Continuous Kidney Replacement Therapy Practices in Pediatric Intensive Care Units Across Europe

IMPORTANCE

Continuous kidney replacement therapy (CKRT) is the preferred method of kidney support for children with critical illness in pediatric intensive care units (PICUs). However, there are no data on the current CKRT management practices in European PICUs.

OBJECTIVE

To describe current CKRT practices across European PICUs.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey of PICUs in 20 European countries was conducted by the Critical Care Nephrology Section of the European Society of Pediatric and Neonatal Intensive Care from April 1, 2020, to May 31, 2022. Participants included intensivists and nurses working in European PICUs. The survey was developed in English and distributed using SurveyMonkey. One response from each PICU that provided CKRT was included in the analysis. Data were analyzed from June 1 to June 30, 2022.

MAIN OUTCOME AND MEASURES

Demographic characteristics of European PICUs along with organizational and delivery aspects of CKRT (including prescription, liberation from CKRT, and training and education) were assessed.

RESULTS

Of 283 survey responses received, 161 were included in the analysis (response rate, 76%). The attending PICU consultant (70%) and the PICU team (77%) were mainly responsible for CKRT prescription, whereas the PICU nurses were responsible for circuit setup (49%) and bedside machine running (67%). Sixty-one percent of permanent nurses received training to use CKRT, with no need for certification or recertification in 36% of PICUs. Continuous venovenous hemodiafiltration was the preferred dialytic modality (51%). Circuit priming was performed with normal saline (67%) and blood priming in children weighing less than 10 kg (56%). Median (IQR) CKRT dose was 35 (30-50) mL/kg/h in neonates and 30 (30-40) mL/kg/h in children aged 1 month to 18 years. Forty-one percent of PICUs used regional unfractionated heparin infusion, whereas 35% used citrate-based regional anticoagulation. Filters were changed for filter clotting (53%) and increased transmembrane pressure (47%). For routine circuit changes, 72 hours was the cutoff in 62% of PICUs. Some PICUs (34%) monitored fluid removal goals every 4 hours, with variation from 12 hours (17%) to 24 hours (13%). Fluid removal goals ranged from 1 to 3 mL/kg/h. Liberation from CKRT was performed with a diuretic bolus followed by an infusion (32%) or a diuretic bolus alone (19%).

CONCLUSIONS AND RELEVANCE

This survey study found a wide variation in current CKRT practice, including organizational aspects, education and training, prescription, and liberation from CKRT, in European PICUs. This finding calls for concerted efforts on the part of the pediatric critical care and nephrology communities to streamline CKRT education and training, research, and guidelines to reduce variation in practice.

Comparison of thermal and chemical enhanced recovery of DNAPL in saturated porous media: 2D tank pumping experiments and two-phase flow modelling

Pumping experiments were performed in a 2D tank in order to estimate the recovery yield of pure heavy chlorinated organic compounds (DNAPL; dense non-aqueous phase liquids) by varying different parameters: permeability of the saturated zone, pumping flow rates, addition of surfactant and heating. Surfactant was added to decrease capillary forces involved in the entrapment of DNAPL in porous media while temperature was increased to reduce DNAPL viscosity (and hence increase its mobility). Chemical enhancement was performed with the addition of Sodium Dodecyl Benzene Sulfonate (SDBS) (at its Critical Micelle Concentration, to avoid DNAPL dissolution) and thermal enhancement was performed at 50 °C (to avoid DNAPL volatilization). The experiments were monitored with photography allowing, on the basis of image interpretation, to convert optical densities (OD) into water saturations (S_w). Image interpretations were compared with modelling results. The two-phase flow modelling was performed with the pressure-pressure formulation using capillary pressure and relative permeability functions based on the van Genuchten-Mualem equations. Measured volumes of DNAPL recovered as well as the displacement of the DNAPL-water interface (radius and height of the cone of depression) are consistent with the modelling results. Furthermore, chemical enhancement results in a significant increase in the recovery rates of DNAPL. The observed improvement in the recovery of DNAPL with chemical enhancement is due to the fact that: (i) the residual saturation inside the cone of depression is lower and (ii) the cone of depression radius and height increase. Thermal enhancement had no beneficial effect on DNAPL recovery rate or yield. This study shows that it is possible to accurately determine water and DNAPL saturations by image interpretation during pumping tests in a 2D tank in the laboratory. For field-scale applications, the two-phase flow model allows to determine remediation yields as well as the volumes of the cone of depression according to the different operating conditions.

Pan-tumor prognostic value of multiple immune protein expressions

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Background: Using multiple immune-checkpoint proteins (ICP) screening in clinical routine could improve the evaluation of patients’ prognosis and ultimately tailor their treatment choice. We have evaluated this hypothesis in the context of early drug clinical trials. Methods: Patients included in MOSCATO-02 trial had refractory cancers and were candidate for phase 1 study. They were proposed to have a biopsy on an accessible tumor site for the analysis of four proteins by immunohistochemistry (IHC) and RNAseq: PD-L1, CD3, CD8 and FOXP3. Quantification of IHC staining was separated between intratumoral, intersitial and stromal by semi-quantitative method. Their relations to prognosis have been evaluated by survival Random Forest and compared to classical prognosis clinical variables, such as age and RMH score (calculated by the number of metastatic sites, lactate dehydrogenase (LDH) and serum albumin). Results: From April 2016 to September 2017, 228 patients included in MOSCATO-02 had a successful biopsy procedure with available IHC expression analysis. The main tumor subtypes were gastro-intestinal, urological, head and neck, breast and lung. RNAseq analyzes were performed for two thirds of the patients (N=170). Median overall survival was 8.1 months (CI95% 7.79 – 10, 65). We found that, in a cohort of phase I patients, RMH score was the most important variable used to estimate prognosis. Prognosis value of immune proteins were considerably inferior compared to clinical criteria. Among those proteins, the percentage of PD-L1 low score (1+) and average staining intensity of CD3 were the most valuables for prognosis evaluation. Variables with very few importance to prognosis estimation were CD8 and FOXP3 IHC scores, biopsy site and cancer types, subsequent treatments by immunotherapies or targeted therapies. Conclusions: In this cohort of patients with refractory cancers, the RMH score is confirmed as highly prognosis. Immune proteins could be used as a support to guide patient’s selection but does not constitute effective prognosis criteria.

Acute renal dysfunction after cardiac surgery with cardiopulmonary bypass is associated with plasmatic IL6 increase

BACKGROUND

Acute renal dysfunction (ARD) is common after cardiac surgery with cardiopulmonary bypass (CPB). CPB results in a sudden systemic inflammatory response. Systemic and local pro-inflammatory cytokines synthesis has been linked with sub-clinical renal injury, especially tubular lesions. Therefore, we sought to assess the systemic synthesis pro-inflammatory cytokines and its association with perioperative ARD after cardiac surgery with CPB.

METHODS

Sixty-two patients undergoing cardiac surgery with CPB were prospectively included. Four groups of patients were defined according to blood creatinine increase: no ARD (less than 25% increase), faint ARD (25-50% increase), moderate ARD (50-100% increase), severe ARD (more than 100% increase).

RESULTS

Within the 48 post-operative hours was ARD observed as no dysfunction (41.9%), faint (32.2%), moderate (16.1%), severe (9.6%). One patient had to undergo a dialysis. Pre-operative characteristics were homogenous between the four groups excepted the left ventricle ejection fraction. ARD was associated with a low urinary output with high sodium excretion fraction. Significant increase of IL-6 level occurred when patients underwent a severe ARD despite no significant differences for the CRP and TNF-alpha concentrations.

CONCLUSION

Severe acute renal dysfunction after cardiac surgery with CPB is associated with a significant increased IL-6 systemic production.

[Evaluation of the renal function in cardiac surgery with CPB: role of the cystatin C and the calculated creatinine clearance]

OBJECTIVES

The evaluation of the renal function in cardiac surgery is difficult. The gold standard remains the creatinine clearance in clinical practice. Cystatin C was recently proposed in order to evaluate the renal function. The aim of our study was to evaluate the cystatin C in cardiac surgery with CPB.

PATIENTS AND METHODS

After informed consent and ethical committee agreement, 60 patients operated in cardiac surgery with CPB were prospectively included. Cystatin C,measured and calculated (Cockcroft and MDRD methods) creatinine were compared with the Student t-test and with the Bland and Altman method. p<0,05 was considered as a significant threshold.

RESULTS

The reproducibility of the calculated creatinine clearance was better when the urinary collecting time was below 400 minutes. The estimation of the creatinine clearance by the Cockcroft and MDRD methods is better when the clearance is low. A significant correlation between the creatinine clearance and the cystatin C does exist, but the correlation coefficient was low. In case of acute renal dysfunction, the increase of the creatinine occurred earlier than the increase of the cystatin C.

CONCLUSION

In cardiac surgery with CPB, the evaluation of the renal function was not improved by the cystatin C.

[Arterial gas embolism originating from the lung in anaesthesia and intensive care]

We report seven cases of arterial gas embolism originating from the lung that occurred in anaesthesia and intensive care unit in the very hospital where our regional hyperbaric oxygen facility is. They complicated lung surgery or trauma and/or followed a support by positive-pressure ventilation. Diagnosis was most often delayed, because of some scepticism of the physicians confronted with a variety of clinical features. The prognosis was bad with four deaths, despite treatment with hyperbaric oxygen in three cases.

[A standardised histopathological worksheet for the histopathologic examination of primary cutaneous melanomas. Experiences at the Gustave-Roussy Institute]

A standardised worksheet for the histopathology report of primary cutaneous melanoma used at the Gustave-Roussy Institute is described. Each item is discussed.

[Dominant cystoid macular dystrophy (author's transl)]

Dominant cystoid macular dystrophy (D.C.M.D.) is characterized by a macular dystrophy but at the same time by a pigmentary dystrophy of the retinal periphery. Ultimately D.C.M.D. resembles an atypical pigmentary dystrophy, in some cases that of a pericentral retinitis pigmentosa. In an early stage the results of the EOG and darkadaptation curve reflect the process at the level of the peripheral retina, while only in a late stage we may expect some diffuse ERG pathology. D.C.M.D. might be classified as a tapetoretinal dystrophy and in particular as a form of retinitis pigmentosa with an atypical visual disturbance and an atypical fundus appearance (Leber, 1871). In doing so attention is paid to the fact that D.C.M.D. is more than a macular dystrophy. The denomination of the disease as D.C.M.D. reflects the most important features at a relatively young age.

Biochemical aspects of the visual process. XXVII. Stereospecificity of ocular retinol dehydrogenases and the visual cycle

A comparative study is made of the stereospecificity of two particulate retinol dehydrogenases from bovine eyes and of horse liver alcohol dehydrogenase. The particulate retinol dehydrogenase of outer segments reacts with the all-trans isomers of retinaldehyde and retinol but not with the 11-cis compounds. In contrast, a particulate retinol dehydrogenase present in pigment epithelium reacts preferentially with the 11-cis compounds. Horse liver alcohol dehydrogenase (EC 1.1.1.1.) can convert both isomers, but the all-trans isomers are clearly preferred. Differences with regard to cofactor preference and stability are also noted. The outer segment enzyme clearly functions in the rhodopsin cycle. It is unlikely that the 11-cis retinol dehydrogenase from pigment epithelium is directly involved in providing 11-cis retinaldehyde from rhodopsin regeneration, but it may serve to make available 11-cis retinaldehyde from rhodopdsin, digested in phagocytized rod sacs, for the synthesis of visual pigment by the visual cells.