Search

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]

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]

Objective To assess the outcome of patients with cancer-related sepsis requiring continuous renal replacement therapy (CRRT) in a single-center pediatric intensive care unit (PICU). Method Children with sepsis who necessitate CRRT from January 2017 to December 2021 were enrolled. The patients with leukemia/lymphoma or solid tumors were defined as underlying cancer. Multivariate logistic regression analysis was performed to identify the death risk factors in patients with cancer-related sepsis. Results A total of 146 patients were qualified for inclusion. Forty-six (31.5%) patients with cancer-related sepsis and 100 (68.5%) non-cancer-related sepsis. The overall PICU mortality was 28.1% (41/146), and mortality was significantly higher in cancer-related sepsis patients compared with non-cancer patients (41.3% vs. 22.0%, p = 0.016). Need mechanical ventilation, p-SOFA, acute liver failure, higher fluid overload at CRRT initiation, hypoalbuminemia, and high inotropic support were associated with PICU mortality in cancer-related sepsis patients. Moreover, levels of IL-6, total bilirubin, creatinine, blood urea nitrogen, and international normalized ratio were significantly higher in non-survivors than survivors. In multivariate logistic regression analysis, pediatric sequential organ failure assessment (p-SOFA) score (OR:1.805 [95%CI: 1.047–3.113]) and serum albumin level (OR: 0.758 [95%CI: 0.581 -0.988]) were death risk factors in cancer-related sepsis receiving CRRT, and the AUC of combined index of p-SOFA and albumin was 0.852 (95% CI: 0.730–0.974). Conclusion The overall PICU mortality is high in cancer-related sepsis necessitating CRRT. Higher p-SOFA and lower albumin were independent risk factors for PICU mortality. [ABSTRACT FROM AUTHOR]

Objective: To compare the clinical efficacy and safety of local citrate anticoagulation and systemic low-molecular-weight heparin anticoagulation in CRRT for patients with severe tuberculosis. Methods: From October 2021 to September 2023, 60 patients with severe tuberculosis who were treated with CRRT in our hospital were selected and divided into the observation group (local citrate anticoagulation) and the control group (systemic low-molecular-weight heparin anticoagulation), 30 patients in each group. Compare the blood routine, liver and kidney function indicators, prognosis level, and incidence of complications between the two groups. Result: After treatment, PLT levels decreased in both groups of patients, while INR and APTT levels increased, with statistical significance (P<0.05); After treatment, the Scr, BUN levels, SOFA, and APACHE II scores of both groups of patients decreased, and there was a significant difference between the observation group and the control group (P<0.05); The service life of the observation group filter was higher than that of the control group, and the incidence of bleeding was lower than that of the control group (P<0.05). Conclusion: For severe tuberculosis patients, local citrate anticoagulation is better, while local citrate anticoagulation can improve the renal function, improve the prognosis of patients, improve the service life of the filter, and reduce the incidence of bleeding. [ABSTRACT FROM AUTHOR]

An acute kidney injury (AKI) is the most common complication following cardiac surgery, and can lead to the initiation of continuous renal replacement therapy (CRRT). However, there is still insufficient evidence for when patients should be liberated from CRRT. Proenkephalin A 119–159 (PENK) is a novel biomarker that reflects kidney function independently of other factors. This study investigated whether PENK could guide successful liberation from CRRT. Therefore, we performed a prospective, observational, single-center study at the Medical University of Vienna between July 2022 and May 2023, which included adult patients who underwent cardiac surgery for a cardiopulmonary bypass; patients on preoperative RRT were excluded. The PENK levels were measured at the time of AKI diagnosis and at the initiation of and liberation from CRRT, and were subsequently compared to determine whether the patients were successfully liberated from CRRT. We screened 61 patients with postoperative AKI; 20 patients experienced a progression of AKI requiring CRRT. The patients who were successfully liberated from CRRT had mean PENK levels of 113 ± 95.4 pmol/L, while the patients who were unsuccessfully liberated from CRRT had mean PENK levels of 290 ± 175 pmol/L (p = 0.018). For the prediction of the successful liberation from CRRT, we found an area under the curve of 0.798 (95% CI, 0.599–0.997) with an optimal threshold value of 126.7 pmol/L for PENK (Youden Index = 0.53, 95% CI, 0.10–0.76) at the time of CRRT liberation (sensitivity = 0.64, specificity = 0.89). In conclusion, PENK is a novel biomarker that has the potential to predict the successful liberation from CRRT for patients with AKI after cardiac surgery. [ABSTRACT FROM AUTHOR]

Background Aims Study Design Results Conclusions Relevance to Clinical Practice Evidence suggests that 8%–10% of ICU patients receive renal replacement therapy. However, there is a high rate of unplanned CRRT interruption, ranging between 17% and 74%. Studies on unplanned interruption of CRRT mainly focused on the retrospective investigation of related risk factors and conclusions have been diverse.This article aims to clarify the main influencing factors related to unplanned interruption of continuous renal replacement therapy (CRRT) in adult patients in intensive care units (ICUs).A literature review and meta‐analysis were undertaken. Following the application of the Newcastle–Ottawa Scale (NOS), a total of 15 articles were included in a total of 2132 patients who underwent 3690 CRRT procedures and 2181 unplanned interruption times. The methodological guideline of a scoping review was applied for the evidence synthesis while applying the meta‐analysis quantitative methodological guideline to identify and clarify main influencing factors related to unplanned interruption of CRRT. The reporting Prisma Protocol was followed.Longer filter life and prothrombin activation time, higher red blood cell count, greater transmembrane pressure, faster blood flow rate, intermittent saline irrigation, lower creatinine level, low prothrombin activity and pre‐dilution are factors identified to potentially affect unplanned CRRT in ICU patients.Available evidence suggests four clinical challenges associated with unplanned CRRT interruption, namely: (a) effects of red blood cell count, filter life, cross‐mode pressure, blood flow velocity, prothrombin activity and activated partial thrombin time on unplanned interruption; (b) influence of dilution mode on unplanned interruption; (c) influence of intermittent saline irrigation on unplanned interruption; (d) influence of Scr level on unplanned interruption.The potential to increase the ability to better manage unplanned CRRT in ICUs has been identified in this article and constitutes a relevant potential health care management contribution that can be implemented by nurses. [ABSTRACT FROM AUTHOR]

Metformin-associated lactic acidosis is seen in conditions that disrupt haemodynamics such as renal failure, hepatic failure, sepsis, septic shock or in acute poisoning. Since the mortality rate of metforminassociated lactic acidosis is high, early diagnosis and treatment is important in reducing mortality. Continuous renal replacement therapy is preferred especially in clinical conditions such as severe metabolic acidosis with haemodynamic instability, intoxication, hyperkalaemia and volume overload. In our patient with lactic acidosis due to metformin intoxication, we aimed to emphasise the efficacy of continuous renal replacement therapy because of the lack of response despite two intermittent haemodialysis and haemodynamic instability. [ABSTRACT FROM AUTHOR]

Background: Renal replacement therapy (RRT), widely used in the treatment of renal injury during sepsis, aims to eliminate the toxins and proinflammatory cytokines involved in the pathomechanism underlying septic shock. Dialysis filters are characterized by a high adsorption potential for cytokines in RRT in the case of septic renal injury. For the treatment of sepsis with antibiotics, it is of key importance to achieve the desired values of PK/PD indices. Continuous renal replacement therapy (CRRT) may affect antimicrobial clearance, increasing their elimination in some cases. Methods: The aim of this study was to determine the degree of adsorption for linezolid on three different types of filters used in CRRT. In our in vitro study, a continuous veno-venous hemofiltration (CVVH) was conducted using three types of filters: polysulfone (PS), polyethyleneimine-treated polyacrylonitrile (PAN PEI), and non-PEI-treated polyacrylonitrile (PAN). Each type of filter was used in three CVVH cycles, involving the use of 600 mg of linezolid dissolved in 700 mL of bovine blood or in 700 mL of 0.9% NaCl. In each case, the total volume of the obtained solution was 1000 mL. Blood samples were collected at particular time points to measure their drug concentration. The differences in mean drug/NaCl adsorption and drug/blood adsorption were determined using a one-way ANOVA with multiple comparisons via Tukey's post hoc test; a p-value of <0.05 was considered significant. Results: A significant adsorption of linezolid was found for PAN PEI filters, both in samples obtained from bovine blood and 0.9% NaCl solutions, at the endpoint. In PAN PEI samples, the concentration of linezolid in 0.9% NaCl solutions decreased from 594.74 μg/mL to 310.66 μg/mL after 120 min (the difference was established at 52%). In blood samples, the initial concentration was 495.18 μg/mL, which then decreased to 359.84 μg/mL (73% of the beginning value). No significant adsorption was demonstrated on PAN or PS filters. Conclusion: There is a need for in vivo research to confirm the effect of filter type on linezolid concentration in patients undergoing CRRT. [ABSTRACT FROM AUTHOR]

Background: To investigate the efficacy of bilirubin reduction by hemoadsorption with CytoSorb® in patients with acute‐on‐chronic liver failure (ACLF) receiving continuous renal replacement therapy (CRRT). Methods: A prospective, randomized, single‐center, open‐label, controlled pilot trial. Patients with ACLF, acute kidney injury, and serum bilirubin ≥5 mg/dL were assigned 1:1:1 to one of three study groups (CRRT with or without hemoadsorption, no CRRT). In the hemoadsorption group, the CytoSorb adsorber was incorporated into the CRRT system, replaced after 12, 24, and 48 h, and removed after 72 h. The primary endpoint was the serum bilirubin level after 72 h. Results: CYTOHEP was terminated early due to difficulties in recruiting patients and ethical concerns. Three of 9 patients (33%) were treated in each group. Comparing the three groups, mean bilirubin levels after 72 h were lower by −8.0 mg/dL in the "CRRT with hemoadsorption" group compared to "CRRT without hemoadsorption" (95% CI, −21.3 to 5.3 mg/dL; p = 0.17). The corresponding mean difference between "CRRT without hemoadsorption" and "no CRRT" was −1.4 mg/dL (95% CI, −14.2 to 11.5 mg/dL; p = 0.78). Comparing "CRRT with hemoadsorption" and "no CRRT," it was −9.4 mg/dL (95% CI, −20.8 to 2.1 mg/dL; p = 0.0854). Only 1/9 patients (11%, "no CRRT" group) survived day 30 after study inclusion but died on day 89. IL‐6, liver function parameters, and clinical scores were similar between the study groups. Conclusions: CYTOHEP failed to demonstrate that extracorporeal hemoadsorption combined with CRRT can reduce serum bilirubin in ACLF patients with acute kidney failure. [ABSTRACT FROM AUTHOR]

Introduction: Anticoagulants are used in continuous renal replacement therapy (CRRT) to prolong filter life. There are no prior investigations directly comparing epoprostenol to more commonly used forms of anticoagulation in children. Therefore, the primary aim of this study was to assess the efficacy and safety of epoprostenol as compared to heparin and citrate anticoagulation in a pediatric cohort. Methods: We performed a retrospective analysis of all patients <18 years of age admitted to an academic quaternary care children's hospital from 2017–2022 who received epoprostenol, heparin, or citrate exclusively for CRRT anticoagulation. Efficacy was evaluated by comparing the hours to the first unintended filter change and the ratio of filters used to CRRT days. Safety was assessed by evaluating changes in platelet count and vasoactive-ionotropic score (VIS). Results: Of 101 patients, 44 received epoprostenol (43.6%), 38 received heparin (37.6%), and 19 received citrate (18.8%). The first filter change was more commonly planned in patients receiving anticoagulation with epoprostenol (43%) as compared to citrate (11%) or heparin (29%) (p = 0.034). Of those patients where the first filter change was unintended (n = 33), there were greater median hours until the filter was replaced in those receiving epoprostenol (29) when compared to citrate (21) (p = 0.002) or heparin (18) (p = 0.003). There was a smaller median ratio of filters used to days on therapy in the patients that received epoprostenol (0.53) when compared to citrate (1) (p = 0.003) or heparin (0.75) (p = 0.001). For those receiving epoprostenol, there was no significant decrease in platelet count when comparing values prior to CRRT initiation through 7 days of therapy. There was no significant difference in VIS when comparing values prior to CRRT initiation through the first 2 days of CRRT. Conclusions: Epoprostenol-based anticoagulation is effective when compared to other anticoagulation strategies used in pediatric CRRT with a favorable side effect profile. [ABSTRACT FROM AUTHOR]

Introduction: Enkephalins, endogenous opioid peptides, are involved in the regulation of renal function. One derived molecule, proenkephalin A, also known as penKid, has been demonstrated to be a reliable biomarker for kidney function and its plasma concentration correlates with measured glomerular filtration rate. penKid is used for prediction and diagnosis of AKI and need of renal replacement therapy (RRT). penKid has also been used to predict the successful weaning from RRT in patients with AKI. Whether the concentration of penKid is affected or not by RRT is a controversial point and there are no studies describing the kinetics of the molecule in such conditions. The low molecular weight (4.5 kDa) would imply free removal by the glomerulus and the dialysis membranes. During RRT, this reduction could not be detected in clinical practice due to the complex kinetics involving either low dialytic clearance or increased production in response to impaired kidney function. The aim of this study was to determine the sieving coefficient and the diffusive clearance of the penKid molecule in conditions of in vitro continuous veno-venous hemofiltration (CVVH) and continuous veno-venous hemodialysis (CVVHD), respectively, and also the penKid removal ratio in conditions of in vitro hemoadsorption (HA) using a synthetic microporous resin. Methods: Blood spiked with a lyophilized penKid peptide solved in 20 mm dipotassium phosphate and 6 mm disodium EDTA [pH 8] to reach target concentrations is used as testing solution. In each experiment, the blood batch was adjusted at a volume of 1,000 mL, maintained at 37°, and continuously stirred. Samples were collected from blood, ultrafiltrate, and spent dialysate at different times during the experiments. Sieving, clearance, and removal ratio were calculated. Results: Significant removal of penKid was observed in CVVH (sieving 1.04 ± 0.27), in CVVHD (clearance 23.08 ± 0.89), and in HA (removal ratio 76.1 ± 1% after 120 min). Conclusion: penKid is effectively removed by extracorporeal therapies. In presence of anuria, penKid generation kinetics can be calculated based on extracorporeal removal and volume variation. In steady state conditions, declining values may be the result of an initial renal function recovery and may suggest discontinuation and successful liberation from RRT. [ABSTRACT FROM AUTHOR]

Introduction: The main objective of this study was to evaluate the impact of hemoadsorption on the elimination of inflammatory mediators. Methods: A prospective, bicenter, observational cohort study was conducted between March 2020 and February 2022 to explore the immunomodulatory response, demographic and clinical characteristics of individuals with COVID-19 admitted to the ICU with severe acute respiratory failure and in need of CRRT with Oxiris® with or without AKI. Results: Sixty-four patients were analyzed. Statistically significant differences were observed between exposed and unexposed groups, in relation to the reduction in D-dimer levels −15,614 (24,848.9) versus −4,136.5 (9,913.47) (p 0.031, d: 1.59, 95% CI: −21,830, −1,126). An increase in PCT was observed 0.47 (2.08) versus −0.75 (2.3) (p 0.044 95% CI: 0.03, 2.44). No differences were found in a decrease in CRP −4.21 (7.29) versus −1.6 (9.02) (p 0.22) nor in the rest of inflammatory parameters fibrinogen, IL-6, ferritin, lymphocytes, and neutrophils. Subgroup analysis in patients exposed to therapy also showed a significant decrease in D-dimer of 55% from baseline: 6,000 (1,984.5–27,750) pre-therapy versus 2,700 (2,119.5–6,145) (95% CI: −23,000, −2,489) post-therapy with a strong effect size (p 0.001, d: 0.65). Conclusion: The hemoadsorptive therapy in COVID-19 was associated with a significant decrease in D-dimer parameters without showing decreases in the rest of the clinical, inflammatory parameters and severity scales analyzed. [ABSTRACT FROM AUTHOR]

Timely diagnosis and management of pediatric acute liver failure (PALF) is of paramount importance to improve survival. The Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition invited national and international experts to identify and review important management and research questions. These covered the definition, age appropriate stepwise workup for the etiology, non-invasive diagnosis and management of cerebral edema, prognostic scores, criteria for listing for liver transplantation (LT) and bridging therapies in PALF. Statements and recommendations based on evidences assessed using the modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) system were developed, deliberated and critically reappraised by circulation. The final consensus recommendations along with relevant published background information are presented here. We expect that these recommendations would be followed by the pediatric and adult medical fraternity to improve the outcomes of PALF patients. [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 Methods Results Conclusions 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.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).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).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]

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 FROM AUTHOR]

Background: Regional citrate anticoagulation (RCA) has emerged as a treatment modality that reduces bleeding risk and filter clotting. With initial experience of using RCA with continuous renal replacement therapy (CRRT), we have formulated a working protocol based on published literature. Objective: The study aimed to evaluate the protocol for routine use of RCA during CRRT requiring anticoagulation and evaluation of filter life. Methodology: It is a single-center, open-label, prospective, non-randomized, non-interventional, single-arm, observational study conducted at a tertiary care hospital between September 2022 and July 2023. All adult patients with acute kidney injury (AKI) or hyperammonemia requiring CRRT and necessitating the use of anticoagulation were enrolled in the study. The study used Prisma Flex M100 AN 69 dialyzer on Prisma Flex (Baxter) CRRT machines during continuous venovenous hemodiafiltration (CVVHDF). The targeted CRRT dose in all the study patients was 25-30 mL/kg/hour. Based on the published literature, we have developed a working protocol (Appendix 1) for managing patients on CRRT using RCA. Results: A total of 159 patients were analyzed for the study. The median [interquartile range (IQR)] filter life using RCA was 30 (12-55) hours. Filter clotting was observed in 33.3% of patients. Citrate accumulation was present in 52.25% of patients, but no CRRT was discontinued as citrate accumulation resolved after following the corrective steps in the protocol. None of the patients had citrate toxicity. Chronic liver disease (CLD) (p ≤ 0.001) and those who were post-living donor liver transplant recipients (p = 0.004) had a statistically significant increase in citrate accumulation. Also, patients who had higher lactate at baseline (6 hours post-CRRT initiation), had a higher chance of citrate accumulation. Conclusion: Our RCA protocol provides a safe approach to regional anticoagulation during CRRT in critically ill patients. [ABSTRACT FROM AUTHOR]

Background: It is imperative to note that integrated system continuous renal replacement therapy (CRRT) necessitates a sophisticated and costly apparatus, potentially limiting its availability within resource‐limited settings. The introduction of a separated system for continuous veno‐venous hemofiltration (CVVH), characterized by uncomplicated setup procedures with a hemoperfusion machine, holds promise as a feasible alternative to CRRT for critically ill patients with acute kidney injury (AKI). Methods: We aimed to retrospectively analyze the effectiveness and safety of separated CRRT applied from a hemoperfusion machine in critically ill patients with AKI during the January 2015 to December 2021 period. We also examine the in‐hospital mortality rate and multivariate logistic regression analysis to uncover the factors that affect mortality. Results: We included a total of 129 critically ill patients who received separated system CRRT. The SOFA score at CRRT initiation was 12.6 ± 3.8. The fluid accumulation at the day of CRRT initiation was 3900 mL (622–8172 mL) All patients received pre‐ and postdilution CVVH. The mean prescribed CRRT dose was 22.4 ± 3.1 mL/kg/h. We found no serious complications including circuit explosion and air embolism. The in‐hospital mortality rate was 68.9%. High SOFA score and positive fluid accumulation at CRRT initiation serve as predictors of survival. Conclusions: Separated system CRRT using a hemoperfusion machine provides a simplified system to operate and is proven to be effective and safe in real‐life practice, especially in resource‐limited areas. [ABSTRACT FROM AUTHOR]

Introduction: Continuous renal replacement therapy (CRRT) is a primary form of renal support for patients with acute kidney injury in an intensive care unit. Making an accurate decision of discontinuation is crucial for the prognosis of patients. Previous research has mostly focused on the univariate and multivariate analysis of factors in CRRT, without the capacity to capture the complexity of the decision-making process. The present study thus developed a dynamic, interpretable decision model for CRRT discontinuation. Method: The study adopted a cohort of 1,234 adult patients admitted to an intensive care unit in the MIMIC-IV database. We used the eXtreme Gradient Boosting (XGBoost) machine learning algorithm to construct dynamic discontinuation decision models across 4 time points. SHapley Additive exPlanation (SHAP) analysis was conducted to exhibit the contributions of individual features to the model output. Result: Of the 1,234 included patients with CRRT, 596 (48.3%) successfully discontinued CRRT. The dynamic prediction by the XGBoost model produced an area under the curve of 0.848, with accuracy, sensitivity, and specificity of 0.782, 0.786, and 0.776, respectively. The performance of the XGBoost model was far superior to other test models. SHAP demonstrated that the features that contributed most to the model results were the Sequential Organ Failure Assessment score, serum lactate level, and 24-h urine output. Conclusion: Dynamic decision models supported by machine learning are capable of dealing with complex factors in CRRT and effectively predicting the outcome of discontinuation. [ABSTRACT FROM AUTHOR]

Introduction: Acute kidney injury (AKI) and continuous renal replacement therapy (CRRT) are critical areas in nephrology. The effectiveness of ChatGPT in simpler, patient education-oriented questions has not been thoroughly assessed. This study evaluates the proficiency of ChatGPT 4.0 in responding to such questions, subjected to various linguistic alterations. Methods: Eighty-nine questions were sourced from the Mayo Clinic Handbook for educating patients on AKI and CRRT. These questions were categorized as original, paraphrased with different interrogative adverbs, paraphrased resulting in incomplete sentences, and paraphrased containing misspelled words. Two nephrologists verified the questions for medical accuracy. A χ2 test was conducted to ascertain notable discrepancies in ChatGPT 4.0's performance across these formats. Results: ChatGPT provided notable accuracy in handling a variety of question formats for patient education in AKI and CRRT. Across all question types, ChatGPT demonstrated an accuracy of 97% for both original and adverb-altered questions and 98% for questions with incomplete sentences or misspellings. Specifically for AKI-related questions, the accuracy was consistently maintained at 97% for all versions. In the subset of CRRT-related questions, the tool achieved a 96% accuracy for original and adverb-altered questions, and this increased to 98% for questions with incomplete sentences or misspellings. The statistical analysis revealed no significant difference in performance across these varied question types (p value: 1.00 for AKI and 1.00 for CRRT), and there was no notable disparity between the artificial intelligence (AI)'s responses to AKI and CRRT questions (p value: 0.71). Conclusion: ChatGPT 4.0 demonstrates consistent and high accuracy in interpreting and responding to queries related to AKI and CRRT, irrespective of linguistic modifications. These findings suggest that ChatGPT 4.0 has the potential to be a reliable support tool in the delivery of patient education, by accurately providing information across a range of question formats. Further research is needed to explore the direct impact of AI-generated responses on patient understanding and education outcomes. [ABSTRACT FROM AUTHOR]

Acute kidney injury (AKI) is a common complication of severe burn injury and is associated with significant morbidity and mortality. Continuous Renal Replacement Therapy (CRRT) is the preferred treatment for stage 3 AKI due to severe burn. This retrospective cohort study at a single institution aimed to examine the long-term renal outcomes after discharge of burn survivors who underwent CRRT during their ICU stay between 2012–2021 due to burn-related AKI, hypothesizing a return to baseline renal function in the long term. Among the 31 patients meeting inclusion criteria, 22 survived their burn injuries, resulting in a 29 % mortality rate. No significant disparities were observed in demographics, comorbidities, burn characteristics, or critical care interventions between survivors and non-survivors. Serum creatinine and eGFR values normalized for 91 % of patients at discharge. Impressively, 91 % of survivors demonstrated a return to baseline renal function during long-term (>3 years) follow-up. Furthermore, only 18 % underwent dialysis after discharge, primarily within the first year. Cumulative mortality rates were 18.2 %, 22.7 %, and 31.8 % at 1, 3, and > 3 years after discharge, respectively. Causes of death were primarily non-renal. These results suggest that burn-related AKI with CRRT results in lower rates of conversion to ongoing renal dysfunction compared to general ICU cohorts. Despite limitations, this study contributes vital insights into the underexplored issue of long-term outcomes after dicharge in this patient population. • 29 % in-hospital mortality rate for severe burn patients requiring CRRT during admission. • Most severe burn patients maintained normal renal function after discharge. • Low long-term mortality rates in severe burn patients requiring in-hospital CRRT. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Castleman disease (CD) is a rare lymphoproliferative disorder, with non‐specific clinical manifestations, often delayed diagnosis and treatment, which pose a significant challenge in the present times. Patients diagnosed with this disease have poor prognosis due to the limited treatment options. Multicentric CD occurs at multiple lymph node stations and is associated with a proinflammatory response that leads to the development of the so‐called 'B symptoms'. IL‐6 seems to be a key cytokine involved in various manifestations such as lymphadenopathies, hepatosplenomegaly, and polyclonal hypergammaglobulinemia. Its levels correlate with the activity of the disease. Other consequences of MCD include increased fibrinogen levels leading to deep vein thrombosis and thromboembolic disorders, high hepcidin levels causing anaemia, elevated VEGF levels promoting angiogenesis and vascular permeability, which, along with hypoalbuminemia, induce oedema, ascites, pleural and pericardial effusions, and in severe cases, generalized anasarca. In extreme cases multiple organ failure can occur, often resulting in death. We propose the use of continuous renal replacement therapy (CRRT) in managing severe multicentric CD. Our arguments are based on the principles that CRRT is able to remove IL‐6 from circulation thus attenuating the cytokine storm, can influence hepcidin levels, and reduction in oedema, and is often used in multiple organ failure to regain homeostasis control. Therefore, it could be used as a therapy or bridge therapy in severe cases. To sustain our hypothesis with evidence, we have gathered several studies from the literature confirming the successful removal of cytokines, especially IL‐6 from circulation, which can be used as a starting point. [ABSTRACT FROM AUTHOR]

Abstract 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

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.

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.

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.

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.

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.

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]

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 Hypothermia is a relatively common complication in patients receiving continuous renal replacement therapy (CRRT). However, few studies have reported the factors associated with hypothermia. Methods A retrospective cohort study was performed in five intensive care units (ICUs) to evaluate the incidence of hypothermia and the predictive factors for developing hypothermia during CRRT, with hypothermia defined as a time-weighted average temperature 70 years (odds ratio [OR], 2.59; 95% CI, 1.38–4.98; P=0.004), higher positive fluid balance on the day before CRRT (OR, 1.11; 95% CI, 1.02–1.22; P=0.02), and CRRT dose (OR, 1.003; 95% CI, 1.00–1.01; P=0.04) were significantly associated with hypothermia. Conversely, a higher body weight was independently associated with mitigated risk of hypothermia (OR, 0.89; 95% CI, 0.81–0.97; P=0.01). Moreover, a higher coefficient of variance of temperature was associated with greater ICU mortality (OR, 1.41; 95% CI, 1.13–1.78; P=0.003). Conclusion Hypothermia during CRRT is a relatively common occurrence, and factors associated with hypothermia onset in the first 24 hours include older age, lower body weight, higher positive fluid balance on the day before CRRT, and higher CRRT dose. Greater temperature variability was associated with increased ICU mortality.

Abstract Background To explore the feasibility and effectiveness of a segmented sodium citrate solution anticoagulation strategy in patients receiving CRRT. Methods A prospective, randomized controlled study was conducted. Results According to the inclusion and exclusion criteria, 80 patients were included and randomly divided into two groups. Moreover, coagulation indices, liver function indices, renal function indices, and SOFA and APACHE II scores did not significantly differ between the two groups (P > 0.05). The coagulation grade of the venous ports in the experimental group was lower than that in the control group and the two groups of filters, but the difference was not statistically significant (P = 0.337). Both sodium citrate solution infusion methods maintained a low blood calcium concentration (0.25–0.45 mmol/L) in the peripheral circulation pathway, and no patient developed hypocalcaemia (

Continuous renal replacement therapy (CRRT) is one of the commonly used extracorporeal blood purification therapies and its use in the pediatric population has increased in the past two decades due to the availability of safer machines which allow lower blood flow rate and dialysate flow rate. The usual indication for initiation of CRRT is for solute clearance and or fluid removal in oliguric patients with acute kidney injury. Knowledge regarding the principles of solute removal and fluid removal along with the application of these mechanisms in different modes of CRRT helps the physician to decide on the appropriate therapy for the given patient. Understanding the concept of CRRT dose and the factors to be considered in the prescription for achieving the preset targets of CRRT is vital for the efficient utilization of the therapy.

Abstract Background Dengue fever is a mosquito-borne viral infection with a broad spectrum of clinical manifestations. Expanded dengue syndrome includes unusual manifestations that do not fall into the categories of dengue fever, dengue hemorrhagic fever, or dengue shock syndrome. Rhabdomyolysis causing acute renal failure in dengue is one such unusual manifestation, the pathophysiology of which is incompletely understood. Case presentation We describe a 21-year-old Sri Lankan man with dengue fever who developed severe rhabdomyolysis and acute kidney injury with extremely high creatinine phosphokinase levels (> 2 million U/L). Management of this patient was challenging as his creatinine phosphokinase kept rising with persistent anuria despite hydration, intermittent hemodialysis, and, later, continuous venovenous hemodiafiltration. Further therapeutic options were explored, and CytoSorb® adsorber was added as an adjunct to continuous venovenous hemodiafiltration, following which we observed a marked reduction in his creatinine phosphokinase and myoglobin levels over the next 12 hours and complete renal recovery over the next 5 weeks. Conclusion We report a rare case of significant rhabdomyolysis secondary to dengue infection leading to acute kidney injury. Continuous venovenous hemodiafiltration performed with the hemofilter Pecopen 140 was ineffective, and the addition of CytoSorb® adsorber as an adjunct therapy to continuous venovenous hemodiafiltration may have a potential benefit in removing high-molecular-weight proteins such as myoglobin.

Background Identifying risk factors and improving prognostication for mortality among patients with sepsis-associated acute kidney injury (AKI) undergoing continuous kidney replacement therapy (CKRT) is important in improving the adverse prognosis of this patient population. This study aimed to compare the prognostic value of existing systemic inflammation biomarkers and determine the optimal systemic inflammation biomarker in patients with sepsis-associated AKI receiving CKRT. Methods This multi-center, retrospective, observational cohort study included 1,500 patients with sepsis-associated AKI treated with intensive care and CKRT. The main predictor was a panel of 13 different systemic inflammation biomarkers. The primary outcome was 28-day mortality after CKRT initiation. Secondary outcomes included 90-day mortality after CKRT initiation, CKRT duration, kidney replacement therapy dependence at discharge, and lengths of intensive care unit (ICU) and hospital stays. Results When added to the widely accepted Acute Physiology and Chronic Health Evaluation II score, platelet-to-albumin ratio (PAR) and neutrophil-platelet score (NPS) had the highest improvements in prognostication of 28-day mortality, where the corresponding increases in C-statistic were 0.01 (95% confidence interval [CI], 0.00–0.02) and 0.02 (95% CI, 0.01–0.03). Similar findings were observed for 90-day mortality. The 28- and 90-day mortality rates were significantly lower for the higher PAR and NPS quartiles. These associations remained significant even after adjustment for potential confounding variables in multivariable Cox proportional hazards models. Conclusion Of the available systemic inflammation biomarkers, the addition of PAR or NPS to conventional ICU prediction models improved the prognostication of patients with sepsis-associated AKI receiving intensive care and CKRT.

Background Continuous renal replacement therapy (CRRT) has become the standard modality of renal replacement therapy (RRT) in critically ill patients. However, consensus is lacking regarding the criteria for discontinuing CRRT. Here we validated the usefulness of the prediction model for successful discontinuation of CRRT in a multicenter retrospective cohort. Methods One temporal cohort and four external cohorts included 1,517 patients with acute kidney injury who underwent CRRT for >2 days from 2018 to 2020. The model was composed of four variables: urine output, blood urea nitrogen, serum potassium, and mean arterial pressure. Successful discontinuation of CRRT was defined as the absence of an RRT requirement for 7 days thereafter. Results The area under the receiver operating characteristic curve (AUROC) was 0.74 (95% confidence interval, 0.71–0.76). The probabilities of successful discontinuation were approximately 17%, 35%, and 70% in the low-score, intermediate-score, and high-score groups, respectively. The model performance was good in four cohorts (AUROC, 0.73–0.75) but poor in one cohort (AUROC, 0.56). In one cohort with poor performance, attending physicians primarily controlled CRRT prescription and discontinuation, while in the other four cohorts, nephrologists determined all important steps in CRRT operation, including screening for CRRT discontinuation. Conclusion The overall performance of our prediction model using four simple variables for successful discontinuation of CRRT was good, except for one cohort where nephrologists did not actively engage in CRRT operation. These results suggest the need for active engagement of nephrologists and protocolized management for CRRT discontinuation.

Background The reliability of presepsin as a biomarker of sepsis may be reduced in patients with acute kidney injury (AKI) requiring continuous kidney replacement therapy (CKRT). This study analyzed the utility of plasma presepsin values in predicting mortality in patients with AKI requiring CKRT, particularly those with sepsis-associated AKI. Methods This single-center retrospective study included 57 patients who underwent CKRT, with plasma presepsin measurements, from April 2022 to March 2023; 35 had sepsis-associated AKI. The predictive values of plasma presepsin, as well as Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, for 28-day mortality were analyzed using receiver operating characteristic curves. Multivariate Cox regression analysis was performed to identify risk factors for 28-day mortality in the sepsis-associated AKI subgroup. Results Overall, plasma presepsin showed a lower area under the curve value (0.636; 95% confidence interval [CI], 0.491–0.781) than the APACHE II (0.663; 95% CI, 0.521–0.804) and SOFA (0.731; 95% CI, 0.599–0.863) scores did. However, in sepsis-associated AKI, the area under the curve increased to 0.799 (95% CI, 0.653–0.946), which was higher than that of the APACHE II (0.638; 95% CI, 0.450–0.826) and SOFA (0.697; 95% CI, 0.519–0.875) scores. In the multivariate Cox regression analysis, a high presepsin level was an independent risk factor for 28-day mortality in sepsis-associated AKI (hazard ratio, 3.437; p = 0.03). Conclusion Presepsin is a potential prognostic marker in patients with sepsis-associated AKI requiring CKRT.

Background Continuous kidney replacement therapy (CKRT) is crucial in the management of acute kidney injury in intensive care units (ICUs). Nonetheless, the optimal anticoagulation strategy for patients with bleeding tendencies remains debated. This study aimed to evaluate patient outcomes and safety of nafamostat mesylate (NM) compared with no anticoagulation (NA) in critically ill patients with bleeding tendencies who were undergoing CKRT. Methods This retrospective study enrolled 2,313 patients who underwent CKRT between March 2013 and December 2022 at the third affiliated hospital in South Korea. After applying the exclusion criteria, 490 patients were included in the final analysis, with 245 patients in the NM and NA groups each, following 1:1 propensity score matching. Subsequently, in-hospital mortality, incidence of bleeding complications, agranulocytosis, hyperkalemia, and length of hospital stay were assessed. Results No significant differences were observed between the groups regarding the lengths of hospital and ICU stays or the incidence of agranulocytosis and hyperkalemia. The NM group showed a smaller decrease in hemoglobin levels during CKRT (–1.90 g/dL vs. –2.39 g/dL) and less need for blood product transfusions than the NA group. Furthermore, the NM group exhibited a survival benefit in patients who required transfusion of all three blood products. Conclusion NM is an effective and safe anticoagulant for CKRT in critically ill patients, especially those requiring transfusion of all three blood products. Although these findings are promising, further multicenter studies are needed to validate them and explore the mechanisms underlying the observed benefits.

Background Whether advanced age is associated with poor outcomes of elderly patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) is controversial. This study aimed to evaluate age effect and predictors for mortality in elderly AKI patients undergoing CRRT. Methods Data of 480 elderly AKI patients who underwent CRRT were retrospectively analyzed. Subjects were stratified into two groups according to age: younger-old (age, 65–74 years; n = 205) and older-old (age, ≥75 years; n = 275). Predictors for 28-day and 90-day mortality and age effects were analyzed using multivariable Cox regression analysis and propensity score matching. Results Urine output at the start of CRRT (adjusted hazard ratio [aHR], 0.99; 95% confidence interval [CI], 0.99–1.00; p = 0.04), operation (aHR, 0.53; 95% CI, 0.30–0.93; p = 0.03), and use of an intra-aortic balloon pump (aHR, 3.60; 95% CI, 1.18–10.96; p = 0.02) were predictors for 28-day mortality. Ischemic heart disease (aHR, 1.74; 95% CI, 1.02–2.98; p = 0.04) and use of a ventilator (aHR, 0.56; 95% CI, 0.36–0.89; p = 0.01) were predictors for 90-day mortality. The older-old group did not exhibit a higher risk for 28-day or 90-day mortality than the younger-old group in multivariable or propensity score-matched models. Conclusion Advanced age was not a risk factor for mortality among elderly AKI patients undergoing CRRT, suggesting that advanced age should not be considered for therapeutic decisions in critically ill elderly patients with AKI requiring CRRT.

Abstract Background Regional citrate anticoagulation (RCA) is recommended during continuous renal replacement therapy. Compared to systemic anticoagulation, RCA provides a longer filter lifespan with the risk of metabolic alkalosis and impaired calcium homeostasis. Surprisingly, most RCA protocols are designed for continuous veno-venous hemodialysis or hemodiafiltration. Effective protocols for continuous veno-venous hemofiltration (CVVH) are rare, although CVVH is a standard treatment for high-molecular-weight clearance. Therefore, we evaluated a new RCA protocol for postdilution CVVH. Methods This is a monocentric prospective interventional study to evaluate a new RCA protocol for postdilution CVVH. We recruited surgical patients with stage III acute kidney injury who needed renal replacement therapy. We recorded dialysis and RCA data and hemodynamic and laboratory parameters during treatment sessions of 72 h. The primary endpoint was filter patency at 72 h. The major safety parameters were metabolic alkalosis and severe hypocalcemia at any time. Results We included 38 patients who underwent 66 treatment sessions. The mean filter lifespan was 66 ± 12 h, and 44 of 66 (66%) filters were patent at 72 h. After censoring for non-CVVH-related cessation of treatment, 83% of all filters were patent at 72 h. The delivered dialysis dose was 28 ± 5 ml/kgBW/h. The serum levels of creatinine, urea and beta2-microglobulin decreased significantly from day 0 to day 3. Metabolic alkalosis occurred in one patient. An iCa++ below 1.0 mmol/L occurred in four patients. Citrate accumulation did not occur. Conclusions We describe a safe, effective, and easy-to-use RCA protocol for postdilution CVVH. This protocol provides a long and sustained filter lifespan without serious adverse effects. The risk of metabolic alkalosis and hypocalcemia is low. Using this protocol, a recommended dialysis dose can be safely administered with effective clearance of low- and middle-molecular-weight molecules. Trial registration The study was approved by the medical ethics committee of Heinrich-Heine University Duesseldorf (No. 2018-82KFogU). The trial was registered in the local study register of the university (No: 2018044660) on 07/04/2018 and was retrospectively registered at ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT03969966) on 31/05/2019.

Abstract Background The aim of this experimental study was to elucidate whether different distances between central venous catheter tips can affect drug clearance during continuous renal replacement therapy (CRRT). Central venous catheters (CVCs) are widely used in intensive care patients for drug infusion. If a patient receives CRRT, a second central dialysis catheter (CDC) is required. Where to insert CVCs is directed by guidelines, but recommendations regarding how to place multiple catheters are scarce. There are indications that a drug infused in a CVC with the tip close to the tip of the CDC, could be directly aspirated into the dialysis machine, with a risk of increased clearance. However, studies on whether clearance is affected by different CVC and CDC tip positions, when the two catheters are in the same vessel, are few. Methods In this model with 18 piglets, gentamicin (GM) and vancomycin (VM) were infused through a CVC during CRRT. The CVC tip was placed in different positions in relation to the CDC tip from caudal, i.e., proximal to the heart, to cranial, i.e., distal to the heart. Serum and dialysate concentrations were sampled after approximately 30 min of CRRT at four different positions: when the CVC tip was 2 cm caudally (+ 2), at the same level (0), and at 2 (− 2) and 4 (− 4) cm cranially of the tip of the CDC. Clearance was calculated. A mixed linear model was performed, and level of significance was set to p

Abstract Optimal strategy for volume control and the clinical implication of achieved volume control are unknown in patients with sepsis-associated acute kidney injury (AKI) receiving continuous renal replacement therapy (CRRT). This randomized controlled trial aimed to compare the survival according to conventional or bioelectrical impedance analysis (BIA)-guided volume control strategy in patients with sepsis-associated AKI receiving CRRT. We also compared patient survival according to achieved volume accumulation rate ([cumulative fluid balance during 3 days × 100]/fluid overload measured by BIA at enrollment) as a post-hoc analysis. We randomly assigned patients to conventional volume control strategy (n = 39) or to BIA-guided volume control strategy (n = 34). There were no differences in 28-day mortality (HR, 1.19; 95% CI, 0.63–2.23) or 90-day mortality (HR, 0.99; 95% CI 0.57–1.75) between conventional and BIA-guided volume control group. In the secondary analysis, achieved volume accumulation rate was significantly associated with patient survival. Compared with the achieved volume accumulation rate of ≤ − 50%, the HRs (95% CIs) for the risk of 90-day mortality were 1.21 (0.29–5.01), 0.55 (0.12–2.48), and 7.18 (1.58–32.51) in that of − 50–0%, 1–50%, and > 50%, respectively. Hence, BIA-guided volume control in patients with sepsis-associated AKI receiving CRRT did not improve patient outcomes. In the secondary analysis, achieved volume accumulation rate was associated with patient survival.

Abstract Introduction Acute kidney injury (AKI) is linked to disease severity and prognosis in patients with coronavirus disease 2019 (COVID-19), and mortality increases even with milder stages. This study primarily investigated the effects of continuous renal replacement therapy (CRRT) timing on intensive care unit (ICU) mortality in patients with COVID-19 with acute respiratory distress syndrome (ARDS) and AKI. Secondary goals were secondary goals for the ICU, days without life support treatment, and change in post-CRRT day biomarker levels, the length of ICU and overall hospital stay. Methods In this retrospective study, patients with COVID-19 with ARDS and AKI were divided into CRRT initiated at AKI stages 1 and 2, early-CRRT (E-CRRT) and AKI stage 3, late-CRRT (L-CRRT) and followed until discharge or death. Results E-CRRT had 20 patients and L-CRRT had 18 patients. No association between CRRT timing and ICU mortality was detected (p = 0.724). Moreover, the timing was not associated with ICU, total hospital stay, or days without life support treatment. However, it was associated with D-dimer levels for both groups and ferritin and C-reactive protein (CRP) levels for E-CRRT. There were no associations for other markers, such as procalcitonin, troponin T, pro-brain natriuretic peptide (pro-BNP), interleukin-6, fibrinogen, or antithrombin III levels. Conclusions CRRT timing was not associated with ICU mortality, total hospital stay, or days without life support treatment in this cohort. For E-CRRT, ferritin and CRP levels, and for both groups, D-dimer levels, were associated with CRRT timing. Randomized controlled trials are needed to examine the effects of CRRT timing in patients with COVID-19 with ARDS and AKI.

Abstract Background Acute kidney injury (AKI) is a common and serious condition, particularly among elderly patients. It is associated with high morbidity and mortality rates, further compounded by the need for continuous renal replacement therapy in severe cases. To improve clinical decision-making and patient management, there is a need for accurate prediction models that can identify patients at a high risk of mortality. Methods Data were extracted from the Dryad Digital Repository. Multivariate analysis was performed using least absolute shrinkage and selection operator (LASSO) logistic regression analysis to identify independent risk factors and construct a predictive nomogram for mortality within 28 days after continuous renal replacement therapy in elderly patients with acute kidney injury. The discrimination of the model was evaluated in the validation cohort using the area under the receiver operating characteristic curve (AUC), and calibration was evaluated using a calibration curve. The clinical utility of the model was assessed using decision curve analysis (DCA). Results A total of 606 participants were enrolled and randomly divided into two groups: a training cohort (n = 424) and a validation cohort (n = 182) in a 7:3 proportion. A risk prediction model was developed to identify independent predictors of 28-day mortality in elderly patients with AKI. The predictors included age, systolic blood pressure, creatinine, albumin, phosphorus, age-adjusted Charlson Comorbidity Index (CCI), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and sequential organ failure assessment (SOFA) score. These predictors were incorporated into a logistic model and presented in a user-friendly nomogram. In the validation cohort, the model demonstrated good predictive performance with an AUC of 0.799. The calibration curve showed that the model was well calibrated. Additionally, DCA revealed significant net benefits of the nomogram for clinical application. Conclusion The development of a nomogram for predicting 28-day mortality in elderly patients with AKI receiving continuous renal replacement therapy has the potential to improve prognostic accuracy and assist in clinical decision-making.

Abstract There remains no optimal anticoagulation protocol for continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) in pediatric patients with elevated D-dimer levels. We aimed to assess the effects of different anticoagulation strategies on the risk of CRRT filter clotting in these patients. Pediatric patients undergoing CRRT were retrospectively grouped based on pre-CRRT D-dimer levels and anticoagulant: D-RCA group (normal D-dimer, RCA only, n = 22), D+ RCA group (elevated D-dimer, RCA only, n = 50), and D+ RCA+ systemic heparin anticoagulation (SHA) group (elevated D-dimer, RCA combined with SHA, n = 55). The risk of filter clotting and incidence of bleeding were compared among the groups. Among the groups, the D+ RCA+ SHA group had the longest filter lifespan; further, the incidence of bleeding was not increased by concurrent use of low-dose heparin for anticoagulation. Moreover, concurrent heparin anticoagulation was associated with a decreased risk of filter clotting. Contrastingly, high pre-CRRT hemoglobin and D-dimer levels and post-filter ionized calcium level > 0.4 mmol/L were associated with an increased risk of filter clotting. RCA combined with low-dose heparin anticoagulation could reduce the risk of filter clotting and prolong filter lifespan without increasing the risk of bleeding in patients with elevated D-dimer levels undergoing CRRT.

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]