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Ran KR, Ejimogu NE, Yang W, Kilgore CB, Nair SK, Monroy Trujillo JM, Jackson CM, Mukherjee D, Anderson WS, Gallia GL, Weingart JD, Robinson S, Cohen AR, Bettegowda C, Huang J, Tamargo RJ, Xu R. Risk of Subdural Hematoma Expansion in Patients With End-Stage Renal Disease: Continuous Venovenous Hemodialysis Versus Intermittent Hemodialysis. Neurosurgery 2024; 94:567-574. [PMID: 37800923 DOI: 10.1227/neu.0000000000002708] [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: 06/20/2023] [Accepted: 08/10/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Subdural hematoma (SDH) patients with end-stage renal disease (ESRD) require renal replacement therapy in addition to neurological management. We sought to determine whether continuous venovenous hemodialysis (CVVHD) or intermittent hemodialysis (iHD) is associated with higher rates of SDH re-expansion as well as morbidity and mortality. METHODS Hemodialysis-dependent patients with ESRD who were discovered to have an SDH were retrospectively identified from 2016 to 2022. Rates of SDH expansion during CVVHD vs iHD were compared. Hemodialysis mode was included in a multivariate logistic regression model to test for independent association with SDH expansion and mortality. RESULTS A total of 123 hemodialysis-dependent patients with ESRD were discovered to have a concomitant SDH during the period of study. Patients who received CVVHD were on average 10.2 years younger ( P < .001), more likely to have traumatic SDH (47.7% vs 19.0%, P < .001), and more likely to have cirrhosis (25.0% vs 10.1%, P = .029). SDH expansion affecting neurological function occurred more frequently during iHD compared with CVVHD (29.7% vs 12.0%, P = .013). Multivariate logistic regression analysis found that CVVHD was independently associated with decreased risk of SDH affecting neurological function (odds ratio 0.25, 95% CI 0.08-0.65). Among patients who experienced in-hospital mortality or were discharged to hospice, 5% suffered a neurologically devastating SDH expansion while on CVVHD compared with 35% on iHD. CONCLUSION CVVHD was independently associated with decreased risk of neurologically significant SDH expansion. Therefore, receiving renal replacement therapy through a course of CVVHD may increase SDH stability in patients with ESRD.
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Affiliation(s)
- Kathleen R Ran
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Nna-Emeka Ejimogu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Collin B Kilgore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Sumil K Nair
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jose M Monroy Trujillo
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - William S Anderson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jon D Weingart
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Shenandoah Robinson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Alan R Cohen
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
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Zhou L, Zhang D, Kong L, Xu X, Gong D. Clinical improvement of sepsis by extracorporeal centrifugal leukocyte apheresis in a porcine model. J Transl Med 2022; 20:538. [PMID: 36419190 PMCID: PMC9682844 DOI: 10.1186/s12967-022-03752-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 11/04/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Extracorporeal blood purification therapies targeting removal of the downstream products of the inflammatory cascade in sepsis have failed to improve mortality. As an upstream process of the inflammatory cascade, activated white blood cells should be a potential therapeutic target for sepsis, and the effect of removing such cells by extracorporeal centrifugal leukocytapheresis (LCAP) is worth considering. METHODS Fourteen peritonitis-induced septic pigs were randomly assigned to receive a sham operation (control group, n = 7) or one session of LCAP at 12 h after sepsis induction (treatment group, n = 7). Samples from peripheral blood at various time-points and from LCAP collection were tested. All pigs were euthanized at 48 h, and lung, kidney, liver and spleen tissues were obtained for histopathological examination. RESULTS Two pigs died in accidents before the induction of sepsis, and 12 pigs were finally included for the statistical analysis. A significant clinical improvement was present in the treatment group relative to the control group in terms of the mean arterial blood pressure (MAP), oxygen tension (PaO2), lactic acid level, oxygenation index (PaO2/FiO2), and carbon dioxide tension (PaCO2, P < 0.05). Flow cytometry tests showed that a mixture of B cells, dendritic cells, T helper cells, cytotoxic T cells, monocytes and neutrophils were removed from the circulation by LCAP, resulting in sepsis-induced change trends in the control cells; these change trends were all flattened in the treatment group, although nonsignificantly. CONCLUSIONS LCAP may exert a wide-spectrum and bidirectional immunomodulatory effect on sepsis, accompanied by improvements in hemodynamics and oxygenation status.
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Affiliation(s)
- Lei Zhou
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, 305 Zhongshan East Road, Xuanwu District, Nanjing, 210016, China
| | - Dong Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, 305 Zhongshan East Road, Xuanwu District, Nanjing, 210016, China
| | - Ling Kong
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, 305 Zhongshan East Road, Xuanwu District, Nanjing, 210016, China
| | - Xiaodong Xu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, 305 Zhongshan East Road, Xuanwu District, Nanjing, 210016, China
| | - Dehua Gong
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, 305 Zhongshan East Road, Xuanwu District, Nanjing, 210016, China.
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Griffin BR, Eyck PT, Faubel S, Jalal D, Gallagher M, Bellomo R. Platelet Decreases following Continuous Renal Replacement Therapy Initiation as a Novel Risk Factor for Renal Nonrecovery. Blood Purif 2022; 51:559-566. [PMID: 34521084 PMCID: PMC8918433 DOI: 10.1159/000517232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/12/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) is a form of dialysis used in critically ill patients, and has recently been associated with renal nonrecovery. Decreases in platelets following CRRT initiation are common and are associated with mortality, but associations with renal recovery are unclear. Our objective was to determine if platelet nadir or the degree of platelet decrease following CRRT initiation was associated with renal nonrecovery. METHODS This is a secondary analysis of the Randomized Evaluation of Normal versus Augmented Level (RENAL) trial. Primary predictors were platelet nadir discretized by median value and percent platelet decrease following CRRT initiation, with cut points evaluated by decile from 30 to 60%. The 2 primary outcomes were time to RRT-independence and RRT-free days. Secondary outcomes were 28-day mortality, 90-day mortality, intensive care unit (ICU)-free, and hospital-free days. RESULTS Time to RRT independence censored for death was achieved less frequently in patients with low platelet nadir (hazard ratio [HR] 0.77, confidence interval [CI] 0.66-0.91) and in those with >50% platelet decrease (HR 0.84, CI 0.72-0.97). RRT-free days were lower in both low platelet nadir (odds ratio [OR] 0.94, CI 0.90-0.97) and >50% platelet decrease (OR 0.91, CI 0.88-0.95). These groups also had higher rates of 28- and 90-day mortality and fewer ICU-free and hospital-free days. Thrombocytopenia at CRRT initiation was also associated with renal nonrecovery, although the clinical effect was small. CONCLUSIONS Platelet nadir <100 × 103/µL and platelet decrease by >50% following CRRT initiation were both associated with lower rates of renal recovery. Further research is needed to evaluate mechanisms-linking platelet changes and renal nonrecovery in CRRT.
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Affiliation(s)
- Benjamin R Griffin
- Division of Nephrology, University of Iowa Carver College of Medicine, Iowa City, IA, USA, Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Patrick Ten Eyck
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Sarah Faubel
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Diana Jalal
- Division of Nephrology, University of Iowa Carver College of Medicine, Iowa City, IA, USA, Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Martin Gallagher
- The Renal and Metabolic Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Rinaldo Bellomo
- The Renal and Metabolic Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
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Toyoda Y, Tateno K, Takeda Y, Kobayashi Y. Significance of mild thrombocytopenia in maintenance hemodialysis patients; a retrospective cohort study. Platelets 2021; 33:735-742. [PMID: 34672911 DOI: 10.1080/09537104.2021.1983531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Platelet activation in the hemodialysis (HD) circuit often causes thrombocytopenia. However, its clinical and pathophysiological significance has rarely been explored. Herein, we investigated the predictive value of thrombocytopenia for cardiovascular events (CVE) in maintenance HD patients and attempted to explore its mechanistic background considering recent knowledge of platelet dynamics. We conducted a retrospective cohort study on HD patients with the composite primary endpoint of predicting CVE, i.e., myocardial infarction, ischemic stroke, and cardiovascular death. Baseline clinical data were analyzed and explored. Multivariate Cox regression analysis showed that platelet decrease was independently associated with CVE. Thrombocytopenia was correlated with the disuse of antiplatelet therapy (APT) and macrocytosis. These findings are possibly associated with platelet activation and senescent hematopoiesis. The prognostic significance of thrombocytopenia was more prominent in patients undergoing APT, implying the presence of APT-resistant platelets in such patients. To fully explain these results, we hypothesized that HD-activated platelets induce the biological aging of hematopoiesis, which is presumably extramedullary in the lung, where activated platelets could deliver massive amounts of inflammatory cytokines and reactive oxidative species. This results in the production of qualitatively altered and hyper-reactive platelets, a process that could form a vicious cycle that induces CVE-associated thrombocytopenia. Further investigations focusing on the dynamics of the biological aging of platelets in HD patients are warranted.
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Affiliation(s)
- Yukiko Toyoda
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kaoru Tateno
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.,Department of Hemodialysis, Yamanouchi Hospital, Mobara, Japan.,Department of Cardiology, International University of Health and Welfare Narita Hospital, Narita, Japan
| | - Yorinobu Takeda
- Department of Hemodialysis, Yamanouchi Hospital, Mobara, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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The Association of Platelet Decrease Following Continuous Renal Replacement Therapy Initiation and Increased Rates of Secondary Infections. Crit Care Med 2021; 49:e130-e139. [PMID: 33372743 PMCID: PMC8530244 DOI: 10.1097/ccm.0000000000004763] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Thrombocytopenia is common in critically ill patients treated with continuous renal replacement therapy and decreases in platelets following continuous renal replacement therapy initiation have been associated with increased mortality. Platelets play a role in innate and adaptive immunity, making it plausible that decreases in platelets following continuous renal replacement therapy initiation predispose patients to development of infection. Our objective was to determine if greater decreases in platelets following continuous renal replacement therapy correlate with increased rates of secondary infection. DESIGN Retrospectivecohort analysis. SETTING This study uses a continuous renal replacement therapy database from Mayo Clinic (Rochester, MN), a tertiary academic center. PARTICIPANTS Adult patients who survived until ICU discharge and were on continuous renal replacement therapy for less than 30 days were included. A subgroup analysis was also performed in patients with thrombocytopenia (platelets < 100 × 103/µL) at continuous renal replacement therapy initiation. MEASUREMENTS AND MAIN RESULTS The primary predictor variable was a decrease in platelets from precontinuous renal replacement therapy levels of greater than 40% or less than or equal to 40%, although multiple cut points were analyzed. The primary outcome was infection after ICU discharge, and secondary endpoints included post-ICU septic shock and post-ICU mortality. Univariable, multivariable, and propensity-adjusted analyses were used to determine associations between the predictor variable and the outcomes. RESULTS Among 797 eligible patients, 253 had thrombocytopenia at continuous renal replacement therapy initiation. A greater than 40% decrease in platelets after continuous renal replacement therapy initiation was associated in the multivariable-adjusted models with increased odds of post-ICU infection in the full cohort (odds ratio, 1.49; CI, 1.02-2.16) and in the thrombocytopenia cohort (odds ratio, 2.63; CI, 1.35-5.15) cohorts. CONCLUSIONS Platelet count drop by greater than 40% following continuous renal replacement therapy initiation is associated with an increased risk of secondary infection, particularly in patients with thrombocytopenia at the time of continuous renal replacement therapy initiation. Further research is needed to evaluate the impact of both continuous renal replacement therapy and platelet loss on subsequent infection risk.
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Griffin JM, Tariq A, Menez S, Kyeso Y, Chedid A, Ramakrishnan V, Schulman SP, Sperati CJ, Choi MJ, McEvoy JW, McMahon BA. Higher Prevalence of Concurrent Thrombocytopenia in Patients Receiving Continuous Renal Replacement Therapy in the Cardiac Intensive Care Unit. Blood Purif 2021; 50:891-898. [PMID: 33631762 DOI: 10.1159/000513366] [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: 01/31/2020] [Accepted: 11/09/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Thrombocytopenia (TCP) is a common finding in patients receiving continuous renal replacement therapy (CRRT). OBJECTIVE The purpose of this study was to assess the nature of TCP in patients receiving CRRT. METHODS This is a single-center case-control observational study of 795 patients involving over 166,950 h of delivered CRRT at Johns Hopkins Hospital. Concurrent TCP in patients receiving CRRT was defined as a decrease in platelet count of ≥50% any time within 72 h of initiation of CRRT with strict exclusion criteria. RESULTS There was a higher incidence of TCP in the cardiac intensive care unit (CICU) (22.5%) compared to medical ICU (MICU) (13.1%). Using logistic regression, the odds of developing concurrent TCP in patients receiving CRRT was 2.46 (95% CI 1.32-3.57, p < 0.05) times higher in the CICU compared with the MICU. There was no difference in the incidence of severe or profound TCP or timing of acute TCP between the CICU and MICU. CONCLUSION Safe delivery of dialysis care in the ICU is paramount and creating awareness of potential risks such as concurrent TCP in patients receiving CRRT should be part of this care.
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Affiliation(s)
- Jan M Griffin
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Anam Tariq
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Steven Menez
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Yousuf Kyeso
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alice Chedid
- Department of Medicine, University of Tennessee, Memphis, Tennessee, USA
| | | | - Steve P Schulman
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - C John Sperati
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Michael J Choi
- Department of Medicine, MedStar Georgetown University Hospital, Washington D.C., District of Columbia, USA
| | - J William McEvoy
- Department of Cardiology, University College Hospital Galway, Discipline of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Blaithin A McMahon
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA, .,Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA,
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Fay L, Rechner-Neven G, Hammond DA, DeMott JM, Sullivan MJ. Evaluating the Risk of Developing Thrombocytopenia Within Five Days of Continuous Renal Replacement Therapy Initiation in Septic Patients. J Pharm Pract 2020; 35:94-100. [PMID: 32954962 DOI: 10.1177/0897190020959175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The differential diagnosis for thrombocytopenia in critical illness is often extensive. This study was performed to determine the incidence of thrombocytopenia in septic patients undergoing continuous renal replacement therapy (CRRT) versus those not undergoing CRRT. OBJECTIVE The primary outcome of this study was to compare the development of thrombocytopenia, defined as a platelet count ≤ 100 × 103/mm3, in septic patients within 5 days of time zero. Time zero was defined as the baseline platelet count upon hospital admission or CRRT initiation. METHODS An IRB approved, retrospective cohort study was conducted evaluating thrombocytopenia development in critically ill, septic patients who were initiated on CRRT versus those whom were not. Baseline and clinical characteristics were displayed using descriptive statistics. The primary outcome was evaluated overall and in subgroups of CRRT using Chi-square tests. RESULTS One hundred sixty patients, 80 per arm, were included in the study. Thrombocytopenia development within 5 days occurred more frequently in the renal replacement therapy (RRT) group compared to the control group (67.5% vs. 6.3%, p < 0.001). In the subgroup analysis of the RRT cohort, thrombocytopenia development within 5 days occurred more frequently in the continuous veno-venous hemofiltration (CVVH) group compared to the accelerated veno-venous hemofiltration (AVVH) group (76% vs. 53.3%, p = 0.049). CONCLUSION There is a high likelihood that septic patients initiated on CRRT will develop thrombocytopenia during their hospital stay. Patients receiving CVVH may develop thrombocytopenia more frequently than those receiving AVVH. Overall, CRRT should remain a differential diagnosis for thrombocytopenia development in this patient population.
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Affiliation(s)
- Lauren Fay
- Spectrum Health-Pharmacy, Grand Rapids, MI, USA
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Deng L, Xia Q, Chi C, Hu G. Awake veno-arterial extracorporeal membrane oxygenation in patients with perioperative period acute heart failure in cardiac surgery. J Thorac Dis 2020; 12:2179-2187. [PMID: 32642123 PMCID: PMC7330313 DOI: 10.21037/jtd.2020.04.38] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is an effective extracorporeal life support technology that has been applied to treat cardiorespiratory failure patients. Some medical centers have started using ECMO on awake, non-intubated, spontaneously breathing patients, as this strategy offers several benefits over mechanical ventilation. However, most awake-ECMO methods focus on venovenous ECMO, and few cases of awake veno-arterial ECMO (V-A ECMO) have been reported, especially in perioperative acute heart failure. Therefore, our study aimed to examine awake—V-A ECMO cases that were not given continuous sedation or invasive mechanical ventilation (IMV) during perioperative heart failure. Method In total, 40 ECMO patients from December 2013 to November 2019 were divided into 2 groups (the awake-ECMO group and the asleep-ECMO group) according to the ventilation use. The demographics, patient outcomes, and ECMO parameters were collected and retrospectively analyzed. Results We identified 12 cases of awake ECMO without continuous ventilation, and 28 cases of simultaneous IMV and ECMO (asleep ECMO). Awake-ECMO patients showed fewer complications and better outcomes compared to ventilation patients. All patients in the awake group were successfully weaned off ECMO, while only 5 (18%) patients were weaned off ECMO in the asleep group. Furthermore, 9 (75%) patients survived until discharge in the awake group vs. 3 (11%) in the asleep group; 3 patients died of septic shock after weaning in the awake group, while 25 patients died of septic shock, hemodynamic disorder, bleeding, cerebral hemorrhage, etc., in the asleep group. These complications, including bleeding, pneumonia, hemolysis, and abdominal distension, etc., occurred less frequently in the asleep group compared to the awake group (P<0.05). Conclusions Awake V-A ECMO is an effective, feasible, and safe strategy in patients with perioperatively acute heart failure and can be applied as a bridge to cardiac function recovery or transplantation.
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Affiliation(s)
- Li Deng
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Qingping Xia
- Department of Medical Research Center, Mudanjiang Medical University, Mudanjiang 157011, China
| | - Chao Chi
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Guang Hu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
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Effects of Baseline Thrombocytopenia and Platelet Decrease Following Renal Replacement Therapy Initiation in Patients With Severe Acute Kidney Injury. Crit Care Med 2020; 47:e325-e331. [PMID: 30585829 DOI: 10.1097/ccm.0000000000003598] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Thrombocytopenia is common in critically ill patients with severe acute kidney injury and may be worsened by the use of renal replacement therapy. In this study, we evaluate the effects of renal replacement therapy on subsequent platelet values, the prognostic significance of a decrease in platelets, and potential risk factors for platelet decreases. DESIGN Post hoc analysis of the Acute Renal Failure Trial Network Study. SETTING The Acute Renal Failure Trial Network study was a multicenter, prospective, randomized, parallel-group trial of two strategies for renal replacement therapy in critically ill patients with acute kidney injury conducted between November 2003 and July 2007 at 27 Veterans Affairs and university-affiliated medical centers. SUBJECTS The Acute Renal Failure Trial Network study evaluated 1,124 patients with severe acute kidney injury requiring renal replacement therapy. INTERVENTIONS Predictor variables were thrombocytopenia at initiation of renal replacement therapy and platelet decrease following renal replacement therapy initiation. MEASUREMENTS AND MAIN RESULTS Outcomes were mortality at 28 days, 60 days, and 1 year, renal recovery, renal replacement therapy free days, ICU-free days, and hospital-free days. Baseline thrombocytopenia in patients requiring renal replacement therapy was associated with increased mortality and was also associated with lower rates of renal recovery. A decrease in platelet values following renal replacement therapy initiation was associated with increased mortality. Continuous renal replacement therapy was not an independent predictor of worsening thrombocytopenia compared with those treated with intermittent hemodialysis. CONCLUSIONS Baseline thrombocytopenia and platelet decrease following renal replacement therapy initiation were associated with increased mortality, and baseline thrombocytopenia was associated with decreased rates of renal recovery. Continuous renal replacement therapy did not decrease platelets compared with hemodialysis.
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Laliberte B, Reed BN. Use of an argatroban-based purge solution in a percutaneous ventricular assist device. Am J Health Syst Pharm 2019; 74:e163-e169. [PMID: 28438820 DOI: 10.2146/ajhp160212] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE The use of an argatroban-based percutaneous ventricular assist device (pVAD) purge solution in a patient with suspected heparin-induced thrombocytopenia (HIT) is described. SUMMARY A 70-year-old woman in cardiogenic shock was admitted to a coronary care unit after being discovered unresponsive at home. A transthoracic echocardiogram revealed a low ejection fraction and findings consistent with takotsubo cardiomyopathy. Administration of multiple inotropes and vasopressors was initially required for hemodynamic support. The patient was implanted with an Impella pVAD (Abiomed, Inc., Danvers, MA) using a heparin-based purge solution; an i.v. heparin infusion was initiated for supplemental systemic anticoagulation. Over the next 24 hours, the patient's platelet count decreased from 168,000 to 37,000 cells/μL. Given a differential diagnosis that included HIT, the patient was transitioned to an argatroban-based purge solution. Due to prolonged activated partial thromboplastin times, a systemic argatroban infusion was not initiated, and the patient remained fully anticoagulated throughout pVAD support with only the argatroban-based purge solution. An HIT antibody test was negative. On hospitalization day 9 (day 6 of pVAD support with argatroban use), the patient became hemodynamically stable and was weaned off pVAD support. Three days later, the platelet count had recovered to 117,000 cells/μL (from a nadir of 21,000 cells/μL). During pVAD support, the patient developed hemolytic anemia with minimal bleeding complications. CONCLUSION Argatroban was used as a purge solution anticoagulant in a patient with an Impella pVAD and found to be a safe and effective alternative to heparin.
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Affiliation(s)
| | - Brent N Reed
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD.
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Lin J, Gallagher M, Bellomo R, Duan M, Trongtrakul K, Wang AY. SOFA coagulation score and changes in platelet counts in severe acute kidney injury: Analysis from the randomized evaluation of normal versus augmented level (RENAL) study. Nephrology (Carlton) 2019; 24:518-525. [DOI: 10.1111/nep.13387] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Jin Lin
- The George Institute for Global HealthUniversity of New South Wales Sydney New South Wales Australia
- Beijing Friendship HospitalCapital Medical University Beijing China
| | - Martin Gallagher
- The George Institute for Global HealthUniversity of New South Wales Sydney New South Wales Australia
- Concord Repatriation General Hospital Concord New South Wales Australia
| | - Rinaldo Bellomo
- The George Institute for Global HealthUniversity of New South Wales Sydney New South Wales Australia
- Department of Intensive CareAustin Hospital Melbourne Victoria Australia
| | - Meili Duan
- Beijing Friendship HospitalCapital Medical University Beijing China
| | - Konlawi Trongtrakul
- Department of Emergency Medicine, Faculty of Medicine Vajira HospitalNavamindradhiraj University Bangkok Thailand
| | - Amanda Ying Wang
- The George Institute for Global HealthUniversity of New South Wales Sydney New South Wales Australia
- Faculty of Medicine & Health SciencesMacquarie University Sydney New South Wales Australia
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12
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Cho AY, Yoon HJ, Lee KY, Sun IO. Clinical characteristics of sepsis-induced acute kidney injury in patients undergoing continuous renal replacement therapy. Ren Fail 2018; 40:403-409. [PMID: 30015549 PMCID: PMC6052425 DOI: 10.1080/0886022x.2018.1489288] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective: The aim of this study was to investigate the clinical characteristics of sepsis-induced acute kidney injury (AKI) in patients undergoing continuous renal replacement therapy (CRRT). Methods: From 2011 to 2015, we enrolled 340 patients who were treated with CRRT for sepsis at the Presbyterian Medical Center. In all patients, CRRT was performed using the PRISMA platform. We divided these patients into two groups (survivors and non-survivors) according to the 28-day all-cause mortality. We compared clinical characteristics and analyzed the predictors of mortality. Results: The 28-day all-cause mortality was 62%. Survivors were younger than non-survivors and had higher platelet counts (178 ± 101 × 103/mL vs. 134 ± 84 × 103/mL, p < .01) and serum creatinine levels (4.2 ± 2.8 vs. 3.3 ± 2.7, p < .01). However, survivors had lower red blood cell distribution width (RDW) scores (14.9 ± 2.1 vs. 16.1 ± 3.3, p < .01) and APACHE II scores (24.5 ± 5.8 vs. 26.9 ± 5.7, p < .01) than non-survivors. Furthermore, survivors were more likely than non-survivors to have a urine output of >0.05 mL/kg/h (66% vs. 86%, p = .001) in the first day. In a multivariate logistic regression analysis, age, platelet count, RDW score, APACHE II score, serum creatinine level, and a urine output of <0.05 mL/kg/h the first day were prognostic factors for the 28-day all-cause mortality. Conclusion: Age, platelet count, APACHE II score, RDW score, serum creatinine level, and urine output the first day are useful predictors for the 28-day all-cause mortality in sepsis patients requiring CRRT.
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Affiliation(s)
- A Young Cho
- a Department of Internal Medicine, Division of Nephrology , Presbyterian Medical Center , Jeonju , Korea
| | - Hyun Ju Yoon
- a Department of Internal Medicine, Division of Nephrology , Presbyterian Medical Center , Jeonju , Korea
| | - Kwang Young Lee
- a Department of Internal Medicine, Division of Nephrology , Presbyterian Medical Center , Jeonju , Korea
| | - In O Sun
- a Department of Internal Medicine, Division of Nephrology , Presbyterian Medical Center , Jeonju , Korea
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Droege CA, Ernst NE, Messinger NJ, Burns AM, Mueller EW. Evaluation of Thrombocytopenia in Critically Ill Patients Receiving Continuous Renal Replacement Therapy. Ann Pharmacother 2018; 52:1204-1210. [PMID: 29871503 DOI: 10.1177/1060028018779200] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) may be associated with thrombocytopenia in critically ill patients. A confounding factor is concomitant use of unfractionated heparin (UFH) and suspicion for heparin-induced thrombocytopenia (HIT). OBJECTIVE To determine the impact of CRRT on platelet count and development of thrombocytopenia. METHODS Retrospective analyses evaluated the intrapatient change in platelet count following CRRT initiation. Critically ill adult patients who received CRRT for at least 48 hours were included. The primary outcome was intrapatient change in platelet count from CRRT initiation through the first 5 days of therapy. Secondary outcomes included thrombocytopenia incidence, identification of concomitant factors associated with thrombocytopenia, and frequency of HIT. RESULTS 80 patients were included. Median platelet count at CRRT initiation (D0) was 128000/µL (81500-212500/µL), which was higher than those on subsequent post-CRRT days (D1: 104500/µL [63000-166750/µL]; D2: 88500/µL [53500-136750/µL]; D3: 91000/µL [49000-138000/µL]; D4: 93000/µL [46000-134000/µL]; and D5: 76000/µL [45500-151000/µL]; P < 0.05 for all). Twenty-five (35%) patients had thrombocytopenia on CRRT D0 compared with D2 (56.3%), D3 (58.7%), and D5 (59.1%); P < 0.05 for all. Controlling for potential confounders, Sequential Organ Failure Assessment score at the time of CRRT initiation was the only independent factor associated with thrombocytopenia. One (1.3%) patient had confirmed HIT. Conclusion and Relevance: This study is the first to demonstrate serial decreases in platelet count across multiple days after CRRT initiation. These data may provide additional insight to thrombocytopenia development in critically ill patients receiving heparin while on CRRT that is not associated with HIT.
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Affiliation(s)
- Christopher A Droege
- 1 University of Cincinnati Medical Center, OH, USA.,2 University of Cincinnati James L. Winkle College of Pharmacy, OH, USA
| | - Neil E Ernst
- 1 University of Cincinnati Medical Center, OH, USA.,2 University of Cincinnati James L. Winkle College of Pharmacy, OH, USA
| | | | | | - Eric W Mueller
- 1 University of Cincinnati Medical Center, OH, USA.,2 University of Cincinnati James L. Winkle College of Pharmacy, OH, USA
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Abstract
OBJECTIVE This report describes three patients with Ebola virus disease who were treated in the United States and developed for severe critical illness and multiple organ failure secondary to Ebola virus infection. The patients received mechanical ventilation, renal replacement therapy, invasive monitoring, vasopressor support, and investigational therapies for Ebola virus disease. DATA SOURCES Patient medical records from three tertiary care centers (Emory University Hospital, University of Nebraska Medical Center, and Texas Health Presbyterian Dallas Hospital). STUDY SELECTION Not applicable. DATA EXTRACTION Not applicable. DATA SYNTHESIS Not applicable. CONCLUSION In the severe form, patients with Ebola virus disease may require life-sustaining therapy, including mechanical ventilation and renal replacement therapy. In conjunction with other reported cases, this series suggests that respiratory and renal failure may occur in severe Ebola virus disease, especially in patients burdened with high viral loads. Ebola virus disease complicated by multiple organ failure can be survivable with the application of advanced life support measures. This collective, multicenter experience is presented with the hope that it may inform future treatment of patients with Ebola virus disease requiring critical care treatment.
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