Continuous renal replacement therapy in COVID-19-associated AKI: adding heparin to citrate to extend filter life-a retrospective cohort study

Development and external validation of a prediction model for the premature circuit clotting of continuous renal replacement therapy in critically ill patients

OBJECTIVE

This study aimed to develop and validate a prediction model for premature circuit clotting of continuous renal replacement therapy (CRRT) in critically ill patients.

DESIGN

A retrospective cohort study was conducted on ICU patients undergoing CRRT. The Medical Information Mart for Intensive Care-III Clinical Database CareVue subset and Medical Information Mart for Intensive Care-IV were utilized for model development, while the eICU Collaborative Research Database was employed for external validation. Predictive factors were selected through Least Absolute Shrinkage and Selection Operator Regression and univariate logistic regression. A prediction model was then developed using binary logistic regression. Internal and external validations assessed the model's discrimination, calibration, and clinical net benefit.

RESULTS

This study encompassed 2531 patients overall, with a premature circuit clotting rate of 31.88 %. The prediction model comprises five variables: body temperature, anticoagulation, mean arterial pressure, maximum transmembrane pressure change within two hours, and vasopressor. The model demonstrated robust predictive performance, achieving an area under the receiver operating characteristic curve of 0.897 (95 % CI: 0.879-0.915) in the training set and 0.877 (95 % CI: 0.852-0.902) in the external validation set. Internal validation yielded a Brier score of 0.087, while external validation showed a Brier score of 0.120. Calibration curves indicated good model calibration for both validations. The decision curve analysis indicates that the model yields a clinical net benefit across a wide range of decision thresholds.

CONCLUSION

The model demonstrates robust discrimination, calibration, and clinical net benefit, with readily available variables indicating substantial potential for valuable clinical applications.

IMPLICATIONS FOR CLINICAL PRACTICE

Healthcare providers in the ICU can leverage the model to evaluate the risk of premature circuit clotting in critically ill patients undergoing continuous renal replacement therapy, facilitating timely intervention to mitigate its incidence.

Knowledge, attitude, practice, needs, and implementation status of intensive care unit staff toward continuous renal replacement therapy: a survey of 66 hospitals in central and South China

BACKGROUND

Continuous renal replacement therapy (CRRT) is a commonly utilized form of renal replacement therapy (RRT) in the intensive care unit (ICU). A specialized CRRT team (SCT, composed of physicians and nurses) engage playing pivotal roles in administering CRRT, but there is paucity of evidence-based research on joint training and management strategies. This study armed to evaluate the knowledge, attitude, and practice (KAP) of ICU staff toward CRRT, and to identify education pathways, needs, and the current status of CRRT implementation.

METHODS

This study was performed from February 6 to March 20, 2023. A self-made structured questionnaire was used for data collection. Descriptive statistics, T-tests, Analysis of variance (ANOVA), multiple linear regression, and Pearson correlation coefficient tests (α = 0.05) were employed.

RESULTS

A total of 405 ICU staff from 66 hospitals in Central and South China participated in this study, yielding 395 valid questionnaires. The mean knowledge score was 51.46 ± 5.96 (61.8% scored highly). The mean attitude score was 58.71 ± 2.19 (73.9% scored highly). The mean practice score was 18.15 ± 0.98 (85.1% scored highly). Multiple linear regression analysis indicated that gender, age, years of CRRT practice, ICU category, and CRRT specialist panel membership independently affected the knowledge score; Educational level, years of CRRT practice, and CRRT specialist panel membership independently affected the attitude score; Education level and teaching hospital employment independently affected the practice score. The most effective method for ICU staff to undergo training and daily work experience is within the department.

CONCLUSION

ICU staff exhibit good knowledge, a positive attitude and appropriately practiced CRRT. Extended CRRT practice time in CRRT, further training in a general ICU or teaching hospital, joining a CRRT specialist panel, and upgraded education can improve CRRT professional level. Considering the convenience of training programs will enhance ICU staff participation. Training should focus on basic CRRT principles, liquid management, and alarm handling.

The benefits of early continuous renal replacement therapy in critically ill patients with acute kidney injury at high-altitude areas: a retrospective multi-center cohort study

Severe hypoxia would aggravate the acute kidney injury (AKI) in high-altitude areas and continuous renal replacement therapy (CRRT) has been used to treat critically ill patients with AKI. However, the characteristics and outcomes of CRRT in critically ill patients at AKI in high altitudes and the optimal timing of CRRT initiation remain unclear. 1124 patients were diagnosed with AKI and treated with CRRT in the ICU, comprising a high-altitude group (n = 648) and low-altitude group (n = 476). Compared with the low-altitude group, patients with AKI at high altitude showed longer CRRT (4.8 vs. 3.7, P = 0.036) and more rapid progression of AKI stages (P < 0.01), but without any significant minor or major bleeding episodes (P > 0.05). Referring to the analysis of survival and kidney recovery curves, a higher mortality but a lower possibility of renal recovery was observed in the high-altitude group (P < 0.001). However, in the high-altitude group, the survival rate of early CRRT initiation was significantly higher than that of delayed CRRT initiation (P < 0.001). The findings showed poorer clinical outcomes in patients undergoing CRRT for AKI at high altitudes. CRRT at high altitudes was unlikely to increase the adverse events. Moreover, early CRRT initiation might reduce the mortality and promote renal recovery in high-altitude patients.

An Innovative Approach to Minimizing Downtime in Continuous Kidney Replacement Therapy

Continuous kidney replacement therapy (CKRT) is often utilized to stabilize patients with severe acute kidney injury associated with significant electrolyte abnormalities and/or oliguria and concomitant fluid accumulation. Circuit downtime may reduce daily treatment time and affect delivered doses of CKRT. Studies have found clotting to be the leading cause of downtime and underdosing, which are associated with negative treatment outcomes. The NxStage Cartridge Express with Speedswap (NxStage Medical, Inc.) was designed to minimize downtime by allowing filter priming to occur in parallel with ongoing CKRT and by permitting filter exchanges without the need to replace the entire cartridge. Data from pilot studies suggest that filter exchanges using this system interrupt treatment by an average of 4 minutes per exchange-a considerable reduction from traditional systems that require treatment to be discontinued while the filter is primed, which can take 30 minutes or more. In addition to increasing patient time on therapy, this system has the potential to reduce costs for patients who require a high number of filter changes, and reduce nursing labor and environmental impact (reduced plastic waste). Future studies should confirm whether patients at higher risk of clotted/clogged filters benefit from CKRT with a system designed for rapid filter changes.

Continuous KRT: A Contemporary Review

AKI is a common complication of critical illness and is associated with substantial morbidity and risk of death. Continuous KRT comprises a spectrum of dialysis modalities preferably used to provide kidney support to patients with AKI who are hemodynamically unstable and critically ill. The various continuous KRT modalities are distinguished by different mechanisms of solute transport and use of dialysate and/or replacement solutions. Considerable variation exists in the application of continuous KRT due to a lack of standardization in how the treatments are prescribed, delivered, and optimized to improve patient outcomes. In this manuscript, we present an overview of the therapy, recent clinical trials, and outcome studies. We review the indications for continuous KRT and the technical aspects of the treatment, including continuous KRT modality, vascular access, dosing of continuous KRT, anticoagulation, volume management, nutrition, and continuous KRT complications. Finally, we highlight the need for close collaboration of a multidisciplinary team and development of quality assurance programs for the provision of high-quality and effective continuous KRT.

Results of the 2018 Japan Society for Blood Purification in Critical Care survey: current status and outcomes

Background

The Japan Society for Blood Purification in Critical Care (JSBPCC) has reported survey results on blood purification therapy (BPT) for critically ill patients in 2005, 2009, and 2013. To clarify the current clinical status, including details of the modes used, treated diseases, and survival rate, we conducted this cohort study using data from the nationwide JSBPCC registry in 2018.

Methods

We analyzed data of 2371 patients who underwent BPT in the intensive care units of 43 facilities to investigate patient characteristics, disease severity, modes of BPTs, including the dose of continuous renal replacement therapy (CRRT) and hemofilters, treated diseases, and the survival rate for each disease. Disease severity was assessed using Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores.

Results

BPT was performed 2867 times in the 2371 patients. Mean APACHE II and SOFA scores were 23.5 ± 9.4 and 10.0 ± 4.4, respectively. The most frequently used mode of BPT was CRRT (67.4%), followed by intermittent renal replacement therapy (19.1%) and direct hemoperfusion with the polymyxin B-immobilized fiber column (7.3%). The most commonly used anticoagulant was nafamostat mesilate (78.6%). Among all patients, the 28-day survival rate was 61.7%. CRRT was the most commonly used mode for many diseases, including acute kidney injury (AKI), multiple organ failure (MOF), and sepsis. The survival rate decreased according to the severity of AKI (P = 0.001). The survival rate was significantly lower in patients with multiple organ failure (MOF) (34.6%) compared with acute lung injury (ALI) (48.0%) and sepsis (58.0%). Multivariate logistic regression analysis revealed that sepsis, ALI, acute liver failure, cardiovascular hypotension, central nervous system disorders, and higher APACHE II scores were significant predictors of higher 28-day mortality.

Conclusion

This large-scale cohort study revealed the current status of BPT in Japan. It was found that CRRT was the most frequently used mode for critically ill patients in Japan and that 28-day survival was lower in those with MOF or sepsis. Further investigations are required to clarify the efficacy of BPT for critically ill patients.

Trial Registration: UMIN000027678.

Good practice statements for antithrombotic therapy in the management of COVID-19: Guidance from the SSC of the ISTH

Despite the emergence of high quality randomized trial data with the use of antithrombotic agents to reduce the risk of thromboembolism, end-organ failure, and possibly mortality in patients with coronavirus disease 2019 (COVID-19), questions still remain as to optimal patient selection for these strategies, the use of antithrombotics in outpatient settings and in-hospital settings (including critical care units), thromboprophylaxis in special patient populations, and the management of acute thrombosis in hospitalized COVID-19 patients. In October 2021, the International Society on Thrombosis and Haemostasis (ISTH) formed a multidisciplinary and international panel of content experts, two patient representatives, and a methodologist to develop recommendations on treatment with anticoagulants and antiplatelet agents for COVID-19 patients. The ISTH Guideline panel discussed additional topics to be well suited to a non-Grading of Recommendations Assessment, Development, and Evaluation (GRADE) for Good Practice Statements (GPS) to support good clinical care in the antithrombotic management of COVID-19 patients in various clinical settings. The GPS panel agreed on 17 GPS: 3 in the outpatient (pre-hospital) setting, 12 in the hospital setting both in non-critical care (ward) as well as intensive care unit settings, and 2 in the immediate post-hospital discharge setting based on limited evidence or expert opinion that supports net clinical benefit in enacting the statements provided. The antithrombotic therapies discussed in these GPS should be available in low- and middle-income countries.

The importance of anticoagulation in COVID-19-related acute kidney injury requiring continuous renal replacement therapy

Introduction/Objective. In Serbia, the pandemic of the coronavirus disease 2019 (COVID-19) began in early March 2020. The aim of this study is to summarize clinical experience in the treatment of COVID-19-associated acute kidney injury (AKI) by methods of continuous renal replacement therapy (CRRT) with the focus on the amount of the administered dose of unfractionated heparin (UFH). Methods. The study covers 12 patients treated with CRRT at the Clinic for Infectious Diseases at the Clinical Center of Vojvodina from March 6, 2020 to May 20, 2020. Antithrombotic prophylaxis, risk of venous thromboembolism (VTE), applied therapy, biochemical parameters before and after CRRT, anticoagulation and other CRRT parameters were analyzed. Results. The mean age of the patients was 61.54 ? 10.37 years and seven (58.3%) were men. All the patients received standard thromboprophylaxis. Nine (75%) patients had Padua Prediction Score for Risk of VTE ? 4, but none developed a thrombotic event. Seven critically ill patients with multi-organic dysfunction developed AKI dependent on CRRT. The mean CRRT dose was 36.6 ml/kg/h, the mean bolus dose of unfractionated heparin was 3250 ? 1138.18IU, and the continuous dose was 1112.5 ? 334.48IU/kg/h. Discontinuation of CRRT due to the clotting circuit was necessary in only one patient. The values of leukocytes, AST, ALT, GGT, aPTT, PT were significantly higher after CRRT compared to urea, creatinine, potassium, chlorine and magnesium, whose values were significantly lower. Conclusion. In our COVID-19 patients who had high inflammatory parameters and D-dimer and an estimated risk of developing DVT, the implementation pre-dilution CVVHDF with antithrombotic membrane and 1/3 to 1/2 higher UFH doses than the recommended one, the filter life lasted longer with no complications.

Use and misuse of biomarkers and the role of D-dimer and C-reactive protein in the management of COVID-19: A post-hoc analysis of a prospective cohort study

OBJECTIVE

Coronavirus disease 2019 (COVID-19) is associated with high mortality among hospitalized patients and incurs high costs. Severe acute respiratory syndrome coronavirus 2 infection can trigger both inflammatory and thrombotic processes, and these complications can lead to a poorer prognosis. This study aimed to evaluate the association and temporal trends of D-dimer and C-reactive protein (CRP) levels with the incidence of venous thromboembolism (VTE), hospital mortality, and costs among inpatients with COVID-19.

METHODS

Data were extracted from electronic patient records and laboratory databases. Crude and adjusted associations for age, sex, number of comorbidities, Sequential Organ Failure Assessment score at admission, and D-dimer or CRP logistic regression models were used to evaluate associations.

RESULTS

Between March and June 2020, COVID-19 was documented in 3,254 inpatients. The D-dimer level ≥4,000 ng/mL fibrinogen equivalent unit (FEU) mortality odds ratio (OR) was 4.48 (adjusted OR: 1.97). The CRP level ≥220 mg/dL OR for death was 7.73 (adjusted OR: 3.93). The D-dimer level ≥4,000 ng/mL FEU VTE OR was 3.96 (adjusted OR: 3.26). The CRP level ≥220 mg/dL OR for VTE was 2.71 (adjusted OR: 1.92). All these analyses were statistically significant (p<0.001). Stratified hospital costs demonstrated a dose-response pattern. Adjusted D-dimer and CRP levels were associated with higher mortality and doubled hospital costs. In the first week, elevated D-dimer levels predicted VTE occurrence and systemic inflammatory harm, while CRP was a hospital mortality predictor.

CONCLUSION

D-dimer and CRP levels were associated with higher hospital mortality and a higher incidence of VTE. D-dimer was more strongly associated with VTE, although its discriminative ability was poor, while CRP was a stronger predictor of hospital mortality. Their use outside the usual indications should not be modified and should be discouraged.