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de Cássia Almeida Vieira R, de Barros GL, Paiva WS, de Oliveira DV, de Souza CPE, Santana-Santos E, de Sousa RMC. Severe traumatic brain injury and acute kidney injury patients: factors associated with in-hospital mortality and unfavorable outcomes. Brain Inj 2024; 38:108-118. [PMID: 38247393 DOI: 10.1080/02699052.2024.2304885] [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: 06/16/2021] [Accepted: 01/09/2024] [Indexed: 01/23/2024]
Abstract
OBJECTIVE The purpose of this study was to identify the occurrence of AKI, and factors associated with in-hospital mortality and unfavorable outcomes in patients with severe traumatic brain injury (TBI) and acute kidney injury (AKI) severity. METHOD A retrospective cohort study which analyzed data with severe TBI between 2013 and 2017. We examined demographic and clinical information, and outcome by in-hospital mortality, and the Glasgow Outcome Scale six months after TBI. We associated factors to in-hospital mortality and unfavorable outcome in severe TBI and AKI with an association test. RESULTS A total of 219 patients were selected, 39.3% had an AKI, and several factors associated with AKI occurrence after severe TBI. Stage 2 or 3 of AKI (OR 12.489; 95% CI = 4.45-37.94) were independent risk for both outcomes in multivariable models, severity injury by the New Trauma Injury Severity Score (OR 0.97; 95% CI = 0.96-0.99) for mortality, and the New Injury Severity Score (OR1.07; 95% CI = 1.04-1.10) and Trauma and Injury Severity Score (OR = 0.98; 95% CI = 0.965-0.997) for unfavorable outcome. CONCLUSION The findings of our study confirmed that AKI severity and severity of injury was also related to increased mortality and unfavorable outcome after severe TBI.
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Kim JH, Jeong H, Choo YH, Kim M, Ha EJ, Oh J, Shim Y, Kim SB, Jung HG, Park SH, Kim JO, Kim J, Kim HS, Lee S. Optimizing Mannitol Use in Managing Increased Intracranial Pressure: A Comprehensive Review of Recent Research and Clinical Experiences. Korean J Neurotrauma 2023; 19:162-176. [PMID: 37431377 PMCID: PMC10329884 DOI: 10.13004/kjnt.2023.19.e25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 06/12/2023] [Indexed: 07/12/2023] Open
Abstract
Mannitol, derived from mannose sugar, is crucial in treating patients with elevated intracranial pressure (ICP). Its dehydrating properties at the cellular and tissue levels increase plasma osmotic pressure, which is studied for its potential to reduce ICP through osmotic diuresis. While clinical guidelines support mannitol use in these cases, the best approach for its application continues to be debated. Important aspects needing further investigation include: 1) bolus administration versus continuous infusion, 2) ICP-based dosing versus scheduled bolus, 3) identifying the optimal infusion rate, 4) determining the appropriate dosage, 5) establishing fluid replacement plans for urinary loss, and 6) selecting monitoring techniques and thresholds to assess effectiveness and ensure safety. Due to the lack of adequate high-quality prospective research data, a comprehensive review of recent studies and clinical trials is crucial. This assessment aims to bridge the knowledge gap, improve understanding of effective mannitol use in elevated ICP patients, and provide insights for future research. In conclusion, this review aspires to contribute to the ongoing discourse on mannitol application. By integrating the latest findings, this review will offer valuable insights into the function of mannitol in decreasing ICP, thereby informing better therapeutic approaches and enhancing patient outcomes.
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Affiliation(s)
- Jae Hyun Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Heewon Jeong
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
| | - Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Moinay Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jiwoong Oh
- Division of Neurotrauma & Neurocritical Care Medicine, Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Youngbo Shim
- Department of Critical Care Medicine, Kangbuk Samsung Hospital, Seoul, Korea
| | - Seung Bin Kim
- Department of Critical Care Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Han-Gil Jung
- Department of Neurosurgery and Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - So Hee Park
- Department of Neurosurgery, Yeungnam University Medical Center, Daegu, Korea
| | - Jung Ook Kim
- Gachon University Gil Hospital Regional Trauma Center, Incheon, Korea
| | - Junhyung Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Seoul, Korea
| | - Hye Seon Kim
- Department of Neurosurgery, Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon, Korea
| | - Seungjoo Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Parsons AD, Sanscrainte C, Leone A, Griepp DW, Rahme R. Dialysis Disequilibrium Syndrome and Intracranial Pressure Fluctuations in Neurosurgical Patients Undergoing Renal Replacement Therapy: Systematic Review and Pooled Analysis. World Neurosurg 2023; 170:2-6. [PMID: 36494069 DOI: 10.1016/j.wneu.2022.11.142] [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: 10/18/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Dialysis disequilibrium syndrome is a rare, well-known, potentially life-threatening complication of renal replacement therapy (RRT), often involving cerebral edema and increased intracranial pressure (ICP). However, the impact of RRT on ICP and rate of dialysis disequilibrium syndrome in neurosurgical patients have not been systematically assessed. METHODS In February 2022, a systematic review following PRISMA guidelines was conducted using various combinations of 9 keywords in the MEDLINE database. Eleven papers were selected. Individual patient data were extracted, pooled, and analyzed. RESULTS Fifty-eight patients, 44 men and 14 women with a mean age of 48 years (6-78 years), were analyzed. Neurosurgical conditions included the following: spontaneous intracranial hemorrhage (n = 27), traumatic brain injury (n = 16), ischemic stroke/anoxic brain injury (n = 6), intracranial tumor (n = 6), and others (n = 3). Neurosurgical interventions included the following: craniotomy/craniectomy (n = 23), external ventricular drain or ICP monitor placement (n = 16), and burr hole or twist drill craniostomy (n = 4). Intermittent dialysis was used in 33 patients, continuous RRT in 20, and a combination thereof in 4. During RRT, ICP increased in 35 patients (60.3%), remained unchanged in 20, and decreased in 3. Thirty-four patients (65.4%) died. Intermittent dialysis was associated with increased ICP (73% vs. 37.5%, P = 0.01) and mortality (75% vs. 39.1%, P = 0.01). CONCLUSIONS In neurosurgical patients, ICP increases during RRT are common, affecting up to 60%, and potentially life-threatening, with mortality rates as high as 65%. The use of a continuous rather than intermittent RRT technique may reduce the risk of this complication. Prospective studies are warranted.
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Affiliation(s)
- Andrew D Parsons
- Division of Neurosurgery, SBH Health System, Bronx, New York, USA
| | | | - Augusto Leone
- Division of Neurosurgery, SBH Health System, Bronx, New York, USA; Klinik für Neurochirurgie, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Daniel W Griepp
- Division of Neurosurgery, SBH Health System, Bronx, New York, USA; Division of Neurosurgery, Ascension Providence Hospital, College of Human Medicine, Michigan State University, Southfield, Michigan, USA
| | - Ralph Rahme
- Division of Neurosurgery, SBH Health System, Bronx, New York, USA; CUNY School of Medicine, New York, New York, USA.
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Haroon S, Tai BC, Yeo X, Davenport A. Changes in total and segmental extracellular and intracellular volumes with hypotension during hemodialysis measured with bioimpedance spectroscopy. Artif Organs 2021; 46:666-676. [PMID: 34695245 DOI: 10.1111/aor.14096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 09/23/2021] [Accepted: 10/21/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Bioelectrical impedance analysis (BIA) devices have been advocated to guide volume management in hemodialysis (HD) patients. We hypothesized that understanding the dynamics of fluid shifts in different body segments may provide additional insight on preventive measures to reduce the risk of intradialytic hypotension. METHODS A prospective observational study was conducted among 42 HD patients at risk of hypotension who were admitted as emergencies inpatient. RESULTS A total of 191 BIA measurements were made during the 42 HD sessions, and hypotension occurred during 52 measurements (27%). The extracellular water (ECW) to intracellular water ratio (EIR) was measured in different body segments and declined significantly only in the non-access arm with increasing HD session duration (β = -0.04; 95% confidence interval (CI): -0.05 to -0.03, p < 0.01). There was no significant association between EIR and hypotension with respect to the different body segments. Only pre-HD N-terminal-pro b-type natriuretic peptide was significantly associated with hypotension (β = 0.20, 95% CI: 0.04 to 0.89, p = 0.04). There was no association between relative blood volume monitoring change and EIR. CONCLUSION In summary, we found that segmental BIA during HD was unable to detect or predict hypotension during dialysis. Although BIA is able to provide information about ECW and guide clinical assessment of volume in HD patients prior to dialysis, our findings did not suggest the use of serial measurements of changes in EIR in different body segments during HD provided sufficient information to predict intradialytic hypotension. Similarly, changes in EIR did not provide information on changes in plasma volume that could potentially trigger interventions to prevent or reduce intra-dialytic hypotension.
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Affiliation(s)
- Sabrina Haroon
- Division of Nephrology, National University Hospital, Singapore, Singapore
| | - Bee Choo Tai
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Xier Yeo
- Epidemiology Unit, National University Hospital, Singapore, Singapore
| | - Andrew Davenport
- UCL Center for Nephrology, Royal Free Hospital, University College London, London, UK
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Excessive elevation of serum phosphate during tumor lysis syndrome: Lessons from a particularly challenging case. Clin Nephrol Case Stud 2021; 9:39-44. [PMID: 33884255 PMCID: PMC8056318 DOI: 10.5414/cncs110086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 12/09/2020] [Indexed: 11/18/2022] Open
Abstract
Burkitt’s lymphoma is a common cause of tumor lysis syndrome (TLS) and, in the era of aggressive utilization of prophylactic allopurinol and recombinant uricase enzyme, nephrologists are increasingly witnessing monovalent or divalent cation abnormalities without marked uric acid elevation. An 18-year-old male received his 1st cycle of intensive chemotherapy for Burkitt’s lymphoma and developed TLS as defined by the Cairo Bishop criteria. Lactate dehydrogenase peaked at 9,105 U/L (range: 130 – 250) and was accompanied by acute kidney injury, including serum creatinine 2.2 mg/dL on the 4th day with oliguria, hyperkalemia, extreme hyperphosphatemia (21.4 mg/dL), hypermagnesemia, and hypocalcemia. Renal replacement therapy decision was made based on life-threatening electrolyte disturbances. The competing necessity to effectively control hyperphosphatemia and avoid the complication of dialysis disequilibrium syndrome prompted us to perform an initial intermittent hemodialysis with simultaneous intravenous mannitol administration, followed by continuous hemodialysis to manage the continued production of phosphorus from cell lysis. Osmotic stability during the therapy session was affirmatively demonstrated (322, 319 mOsm/kg, respectively). The patient showed excellent tolerance for these therapies and eventually recovered renal function as demonstrated during follow-up visits.
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Ghoshal S, Freedman BI. Renal Replacement Therapy and Dialysis-associated Neurovascular Injury (DANI) in the Neuro ICU: a Review of Pathophysiology and Preventative Options. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-020-00661-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Chousterman BG, Jamme M, Tabibzadeh N, Gaugain S, Damoisel C, Barthélémy R. Delaying Renal Replacement Therapy Could Be Harmful in Patients with Acute Brain Injury. Am J Respir Crit Care Med 2020; 200:645-646. [PMID: 31091956 PMCID: PMC6727164 DOI: 10.1164/rccm.201903-0527le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Benjamin G Chousterman
- Assistance Publique - Hôpitaux de ParisParis, France.,Sorbonne Paris CitéParis, France.,Inserm U942Paris, France
| | - Matthieu Jamme
- Poissy Saint Germain HospitalPoissy, Franceand.,Versailles Saint-Quentin-en-Yvelines UniversityVillejuif, France
| | - Nahid Tabibzadeh
- Assistance Publique - Hôpitaux de ParisParis, France.,Sorbonne Paris CitéParis, France
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Fülöp T, Zsom L, Rodríguez RD, Chabrier-Rosello JO, Hamrahian M, Koch CA. Therapeutic hypernatremia management during continuous renal replacement therapy with elevated intracranial pressures and respiratory failure. Rev Endocr Metab Disord 2019; 20:65-75. [PMID: 30848433 DOI: 10.1007/s11154-019-09483-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cerebral edema and elevated intracranial pressure (ICP) are common complications of acute brain injury. Hypertonic solutions are routinely used in acute brain injury as effective osmotic agents to lower ICP by increasing the extracellular fluid tonicity. Acute kidney injury in a patient with traumatic brain injury and elevated ICP requiring renal replacement therapy represents a significant therapeutic challenge due to an increased risk of cerebral edema associated with intermittent conventional hemodialysis. Therefore, continuous renal replacement therapy (CRRT) has emerged as the preferred modality of therapy in this patient population. We present our current treatment approach, with demonstrative case vignette illustrations, utilizing hypertonic saline protocols (3% sodium-chloride or, with coexisting severe combined metabolic and respiratory acidosis, with 4.2% sodium-bicarbonate) in conjunction with the CRRT platform, to induce controlled hypernatremia of approximately 155 mEq/L in hemodynamically unstable patients with acute kidney injury and elevated ICP due to acute brain injury. Rationale, mechanism of activation, benefits and potential pitfalls of the therapy are reviewed. The impact of hypertonic citrate solution during regional citrate anticoagulation is specifically discussed. Maintaining plasma hypertonicity in the setting of increased ICP and acute kidney injury could prevent the worsening of ICP during renal replacement therapy by minimizing the osmotic gradient across the blood-brain barrier and maximizing cardiovascular stability.
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Affiliation(s)
- Tibor Fülöp
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA.
- Medical Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA.
| | - Lajos Zsom
- Fresenius Medical Care Hungary Kft, Cegléd, Hungary
| | - Rafael D Rodríguez
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Jorge O Chabrier-Rosello
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Mehrdad Hamrahian
- Department of Medicine - Division of Nephrology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Christian A Koch
- Medicover GmbH, Berlin, Germany.
- Carl von Ossietzky University of Oldenburg, Oldenburg, Germany.
- Technical University of Dresden, Dresden, Germany.
- University of Tennessee Health Science Center, Memphis, TN, USA.
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Factors Associated with Early Mortality in Critically Ill Patients Following the Initiation of Continuous Renal Replacement Therapy. J Clin Med 2018; 7:jcm7100334. [PMID: 30297660 PMCID: PMC6210947 DOI: 10.3390/jcm7100334] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 09/30/2018] [Accepted: 10/05/2018] [Indexed: 01/11/2023] Open
Abstract
Continuous renal replacement therapy (CRRT) is an important modality to support critically ill patients, and the need for CRRT treatment has been increasing. However, CRRT management is costly, and the associated resources are limited. Thus, it remains challenging to identify patients that are likely to have a poor outcome, despite active treatment with CRRT. We sought to elucidate the factors associated with early mortality after CRRT initiation. We analyzed 240 patients who initiated CRRT at an academic medical center between September 2016 and January 2018. We compared baseline characteristics between patients who died within seven days of initiating CRRT (early mortality), and those that survived more than seven days beyond the initiation of CRRT. Of the patients assessed, 130 (54.2%) died within seven days of CRRT initiation. Multivariate logistic regression models revealed that low mean arterial pressure, low arterial pH, and high Sequential Organ Failure Assessment score before CRRT initiation were significantly associated with increased early mortality in patients requiring CRRT. In conclusion, the mortality within seven days following CRRT initiation was very high in this study. We identified several factors that are associated with early mortality in patients undergoing CRRT, which may be useful in predicting early outcomes, despite active treatment with CRRT.
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10
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Kidney disease improving global outcome for predicting acute kidney injury in traumatic brain injury patients. J Acute Med 2016. [DOI: 10.1016/j.jacme.2016.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Davenport A. Changing the hemodialysis prescription for hemodialysis patients with subdural and intracranial hemorrhage. Hemodial Int 2014; 17 Suppl 1:S22-7. [PMID: 24134327 DOI: 10.1111/hdi.12085] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Although continuous modalities of renal replacement therapy offer an advantage to the patient with compromised cerebral perfusion and intracranial hypertension, they are generally limited to the intensive care unit setting. Many hemodialysis patients admitted with strokes and subdural hematoma are managed on general wards. As such, these patients are generally treated by intermittent hemodialysis, and their dialysis prescription should be altered to minimize changes in serum osmolality, and fall in blood pressure during dialysis. Such patients require more frequent but shorter dialysis sessions, using minimally bioincompatible small surface area dialyzers with lower blood flows, in combination with higher sodium and cooled dialysate. In patients at risk of intracranial hemorrhage and those with invasive intracranial monitoring, systemic anticoagulants should be avoided, choosing no anticoagulation protocols or regional anticoagulants.
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Affiliation(s)
- Andrew Davenport
- UCL Center for Nephrology, University College London Medical School, London, UK
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12
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Bansal VK, Bansal S. Nervous system disorders in dialysis patients. HANDBOOK OF CLINICAL NEUROLOGY 2014; 119:395-404. [DOI: 10.1016/b978-0-7020-4086-3.00025-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Wu VC, Huang TM, Shiao CC, Lai CF, Tsai PR, Wang WJ, Huang HY, Wang KC, Ko WJ, Wu KD. The hemodynamic effects during sustained low-efficiency dialysis versus continuous veno-venous hemofiltration for uremic patients with brain hemorrhage: a crossover study. J Neurosurg 2013; 119:1288-95. [PMID: 23706048 DOI: 10.3171/2013.4.jns122102] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Hemodynamic instability occurs frequently during dialysis treatment and remains a significant cause of patient morbidity and mortality, especially in patients with brain hemorrhage. This study aims to compare the effects of hemodynamic parameters and intracranial pressure (ICP) between sustained low-efficiency dialysis (SLED) and continuous veno-venous hemofiltration (CVVH) in dialysis patients with brain hemorrhage. METHODS End-stage renal disease (ESRD) patients with brain hemorrhage undergoing ICP monitoring were enrolled. Patients were randomized to receive CVVH or SLED on the 1st day and were changed to the other modality on the 2nd day. The ultrafiltration rate was set at between 1.0 kg/8 hrs and 1.5 kg/8 hrs according to the patient's fluid status. The primary study end point was the change in hemodynamics and ICP during the dialytic periods. The secondary end point was the difference between cardiovascular peptides and oxidative and inflammatory assays. RESULTS Ten patients (6 women; mean age 59.9 ± 3.6 years) were analyzed. The stroke volume variation was higher with SLED than CVVH (generalized estimating equations method, p = 0.031). The ICP level increased after both SLED and CVVH (time effect, p = 0.003) without significant difference between modalities. The dialysis dose quantification after 8-hour dialysis was higher in SLED than CVVH (equivalent urea clearance by convection, 62.7 ± 4.4 vs 50.2 ± 3.9 ml/min; p = 0.002). Additionally, the endothelin-1 level increased after CVVH treatment (p = 0.019) but not SLED therapy. CONCLUSIONS With this controlled crossover study, the authors provide the pilot evidence that both SLED and CVVH display identical acute hemodynamic effects and increased ICP after dialysis in brain hemorrhage patients. CLINICAL TRIAL REGISTRATION NO.: NCT01781585 (ClinicalTrials.gov).
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Ko SB, Choi HA, Gilmore E, Schmidt JM, Claassen J, Lee K, Mayer SA, Badjatia N. Pearls & Oysters: the effects of renal replacement therapy on cerebral autoregulation. Neurology 2012; 78:e36-8. [PMID: 22311932 DOI: 10.1212/wnl.0b013e318245d270] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- S-B Ko
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA
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Regolisti G, Maggiore U, Cademartiri C, Cabassi A, Caiazza A, Tedeschi S, Antonucci E, Fiaccadori E. Cerebral blood flow decreases during intermittent hemodialysis in patients with acute kidney injury, but not in patients with end-stage renal disease. Nephrol Dial Transplant 2012; 28:79-85. [DOI: 10.1093/ndt/gfs182] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Schmid H, Schiffl H, Lederer SR. [Acute kidney injury]. Med Klin Intensivmed Notfmed 2012; 107:141-6. [PMID: 22437194 DOI: 10.1007/s00063-012-0098-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 01/16/2011] [Accepted: 02/07/2011] [Indexed: 11/27/2022]
Abstract
Acute kidney injury plays a pivotal role in intensive care medicine and exerts crucial adverse effects on the course of the disease and overall prognosis of the critically ill patient. Intensive renal support, including initiation of earlier dialysis or maximal uremic toxin removal by higher dosage and frequency of renal replacement therapy, and individualized selection of modality were not able to decrease excessive mortality in this population. Systemic acute inflammation, mediated, at least in part, by cytokines, and not secondary uremic side effects, seems to have a major impact on nonrenal organ damage. Assessment of short-term outcome in critically ill patients who develop acute kidney injury may underestimate the true burden of disease. The overall survival at 5 years in patients discharged alive after severe acute kidney injury necessitating renal replacement therapy is only 20-30%, comparable to cancer patients. In addition, acute renal damage was identified as an independent risk factor for progression of chronic renal insufficiency. Current research focuses on strategies for the prevention of acute kidney injury and on the establishment of effective biomarkers for the early recognition and accurate diagnosis of subclinical renal damage.
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Affiliation(s)
- H Schmid
- KfH Kuratorium für Dialyse und Nierentransplantation e.V., KfH Nierenzentrum, Elsenheimerstr. 63, 80687, München, Deutschland
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Treatment of Elevated Intracranial Pressure with Hyperosmolar Therapy in Patients with Renal Failure. Neurocrit Care 2012; 17:388-94. [DOI: 10.1007/s12028-012-9676-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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19
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Abstract
Fortunately, the incidence of acute kidney injury (AKI) in neurotrauma is low and decreasing. Whereas the majority of AKI occurs in older patients with pre-existing chronic kidney disease, neurotrauma typically occurs in children and young adults with normal renal function. The development of outreach trauma teams has improved initial resuscitation, reducing both volume responsive and volume unresponsive cases of AKI. Most cases occur in the setting of multiple organ trauma with muscle injury, or patients who subsequently develop multiple organ failure. Once AKI has developed and renal replacement therapy is required, continuous modalities of renal replacement therapy offer an advantage to the patient with compromised cerebral perfusion and intracranial hypertension, by reducing the rate of change in serum urea, compared with standard intermittent therapies of hemodialysis and hemofiltration, thus minimizing abrupt changes in serum osmolality. Continuous hemodialysis and hemofiltration are better suited to maintain a normal or high serum sodium and thermal losses through the extracorporeal circuit, than peritoneal dialysis. Dialyzers should preferably be minimally bioincompatible and of a small surface area. In patients at risk of intracranial hemorrhage and those with invasive intracranial monitoring, systemic anticoagulants should either be avoided or regional anticoagulants should be used.
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Affiliation(s)
- Andrew Davenport
- UCL Center for Nephrology, University College London Medical School, London, UK.
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20
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Continuous Renal Replacement Therapy for Refractory Intracranial Hypertension? ACTA ACUST UNITED AC 2010; 68:1506-9. [DOI: 10.1097/ta.0b013e3181dbbf1b] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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21
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Fletcher JJ, Bergman K, Feucht EC, Blostein P. Continuous renal replacement therapy for refractory intracranial hypertension. Neurocrit Care 2009; 11:101-5. [PMID: 19267223 DOI: 10.1007/s12028-009-9197-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Little is known about the effects of hemodialysis on the injured brain, however; concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy. Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety. Furthermore, exacerbations of cerebral edema have been reported. CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance. We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension. METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma. He required significant volume resuscitation. Intensive care unit course was complicated by shock, acute respiratory distress syndrome, ventilator associated pneumonia, and development of intracranial hypertension (IH). Data were collected by retrospective chart review. RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy. Within hours of initiation increase, ICP improved and normalized. Hemofiltration was safely discontinued after 48 h. Modified Rankin Score was 2 at 90 days. CONCLUSION Though unproven, CRRT may be beneficial in patients with IH due to gentle removal of fluid, solutes, and inflammatory cytokines. Given the limited data on safety of CRRT in patients with ABI, we encourage further reports.
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Affiliation(s)
- Jeffrey J Fletcher
- Department of Neurology (Neurocritical Care), Bronson Methodist Hospital, 601 John Street Suite M-124, Kalamazoo, MI 49007, USA.
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22
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Abstract
Acute neurological injury may occur in patients with end-stage kidney disease on dialysis. Less frequently, acute kidney injury requiring renal dialytic support develops following acute neurological injury. Surrounding any site of neurological injury there is a penumbra of damage which is potentially reversible. To maximize full potential neurological recovery in patients requiring renal dialytic support, it is important that treatments do not themselves cause further cerebral ischemia. Standard intermittent hemodialysis is associated with cerebral swelling even in healthy outpatients and often with episodes of intradialytic hypotension. Continuous modes of renal replacement therapy have been shown to cause fewer surges in intracranial pressure and greater stability of cerebral perfusion pressure than standard intermittent techniques. In patients with acute neurological injury, renal replacement therapy should be carefully adapted to minimize cardiovascular instability and reduce the rate of change of serum osmolality.
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Affiliation(s)
- Andrew Davenport
- UCL Center for Nephrology, Royal Free & University College Medical School, Hampstead Campus, Rowland Hill Street, London, UK.
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