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Wang F, Zhang R, Tan L, Mei T, Chen H, Zhang Y, Zeng Y, Chen Z, Cao Y. A predictive model for real-time LSTM methods: Monitoring dynamic transmembrane pressure improves loop life and anticoagulant therapy accuracy in continuous renal replacement therapy. Technol Health Care 2025:9287329251337277. [PMID: 40397109 DOI: 10.1177/09287329251337277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2025]
Abstract
BackgroundContinuous Renal Replacement Therapy (CRRT), is essential for managing acute kidney injury (AKI) Dynamic monitoring of transmembrane pressure (TMP) during CRRT is crucial for predicting filter clotting and optimizing filter lifespan, which indirectly supports anticoagulation management.ObjectiveTo prolong the lifespan of CRRT circuits and enhance the precision of anticoagulation therapy by developing a predictive early warning model for CRRT circuit life, based on dynamic TMP monitoring.MethodsWe conducted a retrospective analysis in the ICU of the First Affiliated Hospital of Army Medical University. Leveraging the TMP data recorded by CRRT machines, we established an adaptive real-time predictive modeling framework, termed DTP (Dynamic Transmembrane Pressure Prediction), utilizing Long Short-Term Memory (LSTM) networks. This framework predicts TMP trends as an early indicator of filter clotting. Our models were validated using over 20,000 min of clinical data from 405 CRRT cases, predicting TMP trajectories within 50 min.ResuitsIn simulated treatment evaluations, our LSTM models accurately identified impending TMP increases, achieving recall rates exceeding 0.97 and F2 scores above 0.93. Notably, an average warning time of 23 min was provided prior to the TMP reaching the critical 260 mmHg threshold, indicating substantial filter clotting. An analysis of false alarms revealed patterns consistent with emerging instability and transient artifacts.ConclusionThe personalized early warning model developed within the DTP framework effectively predicts TMP changes, enhancing the accuracy and timeliness of medical interventions. This improvement reduces the incidence of adverse events, maximizes the lifespan of CRRT circuits, and ultimately decreases treatment and personnel costs.
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Affiliation(s)
- Fangzheng Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of the Army Medical University, Chongqing, China
| | - Rui Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of the Army Medical University, Chongqing, China
| | - Liang Tan
- Department of Critical Care Medicine, The First Affiliated Hospital of the Army Medical University, Chongqing, China
| | - Tieniu Mei
- Department of Critical Care Medicine, The First Affiliated Hospital of the Army Medical University, Chongqing, China
| | - Hongya Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of the Army Medical University, Chongqing, China
| | - Yonghui Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of the Army Medical University, Chongqing, China
| | - Yu Zeng
- Department of Critical Care Medicine, The First Affiliated Hospital of the Army Medical University, Chongqing, China
| | - Zuzhi Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of the Army Medical University, Chongqing, China
| | - Ying Cao
- Department of Critical Care Medicine, The First Affiliated Hospital of the Army Medical University, Chongqing, China
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Peng D, Cai Z, He J, Duan W, Zhang X. Comparison of regional citrate anticoagulation and nafamostat mesylate anticoagulation during plasma exchange for children at high bleeding risk: a retrospective study. Ital J Pediatr 2025; 51:114. [PMID: 40221768 PMCID: PMC11994001 DOI: 10.1186/s13052-025-01954-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 03/27/2025] [Indexed: 04/14/2025] Open
Abstract
BACKGROUND There is currently no established optimal anticoagulation protocol for plasma exchange (PE) in pediatric patients at a high risk of bleeding. Therefore, we aimed to evaluate the efficacy and safety of regional citrate anticoagulation (RCA) and nafamostat mesylate (NM) for PE anticoagulation in this patient group. METHODS This retrospective study analyzed data from 66 children with high bleeding risk who underwent PE in the Pediatric Intensive Care Unit of Hunan Children's Hospital between June 2018 and January 2023. Patients were divided into two groups: RCA-PE (n = 45) and NM-PE (n = 21), and filter performance and adverse reaction rates were compared. Statistical analysis utilized SPSS 25.0, comprising two-sample t-tests, chi-square or Fisher's exact tests, and Mann-Whitney U tests, as appropriate. Data visualization was performed using ggplot2 in R-studio. P < 0.05 was considered statistically significant. RESULTS No statistically significant differences were found between the two groups in initial transmembrane pressure (TMP) [17.0 (14.0, 21.5) mmHg vs. 16.0 (14.0, 19.5) mmHg, P = 0.614], maximum TMP [46.0 (42.0, 49.5) mmHg vs. 43.0 (41.5, 49.5) mmHg, P = 0.689], and final TMP [40.0 (35.5, 45.0) mmHg vs. 38.0 (35.0, 42.0) mmHg, P = 0.298]. Filter grade distribution and bleeding events also showed no statistically significant difference between the groups. However, the NM-PE group had significantly lower overall adverse reaction and metabolic alkalosis rates (both P < 0.05) compared to the RCA-PE group. CONCLUSIONS NM demonstrates similar efficacy but superior safety compared with RCA, making it a more suitable anticoagulation strategy for children with high bleeding risk. Study limitations include single-center design, selection bias, and uncertain NM dosage.
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Affiliation(s)
- Dan Peng
- Department of Critical Care Medicine, Affiliated Children's Hospital of Xiangya School of Medicine, Central South University, Hunan Children's Hospital, Changsha, 410007, Hunan, China
| | - Zili Cai
- Health Management Center, Affiliated Children's Hospital of Xiangya School of Medicine, Central South University, Hunan Children's Hospital, Changsha, 410007, Hunan, China
| | - Jie He
- Department of Critical Care Medicine, Affiliated Children's Hospital of Xiangya School of Medicine, Central South University, Hunan Children's Hospital, Changsha, 410007, Hunan, China
| | - Wei Duan
- Complex Disease Ward, Affiliated Children's Hospital of Xiangya School of Medicine, Central South University, Hunan Children's Hospital, Changsha, 410007, Hunan, China
| | - Xinping Zhang
- Department of Critical Care Medicine, Affiliated Children's Hospital of Xiangya School of Medicine, Central South University, Hunan Children's Hospital, Changsha, 410007, Hunan, China.
- Pediatric Intensive Care Unit, The Affiliated Children's Hospital of Xiangya School of Medicine, Central South University/Hunan Children's Hospital, No. 86 Ziyuan Rd, Yuhua District, Changsha, 410007, China.
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Mateos-Dávila A, Betbesé Roig AJ, Santos Rodríguez JA, Guix-Comellas EM. Change in prefilter pressure as a key determinant in the decision to return blood in continuous renal replacement therapy: An observational study. Nurs Crit Care 2024; 29:1441-1449. [PMID: 37277948 DOI: 10.1111/nicc.12933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND During continuous renal replacement therapy (CRRT), circuit coagulation is an important event that can result in suboptimal outcomes. Nurses must remain alert throughout the treatment and observe machine pressures. Transmembrane pressure (TMP) is commonly used for monitoring but it is sometimes too late to return blood to the patient. AIM To compare the capacity of prefilter pressure (FP) versus TMP to predict the risk of circuit coagulation in adult patients with acute renal failure on CRRT. STUDY DESIGN An observational, longitudinal, prospective study. This study was carried out in a tertiary referral hospital over 2 years. Data collected included the following variables: TMP, filter or FP, effluent pressure, venous and arterial pressure, filtration fraction, and ultrafiltration constant of each circuit. Means and their trends over time were collected, for both diffusive and convective therapy and for two membrane types. RESULTS A total of 151 circuits (24 polysulfone and 127 acrylonitrile) were analysed, from 71 patients (n = 22 [34%] women; mean age, 66.5 [36-84] years). Of the total treatments, 80 were diffusive, and the rest were convective or mixed. In the diffusive circuits, a progressive rise in FP was observed without an increase in TMP and with an increasing trend in effluent pressure. Circuit lifespan was between 2 and 90 h. In 11% (n = 17) of the cases, the blood could not be returned to the patient. CONCLUSION These findings allowed the creation of graphs that indicate the appropriate point to return blood to the patient. FP was a major determinant in this decision; in most cases, TMP was not a reliable parameter. Our findings are applicable to convective, diffusive, and mixed treatments as well as both types of membranes used in this acute setting. RELEVANCE TO CLINICAL PRACTICE This study provides two clear reference graphs showing risk scales for the assessment of circuit pressures in CRRT. The graphs proposed here can be used to evaluate any machine on the market and the two types of membranes used in this acute setting. Both convective and diffusive circuits can be assessed, allowing safer evaluation in patients who change treatment.
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Affiliation(s)
- Almudena Mateos-Dávila
- Nursing and Health PhD program, Department of Fundamental and Medico-Surgical Nursing, Nursing school, Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
- Nursing Care Research Group, Sant Pau Biomedical Research Institute (IIB SANT PAU), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Antonio Jorge Betbesé Roig
- Sant Pau Biomedical Research Institute (IIB SANT PAU), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Eva Maria Guix-Comellas
- Department of Fundamental and Medico-Surgical Nursing. Nursing school. Faculty of Medicine and Health Sciences. Campus Clinic, Universitat de Barcelona, Barcelona, Spain
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Yang E, Wang Q, Guo J, Wei J, Zhang C, Zhao W, He X, Bo E, Mao Y, Yang H. Development and external validation of a prediction model for the premature circuit clotting of continuous renal replacement therapy in critically ill patients. Intensive Crit Care Nurs 2024; 84:103703. [PMID: 38704337 DOI: 10.1016/j.iccn.2024.103703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/11/2024] [Accepted: 04/03/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVE This study aimed to develop and validate a prediction model for premature circuit clotting of continuous renal replacement therapy (CRRT) in critically ill patients. DESIGN A retrospective cohort study was conducted on ICU patients undergoing CRRT. The Medical Information Mart for Intensive Care-III Clinical Database CareVue subset and Medical Information Mart for Intensive Care-IV were utilized for model development, while the eICU Collaborative Research Database was employed for external validation. Predictive factors were selected through Least Absolute Shrinkage and Selection Operator Regression and univariate logistic regression. A prediction model was then developed using binary logistic regression. Internal and external validations assessed the model's discrimination, calibration, and clinical net benefit. RESULTS This study encompassed 2531 patients overall, with a premature circuit clotting rate of 31.88 %. The prediction model comprises five variables: body temperature, anticoagulation, mean arterial pressure, maximum transmembrane pressure change within two hours, and vasopressor. The model demonstrated robust predictive performance, achieving an area under the receiver operating characteristic curve of 0.897 (95 % CI: 0.879-0.915) in the training set and 0.877 (95 % CI: 0.852-0.902) in the external validation set. Internal validation yielded a Brier score of 0.087, while external validation showed a Brier score of 0.120. Calibration curves indicated good model calibration for both validations. The decision curve analysis indicates that the model yields a clinical net benefit across a wide range of decision thresholds. CONCLUSION The model demonstrates robust discrimination, calibration, and clinical net benefit, with readily available variables indicating substantial potential for valuable clinical applications. IMPLICATIONS FOR CLINICAL PRACTICE Healthcare providers in the ICU can leverage the model to evaluate the risk of premature circuit clotting in critically ill patients undergoing continuous renal replacement therapy, facilitating timely intervention to mitigate its incidence.
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Affiliation(s)
- Erming Yang
- School of Nursing, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Qiaohong Wang
- Department of Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Jing Guo
- Department of Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Jilin Wei
- Department of Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Chiyu Zhang
- Department of Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Wenfang Zhao
- Department of Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xingyue He
- School of Nursing, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Enhui Bo
- School of Nursing, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Ya Mao
- School of Nursing, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Hui Yang
- School of Nursing, Shanxi Medical University, Taiyuan, Shanxi, China; The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China.
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Hu C, Shui P, Zhang B, Xu X, Wang Z, Wang B, Yang J, Xiang Y, Zhang J, Ni H, Hong Y, Zhang Z. How to safeguard the continuous renal replacement therapy circuit: a narrative review. Front Med (Lausanne) 2024; 11:1442065. [PMID: 39234046 PMCID: PMC11373359 DOI: 10.3389/fmed.2024.1442065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Accepted: 07/30/2024] [Indexed: 09/06/2024] Open
Abstract
The high prevalence of acute kidney injury (AKI) in ICU patients emphasizes the need to understand factors influencing continuous renal replacement therapy (CRRT) circuit lifespan for optimal outcomes. This review examines key pharmacological interventions-citrate (especially in regional citrate anticoagulation), unfractionated heparin (UFH), low molecular weight heparin (LMWH), and nafamostat mesylate (NM)-and their effects on filter longevity. Citrate shows efficacy with lower bleeding risks, while UFH remains cost-effective, particularly in COVID-19 cases. LMWH is effective but associated with higher bleeding risks. NM is promising for high-bleeding risk scenarios. The review advocates for non-tunneled, non-cuffed temporary catheters, especially bedside-inserted ones, and discusses the advantages of surface-modified dual-lumen catheters. Material composition, such as polysulfone membranes, impacts filter lifespan. The choice of treatment modality, such as Continuous Veno-Venous Hemodialysis (CVVHD) or Continuous Veno-Venous Hemofiltration with Dialysis (CVVHDF), along with the management of effluent volume, blood flow rates, and downtime, are critical in prolonging filter longevity in CRRT. Patient-specific conditions, particularly the type of underlying disease, and the implementation of early mobilization strategies during CRRT are identified as influential factors that can extend the lifespan of CRRT filters. In conclusion, this review offers insights into factors influencing CRRT circuit longevity, supporting evidence-based practices and suggesting further multicenter studies to guide ICU clinical decisions.
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Affiliation(s)
- Chaomin Hu
- Department of Emergency Medicine, Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou, China
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Pengfei Shui
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bo Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xin Xu
- Department of Emergency Medicine, Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou, China
| | - Zhengquan Wang
- Department of Emergency Medicine, Yuyao City People's Hospital, Yuyao, China
| | - Bin Wang
- Department of Emergency Medicine, Anji People’s Hospital, Anji, China
| | - Jie Yang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yang Xiang
- Department of Emergency Medicine, Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou, China
| | - Jun Zhang
- Department of Emergency Medicine, Yuyao City People's Hospital, Yuyao, China
| | - Hongying Ni
- Department of Critical Care Medicine, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- School of Medicine, Shaoxing University, Shaoxing, Zhejiang, China
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Hadley S, Thompson J, Beltramo F, Marcum J, Reuter-Rice K. Impact of Continuous Renal Replacement Therapy Initiation Time, Kidney Injury, and Hypervolemia in Critically Ill Children. Crit Care Nurse 2024; 44:28-35. [PMID: 38821525 DOI: 10.4037/ccn2024440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
BACKGROUND The mortality rate of pediatric patients who require continuous renal replacement therapy is approximately 42%, and outcomes vary considerably depending on underlying disease, illness severity, and time of dialysis initiation. Delay in the initiation of such therapy may increase mortality risk, prolong intensive care unit stay, and worsen clinical outcomes. LOCAL PROBLEM In the pediatric intensive care unit of an urban level I trauma children's hospital, continuous renal replacement therapy initiation times and factors associated with delays in therapy were unknown. METHODS This quality improvement process involved a retrospective review of data on patients who received continuous dialysis in the pediatric intensive care unit from January 1, 2017, to December 31, 2021. The objectives were to examine the characteristics of the children requiring continuous renal replacement therapy, therapy initiation times, and factors associated with initiation delays that might affect unit length of stay and mortality. RESULTS During the study period, 175 patients received continuous renal replacement therapy, with an average initiation time of 11.9 hours. Statistically significant associations were found between the degree of fluid overload and mortality (P < .001) and between the presence of acute kidney injury and prolonged length of stay (P = .04). No significant association was found between therapy initiation time and unit length of stay or mortality, although the average initiation time of survivors was 5.9 hours shorter than that of nonsurvivors. CONCLUSION Future studies are needed to assess real time delays and to evaluate if the implementation of a standardized initiation process decreases initiation time.
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Affiliation(s)
- Sierra Hadley
- Sierra Hadley is an acute care pediatric nurse practitioner in the pediatric intensive care unit at Children's Hospital Los Angeles, California
| | - Julie Thompson
- Julie Thompson is a consulting associate at the Duke University School of Nursing, Durham, North Carolina
| | - Fernando Beltramo
- Fernando Beltramo is an attending physician, an intensivist, and Director of the pediatric intensive care unit at Children's Hospital Los Angeles and an assistant professor of clinical pediatrics at the Keck School of Medicine of USC, Los Angeles, California
| | - John Marcum
- John Marcum is an attending physician and an intensivist at Children's Hospital Los Angeles and an assistant professor of clinical pediatrics at the Keck School of Medicine of USC
| | - Karin Reuter-Rice
- Karin Reuter-Rice is an associate professor at the Duke University School of Nursing, School of Medicine, and the Duke Institute for Brain Sciences. She is also faculty in the Division of Pediatric Critical Care, Duke University Health System
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Yoshimoto K, Matsuura R, Komaru Y, Yoshida T, Miyamoto Y, Hamasaki Y, Inokuchi R, Nangaku M, Doi K. Solute Clearance Evaluation and Filter Clotting Prediction in Continuous Renal Replacement Therapy. J Clin Med 2023; 12:7703. [PMID: 38137772 PMCID: PMC10743554 DOI: 10.3390/jcm12247703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/06/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
Unexpected filter clotting is a major problem in continuous renal replacement therapy (CRRT). Reduced solute clearance is observed prior to filter clotting. This single-center, retrospective, observational study aimed to determine whether reduced solute clearance of low- and medium-molecular-weight molecules in CRRT can predict filter clotting. Solute clearances of urea and myoglobin (Mb) were measured at 24 h after initiation of continuous hemodiafiltration (CHDF). Clearance per flow (CL/F) was calculated. The primary outcome was clotting of the filter in the subsequent 24 h, and 775 CHDF treatments conducted on 230 patients for at least 24 consecutive hours in our ICU were analyzed. Filter clotting was observed in 127 treatments involving 39 patients. Urea and Mb CL/F at 24 h were significantly lower in the patients who experienced clotting. Further analysis was limited to the first CHDF treatment of each patient to adjust for confounding factors. Multivariate logistic regression analysis revealed that both urea CL/F < 94% and Mb CL/F < 64% were significant predictors of clotting within the next 24 h. Lower urea and Mb CL/F measured at 24 h after CRRT initiation were associated with filter clotting in the next 24 h. Further study is necessary to ascertain whether measurement of urea and MB CL/F will help with avoiding unexpected filter clotting.
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Affiliation(s)
- Kohei Yoshimoto
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.Y.)
| | - Ryo Matsuura
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo 113-8655, Japan (T.Y.)
| | - Yohei Komaru
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.Y.)
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo 113-8655, Japan (T.Y.)
| | - Teruhiko Yoshida
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo 113-8655, Japan (T.Y.)
| | - Yoshihisa Miyamoto
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo 113-8655, Japan (T.Y.)
| | - Yoshifumi Hamasaki
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo 113-8655, Japan (T.Y.)
| | - Ryota Inokuchi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.Y.)
| | - Masaomi Nangaku
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo 113-8655, Japan (T.Y.)
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.Y.)
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8
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Anticoagulation in patients with acute kidney injury undergoing kidney replacement therapy. Pediatr Nephrol 2022; 37:2303-2330. [PMID: 34668064 DOI: 10.1007/s00467-021-05020-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/13/2020] [Accepted: 02/18/2021] [Indexed: 10/20/2022]
Abstract
Kidney replacement therapy (KRT) is used to provide supportive therapy for critically ill patients with severe acute kidney injury and various other non-renal indications. Modalities of KRT include continuous KRT (CKRT), intermittent hemodialysis (HD), and sustained low efficiency daily dialysis (SLED). However, circuit clotting is a major complication that has been investigated extensively. Extracorporeal circuit clotting can cause reduction in solute clearances and can cause blood loss, leading to an upsurge in treatment costs and a rise in workload intensity. In this educational review, we discuss the pathophysiology of the clotting cascade within an extracorporeal circuit and the use of various types of anticoagulant methods in various pediatric KRT modalities.
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Buccione E, Bambi S, Rasero L, Tofani L, Piazzini T, Della Pelle C, El Aoufy K, Ricci Z, Romagnoli S, Villa G. Regional Citrate Anticoagulation and Systemic Anticoagulation during Pediatric Continuous Renal Replacement Therapy: A Systematic Literature Review. J Clin Med 2022; 11:jcm11113121. [PMID: 35683511 PMCID: PMC9181744 DOI: 10.3390/jcm11113121] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 05/24/2022] [Accepted: 05/30/2022] [Indexed: 12/20/2022] Open
Abstract
Background: Clotting is a major drawback of continuous renal replacement therapy (CRRT) performed on critically ill pediatric patients. Although anticoagulation is recommended to prevent clotting, limited results are available on the effect of each pharmacological strategy in reducing filter clotting in pediatric CRRT. This study defines which anticoagulation strategy, between regional citrate anticoagulation (RCA) and systemic anticoagulation with heparin, is safer and more efficient in reducing clotting, patient mortality, and treatment complications during pediatric CRRT. Methods: A systematic literature review was run considering papers published in English until December 2021 and describing patients’ and treatments’ complications in CRRT performed with heparin and RCA on patients aged less than 18 years. Results: Eleven studies were considered, cumulatively comprising 1.706 CRRT sessions (62% with systemic anticoagulation and 38% with RCA). Studies have consistently identified RCA’s superiority over systemic anticoagulation with heparin in prolonging circuit life. The pooled estimate (95% CI) of filter clotting risk showed that RCA is a protective factor for clotting risk (RR = 0.204). Conclusions: RCA has a potential role in prolonging circuit life and seems superior to systemic anticoagulation with heparin in decreasing the risk of circuit clotting during CRRT performed in critically ill pediatric patients.
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Affiliation(s)
- Emanuele Buccione
- Neonatal Intensive Care Unit, 65124 Pescara, Italy
- Correspondence: ; Tel.: +39-349-809-8954
| | - Stefano Bambi
- Health Sciences Department, University of Florence, 50139 Florence, Italy; (S.B.); (L.R.)
| | - Laura Rasero
- Health Sciences Department, University of Florence, 50139 Florence, Italy; (S.B.); (L.R.)
| | - Lorenzo Tofani
- Section of Anesthesiology, Intensive Care and Pain Medicine, Department of Health Sciences, University of Florence, 50139 Florence, Italy; (L.T.); (T.P.); (Z.R.); (S.R.); (G.V.)
| | - Tessa Piazzini
- Section of Anesthesiology, Intensive Care and Pain Medicine, Department of Health Sciences, University of Florence, 50139 Florence, Italy; (L.T.); (T.P.); (Z.R.); (S.R.); (G.V.)
| | | | - Khadija El Aoufy
- Department of Experimental and Clinical Medicine, Azienda Ospedaliero Universitaria Careggi, 50134 Florence, Italy;
| | - Zaccaria Ricci
- Section of Anesthesiology, Intensive Care and Pain Medicine, Department of Health Sciences, University of Florence, 50139 Florence, Italy; (L.T.); (T.P.); (Z.R.); (S.R.); (G.V.)
- Pediatric Intensive Care Unit, Meyer Children’s University Hospital, 50139 Florence, Italy
| | - Stefano Romagnoli
- Section of Anesthesiology, Intensive Care and Pain Medicine, Department of Health Sciences, University of Florence, 50139 Florence, Italy; (L.T.); (T.P.); (Z.R.); (S.R.); (G.V.)
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, 50139 Florence, Italy
| | - Gianluca Villa
- Section of Anesthesiology, Intensive Care and Pain Medicine, Department of Health Sciences, University of Florence, 50139 Florence, Italy; (L.T.); (T.P.); (Z.R.); (S.R.); (G.V.)
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, 50139 Florence, Italy
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10
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Raina R, Agrawal N, Kusumi K, Pandey A, Tibrewal A, Botsch A. A Meta-Analysis of Extracorporeal Anticoagulants in Pediatric Continuous Kidney Replacement Therapy. J Intensive Care Med 2022; 37:577-594. [PMID: 33688766 DOI: 10.1177/0885066621992751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Continuous kidney replacement therapy (CKRT) is the primary therapeutic modality utilized in hemodynamically unstable patients with severe acute kidney injury. As the circuit is extracorporeal, it poses an increased risk of blood clotting and circuit loss; frequent circuit losses affect the provider's ability to provide optimal treatment. The objective of this meta-analysis is to evaluate the safety and efficacy of the extracorporeal anticoagulants in the pediatric CKRT population. DATA SOURCES We conducted a literature search on PubMed/Medline and Embase for relevant citations. STUDY SELECTION Studies were included if they involved patients under the age of 18 years undergoing CKRT, with the use of anticoagulation (heparin, citrate, or prostacyclin) as a part of therapy. Only English articles were included in the study. DATA EXTRACTION Initial search yielded 58 articles and a total of 24 articles were included and reviewed. A meta-analysis was performed focusing on the safety and effectiveness of regional citrate anticoagulation (RCA) vs unfractionated heparin (UFH) anticoagulants in children. DATA SYNTHESIS RCA had statistically significantly longer circuit life of 50.65 hours vs. UFH of 42.10 hours. Two major adverse effects metabolic alkalosis and electrolyte imbalance seen more commonly in RCA compared to UFH. There was not a significant difference in the risk of systemic bleeding when comparing RCA vs. UFH. CONCLUSION RCA is the preferred anticoagulant over UFH due to its significantly longer circuit life, although vigilant circuit monitoring is required due to the increased risk of electrolyte disturbances. Prostacyclin was not included in the meta-analysis due to the lack of data in pediatric patients. Additional studies are needed to strengthen the study results further.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Nirav Agrawal
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Kirsten Kusumi
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Avisha Pandey
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Abhishek Tibrewal
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Alexander Botsch
- Division of Critical Care Medicine, Summa Health, Akron, OH, USA
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Reis T, Anwar S, Neves FDADR, Ronco C. Disruptive technologies for hemodialysis: medium and high cutoff membranes. Is the future now? ACTA ACUST UNITED AC 2021; 43:410-416. [PMID: 33836041 PMCID: PMC8428648 DOI: 10.1590/21758239-jbn-2020-0273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/04/2021] [Indexed: 01/19/2023]
Abstract
In the past decade, a new class of hemodialysis (HD) membranes (high retention
onset class) became available for clinical use. The high cutoff (HCO) and the
medium cutoff (MCO) membranes have wider pores and more uniformity in pore size,
allowing an increased clearance of uremic toxins. Owing to the mechanism of
backfiltration/internal filtration, middle molecules are dragged by the
convective forces, and no substitution solution is needed. The HCO dialyzer is
applied in septic patients with acute kidney injury requiring continuous kidney
replacement therapy. The immune response is modulated thanks to the removal of
inflammatory mediators. Another current application for the HCO dialyzer is in
hematology, for patients on HD secondary to myeloma-kidney, since free light
chains are more efficiently removed with the HCO membrane, reducing their
deleterious effect on the renal tubules. In its turn, the MCO dialyzer is used
for maintenance HD patients. A myriad of clinical trials published in the last
three years consistently demonstrates the ability of this membrane to remove
uremic toxins more efficiently than the high-flux membrane, an evolutionary
disruption in the HD standard of care. Safety concerns regarding albumin loss as
well as blood contamination from pyrogens in the dialysate have been overcome.
In this update article, we explore the rise of new dialysis membranes in the
light of the scientific evidence that supports their use in clinical
practice.
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Affiliation(s)
- Thiago Reis
- Universidade de Brasília, Faculdade de Ciências da Saúde, Laboratório de Farmacologia Molecular, Brasília, DF, Brasil.,San Bortolo Hospital, International Renal Research Institute of Vicenza, Department of Nephrology, Dialysis and Transplantation, Vicenza, Italy.,Clínica de Doenças Renais de Brasília, Departamento de Nefrologia, Brasília, DF, Brasil.,Academia Nacional de Medicina, Programa Jovens Lideranças Médicas, Rio de Janeiro, RJ, Brasil
| | - Siddiq Anwar
- Abu Dhabi Health Services (SEHA) Company, Department of Nephrology, Abu Dhabi, United Arab Emirates
| | | | - Claudio Ronco
- San Bortolo Hospital, International Renal Research Institute of Vicenza, Department of Nephrology, Dialysis and Transplantation, Vicenza, Italy.,University of Padova, Department of Medicine, Padova, Italy
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Ronco C, Reis T. Continuous renal replacement therapy and extended indications. Semin Dial 2021; 34:550-560. [PMID: 33711166 DOI: 10.1111/sdi.12963] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/02/2021] [Accepted: 02/08/2021] [Indexed: 01/16/2023]
Abstract
Extracorporeal blood purification (EBP) techniques provide support for critically ill patients with single or multiple organ dysfunction. Continuous renal replacement therapy (CRRT) is the modality of choice for kidney support for those patients and orchestrates the interactions between the different artificial organ support systems. Intensive care teams should be familiar with the concept of sequential extracorporeal therapy and plan on how to incorporate new treatment modalities into their daily practices. Importantly, scientific evidence should guide the decision-making process at the bedside and provide robust arguments to justify the costs of implementing new EBP treatments. In this narrative review, we explore the extended indications for CRRT as an adjunctive treatment to provide support for the heart, lung, liver, and immune system. We detail practicalities on how to run the treatments and how to tackle the most frequent complications regarding each of the therapies, whether applied alone or integrated. The physicochemical processes and technologies involved at the molecular level encompassing the interactions between the molecules, membranes, and resins are spotlighted. A clinical case will illustrate the timing for the initiation, maintenance, and discontinuation of EBP techniques.
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Affiliation(s)
- Claudio Ronco
- Department of Medicine (DIMED), University of Padova, Padova, Italy.,Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy.,National Academy of Medicine, Young Leadership Physicians Program, Rio de Janeiro, Brazil
| | - Thiago Reis
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy.,Department of Nephrology, Clínica de Doenças Renais de Brasília, Molecular Pharmacology Laboratory, University of Brasília, Brasilia, Brazil
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The Effect of Patient- and Treatment-Related Factors on Circuit Lifespan During Continuous Renal Replacement Therapy in Critically Ill Children. Pediatr Crit Care Med 2020; 21:578-585. [PMID: 32343111 DOI: 10.1097/pcc.0000000000002305] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To examine the effects of patient and treatment variables on circuit lifespan in critically ill children requiring continuous renal replacement therapy. DESIGN Retrospective observational study based on a prospective registry. SETTING Tertiary referral 30-bed PICU. PATIENTS One hundred sixty-one critically ill children undergoing continuous renal replacement therapy during an 8-year period (2007-2014) were included in the study. INTERVENTIONS Continuous renal replacement therapy. MEASUREMENTS AND MAIN RESULTS During the study period, 161 patients received a total of 22,190 hours of continuous renal replacement therapy, with a median duration of 74.75 hours (interquartile range, 32-169.5) per patient. Of the 572 filter circuits used, 276 (48.3%) were changed due to circuit clotting and 262 (45.8%) were electively changed. Median circuit life was 24.62 hours (interquartile range, 10.6-55.3) for all filters and significantly longer for those electively removed as compared to those prematurely removed because of clotting (35.50 hr [interquartile range, 16.9-67.6] vs 22.00 hr [interquartile range, 13.8-42.5]; p < 0.001). Multivariate regression analyses revealed that admission diagnosis (p < 0.001), anticoagulation type (p < 0.001), access type (p = 0.016), and circuit size (p = 0.027) were associated with prolonged circuit life, as well as, in patients on heparin anticoagulation, with higher doses of heparin (p < 0.001) and a prolonged activated partial thromboplastin time (p < 0.001). CONCLUSIONS In this study, circuit lifespan in pediatric continuous renal replacement therapy was low and appeared to depend upon the patient's diagnosis, the type of access and anticoagulation used as well as the size of the circuit used.
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