors might significantly improve its predictive power for the short-term death. GNRI is considered to be a useful prognostic factor in patients with severe AKI initiating CRRT, especially in elderly patients. [ABSTRACT FROM AUTHOR]

The survival of critically ill patients with acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT) is highly dependent on their nutritional status. The prognostic nutritional index (PNI) is an indicator used to assess nutritional status and is calculated as: PNI = (serum albumin in g/dL) × 10 + (total lymphocyte count in/mm3) × 0.005. In this retrospective study, we investigated the correlation between this index and clinical outcomes in critically ill patients with AKI receiving CRRT. We analyzed data from 2076 critically ill patients admitted to the intensive care unit at Changhua Christian Hospital, a tertiary hospital in central Taiwan, between January 1, 2010, and April 30, 2021. All these patients met the inclusion criteria of the study. The relationship between PNI and renal replacement therapy-free survival (RRTFS) and mortality was examined using logistic regression models, Cox proportional hazard models, and propensity score matching. High utilization rate of parenteral nutrition (PN) was observed in our study. Subgroup analysis was performed to explore the interaction effect between PNI and PN on mortality. Patients with higher PNI levels exhibited a greater likelihood of achieving RRTFS, with an adjusted odds ratio of 2.43 (95% confidence interval [CI]: 1.98-2.97, p-value < 0.001). Additionally, these patients demonstrated higher survival rates, with an adjusted hazard ratio of 0.84 (95% CI: 0.72-0.98) for 28-day mortality and 0.80 (95% CI: 0.69-0.92) for 90-day mortality (all p-values < 0.05), compared to those in the low PNI group. While a high utilization rate of parenteral nutrition (PN) was observed, with 78.86% of CRRT patients receiving PN, subgroup analysis showed that high PNI had an independent protective effect on mortality outcomes in AKI patients receiving CRRT, regardless of their PN status. PNI can serve as an easy, simple, and efficient measure of lymphocytes and albumin levels to predict RRTFS and mortality in AKI patients with require CRRT. [ABSTRACT FROM AUTHOR]

Aims: This work aimed to analyse retrospective data on hypotension incidence and associated factors among patients requiring continuous renal replacement therapy. Background: The incidence and risk factors of continuous renal replacement therapy‐related hypotension have not been adequately explored. Design: The study was designed as a retrospective analysis. Methods: 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. Results: 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). Conclusions: 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. Summary statement: What is already known about this topic Continuous renal replacement therapy (CRRT) has been widely used in intensive care units for patients with acute kidney injury sepsis, acute pancreatitis, severe electrolyte and metabolic disturbances.Hypotension during CRRT has been reported as one of the most common adverse events.The incidence and risk factors of CRRT‐associated hypotension have not been adequately explored. What this paper adds? Despite its reputation as the dialysis modality with better haemodynamic tolerance, hypotension frequently occurs in patients receiving CRRT, and at any time during the treatment, especially in the early stage.Multiple factors leading to cardiac output or peripheral resistance changes can be linked with hypotension during CRRT include excessive ultrafiltration, vasopressor use, serum albumin and serum calcium level, and carbon dioxide combining power. The implications of this paper: It might not always be an appropriate response to lower the ultrafiltration rate for preventing hypotension during CRRT.There remains a lack of evidence in critically ill patients for CRRT‐related interventions to limit the occurrence of hypotension. [ABSTRACT FROM AUTHOR]

The physiology of the kidney has long been understood, and its mechanisms are well described. The pathology of renal failure is also a deeply researched area. It seems logical, therefore, to create devices that can replace the lost normal function of the kidney. Using the physical processes that take place in the kidney, such as diffusion or convection across a membrane, various renal replacement therapies (RRT) have been created. There are those that are used intermittently and those that are used for longer periods. What they have in common is that all RRTs have the same purpose; to replace the excretory function of the kidney that has been lost. CRRT is an extracorporeal renal replacement therapy that effectively replicates the excretory function of the kidneys in cases of acute renal failure. However, it has become increasingly evident that this rapidly advancing treatment modality offers benefits beyond merely substituting kidney function, with its applications continuing to expand significantly with non-renal and other indications. The use of these devices has raised new questions, many of which are still not clearly answered. When should this start? Who should receive it? How long should it last? What indication should it be for? What modality should it be with? How does it change the pharmacokinetics of the medicines? To answer these questions, it is first worth understanding the mechanisms behind the processes and the factors that influence them. This should not only focus on the procedures used in RRT therapies, but also consider the patient's condition and the physicochemical properties of the drugs. In this review, we aim to provide a literature summary to highlight the factors that may influence the success of RRT therapies. [ABSTRACT FROM AUTHOR]

Introduction: This study characterized the population pharmacokinetics (PK) of vancomycin in patients treated with and without continuous renal replacement therapy (CRRT) or temporary mechanical circulatory support (tMCS), including extracorporeal membrane oxygenation or extracorporeal ventricular assist device. Methods: Critically ill adults with and without tMCS or CRRT prescribed vancomycin were enrolled for population PK modeling. Monte Carlo simulation provided dosing recommendations based on the probability of target attainment (PTA), achieving a 24-h area under curve (AUC24h) of 400–600 mg*h/L. Results: Twenty-five patients with 184 plasma samples were analyzed. The median age was 61.0 years. The final model was a two-compartment PK model. CRRT, serum creatinine, and body weight were significant predictors of clearance. CRRT was a covariate on the central volume of distribution. tMCS significantly decreased the intercompartmental clearance. The simulated mean trough levels at the 48th hour were lower in the tMCS group (13.4 versus 14.2 mg/dL in non-tMCS, p < 0.001) in a 70-kg subject with a creatinine of 1 mg/dL and a daily dose of 20 mg/kg, but the PTA was similar (61.8% versus 62.2%). A reduction of maintenance dose from 30 to 10 mg/kg/day with loading dose from 25 to 15 mg/kg is recommended while serum creatinine progresses from 0.5 to 4.0 mg/dL. For CRRT, the optimal regimen consists of 20–25 mg/kg loading and maintenance of 15 mg/kg/day. Conclusions: The dosing strategy of vancomycin can be based on body weight or renal function, regardless of tMCS. Intercompartmental clearance decreases under tMCS, which can mislead a dosing adjustment based on trough level. [ABSTRACT FROM AUTHOR]

Acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT), secondary to cardiovascular disease and sepsis, is associated with high in-hospital mortality. Although studies have examined cardiovascular disease and sepsis in AKI, the association between AKI and hepatic functional impairment remains unclear. We hypothesized that hepatic function markers would predict mortality in patients undergoing CRRT. We included 1,899 CRRT patients from a multi-centre database. In Phase 1, participants were classified according to the total bilirubin (T-Bil) levels on the day of, and 3 days after, CRRT initiation: T-Bil < 1.2, 1.2 ≤ T-Bil < 2, and T-Bil ≥ 2 mg/dL. In Phase 2, propensity score matching (PSM) was performed to examine the effect of a T-Bil cutoff of 1.2 mg/dL (supported by the Sequential Organ Failure Assessment score); creating two groups based on a T-Bil cutoff of 1.2 mg/dL 3 days after CRRT initiation. The primary endpoint was total mortality 90 days after CRRT initiation, which was 34.7% (n = 571). In Phase 1, the T-Bil, aspartate transaminase (AST), alanine transaminase (ALT), and AST/ALT (De Ritis ratio) levels at CRRT initiation were not associated with the prognosis, while T-Bil, AST, and the De Ritis ratio 3 days after CRRT initiation were independent factors. In Phase 2, T-Bil ≥1.2 mg/dL on day 3 was a significant independent prognostic factor, even after PSM [hazard ratio: 2.41 (95% CI; 1.84-3.17), p < 0.001]. T-Bil ≥1.2 mg/dL 3 days after CRRT initiation predicted 90-day mortality. Changes in hepatic function markers in acute renal failure may enable stratification of high-risk patients. [ABSTRACT FROM AUTHOR]

This single center retrospective study aimed to describe the variables associated with outpatient dialysis dependence in extracorporeal membrane oxygenation (ECMO) patients who needed continuous renal replacement therapy (CRRT) for acute kidney injury (AKI) during their hospitalization. Retrospective study of patients who required ECMO-CRRT. Between the years of 2016 and 2022, 202 patients required ECMO-CRRT. One hundred and six patients (52.5%) survived their hospitalization and were followed up for a median of 391 [133, 1005] days. Eighty-one patients (76.5%) recovered kidney function and were dialysis-free before hospital discharge. Twenty-five patients (23.5%) were hemodialysis-dependent after hospitalization. On multivariate regression analysis, hyperlipidemia (odds ratio, OR 6.08 [1.67–22]) and CRRT duration (OR 1.09 [1.03–1.15]) were associated with the need for dialysis post-hospitalization. In this group, 16 patients eventually became dialysis-free, after a median of 49 [34.7, 78.5] days. These patients had a higher median baseline glomerular filtration rate (GFR) compared to those who never recovered renal function (93 mL/min/1.73 m2 [82.4, 104.3] vs. 63.8 mL/min/1.73 m2 [37.9, 83], p =.009). Their follow-up GFR was lower compared to those who recovered renal function before hospital discharge; (87 mL/min/1.73 m2 [68.2, 98.9] vs. 99 mL/min/1.73 m2 [79, 118], p =.07). AKI requiring CRRT was associated with high mortality in patients receiving ECMO. Nonetheless, most ECMO survivors became dialysis-free before hospital discharge. Variables associated with the need for outpatient dialysis included hyperlipidemia and prolonged need for CRRT during hospitalization. [ABSTRACT FROM AUTHOR]

Purpose: Net ultrafiltration (UFNET) during continuous renal replacement therapy (CRRT) can control fluid balance (FB), but is usually 0 ml·h−1 in patients with vasopressors due to the risk of hemodynamic instability associated with CRRT (HIRRT). We evaluated a UFNET strategy adjusted by functional hemodynamics to control the FB of patients with vasopressors, compared to the standard of care. Methods: In this randomized, controlled, open-label, parallel-group, multicenter, proof-of-concept trial, adults receiving vasopressors, CRRT since ≤ 24 h and cardiac output monitoring were randomized (ratio 1:1) to receive during 72 h a UFNET ≥ 100 ml·h−1, adjusted using a functional hemodynamic protocol (intervention), or a UFNET ≤ 25 ml·h−1 (control). The primary outcome was the cumulative FB at 72 h and was analyzed in patients alive at 72 h and in whom monitoring and CRRT were continuously provided (modified intention-to-treat population [mITT]). Secondary outcomes were analyzed in the intention-to-treat (ITT) population. Results: Between June 2021 and April 2023, 55 patients (age 69 [interquartile range, IQR: 62; 74], 35% female, Sequential Organ Failure Assessment (SOFA) 13 [11; 15]) were randomized (25 interventions, 30 controls). In the mITT population, (21 interventions, 24 controls), the 72 h FB was −2650 [−4574; −309] ml in the intervention arm, and 1841 [821; 5327] ml in controls (difference: 4942 [95% confidence interval: 2736–6902] ml, P < 0.01). Hemodynamics, oxygenation and the number of HIRRT at 72 h, and day-90 mortality did not statistically differ between arms. Conclusion: In patients with vasopressors, a UFNET fluid removal strategy secured by a hemodynamic protocol allowed active fluid balance control, compared to the standard of care. [ABSTRACT FROM AUTHOR]

Purpose: With the development of extracorporeal membrane oxygenation (ECMO) technology, the duration of ECMO support has gradually increased, leading to an increased risk of ECMO-related bacterial resistance. Polymyxin B (PMB) is used to treat drug-resistant bacterial infections. However, the pharmacokinetic (PK) parameters of antibiotics may change during ECMO, resulting in over- or under-exposure. This study aimed to clarify the changes in PK parameters and identify factors influencing PMB levels in patients receiving venovenous or venoarterial ECMO. Patients and Methods: A prospective PK study was performed in 11 patients receiving ECMO with resistant bacteria. After reaching a steady state, the drug concentrations of PMB pre- and post-oxygenator were measured. Nonlinear mixed-effects modelling was used to construct a population PK model for PMB. Microbial results were assessed using repeated cultures at the end of treatment. Semiquantitative microbial culture results were used to form clearance and uncleared groups. Results: The PMB concentrations were not significantly different between pre- and post-oxygenator. A two-compartment model best described the PK of PMB. ECMO flow rate was included as a covariate of clearance (CL). Continuous renal replacement therapy (CRRT) were included as covariates on the volume of the central compartment. The PK parameters central compartment, volume of the peripheral compartment, CL, and inter-compartmental clearance or flow rate(Q) were 20.41 L, 9.86 L, 3.75 L/h, and 3.82 L/h. 7 patients (63.64%) had two consecutive negative bacterial cultures at discharge. The Css,avg shows a significant difference between clearance group (2.26± 0.72) and uncleared group (1.25± 0.24), P< 0.05. Conclusion: There were no significant differences in PMB concentrations between pre- and post-oxygenator. The PK of PMB may be altered in patients receiving CRRT-ECMO. The ECMO flow rate is strongly correlated with the CL. The Css,avg is correlated with the bacterial clearance rate. In clinical practice, increasing the incidence of therapeutic drug monitoring may improve the clinical outcomes. Plain Language Summary: The duration of ECMO support has gradually increased, leading to a heightened risk of ECMO-related bacterial resistance. PMB is used to treat drug-resistant bacterial infections. However, the PK parameters of antibiotics may change during ECMO, resulting to over- or under-exposure. CRRT in combination with ECMO may impact the PK of PMB. The ECMO flow rate is strongly correlated with CL. Css,avg is correlated with the pathogen bacterial clearance rate. In clinical practice, increasing the use of therapeutic drug monitoring may improve the clinical outcomes. [ABSTRACT FROM AUTHOR]

Introduction: This retrospective study aimed to evaluate the 30 and 60‐day survival of critically ill patients with COVID‐19 and AKI. Methods: Inflammatory and biochemical biomarkers, length of intensive care unit (ICU) stay and mortality at Day 30 and Day 60 after ICU admission were analyzed. A total of 44 patients treated with continuous renal replacement therapy (CRRT) with cytokine adsorber (CA group) were compared to 58 patients treated with CRRT alone (non‐CA group). Results: Patients in CA group were younger, had better preserved kidney function prior to the beginning of CRRT and had higher levels of interleukin‐6. There were no statistically significant differences in their comorbidities and in other measured biomarkers between the two groups. The number of patients who died 60 days after ICU admission was statistically significantly higher in non‐CA group (p = 0.029). Conclusion: Treatment with CRRT and cytokine adsorber may have positively influenced 60‐day survival in our COVID‐19 ICU patients with AKI. [ABSTRACT FROM AUTHOR]

Introduction: This is a phenomenologically designed qualitative study conducted to explore and conceptualize the problems experienced by intensive care nurses caring for patients undergoing continuous renal replacement therapy. Methods: Face‐to‐face, semi‐structured interviews were conducted with the participants. The interviews were transcribed verbatim, then thematic analysis was conducted. Results: The study was conducted 12 intensive care nurses. As a result, 3 main and 6 sub‐themes were identified. The themes identified were changing routines, uncertainty in terms of patient benefit, and need for adaptation. Conclusion: It was found that nurses experienced challenges in providing care to patients undergoing continuous renal replacement therapy, spent more effort to prevent complications, and lacked information on the subject. It is recommended to consider institutional and individual actions to meet the educational needs of nurses for implementing continuous renal replacement therapy. [ABSTRACT FROM AUTHOR]

Background/Objectives: Sepsis, a life-threatening organ dysfunction caused by a dysregulated host response to infection, remains a major challenge in ICUs. This study evaluated whether combining haemoadsorption therapy with continuous renal replacement therapy (CRRT) reduces ICU and short-term mortality in patients with severe septic shock and acute kidney injury (AKI) requiring CRRT. Methods: A single-centre retrospective cohort study was conducted at Rambam Health Care Campus, Haifa, Israel, from January 2018 to February 2024. Data were collected from ICU patients with severe septic shock and AKI requiring CRRT. Patients were divided into two groups: those receiving haemoadsorption therapy with CRRT and those receiving CRRT alone. Primary and secondary endpoints included ICU, 30 and 60-day mortality, vasopressor dependency index (VDI), and lactate levels. Results: Out of 545 patients with septic shock, 133 developed AKI requiring CRRT, and 76 met the inclusion criteria. The haemoadsorption group (n = 47) showed significant reductions in blood lactate levels and VDI after 24 h compared to the CRRT alone group (n = 29). ICU mortality was significantly lower in the haemoadsorption group (34.0% vs. 65.5%, p = 0.008), as was 30 and 60-day mortality (34.0% vs. 62.1%, p = 0.02, and 48.9% vs. 75.9%, p = 0.002). Multivariate analysis confirmed haemoadsorption therapy as independently associated with lower ICU and 30-day but not 60-day mortality. Conclusions: Haemoadsorption therapy combined with CRRT in patients with severe septic shock and AKI requiring CRRT is associated with improved lactate clearance, reduced vasopressor requirements, and lower ICU and 30-day mortality. Further high-quality randomized controlled trials are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Abstract Background and objective Critical bedside ultrasound is widely used in clinical practice, and it can monitor renal perfusion. The reduction of renal perfusion and inflammatory injury are two contributing factors to sepsis-associated acute kidney injury (SA-AKI).The aim of this study was to examine whether the oXiris filter was useful in the continuous renal replacement therapy(CRRT) treatment of SA-AKI patients. Design, setting, participants, and measurements We performed a retrospective single-center observational study and enrolled two hundred and forty-three SA-AKI patients from January 2022 to December 2023, who were divided into the oXiris group (n = 88) and the control group (n = 155). The primary endpoints were the 28-day recovery of renal function and 28-day all-cause mortality. The secondary endpoints included renal Doppler markers (RRI, RVSI, and PDU), SOFA, vasoactive-inotropic score (VIS), inflammatory markers (PCT, CRP, IL-10 and TNFα), lactate level, and length of stay in ICU and hospital. Results For the primary endpoint, the rates of complete recovery, partial recovery, and dialysis dependence were observed to be 60.3%, 13.6%, and 26.1% in the oXiris group, respectively, compared to 63.9%, 15.5%, and 20.6% in the control group. The 28-day all-cause mortality was not different in the two groups (22.7% vs. 27.1%). For the secondary endpoint, the oXiris group exhibited greater reductions in VIS scores compared to the control group within the first 24 h (p = 0.001) and 48 h (p 0.05). The levels of RRI at T1 (p = 0.002) and T2 (p = 0.001) were lower in the oXiris group than in the control group. Even after adjusting for AKI stage, multivariable Cox regression analysis showed that SOFA and inflammatory factors (TNFα, IL-10, and IL-6), oXiris were significantly associated with a lower 28-day mortality among SA-AKI patients when compared to M150 [HR = 0.466, 95%CI 0.233–0.934, p = 0.031]. Conclusion Our findings suggest that the use of the oXiris filter in CRRT is associated with reduced inflammatory injury and improvement in renal perfusion. However, it is not associated with improved 28-day recovery of renal function and 28-day all-cause mortality.

Nutrition is one of the cornerstones in the treatment and support of critically ill patients. Nutritional support includes the provision of calories, protein, electrolytes, vitamins, and trace elements through enteral or parenteral routes. Acute kidney injury (AKI) is a common problem in critically ill patients and can lead to severe consequences, impacting metabolism and nutritional status significantly. Furthermore, regardless of the modality used, renal replacement therapy (RRT) has profound effects on metabolism. Evidence on nutritional support during continuous renal replacement therapy (CRRT) is limited, and there are no established clinical guidelines for nutritional adaptations during CRRT in critically ill patients. This review outlines some essential principles for providing micronutrient support in critically ill patients undergoing CRRT and protein requirements in AKI patients.

Abstract Background ICU patients are particularly susceptible to vitamin D3 deficiencies. This can be due to the severity of their underlying disease, the type of treatment they are on, and malnutrition before and inadequate nutrition during the hospitalization preceding ICU admission as well as advanced age. Literature provides no guidance on how to supplement vitamin D3 in severely deficient patients who are undergoing continuous renal replacement therapy (CRRT). Most serum 25(OH)D3 is bound with vitamin D binding protein in a complex whose molecular weight is 10 kDa. This means it can be removed during CRRT via convection mechanism. Critically ill patients undergoing CRRT can therefore be particularly prone to develop severe vitamin D3 deficiency. Methods As the trial design, a randomized controlled, single blinded, multicenter, parallel group approach was chosen to compare a single administration of 750,000 IU of vitamin D3 via the enteral or oral route in ICU patients with severe vitamin D3 deficiency (measured serum 25(OH)D3 levels ≤ 12.5 ng/ml) undergoing CRRT with a single administration of 500,000 IU of vitamin D3. The trial will be performed in up to five university hospitals in Poland. The primary outcome is the percentage of patients that achieved serum 25(OH)D3 levels ≥ 30 ng/ml on days 3 and 7 following vitamin D3 administration. Assuming a drop-out rate of approximately 10%, the number of recruited patients should be 138. Discussion Considering the potential pathophysiological mechanisms underlying hypovitaminosis D in critically ill patients under CRRT, it seems conceivable that these patients will require greater supplementation doses to correct severe deficiency. The study is meant to help answer the question whether increasing the supplementation dose by 50% will ensure a more effective replenishment of vitamin D3 in critically ill patients undergoing CRRT. Trial registration ClinicalTrials.gov Identifier: NCT05657678, registered: December 12 2022, https://clinicaltrials.gov/study/NCT05657678?cond=NCT05657678&rank=1 .

Abstract Background For critically ill patients with acute kidney injury (AKI), there remains controversy regarding the predictive factors affecting the discontinuation of continuous renal replacement therapy (CRRT). This study aims to explore factors associated with successful CRRT discontinuation in AKI patients and to develop predictive models for successful discontinuation. Methods We conducted a retrospective study on adult patients with AKI who received CRRT, sourced from the Medical Information Mart for Intensive Care (MIMIC-IV) database. Successful discontinuation of CRRT was defined as no CRRT requirement within 72 h after stopping CRRT. Predictive factors for successful discontinuation of CRRT were analyzed. Additionally, we utilized machine learning algorithms to develop predictive models, including logistic regression (LR), decision tree (DT), random forest (RF), XGBoost, and K-nearest neighbor (KNN). Results A total of 599 patients were included, of whom 475 (79.3%) successfully discontinued CRRT. Urine output, non-renal SOFA score, bicarbonate, systolic blood pressure, and blood urea nitrogen were identified as risk factors for successful CRRT discontinuation. The KNN model exhibited the highest area under the receiver operating characteristic curve (AUC) (0.870), followed by LR (0.739), DT (0.691), RF (0.847), and XGBoost (0.830). When incorporating all available variables, the AUCs for the LR, DT, RF, XGBoost, and KNN models were 0.708, 0.674, 0.875, 0.866, and 0.816, respectively. Considering the performance of the models in both scenarios, the ensemble learning models (RF and XGBoost) were demonstrated superior performance. Conclusions Our results identified factors associated with successful discontinuation of CRRT in AKI patients. Additionally, we developed promising machine learning models which provided a reference for future research.

This article summarized clinical data and nursing management of a patient with drug-induced hypersensitivity syndrome characterized by toxic epidermal necrolysis and dermatitis combined with multiple organ failure treated with continuous renal replacement therapy (CRRT). Given the complex illness condition of the patient, a comprehensive evaluation on nursing risks was carried out before CRRT. In addition to enhance the nursing cooperation in CRRT, nurses had improved the nursing interventions on symptoms of multiple organ failure, catheter maintanence, skin care, diet guildance and health education during the hospitalizaiton. After effective treatment and meticulous care, the patient's skin condition and psychological state were improved. (本文总结1例以中毒性表皮坏死松解症为表现特征的药物超敏反应综合征样皮炎合并多脏器衰竭患者行连续性肾脏替代治疗(CRRT)的护理经验。患者病情复杂, 入院后积极完善评估和检查, 采取CRRT治疗, 同时加强脏器衰竭护理、CRRT护理、管路护理、皮肤护理, 做好饮食指导和健康宣教, 积极预防并发症, 患者的皮损明显减轻, 生命体征相对恢复稳定。)

Continuous renal replacement therapy (CRRT) in children is quite challenging to manage because of their increased propensity for circuit clotting. The anticoagulant strategies are paramount in reducing the downtime in pediatric CRRT. The most commonly used anticoagulants in pediatrics are unfractionated heparin and citrate anticoagulation. The other less explored options include regional heparin protamine anticoagulation, prostacyclin, low-molecular-weight heparin, and thrombin antagonists. The choice of anticoagulant primarily depends on the patient’s condition, availability and cost of the anticoagulant, potential side effects, and the local expertise for troubleshooting. This article aims to bring about the merits and demerits of the different anticoagulants available for CRRT and the available evidence for the use of each of these anticoagulants.

Abstract Background Skin conditions are common in patients on maintenance hemodialysis and those with pancreatitis. However, there is a lack of research on dermatological issues in patients who have both hemodialysis and pancreatitis concurrently. Case presentation A 62-year-old male patient with a 4-year history of maintenance hemodialysis (MHD) presented with pain and was diagnosed with acute pancreatitis and gallbladder stones. Markedly elevated blood amylase, creatine kinase, and myoglobin were noted, alongside a purplish-red skin discoloration. Treatment included inhibition of digestive fluid secretion, anti-infection measures, blood purification, fasting, rehydration, and symptomatic care. Notably, continuous renal replacement therapy (CRRT) combined with hemoperfusion (HP) was employed. The patient’s dialysis effluent initially appeared red. Upon examination of the patient’s peripheral blood smear, red blood cell debris was not observed. The dialysis effluent (on Day 0) was analyzed, revealing no hemoglobin (0 g/L) but an elevated myoglobin concentration of 80.4 U/L. After the therapeutic intervention, the indicators, including the blood amylase, C-reactive protein, total bilirubin, creatine kinase, and myoglobin were improved. The patient experienced resolution of sternal and upper abdominal pain within two days. After four consecutive days of CRRT and HP treatment, the skin color returned to normal, alongside improved clarity of the dialysis effluent. Subsequently, the patient’s method of blood purification was reverted to conventional hemodialysis. On the eighth day of hospitalization, the patient resumed normal diet and was discharged. Conclusions In the case of the current patient with acute pancreatitis undergoing MHD, it is noteworthy to report the observation of a unique purplish-red skin discoloration. This phenomenon may be attributable to inflammation resulting from acute pancreatitis, and the retention of myoglobin within the body.

Abstract Background Venous air trap chamber designs vary considerably to suit specific continuous renal replacement therapy circuits, with key variables including inflow design and filter presence. Nevertheless, intrachamber flow irregularities do occur and can promote blood coagulation. Therefore, this study employed computational fluid dynamics (CFD) simulations to better understand how venous air trap chamber designs affect flow. Methods The flow within a venous air trap chamber was analyzed through numerical calculations based on CFD, utilizing large eddy simulation. The working fluid was a 33% glycerin solution, and the flow rate was set at 150 ml/min. A model of a venous air trap chamber with a volume of 15 ml served as the computational domain. Calculations were performed for four conditions: horizontal inflow with and without a filter, and vertical inflow with and without a filter. Streamline plots and velocity contour plots were generated to visualize the flow. Results In the horizontal inflow chamber, irrespective of filter presence, ultimately the working fluid exhibited a downstream vortex flow along the chamber walls, dissipating as it progressed, and being faster near the walls than in the chamber center. In the presence of a filter, the working fluid flowed uniformly toward the outlet, while in the absence of a filter the flow became turbulent before reaching the outlet. These observations indicate a streamlining effect of the filter. In the vertical inflow chamber, irrespective of filter presence, the working fluid flowed vertically from the inlet into the main flow direction. Part of the working fluid bounced back at the chamber bottom, underwent upward and downward movements, and eventually flowed out through the outlet. Stagnation was observed at the top of the chamber. Without a filter, more working fluid bounced back from the bottom of the chamber. Conclusions CFD analysis estimated that the flow in a venous air trap chamber is affected by inflow method and filter presence. The “horizontal inflow chamber with filter” was identified as the design creating a smooth and uninterrupted flow throughout the chamber.

Continuous Renal Replacement Therapy (CRRT) serves as an intervention strategy for the management of acute kidney injury (AKI) in critically ill patients. However, owing to its complex nature and the potential for complications, the implementation of CRRT demands continuous monitoring to prevent patient safety risks. This study aims to identify and validate prevalent risks linked to CRRT within a real-world clinical setting, intending to propose preventive measures grounded in expert insights. To systematically categorize and visually depict the risks, their consequences, preventive measures, and recovery controls, our study employed the Bowtie method in conjunction with the Systems Engineering Initiative for Patient Safety (SEIPS) model. In addition to considering patient-related factors that exhibit variability among critically ill individuals, our key findings showed that the most influential risks impacting the effective delivery of CRRT are incidents of clotted filters, bleeding risks arising from the necessity of anticoagulation for filter efficacy, vascular catheter-related bloodstream infections, variations in proficiency levels among healthcare professionals regarding CRRT modalities, especially in operating the CRRT machines, high nursing workload, frequent nursing turnover, occurrences of hypophosphatemia, variability in CRRT prescribing patterns, and issues related to communication among stakeholders. This research sheds light on the primary risks associated with CRRT and provides practical and viable strategies for effective management. Furthermore, the Bowtie diagram developed as part of this study serves as a valuable tool for visually representing the healthcare system and facilitating the identification of system-related risks within healthcare settings.

Background: ICU patients are particularly susceptible to vitamin D3 deficiencies. This can be due to the severity of their underlying disease, the type of treatment they are on, and malnutrition before and inadequate nutrition during the hospitalization preceding ICU admission as well as advanced age. Literature provides no guidance on how to supplement vitamin D3 in severely deficient patients who are undergoing continuous renal replacement therapy (CRRT). Most serum 25(OH)D3 is bound with vitamin D binding protein in a complex whose molecular weight is 10 kDa. This means it can be removed during CRRT via convection mechanism. Critically ill patients undergoing CRRT can therefore be particularly prone to develop severe vitamin D3 deficiency. Methods: As the trial design, a randomized controlled, single blinded, multicenter, parallel group approach was chosen to compare a single administration of 750,000 IU of vitamin D3 via the enteral or oral route in ICU patients with severe vitamin D3 deficiency (measured serum 25(OH)D3 levels ≤ 12.5 ng/ml) undergoing CRRT with a single administration of 500,000 IU of vitamin D3. The trial will be performed in up to five university hospitals in Poland. The primary outcome is the percentage of patients that achieved serum 25(OH)D3 levels ≥ 30 ng/ml on days 3 and 7 following vitamin D3 administration. Assuming a drop-out rate of approximately 10%, the number of recruited patients should be 138. Discussion: Considering the potential pathophysiological mechanisms underlying hypovitaminosis D in critically ill patients under CRRT, it seems conceivable that these patients will require greater supplementation doses to correct severe deficiency. The study is meant to help answer the question whether increasing the supplementation dose by 50% will ensure a more effective replenishment of vitamin D3 in critically ill patients undergoing CRRT. Trial registration: ClinicalTrials.gov Identifier: NCT05657678, registered: December 12 2022, https://clinicaltrials.gov/study/NCT05657678?cond=NCT05657678&rank=1. [ABSTRACT FROM AUTHOR]

Introduction: Paracetamol (acetaminophen)-induced acute liver failure (ALF) with severe hyperammonemia (ammonia >100 µmol⋅L−1) is a life-threatening condition. A strategy based on high-intensity continuous renal replacement therapy (CRRT) without early (up to day seven) transplantation may enable clinicians to safely identify which patients can recover and survive and which patients require transplantation. Methods: We conducted a single-center, retrospective cohort study of patients with severely hyperammonemic paracetamol-induced ALF. The primary outcome was early transplant-free survival. Results: We studied 84 patients (median age: 38; female sex: 79 [85%]) over a 12-year period (median ammonia level at ICU admission: 153 µmol⋅L−1; median peak aspartate aminotransferase (AST): 10,029 U⋅L−1; median lactate: 5.0 mmol⋅L−1; and median INR: 4.4) and 55 (65%) with King’s College criteria for transplantation. Overall, 87% received high-intensity CRRT (92% in 2020–2023). Median CRRT intensity was 54 mL⋅kg−1⋅hr−1 within the first 48 h and increased by 1.8 mL⋅kg−1⋅hr−1 per year during the study period (p = 0.002). Transplant-free survival to day 7 was 86% in 2011–2023 and 96% in 2020–2023. Overall, only 4 patients were transplanted and only 1 (4%) in 2020–2023. On multivariable Cox analysis, factors independently associated with failure to achieve day seven transplant-free survival were higher APACHE III score (HR = 1.05, 95% CI: 1.02–1.08), higher lactate (HR = 1.27, 95% CI: 1.12–1.44), and lower platelet count at ICU admission (HR = 0.85, 95% CI: 0.78–0.93) and the median effluent dose applied within the first 48 h of ICU admission (HR = 0.67, 95% CI: 0.46–0.98). Conclusions: Early transplant-free survival is achievable in most patients with paracetamol-induced ALF and severe hyperammonemia with a treatment based on high-intensity CRRT. Such transplant-free survival increased over time together with increased CRRT dose. [ABSTRACT FROM AUTHOR]

Background: Almost 30-60% of patients treated in the intensive care unit (ICU) experience acute kidney injury (AKI) and approximately 5% of all ICU patients require renal replacement therapy. This study was conducted to determine the difference in length of stay (LOS) and mortality based on continuous renal replacement therapy (CRRT) compared to intermittent hemodialysis (IHD) in AKI patients in the ICU of a tertiary referral hospital in Indonesia. Methodology: A cross-sectional study was conducted on all patients diagnosed with AKI who were treated in the ICU. The study data included age, sex, comorbidities, The Sequential Organ Failure Assessment (SOFA) score, Acute Physiologic and Chronic Health Evaluation (APACHE) score, treatment modality, LOS, and mortality. Results: There were 18 patients in each of the IHD and CRRT groups. The number of study subjects with comorbidities was higher in the CRRT group (12 people (66.7%)), compared to the IHD group (11 people (61.1%)). The SOFA score in the IHD group was higher (6.06) than the CRRT group (5.44). APACHE score in the IHD group (18.50) differed greatly from the CRRT group (18.44). Discussion: Studies have shown no difference in mortality with CRRT compared to IHD. Studies showed higher APACHE scores were associated with shorter LOS, reflecting higher mortality rates. Conclusion: There is a significant difference in the LOS of AKI patients undergoing CRRT with IHD. However, no significant difference in the mortality rate between the CRRT and IHD groups was found. [ABSTRACT FROM AUTHOR]

Introduction: Chloride transfers during continuous renal replacement therapy (CRRT) have not been adequately described and may differ based on CRRT technique. We aimed to measure chloride mass transfer (JS,Cl) during CRRT and identify associated determinants. Methods: We performed a two-centre, prospective, observational study in France and Australia in ICU patients with CRRT initiated for <24 h. Patients received continuous veno-venous hemofiltration (CVVH) or continuous veno-venous haemodialysis (CVVHD, with citrate-CaCl2 regional anticoagulation). Over a 24 h period, plasma and effluent chloride concentrations were measured every 4 h to compute chloride mass transfer (JS,Cl, in mmol.min-1) using a modality-specific model, with negative value indicating chloride transfer towards the patient. Secondary outcomes were the identification of CRRT settings associated with JS,Cl (using multivariate mixed effects regression). Results are presented with median (interquartile range). Results: Between February 2021 and August 2022, we enrolled 37 patients (64 [56–71] years, 67% male), for a total of 20 CVVHD and 20 CVVH sessions. Over 24 h, plasma chloride concentrations were significantly higher, and JS,Cl significantly lower during CVVHD, compared to CVVH (−0.10 [−0.33 to 0.15] vs. 0.01 [−0.10 to 0.13] mmol.min-1, p < 0.05). With both modalities, net ultrafiltration (QUFNET) and plasma chloride concentrations were the principal determinants of JS,Cl, with higher QUFNET being associated with an increase in JS,Cl during CVVHD. Also, CVVHD sessions demonstrated a concentration gradient between the plasma and the effluent chamber of −6 [−9 to −4] mmol.L-1. Finally, CaCl2 reinjection during CVVHD accounted for 35% [32–60%] of total JS,Cl in sessions with a negative JS,Cl. Conclusion: Compared to CVVH, CVVHD with regional citrate anticoagulation was associated with greater chloride mass transfer to the patient and higher plasma chloride concentrations. This was due to high dialysate chloride concentrations and CaCl2 reinjection. This effect could only be controlled by high net ultrafiltration flow rates. [ABSTRACT FROM AUTHOR]

Introduction: Continuous renal replacement therapy (CRRT) is a prolonged continuous extracorporeal blood purification therapy to replace impaired renal function. Typically, CRRT therapy requires routine anticoagulation, but for patients at risk of bleeding and with contraindications to sodium citrate, anticoagulant-free dialysis therapy is necessary. However, this approach increases the risk of CRRT circuit coagulation, leading to treatment interruption and increased resource consumption. In this study, we utilized artificial intelligence machine learning methods to predict the risk of CRRT circuit coagulation based on pre-CRRT treatment metrics. Methods: We retrospectively analyzed 212 patients who underwent anticoagulant-free CRRT from October 2022 to October 2023. Patients were categorized into high-risk and low-risk groups based on CRRT circuit coagulation within 24 h. We employed eight machine learning methods to predict the risk of circuit coagulation. The performance of the model was evaluated using the area under the curve (AUC) of the receiver operating characteristic. 5-fold cross-validation was used to validate the machine learning models. Feature importance and SHAP plots were used to interpret the model's performance and key drivers. Results: We identified 88 patients (41.51%) at high risk of circuit coagulation within 24 h of CRRT. Our machine learning models showed excellent predictive performance, with ensemble learning achieving an AUC of 0.863 (95% CI: 0.860–0.868), outperforming individual algorithms. Random forest was the best single-algorithm model, with an AUC of 0.819 (95% CI: 0.814–0.823). The top three features identified as most important by the SHAP summary plot and feature importance graph are platelet, filtration fraction (FF), and triglycerides. Conclusion: We created a model using machine learning to predict the risk of circuit coagulation during anticoagulant-free CRRT therapy. Our model performs well (AUC 0.863) and identifies key factors like platelets, FF, and triglycerides. This facilitates the development of personalized treatment strategies by clinicians aimed at reducing circuit coagulation risk, thereby enhancing patient outcomes and reducing healthcare expenses. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Pediatric sepsis-associated acute kidney injury (AKI) often requires continuous renal replacement therapy (CRRT), but limited data exist regarding patient characteristics and outcomes. We aimed to describe these features, including the impact of possible dialytrauma (i.e., vasoactive requirement, negative fluid balance) on outcomes, and contrast them to nonseptic patients in an international cohort of children and young adults receiving CRRT. DESIGN: A secondary analysis of Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK), an international, multicenter, retrospective study. SETTING: Neonatal, cardiac and PICUs at 34 centers in nine countries from January 1, 2015, to December 31, 2021. PATIENTS: Patients 0-25 years old requiring CRRT for AKI and/or fluid overload. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 1016 patients, 446 (44%) had sepsis at CRRT initiation and 650 (64%) experienced Major Adverse Kidney Events at 90 days (MAKE-90) (defined as a composite of death, renal replacement therapy [RRT] dependence, or > 25% decline in estimated glomerular filtration rate from baseline at 90 d from CRRT initiation). Septic patients were less likely to liberate from CRRT by 28 days (30% vs. 38%; p < 0.001) and had higher rates of MAKE-90 (70% vs. 61%; p = 0.002) and higher mortality (47% vs. 31%; p < 0.001) than nonseptic patients; however, septic survivors were less likely to be RRT dependent at 90 days (10% vs. 18%; p = 0.011). On multivariable regression, pre-CRRT vasoactive requirement, time to negative fluid balance, and median daily fluid balance over the first week of CRRT were not associated with MAKE-90; however, increasing duration of vasoactive requirement was independently associated with increased odds of MAKE-90 (adjusted OR [aOR], 1.16; 95% CI, 1.05-1.28) and mortality (aOR, 1.20; 95% CI, 1.1-1.32) for each additional day of support. CONCLUSIONS: Septic children requiring CRRT have different clinical characteristics and outcomes compared with those without sepsis, including higher rates of mortality and MAKE-90. Increasing duration of vasoactive support during the first week of CRRT, a surrogate of potential dialytrauma, appears to be associated with these outcomes. [ABSTRACT FROM AUTHOR]

Nutrition is one of the cornerstones in the treatment and support of critically ill patients. Nutritional support includes the provision of calories, protein, electrolytes, vitamins, and trace elements through enteral or parenteral routes. Acute kidney injury (AKI) is a common problem in critically ill patients and can lead to severe consequences, impacting metabolism and nutritional status significantly. Furthermore, regardless of the modality used, renal replacement therapy (RRT) has profound effects on metabolism. Evidence on nutritional support during continuous renal replacement therapy (CRRT) is limited, and there are no established clinical guidelines for nutritional adaptations during CRRT in critically ill patients. This review outlines some essential principles for providing micronutrient support in critically ill patients undergoing CRRT and protein requirements in AKI patients. [ABSTRACT FROM AUTHOR]