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Klimkiewicz J, Grzywacz A, Michałowski A, Gutowski M, Paryż K, Jędrych E, Lubas A. Acute Kidney Injury and Chronic Kidney Disease and Their Impacts on Prognosis among Patients with Severe COVID-19 Pneumonia: An Expert Center Case-Cohort Study. J Clin Med 2024; 13:1486. [PMID: 38592301 PMCID: PMC10932456 DOI: 10.3390/jcm13051486] [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: 01/23/2024] [Revised: 02/13/2024] [Accepted: 02/21/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Acute kidney injury (AKI) is associated with substantial mortality. In this case-control study, we analyzed the impacts of AKI and chronic kidney disease (CKD) on outcomes in a group of 323 patients with severe COVID-19. The correlation of clinical and laboratory data with AKI and CKD was also analyzed. Methods: A retrospective case-control study was conducted among AKI, CKD, and normal kidney function (NKF) groups hospitalized in a COVID-19 center in 2021. Results: AKI patients had higher in-hospital mortality (55.2 vs. 18.8%, p < 0.001), more frequent transfers from the HDU to ICU (57.5 vs. 12.9%, p < 0.001), and prolonged hospital stays (15.4 ± 10.7 vs. 10.7 ± 6.7 days, p < 0.001) compared to the NKF group. AKI was a predictor of death (OR 4.794, 95%CI: 2.906-7.906, p < 0.001). AKI patients also had broader lung parenchymal involvement and higher inflammatory markers compared to the NKF group. Patients with prior CKD had higher in-hospital mortality compared to the NKF group (64.0 vs. 18.8%, p < 0.001, OR 4.044, 95%CI: 1.723-9.490, p = 0.013); however, transfers from the HDU to ICU were not more frequent (16.0 vs. 12.9%, p = 0.753). Conclusions: AKI among COVID-19 patients was correlated with more ICU transfers, higher morbidity, and greater markers of severe disease. Patients with CKD had a higher mortality; however, the rate of ICU transfer was not substantially higher due to their poor prognosis.
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Affiliation(s)
- Jakub Klimkiewicz
- Department of Anesthesiology and Intensive Care, COVID-19 Hospital, Military Institute of Medicine-National Research Institute, Szaserów 128 Str., 04-141 Warsaw, Poland; (A.M.); (M.G.); (K.P.)
| | - Anna Grzywacz
- Department of Nephrology, Internal Diseases and Dialysis, COVID-19 Hospital, Military Institute of Medicine-National Research Institute, Szaserów 128 Str., 04-141 Warsaw, Poland; (A.G.); (E.J.); (A.L.)
| | - Andrzej Michałowski
- Department of Anesthesiology and Intensive Care, COVID-19 Hospital, Military Institute of Medicine-National Research Institute, Szaserów 128 Str., 04-141 Warsaw, Poland; (A.M.); (M.G.); (K.P.)
| | - Mateusz Gutowski
- Department of Anesthesiology and Intensive Care, COVID-19 Hospital, Military Institute of Medicine-National Research Institute, Szaserów 128 Str., 04-141 Warsaw, Poland; (A.M.); (M.G.); (K.P.)
| | - Kamil Paryż
- Department of Anesthesiology and Intensive Care, COVID-19 Hospital, Military Institute of Medicine-National Research Institute, Szaserów 128 Str., 04-141 Warsaw, Poland; (A.M.); (M.G.); (K.P.)
| | - Ewelina Jędrych
- Department of Nephrology, Internal Diseases and Dialysis, COVID-19 Hospital, Military Institute of Medicine-National Research Institute, Szaserów 128 Str., 04-141 Warsaw, Poland; (A.G.); (E.J.); (A.L.)
| | - Arkadiusz Lubas
- Department of Nephrology, Internal Diseases and Dialysis, COVID-19 Hospital, Military Institute of Medicine-National Research Institute, Szaserów 128 Str., 04-141 Warsaw, Poland; (A.G.); (E.J.); (A.L.)
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Chapman R, Shah S, D'Angelo A. Acute kidney injury following induction of chemotherapy: Diagnosis and management in critical care. J Intensive Care Soc 2023; 24:112-116. [PMID: 36874287 PMCID: PMC9975801 DOI: 10.1177/17511437221106441] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A 48-year-old gentleman who had recently commenced chemotherapy for diffuse B-cell lymphoma was admitted to hospital with nausea and generalised weakness. He developed abdominal pain and oliguric acute kidney injury with multiple electrolyte derangements and was transferred to the intensive care unit (ICU). His condition deteriorated, requiring endotracheal intubation and renal replacement therapy (RRT). Tumour lysis syndrome (TLS) is a common and life-threatening complication of chemotherapy and represents an oncological emergency. TLS affects multiple organ systems and is best managed in the ICU with closer monitoring of fluid balance, serum electrolytes, cardiorespiratory and renal function. TLS patients may go on to require mechanical ventilation and RRT. TLS patients require input from a large multidisciplinary team of clinicians and allied health professionals.
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Affiliation(s)
- Robert Chapman
- Critical Care Department, Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Sita Shah
- Critical Care Department, Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Alberto D'Angelo
- Department of Biology & Biochemistry, University of Bath, Bath, UK
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3
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Fayad AI, Buamscha DG, Ciapponi A. Timing of kidney replacement therapy initiation for acute kidney injury. Cochrane Database Syst Rev 2022; 11:CD010612. [PMID: 36416787 PMCID: PMC9683115 DOI: 10.1002/14651858.cd010612.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common condition among patients in intensive care units (ICUs) and is associated with high numbers of deaths. Kidney replacement therapy (KRT) is a blood purification technique used to treat the most severe forms of AKI. The optimal time to initiate KRT so as to improve clinical outcomes remains uncertain. This is an update of a review first published in 2018. This review complements another Cochrane review by the same authors: Intensity of continuous renal replacement therapy for acute kidney injury. OBJECTIVES To assess the effects of different timing (early and standard) of KRT initiation on death and recovery of kidney function in critically ill patients with AKI. SEARCH METHODS We searched the Cochrane Kidney and Transplant's Specialised Register to 4 August 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register, ClinicalTrials and LILACS to 1 August 2022. SELECTION CRITERIA We included all randomised controlled trials (RCTs). We included all patients with AKI in the ICU regardless of age, comparing early versus standard KRT initiation. For safety and cost outcomes, we planned to include cohort studies and non-RCTs. DATA COLLECTION AND ANALYSIS Data were extracted independently by two authors. The random-effects model was used, and results were reported as risk ratios(RR) for dichotomous outcomes and mean difference(MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS We included 12 studies enrolling 4880 participants. Overall, most domains were assessed as being at low or unclear risk of bias. Compared to standard treatment, early KRT initiation may have little to no difference on the risk of death at day 30 (12 studies, 4826 participants: RR 0.97,95% CI 0.87 to 1.09; I²= 29%; low certainty evidence), and death after 30 days (7 studies, 4534 participants: RR 0.99, 95% CI 0.92 to 1.07; I² = 6%; moderate certainty evidence). Early KRT initiation may make little or no difference to the risk of death or non-recovery of kidney function at 90 days (6 studies, 4011 participants: RR 0.91, 95% CI 0.74 to 1.11; I² = 66%; low certainty evidence); CIs included both benefits and harms. Low certainty evidence showed early KRT initiation may make little or no difference to the number of patients who were free from KRT (10 studies, 4717 participants: RR 1.07, 95% CI 0.94 to1.22; I² = 55%) and recovery of kidney function among survivors who were free from KRT after day 30 (10 studies, 2510 participants: RR 1.02, 95% CI 0.97 to 1.07; I² = 69%) compared to standard treatment. High certainty evidence showed early KRT initiation increased the risk of hypophosphataemia (1 study, 2927 participants: RR 1.80, 95% CI 1.33 to 2.44), hypotension (5 studies, 3864 participants: RR 1.54, 95% CI 1.29 to 1.85; I² = 0%), cardiac-rhythm disorder (6 studies, 4483 participants: RR 1.35, 95% CI 1.04 to 1.75; I² = 16%), and infection (5 studies, 4252 participants: RR 1.33, 95% CI 1.00 to 1.77; I² = 0%); however, it is uncertain whether early KRT initiation increases or reduces the number of patients who experienced any adverse events (5 studies, 3983 participants: RR 1.23, 95% CI 0.90 to 1.68; I² = 91%; very low certainty evidence). Moderate certainty evidence showed early KRT initiation probably reduces the number of days in hospital (7 studies, 4589 participants: MD-2.45 days, 95% CI -4.75 to -0.14; I² = 10%) and length of stay in ICU (5 studies, 4240 participants: MD -1.01 days, 95% CI -1.60 to -0.42; I² = 0%). AUTHORS' CONCLUSIONS Based on mainly low to moderate certainty of the evidence, early KRT has no beneficial effect on death and may increase the recovery of kidney function. Earlier KRT probably reduces the length of ICU and hospital stay but increases the risk of adverse events. Further adequate-powered RCTs using robust and validated tools that complement clinical judgement are needed to define the optimal time of KRT in critical patients with AKI in order to improve their outcomes. The surgical AKI population should be considered in future research.
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Affiliation(s)
- Alicia Isabel Fayad
- Pediatric Nephrology, Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina
| | - Daniel G Buamscha
- Pediatric Critical Care Unit, Juan Garrahan Children's Hospital, Buenos Aires, Argentina
| | - Agustín Ciapponi
- Argentine Cochrane Centre, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Buenos Aires, Argentina
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Kim DW, Kim HJ, Kim JM, Jeon YH, Han M, Seong EY, Song SH. Effect of Phoxilium on prognostic predictors in patients undergoing continuous venovenous hemodiafiltration. Kidney Res Clin Pract 2021; 40:457-471. [PMID: 34370933 PMCID: PMC8476306 DOI: 10.23876/j.krcp.20.217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 05/11/2021] [Indexed: 11/04/2022] Open
Abstract
Background Phosphorus-containing dialysis solution is used to prevent hypophosphatemia in patients undergoing continuous venovenous hemodiafiltration (CVVHDF). This study evaluated the effect of phosphorus-containing dialysis solution on mortality in patients undergoing CVVHDF based on changes in phosphorus and red cell distribution width-coefficient of variation (RDW-CV) levels. Methods We included 272 patients with acute kidney injury (AKI) who underwent CVVHDF at the medical intensive care unit from 2017 to 2019 and classified them according to Phoxilium (Baxter Healthcare Ltd.), as a phosphorus-containing dialysis solution, use within 48 hours after CVVHDF initiation. Clinical data were collected at baseline and 48 hours after CVVHDF initiation. The primary outcome was all-cause mortality during the follow-up period. Results The non-Phoxilium (NP) group had higher phosphorus and lower RDW-CV levels than the Phoxilium (P) group (phosphorus, 7.3 ± 4.3 vs. 5.0 ± 2.8 mg/dL; RDW-CV, 14.6 ± 1.9 vs. 15.7 ± 2.6%; all p < 0.001). In the multivariable Cox proportional hazard regression of the NP group, an increase in phosphorus and RDW-CV at 48 hours of CVVHDF was associated with mortality (delta phosphorus: median, >0 mg/dL vs. <-2.0 mg/dL; hazard ratio [HR], 8.62; 95% confidence interval [CI], 2.10-35.32; p = 0.003/delta RDW-CV: median, >0% vs. <-0.2%; HR, 4.34; 95% CI, 1.49-13.18; p = 0.008). Meanwhile, in the P group, an increase in delta RDW-CV was associated with mortality (delta RDW-CV: >0% vs. >-0.2% and <0%; HR, 2.65; 95% CI, 1.12-6.24; p = 0.03), while an increase in delta phosphorus was not. Conclusion In patients with AKI undergoing CVVHDF, the risk factors for all-cause mortality differed according to the initial phosphorus levels and use of Phoxilium.
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Affiliation(s)
- Da Woon Kim
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Hyo Jin Kim
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Jin Mi Kim
- Department of Biostatistics, Clinical Trial Center, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - You Hyun Jeon
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Miyeun Han
- Department of Internal Medicine, Hallym University Hangang Sacred Heart Hospital, Seoul, Republic of Korea
| | - Eun Young Seong
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Sang Heon Song
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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Matuszkiewicz-Rowinska J, Malyszko J. Prevention and Treatment of Tumor Lysis Syndrome in the Era of Onco-Nephrology Progress. Kidney Blood Press Res 2020; 45:645-660. [DOI: 10.1159/000509934] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/04/2020] [Indexed: 11/19/2022] Open
Abstract
Background: Tumor lysis syndrome (TLS) is an oncologic emergency due to a rapid break down of malignant cells usually induced by cytotoxic therapy, with hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and serious clinical consequences such as acute renal injury, cardiac arrhythmia, hypotension, and death. Rapidly expanding knowledge of cancer immune evasion mechanisms and host-tumor interactions has significantly changed our therapeutic strategies in hemato-oncology what resulted in the expanding spectrum of neoplasms with a risk of TLS. Summary: Since clinical TLS is a life-threatening condition, identifying patients with risk factors for TLS development and implementation of adequate preventive measures remains the most critical component of its medical management. In general, these consist of vigilant laboratory and clinical monitoring, vigorous IV hydration, urate-lowering therapy, avoidance of exogenous potassium, use of phosphate binders, and – in high-risk cases – considering cytoreduction before the start of the aggressive agent or a gradual escalation of its dose. Key Messages: In patients with a high risk of TLS, cytotoxic chemotherapy should be given in the facility with ready access to dialysis and a treatment plan discussed with the nephrology team. In the case of hyperkalemia, severe hyperphosphatemia or acidosis, and fluid overload unresponsive to diuretic therapy, the early renal replacement therapy (RRT) should be considered. One must remember that in TLS, the threshold for RRT initiation may be lower than in other clinical situations since the process of cell breakdown is ongoing, and rapid increases in serum electrolytes cannot be predicted.
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6
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Cho AJ, Lee YK, Park HC. Impact of electrolyte-rich dialysate during continuous renal replacement therapy on serum phosphate and potassium in ICU patients. PLoS One 2020; 15:e0238867. [PMID: 32915900 PMCID: PMC7485827 DOI: 10.1371/journal.pone.0238867] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/25/2020] [Indexed: 12/04/2022] Open
Abstract
Background Hypophosphatemia and hypokalemia occur frequently during continuous renal replacement therapy (CRRT). We evaluated serum phosphate and potassium levels in patients administered three different types of dialysis solution. Methods The study population consisted of 324 intensive care unit patients who underwent CRRT between January 2015 and December 2018. Patients were divided into three groups: group 1 (n = 105) received Hemosol B0 (no potassium or phosphate); group 2 (n = 78) received Hemosol B0 and potassium-containing solution (MultiBic); and group 3 (n = 141) received phosphate- and potassium-containing solution (Phoxilium), Hemosol B2, Prismasol 2, and Prismasol 4. A different protocol was followed in each group. Results The incidence rate of hypophosphatemia was 55% lower in group 3 compared to group 1 (incidence rate ratio (IRR) 0.45, 95% confidence interval (CI): 0.33 to 0.61) and 61% lower compared to group 2 (IRR 0.39, 95% CI: 0.29 to 0.53). Group 3 also had a 50% lower incidence rate of hypokalemia compared to group 1 (IRR 0.50, 95% CI: 0.29 to 0.88). The negative slope in phosphate level in group 3 was greater than that in group 1 (ß = 0.19, 95% CI: 0.02 to 0.37, p = 0.032), while the negative slope in the potassium level was greater in group 2 than in group 1(ß = 0.10, 95% CI: 0.03 to 0.17, p = 0.008). Additional intravenous calcium was not used in any case, and most cases of acid-base disturbances were well controlled. Conclusions The use of phosphate- and potassium-containing with a proper CRRT protocol prevented decreases in serum phosphate and potassium levels, thus also preventing hypophosphatemia and hypokalemia, and additional replacement during CRRT.
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Affiliation(s)
- AJin Cho
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Young-Ki Lee
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Hayne Cho Park
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
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Crowley KE, DeGrado JR, Charytan DM. Serum glucose and phosphorus concentrations during continuous renal replacement therapy using commercial replacement solutions with or without phosphorus. Hemodial Int 2020; 24:330-334. [PMID: 32351011 DOI: 10.1111/hdi.12834] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 03/05/2020] [Accepted: 04/02/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Continuous venovenous hemofiltration (CVVH) is a common practice in the intensive care unit often associated with electrolyte derangements. Recently, our institution added a phosphate dialysis solution, Phoxillum®, to our formulary as an option for CVVH fluid in addition to the bicarbonate-based Prismasol® products available. We sought to evaluate the impact of Phoxillum in patients who required CVVH when compared to Prismasol with regard to phosphate and glucose management. METHODS This was a single-center, retrospective, observational cohort analysis approved by Partners Health Care System Institutional Review Board that included patients who received a minimum of 24 hours of either Prismasol 4/2.5 or Phoxillum for CVVH from February 2017 to November 2017. Phosphate and glucose levels were monitored daily while on CVVH. Prevalence of hypoglycemia (glucose <70 mg/dL), hyperglycemia (glucose >180 mg/dL), hypophosphatemia (phosphate <2.5 mg/dL), and hyperphosphatemia (phosphate >4.3 mg/dL) were collected in terms of days of occurrence while on CVVH. Oral and intravenous phosphate repletion requirements were collected for all patients. FINDINGS Hypophosphatemia occurred more frequently while patients were receiving Prismasol as compared to Phoxillum (130 [24.9%] vs. 13 [6.2%], rate ratio [RR] 0.20 [95% confidence interval-CI = 0.10-0.42, P < 0.0001]), and consequently there was a numerically lower need for intravenous phosphorous repletion in the Phoxillum group (RR = 0.58, 95% CI [0.26, 1.30], P = 0.19]. There was a numerically higher incidence of hyperphosphatemia while patients were on Phoxillum therapy as compared to Prismasol (78 [37%] vs. 145 [27.7%], RR 1.25 [95% CI = 0.84, 1.86, P = 0.27]). There was no difference between the Phoxillum and Prismasol groups in terms of hypoglycemia or hyperglycemia. There was no notable difference in the cost found between the two therapies. DISCUSSION The findings suggest that the use of Phoxillum for CVVH may be associated with decreased incidence of hypophosphatemia and a potentially decreased need for phosphate repletion in patients who require CVVH.
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Affiliation(s)
- Kaitlin E Crowley
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Jeremy R DeGrado
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - David M Charytan
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Division of Nephrology, Department of Medicine, NYU Langone Medical Center, New York, NY, USA
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8
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9
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Fayad AII, Buamscha DG, Ciapponi A. Timing of renal replacement therapy initiation for acute kidney injury. Cochrane Database Syst Rev 2018; 12:CD010612. [PMID: 30560582 PMCID: PMC6517263 DOI: 10.1002/14651858.cd010612.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common condition among patients in intensive care units (ICUs), and is associated with high death. Renal replacement therapy (RRT) is a blood purification technique used to treat the most severe forms of AKI. The optimal time to initiate RRT so as to improve clinical outcomes remains uncertain.This review complements another Cochrane review by the same authors: Intensity of continuous renal replacement therapy for acute kidney injury. OBJECTIVES To assess the effects of different timing (early and standard) of RRT initiation on death and recovery of kidney function in critically ill patients with AKI. SEARCH METHODS We searched the Cochrane Kidney and Transplant's Specialised Register to 23 August 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched LILACS to 11 September 2017. SELECTION CRITERIA We included all randomised controlled trials (RCTs). We included all patients with AKI in ICU regardless of age, comparing early versus standard RRT initiation. For safety and cost outcomes we planned to include cohort studies and non-RCTs. DATA COLLECTION AND ANALYSIS Data were extracted independently by two authors. The random-effects model was used and results were reported as risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS We included five studies enrolling 1084 participants. Overall, most domains were assessed as being at low or unclear risk of bias. Compared to standard treatment, early initiation may reduce the risk of death at day 30, although the 95% CI does not rule out an increased risk (5 studies, 1084 participants: RR 0.83, 95% CI 0.61 to 1.13; I2 = 52%; low certainty evidence); and probably reduces the death after 30 days post randomisation (4 studies, 1056 participants: RR 0.92, 95% CI 0.76 to 1.10; I2= 29%; moderate certainty evidence); however in both results the CIs included a reduction and an increase of death. Earlier start may reduce the risk of death or non-recovery kidney function (5 studies, 1076 participants: RR 0.83, 95% CI 0.66 to 1.05; I2= 54%; low certainty evidence). Early strategy may increase the number of patients who were free of RRT after RRT discontinuation (5 studies, 1084 participants: RR 1.13, 95% CI 0.91 to 1.40; I2= 58%; low certainty evidence) and probably slightly increases the recovery of kidney function among survivors who discontinued RRT after day 30 (5 studies, 572 participants: RR 1.03, 95% CI 1.00 to 1.06; I2= 0%; moderate certainty evidence) compared to standard; however the lower limit of CI includes the null effect. Early RRT initiation increased the number of patients who experienced adverse events (4 studies, 899 participants: RR 1.10, 95% CI 1.03 to 1.16; I2 = 0%; high certainty evidence). Compared to standard, earlier RRT start may reduce the number of days in ICU (4 studies, 1056 participants: MD -1.78 days, 95% CI -3.70 to 0.13; I2 = 90%; low certainty evidence), but the CI included benefit and harm. AUTHORS' CONCLUSIONS Based mainly on low quality of evidence identified, early RRT may reduce the risk of death and may improve the recovery of kidney function in critically patients with AKI, however the 95% CI indicates that early RRT might worsen these outcomes. There was an increased risk of adverse events with early RRT. Further adequate-powered RCTs using appropriate criteria to define the optimal time of RRT are needed to reduce the imprecision of the results.
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Affiliation(s)
- Alicia Isabel I Fayad
- Ricardo Gutierrez Children's HospitalPediatric NephrologyInstitute for Clinical Effectiveness and Health PolicyLos Incas Av 4174Buenos AiresArgentina1427
| | - Daniel G Buamscha
- Juan Garrahan Children's HospitalPediatric Critical Care UnitCombate de Los Pozoz Y PichinchaBuenos AiresArgentina
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresArgentinaC1414CPV
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10
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Dhakal P, Rai MP, Thrasher M, Sharma M. Spontaneous tumour lysis syndrome in small cell lung cancer: a rare phenomenon. BMJ Case Rep 2018; 2018:bcr-2018-224512. [PMID: 29898908 DOI: 10.1136/bcr-2018-224512] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Tumour lysis syndrome (TLS) is an oncological emergency. It is caused by cellular death occurring secondary to cancer therapy or spontaneously in rapidly dividing tumours. More common in haematological malignancies, it has also been reported in solid tumours. Out of 14 cases of small cell lung cancer (SCLC) with TLS, only three cases of spontaneous TLS have been reported in literature to date. Here we report a case of SCLC presenting as a spontaneous TLS.
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Affiliation(s)
- Prajwal Dhakal
- Internal Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Manoj P Rai
- Internal Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Modina Thrasher
- Department of Pathology, Sparrow Hospital, Lansing, Michigan, USA
| | - Mukta Sharma
- Internal Medicine, Michigan State University, East Lansing, Michigan, USA
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11
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Heung M, Mueller BA. Prevention of hypophosphatemia during continuous renal replacement therapy-An overlooked problem. Semin Dial 2018; 31:213-218. [PMID: 29405468 DOI: 10.1111/sdi.12677] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Hypophosphatemia is a common and potentially serious complication occurring during continuous renal replacement therapy (CRRT). Phosphate supplementation is required in the vast majority of patients undergoing CRRT, particularly beyond the first 48 hours. Supplementation can be provided either as a standalone oral or parenteral treatment or as an additive to CRRT solutions. Each approach has advantages and disadvantages, and clinicians must weigh the individual factors most relevant in their practice setting. Currently there are no consensus protocols for phosphate replacement in CRRT, and many centers replete phosphate in response to hypophosphatemia as opposed to pre-emptively. Repletion protocols have also been challenged in recent years by shortages in injectable phosphate solutions. More recently a commercially available phosphate-containing CRRT solution was approved in the United States, but there has been limited clinical experience with this product. In this review, we present recommendations for phosphate repletion in CRRT to prevent hypophosphatemia, and describe our experience using phosphate-containing CRRT solutions.
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Affiliation(s)
- Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Bruce A Mueller
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
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12
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Bagshaw SM, Baldwin I, Fealy N, Bellomo R. Fluid Balance Error in Continuous Renal Replacement Therapy: A Technical Note. Int J Artif Organs 2018. [DOI: 10.1177/039139880703000511] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. The reliability and safety of continuous renal replacement therapy (CRRT) machines have improved, yet there still remains the potential for fluid balance errors to occur during treatment. Methods. In vitro testing of two Kimal Hygieia CRRT machines (Plus and Ultima) was performed. Normal saline to simulate the blood circuit and standard bicarbonate-based fluid for replacement were used. All tests were performed in CVVH mode at four ultrafiltration (UF) rates. The testing was based on creation of a voluntary fluid balance error by clamping the line that fills the replacement fluid chamber to stop flow to the (simulated) patient. The time to alarms and fluid balance errors were recorded. The alarms were overridden and the accumulated fluid balance error allowed by the machine was determined. Results. The alarm occurred approximately 1 minute after the replacement fluid line was clamped at all UF rates. There was no limit to the number of times the alarm could be overridden and the accumulated negative fluid balance was proportional to the prescribed UF rate. After the replacement fluid chamber was allowed to re-fill, the machine attempted to correct the fluid deficit and consistently delivered excess fluid to generate a positive fluid balance error. Conclusions. The Hygieia machines appear designed with appropriate alarm and safety features. However, simulated fluid balance errors raise caution for operators. Clinicians and nurses need to understand the clinical implications of alarm overrides. Fluid balance errors caused by failure to acknowledge and correct replacement fluid failure alarms may cause harm to patients.
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Affiliation(s)
- S. M. Bagshaw
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria - Australia
| | - I. Baldwin
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria - Australia
| | - N. Fealy
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria - Australia
| | - R. Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria - Australia
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Naka T, Baldwin I, Bellomo R, Fealy N, Wan L. Prolonged Daily Intermittent Renal Replacement Therapy in ICU Patients by ICU Nurses and ICU Physicians. Int J Artif Organs 2018; 27:380-7. [PMID: 15202815 DOI: 10.1177/039139880402700506] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Prolonged daily intermittent renal replacement therapy (PDIRRT) has been proposed as a new form of treatment for severe acute renal failure (ARF). However, this treatment has so far implied a) full dependence on nephrological input, b) lack of any convective clearance and c) limited purification of dialysate water. The aim of this study was to establish the feasibility and safety of performing PDIRRT in the ICU with a) no nephrological input, b) the addition of some convective clearance with on-line fluid replacement and c) a new advanced water purification system. Design Prospective observational study. Patients Fourteen patients treated with PDIRRT. Setting ICU of tertiary institution. Interventions Treatment of patients with severe ARF and critical illness with PDIRRT. Prescription of treatment by ICU physicians. Conduct of treatment by ICU nurses. Use of combined convective and diffusive therapy with on-line generation of fluid replacement, application of a double-filtration water purification system. Measurements and Main Results We prospectively collected demographic, biochemical, hemodynamic and clinical data in 14 patients, who received 30 PDIRRT treatments for a cumulative treatment time of 205.4 hours. The mean age was 57.9 ± 16.0. Eight patients were male and 6 female. Their mean APACHE II score was 24.6 ± 5.9 and their SAPS II score was 41.7 ± 18.8. PDIRRT was used after at least 24 hours of initial stabilization with continuous veno-venous hemofiltration (CVVH). Blood flow was kept at 100ml/min dialysate flow at 200 ml/min and convective clearance varied from 21 ml/min to 33 ml/min. All patients were either anuric or oliguric (UO < 400 ml/day). Ten patients were on mechanical ventilation and 11 patients on vasopressor support. Mean treatment session time was 6.9 ± 1.8 hours. The mean pre-PDIRRT urea was 19.2 ± 6.9 mmol/L and the creatinine was 274 ± 116 μmol/L. The mean pre-PDIRRT lactate was 2.95 ± 2.24 mmol/L. Following treatment, all had significantly decreased to 13.2 ± 6.3 mmol/L, 215 ± 95 μmol/L and 2.25 ± 1.61 mmol/L, respectively (p=<0.0001, <0.0001, <0.05). Bicarbonate levels remained stable during treatment (23.0 ± 3.8 mmol/L to 23.1 ± 2.5 mmol/L). Mean norepinephrine dose changed from 8.8 ± 11.9 μg/min to 12.9 ± 27.0 μg/min after treatment (NS). There were no complications of therapy. Patient ICU survival was 71.4%. Conclusions PDIRRT with combined diffusive and convective clearance is an efficacious form of renal replacement, which can be safely and effectively conducted by ICU nurses following prescription by ICU physicians without any nephrological involvement and with adequate double filtration water purification.
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Affiliation(s)
- T Naka
- Department of Intensive Care, Austin Hospital and Melbourne University, Melbourne, Australia
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Kim SY, Kim YN, Shin HS, Jung Y, Rim H. The influence of hypophosphatemia on outcomes of low- and high-intensity continuous renal replacement therapy in critically ill patients with acute kidney injury. Kidney Res Clin Pract 2017; 36:240-249. [PMID: 28904875 PMCID: PMC5592891 DOI: 10.23876/j.krcp.2017.36.3.240] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/19/2017] [Accepted: 04/20/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The purpose of this study was to assess the role of hypophosphatemia in major clinical outcomes of patients treated with low- or high-intensity continuous renal replacement therapy (CRRT). METHODS We performed a retrospective analysis of data collected from 492 patients. We divided patients into two CRRT groups based on treatment intensity (greater than or equal to or less than 40 mL/kg/hour of effluent generation) and measured serum phosphate level daily during CRRT. RESULTS We obtained a total of 1,440 phosphate measurements on days 0, 1, and 2 and identified 39 patients (7.9%), 74 patients (15.0%), and 114 patients (23.1%) with hypophosphatemia on each of these respective days. In patients treated with low-intensity CRRT, there were 23 episodes of hypophosphatemia/1,000 patient days, compared with 83 episodes/1,000 patient days in patients who received high-intensity CRRT (P < 0.01). Multiple Cox proportional hazards analysis showed that Acute Physiology and Chronic Health Evaluation (APACHE) III score, utilization of vasoactive drugs, and arterial pH on the second day of CRRT were significant predictors of mortality, while serum phosphate level was not a significant contributor to mortality. CONCLUSION APACHE score, use of vasoactive drugs, and arterial pH on the second CRRT day were identified as significant predictors of mortality. Hypophosphatemia might not be a major risk factor of increased mortality in patients treated with CRRT.
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Affiliation(s)
- Soo Young Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Ye Na Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Ho Sik Shin
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Yeonsoon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Hark Rim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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Lim C, Tan HK, Kaushik M. Hypophosphatemia in critically ill patients with acute kidney injury treated with hemodialysis is associated with adverse events. Clin Kidney J 2017; 10:341-347. [PMID: 28616212 PMCID: PMC5466083 DOI: 10.1093/ckj/sfw120] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/05/2016] [Accepted: 09/29/2016] [Indexed: 02/07/2023] Open
Abstract
Background. Hypophosphatemia in critically ill patients may be exacerbated by renal replacement therapy (RRT). We aimed to identify risk factors and adverse outcomes associated with hypophosphatemia in intensive care patients treated with RRT for acute kidney injury (AKI). Methods. This was a secondary analysis of data from a single-center prospective cohort study of medical and surgical intensive care patients with RRT for AKI between 18 December 2010 and 3 April 2013. Demographic, comorbidity, laboratory and RRT data were retrieved from patient case notes and electronic medical records. Outcomes assessed were hypophosphatemia (serum phosphate <0.94 mmol/L) during RRT, intensive care unit (ICU) mortality, and duration of mechanical ventilation and vasopressor support. Results. Among 96 patients who received acute RRT, 25 (26.0%) developed hypophosphatemia. On multivariate logistic regression, serum phosphate at RRT initiation [adjusted odds ratio (OR) 0.29, 95% confidence interval (CI) (0.09, 0.91), P = 0.03] was independently associated with hypophosphatemia during acute RRT. Patients with hypophosphatemia during RRT required longer ventilatory support [median 12 (interquartile range: 8, 17) days versus 5 (3, 9) days, P < 0.001] and vasopressor support [5 (4, 15) days versus 2 (2, 6) days, P = 0.003] compared with those without hypophosphatemia but there was no significant difference in ICU mortality [5 patients (20.0%) versus 24 patients (33.8%), P = 0.20]. Hypophosphatemia during RRT was independently associated with prolonged mechanical ventilation (≥7 days) [adjusted OR 14.0, 95% CI (1.37, 143.90), P = 0.03]. Conclusion. Hypophosphatemia is common during acute RRT for critically ill patients and was associated with adverse clinical outcomes.
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Affiliation(s)
- Cynthia Lim
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Han Khim Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Manish Kaushik
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
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Tseng RH, Wu CH, Wu KL, Lai GM, Lin JT. Tumor lysis syndrome in a patient with metastatic colon cancer after treatment with oxaliplatin and 5-Fu. JOURNAL OF CANCER RESEARCH AND PRACTICE 2016. [DOI: 10.1016/j.jcrpr.2016.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Criscuolo M, Fianchi L, Dragonetti G, Pagano L. Tumor lysis syndrome: review of pathogenesis, risk factors and management of a medical emergency. Expert Rev Hematol 2016; 9:197-208. [DOI: 10.1586/17474086.2016.1127156] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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18
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Chua HR, Schneider AG, Baldwin I, Collins A, Ho L, Bellomo R. Phoxilium vs Hemosol-B0 for continuous renal replacement therapy in acute kidney injury. J Crit Care 2013; 28:884.e7-14. [PMID: 23683569 DOI: 10.1016/j.jcrc.2013.02.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Revised: 01/12/2013] [Accepted: 02/17/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE This study aimed to compare the biochemical effects of Phoxilium (containing phosphate at 1.2 mmol/L; Gambro Lundia AB, Lund, Sweden) and Hemosol-B0 (Gambro Lundia AB) as dialysate and/or replacement fluid during continuous renal replacement therapy (CRRT). METHODS We examined serum biochemistry in critically ill patients for 42 hours of Phoxilium administration for the prevention of hypophosphatemia during CRRT and compared them with corresponding results in random historical controls who received Hemosol-B0. RESULTS We studied 15 patients in each arm (Phoxilium vs Hemosol-B0). Respective median ages were 57 (49-68) and 64 (57-67) years. Baseline patient illness severity scores, prescribed CRRT effluent rates, and cumulative phosphate intakes were comparable. After 36 to 42 hours of Phoxilium administration, serum phosphate levels increased from 0.95 (0.81-1.13) to 1.44 (1.23-1.78) mmol/L, in contrast to the decline from 1.71 (1.09-2.00) to 0.83 (0.55-1.59) mmol/L with Hemosol-B0 (P=.0001). Serum ionized calcium levels decreased from 1.27 (1.22-1.37) to 1.12 (1.06-1.21) mmol/L with Phoxilium, compared with an increase from 1.09 (0.90-1.19) to 1.20 (1.16-1.25) mmol/L with Hemosol-B0 (P<.0001). Serum bicarbonate, base excess levels, and effective strong ion difference decreased with Phoxilium and were lower than those with Hemosol-B0 at 36 to 42 hours (P<.05). CONCLUSION Phoxilium effectively prevented hypophosphatemia during CRRT but was associated with relative metabolic acidosis and hypocalcemia compared with Hemosol-B0 use.
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Affiliation(s)
- Horng-Ruey Chua
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Division of Nephrology, University Medicine Cluster, National University Hospital, National University Health System, Singapore
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Sharma S, Waikar SS. Phosphate balance in continuous venovenous hemofiltration. Am J Kidney Dis 2013; 61:1043-5. [PMID: 23434061 DOI: 10.1053/j.ajkd.2012.12.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 12/27/2012] [Indexed: 11/11/2022]
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Severe acute hypophosphatemia during renal replacement therapy adversely affects outcome of critically ill patients with acute kidney injury. Int Urol Nephrol 2012; 45:191-7. [PMID: 22227698 DOI: 10.1007/s11255-011-0112-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2011] [Accepted: 12/20/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE Hypophosphatemia during renal replacement therapy (RRT) is common in critically ill patients with acute kidney injury (AKI). The clinical consequences of RRT-induced phosphate depletion are not well defined in this patient population, and there is no evidence that intravenous sodium phosphate supplementation (PS) prevents the clinical sequelae of acute hypophosphatemia. The purpose of this retrospective analysis of the Acute Renal Support Registry of the University of Munich was to examine the association between severe hypophosphatemia and severity of and recovery from AKI. METHODS 289 ICU patients with AKI on intermittent hemodialysis (IHD) were included in the study. One hundred and forty-nine patients received PS during IHD. Outcomes were short-term (at discharge) and long-term (at 1 year) recovery of renal function and mortality. RESULTS The two patient groups did not differ in demographics, clinical features, renal characteristics, and frequency of hypophosphatemia at initiation of IHD. Without PS, the frequency of hypophosphatemia increased from 20 to 35%. Severe hypophosphatemia was found in 50% of these patients. By comparison, PS was not associated with an increased frequency of hypophosphatemia. Compared with patients with acute phosphate depletion, patients receiving PS developed less oliguria during IHD, had shorter duration of AKI, higher incidence of complete renal recovery at discharge, and a lower risk of de novo chronic kidney disease. Hypophosphatemia was associated with higher all-cause in-hospital mortality and higher risk of long-term mortality. CONCLUSIONS This multicenter study indicates for the first time that hypophosphatemia during IHD adversely affects short- and long-term outcome of critically-ill patients with AKI. The clinical consequences of the acute hypophosphatemic syndrome may be prevented by PS.
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Affiliation(s)
- Scott C Howard
- Department of Oncology and International Outreach Program, St. Jude Children's Research Hospital, Memphis, TN 38105-2794, USA.
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Demirjian S, Teo BW, Guzman JA, Heyka RJ, Paganini EP, Fissell WH, Schold JD, Schreiber MJ. Hypophosphatemia during continuous hemodialysis is associated with prolonged respiratory failure in patients with acute kidney injury. Nephrol Dial Transplant 2011; 26:3508-14. [DOI: 10.1093/ndt/gfr075] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Ratanarat R, Brendolan A, Volker G, Bonello M, Salvatori G, Andrikos E, Yavuz A, Crepaldi C, Ronco C. Phosphate Kinetics during Different Dialysis Modalities. Blood Purif 2011; 23:83-90. [PMID: 15627742 DOI: 10.1159/000082016] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND An abnormal serum phosphate concentration is common in acute renal failure patients, with a reported incidence of 65-80%. Phosphate removal and kinetics during intermittent hemodialysis (IHD) have been investigated, but there is no information on its kinetics during slow low-efficiency dialysis (SLED) and continuous renal replacement therapy (CRRT). METHODS Eight IHD, 8 SLED, and 10 continuous venovenous hemofiltration (CVVH) patients with a residual renal clearance of <4.0 ml/min were studied during a single treatment to evaluate phosphate removal and kinetics. CVVH was studied the first 24 h after initiation. Dialysis/replacement fluid contained no phosphate. Kt/V, clearance of urea (Ku), inorganic phosphate (Kp) and solute removal was determined by direct dialysate quantification (DDQ). RESULTS Kp recorded with the three techniques were: IHD, 126.9 +/- 18.4 ml/min; SLED, 58.0 +/- 15.8 ml/min, and CVVH, 31.5 +/- 6.0 ml/min. However, in shorter dialysis treatment the total removal of phosphate was significantly lower than in longer dialysis (IHD, 29.9 +/- 7.7 mmol; SLED, 37.6 +/- 9.6 mmol; CVVH, 66.7 +/- 18.9 mmol, p = 0.001). The duration of treatment is the only factor determining phosphate removal (r = 0.7, p < 0.0001 by linear correlation model). Like IHD, phosphate kinetics during SLED could not be explained by the two-pool kinetic model, and the rebound of phosphate extended beyond 1 h after dialysis. Rebound, however, is less marked than in short dialysis. CONCLUSION These results are reliable evidence about amount of phosphate removal and behavior of intradialytic phosphate kinetics in renal failure patients undergoing different dialysis modalities. These data will help clinicians plan phosphate supplementation and treatment intensity.
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Affiliation(s)
- Ranistha Ratanarat
- Department of Nephrology, Dialysis and Transplantation, St Bortolo Hospital, Vicenza, Italy
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Santiago MJ, López-Herce J, Muñoz R, del Castillo J, Urbano J, Solana MJ, Botrán M. Stability of Continuous Renal Replacement Therapy Solutions After Phosphate Addition: An Experimental Study. Ther Apher Dial 2010; 15:75-80. [DOI: 10.1111/j.1744-9987.2010.00877.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ronco C, Ratanarat R, Bellomo R, Salvatori G, Petras D, Cal MD, Nalasso F, Bonello M, Brendolan A. Multiple organ support therapy for the critically ill patient in intensive care. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/17471060500233109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Tan HK, Uchino S, Bellomo R. Electrolyte Mass Balance During CVVH: Lactate vs. Bicarbonate‐Buffered Replacement Fluids. Ren Fail 2009; 26:149-53. [PMID: 15287198 DOI: 10.1081/jdi-120038495] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To compare the effect of lactate vs. bicarbonate-buffered replacement fluids on electrolyte mass balance during isovolemic continuous veno-venous hemofiltration (CVVH). DESIGN Randomized controlled study with double cross over. SETTING Intensive care unit of a tertiary university hospital. PATIENTS AND PARTICIPANTS Eight patients with acute renal failure (ARF). INTERVENTIONS Isovolemic CVVH (2L/hr of replacement fluid) was performed in random order with either bicarbonate or lactate-buffered replacement fluid delivered pre-filter. MEASUREMENTS AND RESULTS Sodium, potassium, chloride, magnesium, and phosphate, were measured in each sample. There was a mass gain of sodium, which was similar under both conditions (bicarbonate: 23.3+/-4.9 mmol/hr, lactate: 22.7+/-3.5 mmol/hr). Mass chloride gains occurred with bicarbonate-buffered replacement fluid only (12.8+/-5.3 mmol/hr), while there was an overall net loss of chloride with lactate fluids (-2.5+/-5.2 mmol/hr), resulting in a significant difference in chloride mass balance (p<0.0001). Magnesium mass balance was negative with bicarbonate buffer only (-0.6+/-0.2 mmol/hr) and also differed significantly from that obtained with lactate fluids (-0.1+/-0.2 mmol/hr, p<0.0001). Phosphate losses (bicarbonate: -1.7+/-0.7 mmol/hr, lactate: -1.7+/-0.5 mmol/hr) were equivalent with both buffers. Potassium mass balance was neutral. CONCLUSIONS Mass balance during isovolemic CVVH is significantly affected by the type of replacement fluid administered prefilter. Isovolemic CVVH is not isonatremic and the use of bicarbonate-buffered fluid results in a significant accumulation of chloride and a loss of magnesium.
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Affiliation(s)
- Han Khim Tan
- Department of Intensive Care and Surgery, Austin Hospital, Melbourne, Australia
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Choi KA, Lee JE, Kim YG, Kim DJ, Kim K, Ko YH, Oh HY, Kim WS, Huh W. Efficacy of continuous venovenous hemofiltration with chemotherapy in patients with Burkitt lymphoma and leukemia at high risk of tumor lysis syndrome. Ann Hematol 2008; 88:639-45. [DOI: 10.1007/s00277-008-0642-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Accepted: 11/05/2008] [Indexed: 10/21/2022]
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Hypophosphatemia and phosphate supplementation during continuous renal replacement therapy in children. Kidney Int 2008; 75:312-6. [PMID: 19002217 DOI: 10.1038/ki.2008.570] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Severe hypophosphatemia can cause generalized muscle weakness, paralysis of the respiratory muscles, myocardial dysfunction, reduced peripheral vascular resistance, and encephalopathy. Here we conducted a prospective study to determine the incidence of hypophosphatemia in 47 children on continuous renal replacement therapy and to evaluate the efficacy and safety of adding phosphate to the replacement and dialysate solutions of 38 pediatric patients. During continuous renal replacement therapy, 68% of patients were found to have hypophosphatemia, significantly more than the 12% of patients at the beginning of therapy. There was no higher incidence of hypophosphatemia among patients requiring insulin, diuretics, parenteral nutrition, or high doses of vasoactive drugs. In the children to whom phosphate was not added to replacement and dialysate solutions, 85% presented with an incidence of hypophosphatemia and 36% required intravenous phosphate replacement, rates significantly higher than in those patients where phosphate was added to the solutions. Phosphate supplementation did not cause any instability of the mixtures or other complications. We show here that the incidence of hypophosphatemia in children on continuous renal replacement therapy is very high. Further, we show that the addition of phosphate to replacement and dialysate solutions is safe and that it reduces the incidence of hypophosphatemia and the need for intravenous phosphate treatment.
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Baldwin I, Naka T, Koch B, Fealy N, Bellomo R. A pilot randomised controlled comparison of continuous veno–venous haemofiltration and extended daily dialysis with filtration: effect on small solutes and acid–base balance. Intensive Care Med 2007; 33:830-835. [PMID: 17384931 DOI: 10.1007/s00134-007-0596-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2005] [Accepted: 02/21/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND AIMS Continuous veno-venous haemofiltration (CVVH) is an established treatment for acute renal failure (ARF). Recently, extended intermittent dialytic techniques have been proposed for the treatment of ARF. The aim of this study was to compare these two approaches. SETTING Intensive care unit of tertiary hospital. SUBJECTS Sixteen critically ill patients with ARF. DESIGN Randomised controlled trial. INTERVENTION We randomised sixteen patients to three consecutive days of treatment with either CVVH (8) or extended daily dialysis with filtration (EDDf) (8) and compared small-solute, electrolyte and acid-base control. RESULTS There was no significant difference between the two therapies for urea or creatinine levels over 3 days. Of 80 electrolyte measurements taken before treatment, 19 were abnormal. All values were corrected as a result of treatment, except for one patient in the CVVH group who developed hypophosphataemia (0.54 mmol/l) at 72 h. After 3 days of treatment, there was a mild but persistent metabolic acidosis in the EDDf group compared to the CVVH group (median bicarbonate: 20 mmol/l vs. 29 mmol/l: p=0.039; median base deficit: -4 mEq/l vs. -2.1 mEq/l, p=0.033). CONCLUSIONS CVVH and EDDf as prescribed achieved similar control of urea, creatinine and electrolytes. Acidosis was better controlled with CVVH.
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Affiliation(s)
- Ian Baldwin
- Department of Intensive Care, Austin Health, 3084, Heidelberg, Australia.
- School of Nursing and Midwifery, Department of Gerontic Nursing, La Trobe University, Melbourne, Australia.
| | - Toshio Naka
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Bill Koch
- School of Nursing and Midwifery, Department of Gerontic Nursing, La Trobe University, Melbourne, Australia
| | - Nigel Fealy
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
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Ronco C, Bellomo R. Dialysis in Intensive Care Unit Patients with Acute Kidney Injury: Continuous Therapy is Superior. Clin J Am Soc Nephrol 2007; 2:597-600. [PMID: 17699468 DOI: 10.2215/cjn.00430107] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Claudio Ronco
- Department of Nephrology Ospedale San Bortolo, Vicenza, Italy.
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Cho KC, Himmelfarb J, Paganini E, Ikizler TA, Soroko SH, Mehta RL, Chertow GM. Survival by Dialysis Modality in Critically Ill Patients with Acute Kidney Injury. J Am Soc Nephrol 2006; 17:3132-8. [PMID: 17021268 DOI: 10.1681/asn.2006030268] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Among critically ill patients, acute kidney injury (AKI) requiring dialysis is associated with mortality rates generally in excess of 50%. Continuous renal replacement therapies (CRRT) often are recommended and widely used, although data to support its superiority over intermittent hemodialysis (IHD) are lacking. Data from the Program to Improve Care in Acute Renal Disease (PICARD), a multicenter observational study of AKI, were analyzed. Among 398 patients who required dialysis, the risk for death within 60 d was examined by assigned initial dialysis modality (CRRT [n = 206] versus IHD [n = 192]) using standard Kaplan-Meier product limit estimates, proportional hazards ("Cox") regression methods, and a propensity score approach to account for selection effects. Crude survival rates were lower for patients who were treated with CRRT than IHD (survival at 30 d 45 versus 58%; P = 0.006). Adjusted for age, hepatic failure, sepsis, thrombocytopenia, blood urea nitrogen, and serum creatinine and stratified by site, the relative risk for death associated with CRRT was 1.82 (95% confidence interval 1.26 to 2.62). Further adjustment for the propensity score did not materially alter the association (relative risk 1.92; 95% confidence interval 1.28 to 2.89). Among critically ill patients with AKI, CRRT was associated with increased mortality. Although the results could reflect residual confounding by severity of illness, these data provide no evidence for a survival benefit afforded by CRRT. Larger, prospective, randomized clinical trials to compare CRRT and IHD in severe AKI are needed.
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Affiliation(s)
- Kerry C Cho
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA 94118, USA
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Joly LM, Troché G, Trouiller P, Boukhalil M, Zazzo JF. [Prevalence of dysphosphoremia in patients admitted in intensive care unit with an impaired renal function]. ACTA ACUST UNITED AC 2005; 24:791-4. [PMID: 15925478 DOI: 10.1016/j.annfar.2005.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2004] [Accepted: 04/04/2005] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the frequency of dysphosphoremia in patients admitted in intensive care unit with an impaired renal function and to determine the associated risks factors. Study design. - Epidemiological prospective study. PATIENTS AND METHODS The creatinine clearance and the phosphoremia were measured in 134 consecutive patients admitted in intensive care unit over a six-month period. Patients with chronic renal failure were excluded. Known risk factors for hypophosphoremia in intensive care unit were recorded. RESULTS Seventy-nine out of one hundred thirty-four patients (59%) had an impaired renal function (arbitrarily defined by a creatinine clearance < 60 ml/min). The proportion of patients with impaired renal function that where hypo-, normo- (0.8 to 1.2 mmol/l) or hyperphosphoremic was 16, 34 and 50% respectively. Hypophosphoremia was severe (< 0.5 mmol/l) in 5 patients, all with impaired renal function. No risk factors usually associated with hypophosphoremia could be identified. CONCLUSION As opposed to chronic renal failure patients who are mainly hyperphosphoremic, patients admitted in intensive care unit with an impaired renal function may present with a normo-, or hypophosphoremia. These dysphosphoremias are sometimes severe. Phosphate status should be promptly determined at admission.
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Affiliation(s)
- L-M Joly
- Département d'anesthésie-réanimation chirurgicale, hôpital Antoine-Béclère, 157, rue de la porte-de-Trivaux, université Paris-Sud, 92140 Clamart, France.
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Augustine JJ, Sandy D, Seifert TH, Paganini EP. A randomized controlled trial comparing intermittent with continuous dialysis in patients with ARF. Am J Kidney Dis 2004; 44:1000-7. [PMID: 15558520 DOI: 10.1053/j.ajkd.2004.08.022] [Citation(s) in RCA: 240] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Despite the widespread use of continuous renal replacement therapy in critically ill patients with acute renal failure (ARF), there are few data supporting its benefits over conventional intermittent hemodialysis (IHD). We sought to analyze differences in survival between modalities in a study that compared continuous venovenous hemodialysis (CVVHD) with IHD. METHODS Eighty critically ill patients with ARF requiring dialysis were randomized after stratification by severity of illness to treatment with CVVHD or IHD. RESULTS There were no differences in survival or renal recovery between groups. In patients who died, mean survival time was 10.7 +/- 11.2 days for the IHD group versus 14.3 +/- 16.1 days for the CVVHD group (P = not significant). There was greater net volume removal in the CVVHD group during 72 hours. Declines in urine output during 72 hours were similar between groups. Mean arterial pressure off and on dialysis therapy was analyzed retrospectively. There was a significant decrease in mean arterial pressure for patients on IHD therapy not seen in those on CVVHD therapy, but this did not lead to a survival advantage. CONCLUSION Despite greater volume control, CVVHD did not lead to an improvement in survival, preservation of urine output, or renal recovery compared with IHD in patients with ARF.
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Affiliation(s)
- Joshua J Augustine
- Department of Nephrology and Hypertension, Case Western University Hospitals, Cleveland, OH 44106, USA.
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Ronco C, Bellomo R. Acute renal failure and multiple organ dysfunction in the ICU: from renal replacement therapy (RRT) to multiple organ support therapy (MOST). Int J Artif Organs 2003; 25:733-47. [PMID: 12296458 DOI: 10.1177/039139880202500801] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Renal replacement therapy (RRT) has evolved from the concept that we need to treat the dysfunction of a single organ (the kidney). As intensive care units have become more and more complex, it has become clear that the majority of patients with acute renal failure often have dysfunction of several other organs. In order to facilitate single organ support in this setting, continuous renal replacement therapy (CRRT) techniques have been developed. However, CRRT has opened the door to the concept that targeting renal support as the only goal of extracorporeal blood purification may be a simplistic view of our therapeutic aims. In this article we argue that it is now time to move from the simple goal of achieving adequate renal support. The proper goal of extracorporeal blood purification in ICU should be multi-organ support therapy (MOST). We explain why MOST represents the most logical future conceptual and practical evolution of CRRT and illustrates the biological rationale, supplying animal and clinical evidence that confirms the need to move rapidly in this direction theoretically, practically and technologically.
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Affiliation(s)
- C Ronco
- Department of Nephrology, Dialysis and Transplantation, St Bortolo Hospital, Vicenza, Italy.
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Morimatsu H, Uchino S, Bellomo R, Ronco C. Continuous veno-venous hemodiafiltration or hemofiltration: impact on calcium, phosphate and magnesium concentrations. Int J Artif Organs 2002; 25:512-9. [PMID: 12117290 DOI: 10.1177/039139880202500605] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND OBJECTIVES Different techniques of continuous renal replacement therapy (CRRT) might have different effects on calcium, phosphate and magnesium concentrations. Accordingly, we tested whether continuous veno-venous hemodia filtration (CVVHDF) or continuous venovenous hemofiltration (CVVH) would achieve better control of these electrolytes. DESIGN Retrospective controlled study SETTING Two tertiary Intensive Care Units PATIENTS Critically ill patients with acute renal failure (ARF) treated with CVVHDF (n=49) or CVVH (n=50) INTERVENTIONS Retrieval of daily morning ionized calcium, phosphate and magnesium before and after the initiation of CRRT for up to 2 weeks of treatment. MEASUREMENTS AND RESULTS Before treatment, both groups had a high incidence of abnormal ionized calcium concentrations (57.2% for CVVHDF vs 46.0% for CVVH; NS). After treatment, both groups showed a significant increase in serum calcium concentration over the first 48 h (p=0.041 vs p=0.0048) but hypercalcemia was more common during CVVHDF (15.3% vs 0.4%; p<0.0001). However, in both groups, hypocalcemia remained common (30.9% vs 36.7%; NS). Before treatment, abnormal serum phosphate concentrations were also common (65.1% for CVVHDF vs 78.1% for CVVH; NS). After treatment, both groups achieved a significant reduction of serum phosphate within 48 hours (p<0.0001 in both groups). There was no difference in the prevalence of abnormal phosphate levels during treatment (45.5% vs 42.4%; NS). Before treatment, both groups had a high incidence of abnormal magnesium concentrations (50.0% for CVVHDF vs 51.2% for CVVH; NS). During treatment, there was no significant change in serum magnesium concentrations during the first 48 hours or in the prevalence of abnormal magnesium concentrations (56.3% vs 63.4%; p=0.13). However CVVHDF was associated with a higher prevalence of hypomagnesemia (8.1% vs 0.4%; p<0.0001) and a lower incidence of hypermagnesemia (48.2% vs. 63.0%; p=0.0014). CONCLUSIONS In critically ill patients with ARF, calcium, phosphate and magnesium were commonly abnormal and they were only partly corrected by CRRT. CVVH and CVVHDF had a different effect on serum magnesium concentrations.
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Affiliation(s)
- H Morimatsu
- Department of Intensive Care, Austin & Repatriation Medical Centre, Melbourne, Victoria, Australia
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