Continuous renal replacement therapy and the COVID pandemic.
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ABSTRACT:
SUBMITTER: Stevens JS
PROVIDER: S-EPMC8242500 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Coronavirus disease 2019 (COVID-19) appears to be associated with increased arterial and venous thromboembolic disease. These presumed abnormalities in hemostasis have been associated with filter clotting during continuous renal replacement therapy (CRRT). We aimed to characterize the burden of CRRT filter clotting in COVID-19 infection and to describe a CRRT anticoagulation protocol that used anti-factor Xa levels for systemic heparin dosing. Multi-center study of consecutive patients with COVID-19 receiving CRRT. Primary outcome was CRRT filter loss. Sixty-five patients were analyzed, including 17 using an anti-factor Xa protocol to guide systemic heparin dosing. Fifty-four out of 65 patients (83%) lost at least one filter. Median first filter survival time was 6.5 [2.5, 33.5] h. There was no difference in first or second filter loss between the anti-Xa protocol and standard of care anticoagulation groups, however fewer patients lost their third filter in the protocolized group (55% vs. 93%) resulting in a longer median third filter survival time (24 [15.1, 54.2] vs. 17.3 [9.5, 35.1] h, p = 0.04). The rate of CRRT filter loss is high in COVID-19 infection. An anticoagulation protocol using systemic unfractionated heparin, dosed by anti-factor Xa levels is reasonable approach to anticoagulation in this population.
| S-EPMC7539277 | biostudies-literature
Project description:The outbreak of coronavirus disease 2019 (COVID-19) is a global health threat. It is a respiratory disease, and acute kidney injury (AKI) is rare; however, if a patient develops severe AKI, renal replacement therapy (RRT) should be considered. Recently, we had a critically ill COVID-19 patient who developed severe AKI and needed continuous RRT (CRRT). To avoid the potential risk of infection from CRRT effluents, we measured severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) genetic material in the effluents by qRT-PCR, and low copy numbers of the viral genome were detected. Due to unstable hemodynamic status in critically ill patients, CRRT should be the first choice for severe AKI in COVID-19 patients. We suggest prevention of clinical infection and control during administration of RRT in the acute phase of COVID-19 patients with AKI or multiple organ failure.
| S-EPMC7360495 | biostudies-literature
Project description:To report circuit characteristics and survival analysis in children weighing ≤10 kg enrolled in the Prospective Pediatric Continuous Renal Replacement Therapy (ppCRRT) Registry.We conducted prospective cohort analysis of the ppCRRT Registry to: (1) evaluate survival differences in children ≤10 kg compared with other children; (2) determine demographic and clinical differences between surviving and non-surviving children ≤10 kg; and (3) describe continuous renal replacement therapy (CRRT) circuit characteristics differences in children ≤5 kg versus 5-10 kg.The ppCRRT enrolled 84 children ≤10 kg between January 2001 and August 2005 from 13 US tertiary centers. Children ≤10 kg had lower survival rates than children >10 kg (36/84 [43%] versus 166/260 [64%]; P < .001). In children ≤10 kg, survivors were more likely to have fewer days in intensive care unit prior to CRRT, lower Pediatric Risk of Mortality 2 scores at intensive care unit admission and lower mean airway pressure (P(aw)), higher urine output, and lower percent fluid overload (FO) at CRRT initiation. Adjusted regression analysis revealed that Pediatric Risk of Mortality 2 scores, FO, and decreased urine output were associated with mortality. Compared with circuits from children 5-10 kg at CRRT initiation, circuits from children ≤5 kg more commonly used blood priming for initiation, heparin anticoagulation, and higher blood flows/effluent flows for body weight.Mortality is more common in children who are ≤10 kg at the time of CRRT initiation. Like other CRRT populations, urine output and FO at CRRT initiation are independently associated with mortality. CRRT prescription differs in small children.
| S-EPMC5545826 | biostudies-other
Project description:Doripenem is a broad-spectrum parenteral carbapenem with enhanced activity against Pseudomonas aeruginosa. While the initial dosing recommendation for renally competent patients and patients undergoing continuous renal replacement therapy (cRRT) was 500 mg every 8 h (q8h), the dose for renally competent patients was updated to 1 g q8h in June 2012. There are no updated data for the dosing of patients on continuous renal replacement therapy. The original dosing regimen for cRRT patients was based on nonseptic patients, while newer publications chose comparatively low target concentrations for a carbapenem. Thus, there is an urgent need for updated recommendations for dosing during cRRT. In the trial presented here, we included 13 oliguric septic patients undergoing cRRT in an intensive care setting. Five patients each were treated with hemodiafiltration or hemodialysis, while three patients received hemofiltration treatment. All patients received 1 g doripenem every 8 h. Doripenem concentrations in the plasma and ultrafiltrate were measured over 48 h. The mean hemofilter clearance was 36.53 ml/min, and the mean volume of distribution was 59.26 liters. The steady-state trough levels were found at 8.5 mg/liter, with no considerable accumulation. Based on pharmacokinetic and pharmacodynamic considerations, we propose a regimen of 1 g q8h, which may be combined with a loading dose of 1.5 to 2 g for critically ill patients. (This study has been registered with EudraCT under registration no. 2009-018010-18 and at ClinicalTrials.gov under registration no. NCT02018939.).
| S-EPMC4775919 | biostudies-literature
Project description:BackgroundRhabdomyolysis is a condition that is characterised by the breakdown of skeletal muscle tissue and leakage of intracellular myocyte contents into circulating blood. Rhabdomyolysis can lead to acute kidney injury (AKI) and is a potentially life-threatening condition. Studies have indicated that continuous renal replacement therapy (CRRT) may provide benefits for people with rhabdomyolysis by removing potentially damaging myoglobin and stabilising haemodynamic and metabolic status.ObjectivesWe aimed to: i) assess the efficacy of CRRT in removing myoglobin; ii) investigate the influence of CRRT on mortality and kidney-related outcomes; and iii) evaluate the safety of CRRT for the treatment of people with rhabdomyolysis.Search methodsWe searched the Cochrane Renal Group's Specialised Register to 6 January 2014 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. We also searched China National Knowledge Infrastructure (from 1 January 1979 to 16 April 2013) and the Chinese Clinical Trials Register (to 16 April 2013).Selection criteriaAll randomised controlled trials (RCTs) and quasi-RCTs that investigated clinical outcomes of CRRT for people with rhabdomyolysis were included.Data collection and analysisTwo authors independently assessed studies for inclusion and extracted data. We derived risk ratios (RR) for dichotomous data and mean differences (MD) for continuous data with 95% confidence intervals (CI). Methodological risk of bias was assessed using the Cochrane risk of bias tool.Main resultsOf the three included studies (101 participants), one evaluated continuous arteriovenous haemodialysis and two investigated continuous venovenous haemofiltration; all included conventional therapy as control.We found significant decreases in myoglobin in patients among whom CRRT therapy was initiated on days four, eight, and 10 (day 4: MD -11.00 (μg/L), 95% CI -20.65 to -1.35; Day 8: MD -23.00 (μg/L), 95% CI -30.92 to -15.08; day 10: MD -341.87 (μg/L), 95% CI -626.15 to -57.59) compared with those who underwent conventional therapy.Although CRRT was associated with improved serum creatinine, blood urea nitrogen, and potassium levels; reduced duration of the oliguria phase; and was associated with reduced time in hospital, no significant differences were found in mortality rates compared with conventional therapy (RR 0.17, 95% CI 0.02 to 1.37). The included studies did not report on long-term outcomes or prevention of AKI.Overall, we found that study quality was suboptimal: blinding and randomisation allocation were not reported by any of the included studies, leading to the possibility of selection, performance and detection bias.Authors' conclusionsAlthough CRRT may provide some benefits for people with rhabdomyolysis, the poor methodological quality of the included studies and lack of data relating to clinically important outcomes limited our findings about the effectiveness of CRRT for people with rhabdomyolysis.There was insufficient evidence to discern any likely benefits of CRRT over conventional therapy for people with rhabdomyolysis and prevention of rhabdomyolysis-induced AKI.
| S-EPMC10634660 | biostudies-literature
Project description:BackgroundOutcome for critically ill patients with COVID-19 treated with continuous renal replacement therapy (CRRT) is largely unknown. We describe mortality and renal outcome in this group.MethodsThis observational study was conducted at a university hospital in Sweden. We studied critically ill adult COVID-19 patients with Acute Kidney injury (AKI) who received CRRT.ResultsIn 451 patients, AKI incidence was 43.7%. 18.2% received CRRT. Median age of CRRT patients was 60 years (IQR 54-65), 90% were male, median BMI was 29 (IQR 25-32), 23.2% had Diabetes, 37.8% hypertension and 6.1% chronic kidney disease prior to admission. 100% required mechanical ventilation. 8.5% received Extra Corporeal Membrane Oxygenation. Median length of stay was 23 days (IQR 15-26). ICU mortality was 39% and 90-day mortality was 45.1%. Age, baseline creatinine values and body weight change were associated with 60 days mortality. Of the survivors, no patients required dialysis at hospital discharge, 73.8% recovered renal function and a median 10.5% of body weight was lost during admission.ConclusionsCritically ill COVID-19 patients with AKI who received CRRT had a 90-day mortality of 45.1%. At follow-up, three quarters of survivors had recovered renal function. This information is important in the clinical management of COVID-19.
| S-EPMC8052481 | biostudies-literature
Project description:BackgroundDuring the COVID-19 pandemic, maintenance of essential healthcare systems became very challenging. We describe the triage system of our institute, and assess the quality of care provided to critically ill non-COVID-19 patients requiring continuous renal replacement therapy (CRRT) during the pandemic.MethodsWe introduced an emergency triage pathway early in the pandemic. We retrospectively reviewed the medical records of patients who received CRRT in our hospital from January 2016 to March 2021. We excluded end-stage kidney disease patients on maintenance dialysis. Patients were stratified as medical and surgical patients. The time from hospital arrival to intensive care unit (ICU) admission, the time from hospital arrival to intervention/operation, and the in-hospital mortality rate were compared before (January 2016 to December 2019) and during (January 2021 to March 2021) the pandemic.ResultsThe mean number of critically ill patients who received CRRT annually in the surgical department significantly decreased during the pandemic in (2016-2019: 76.5 ± 3.1; 2020: 56; p < 0.010). Age, sex, and the severity of disease at admission did not change, whereas the proportions of medical patients with diabetes (before: 44.4%; after: 56.5; p < 0.005) and cancer (before: 19.4%; after: 32.3%; p < 0.001) increased during the pandemic. The time from hospital arrival to ICU admission and the time from hospital arrival to intervention/operation did not change. During the pandemic, 59.6% of surgical patients received interventions/operations within 6 hours of hospital arrival. In Cox's proportional hazard modeling, the hazard ratio associated with the pandemic was 1.002 (0.778-1.292) for medical patients and 1.178 (0.783-1.772) for surgical patients.ConclusionOur triage system maintained the care required by critically ill non-COVID-19 patients undergoing CRRT at our institution.
| S-EPMC9342846 | biostudies-literature
Project description:Continuous renal replacement therapy (CRRT) is widely utilized to support critically ill patients with acute kidney injury. Artificial intelligence (AI) has the potential to enhance CRRT delivery, but evidence is limited. We reviewed existing literature on the utilization of AI in CRRT with the objective of identifying current gaps in evidence and research considerations. We conducted a scoping review focusing on the development or use of AI-based tools in patients receiving CRRT. Ten papers were identified; 6 of 10 (60%) published in 2021, and 6 of 10 (60%) focused on machine learning models to augment CRRT delivery. All innovations were in the design/early validation phase of development. Primary research interests focused on early indicators of CRRT need, prognostication of mortality and kidney recovery, and identification of risk factors for mortality. Secondary research priorities included dynamic CRRT monitoring, predicting CRRT-related complications, and automated data pooling for point-of-care analysis. Literature gaps included prospective validation and implementation, biases ascertainment, and evaluation of AI-generated health care disparities. Research on AI applications to enhance CRRT delivery has grown exponentially in the last years, but the field remains premature. There is a need to evaluate how these applications could enhance bedside decision-making capacity and assist structure and processes of CRRT delivery.
| S-EPMC9586461 | biostudies-literature
Project description:BackgroundRestart of renal replacement therapy (RRT) after initial discontinuation of continuous RRT (CRRT) is frequently needed. The aim of the present study was to evaluate whether renal markers after discontinuation of CRRT can predict restart of RRT within 90 days.MethodsProspective multicenter observational study in 90 patients, alive, still on the intensive care unit at day 2 after discontinuation of CRRT for expected recovery with urinary neutrophil gelatinase-associated lipocalin (NGAL) available. The endpoint was restart of RRT within 90 days. Baseline and renal characteristics were compared between outcome groups no restart or restart of RRT. Logistic regression and receiver operator characteristic curve analysis were performed to determine the best predictive and discriminative variables.ResultsRestart of RRT was needed in 32/90 (36%) patients. Compared to patients not restarting, patients restarting RRT demonstrated a higher day 2 urinary NGAL, lower day 2 urine output, and higher incremental creatinine ratio (day 2/0). In multivariate analysis, only incremental creatinine ratio (day 2/0) remained independently associated with restart of RRT (OR 5.28, 95% CI 1.45-19.31, p = 0.012). The area under curve for incremental creatinine ratio to discriminate for restart of RRT was 0.76 (95% CI 0.64-0.88). The optimal cutoff was 1.49 (95% CI 1.44-1.62).ConclusionIn this prospective multicenter study, incremental creatinine ratio (day 2/0) was the best predictor for restart of RRT. Patients with an incremental creatinine ratio at day 2 of 1.5 times creatinine at discontinuation are likely to need RRT within 90 days. These patients might benefit from nephrological follow-up.
| S-EPMC6878749 | biostudies-literature
Project description:BackgroundThe survival of critically ill patients with acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT) is highly dependent on their nutritional status.ObjectivesThe 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.MethodsWe 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.ResultsPatients 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.ConclusionsPNI 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.
| S-EPMC11232640 | biostudies-literature