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Vuong KT, Vega MR, Casey L, Swartz SJ, Srivaths P, Osborne SW, Rhee CJ, Arikan AA, Joseph C. Clearance and nutrition in neonatal continuous kidney replacement therapy using the Carpediem™ system. Pediatr Nephrol 2024; 39:1937-1950. [PMID: 38231233 DOI: 10.1007/s00467-023-06237-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Infants with kidney failure (KF) demonstrate poor growth partly due to obligate fluid and protein restrictions. Delivery of liberalized nutrition on continuous kidney replacement therapy (CKRT) is impacted by clinical instability, technical dialysis challenges, solute clearance, and nitrogen balance. We analyzed delivered nutrition and growth in infants receiving CKRT with the Cardio-Renal, Pediatric Dialysis Emergency Machine (Carpediem™). METHODS Single-center observational study of infants receiving CKRT with the Carpediem™ between June 1 and December 31, 2021. We collected prospective circuit characteristics, delivered nutrition, anthropometric measurements, and illness severity Score for Neonatal Acute Physiology-II. As a surrogate to normalized protein catabolic rate in maintenance hemodialysis, we calculated normalized protein nitrogen appearance (nPNA) using the Randerson II continuous dialysis model. Descriptive statistics, Spearman correlation coefficient, Mann Whitney, Wilcoxon signed rank, receiver operating characteristic curves, and Kruskal-Wallis analysis were performed using SAS version 9.4. RESULTS Eight infants received 31.9 (22.0, 49.7) days of CKRT using mostly (90%) regional citrate anticoagulation. Delivered nutritional volume, protein, total calories, enteral calories, nPNA, and nitrogen balance increased on CKRT. Using parenteral nutrition, 90 ml/kg/day should meet caloric and protein needs. Following initial weight loss of likely fluid overload, exploratory sensitivity analysis suggests weight gain occurred after 14 days of CKRT. Despite adequate nutritional delivery, goal weight (z-score = 0) and growth velocity were not achieved until 6 months after CKRT start. Most (5 infants, 62.5%) survived and transitioned to peritoneal dialysis (PD). CONCLUSIONS Carpediem™ is a safe and efficacious bridge to PD in neonatal KF. Growth velocity of infants on CKRT appears delayed despite delivery of adequate calories and protein.
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Affiliation(s)
- Kim T Vuong
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | - Molly R Vega
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Lauren Casey
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Sarah J Swartz
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Poyyapakkam Srivaths
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Scott W Osborne
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Christopher J Rhee
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Ayse Akcan Arikan
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Catherine Joseph
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Imberti S, Comoretto R, Ceschia G, Longo G, Benetti E, Amigoni A, Daverio M. Impact of the first 24 h of continuous kidney replacement therapy on hemodynamics, ventilation, and analgo-sedation in critically ill children. Pediatr Nephrol 2024; 39:879-887. [PMID: 37723304 DOI: 10.1007/s00467-023-06155-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/25/2023] [Accepted: 08/17/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND In a group of children admitted to the paediatric intensive care unit (PICU) receiving continuous kidney replacement therapy (CKRT), we aim to evaluate the data about their hemodynamic, ventilation and analgo-sedation profile in the first 24 h of treatment and possible associations with mortality. METHODS Retrospective cohort study of children admitted to the PICU of the University Hospital of Padova undergoing CKRT between January 2011 and March 2021. Data was collected at baseline (T0), after 1 h (T1) and 24 h (T24) of CKRT treatment. The differences in outcome measures were compared between these time points, and between survivors and non-survivors. RESULTS Sixty-nine patients received CKRT, of whom 38 (55%) died during the PICU stay. Overall, the vasoactive inotropic score and the adrenaline dose increased at T1 compared to T0 (p = 0.012 and p = 0.022, respectively). Compared to T0, at T24 patients showed an improvement in the following ventilatory parameters: Oxygenation Index (p = 0.005), Oxygenation Saturation Index (p = 0.013) PaO2/FiO2 ratio (p = 0.005), SpO2/FiO2 ratio (p = 0.002) and Mean Airway Pressure (p = 0.016). These improvements remained significant in survivors (p = 0.01, p = 0.027, p = 0.01 and p = 0.015, respectively) but not in non-survivors. No changes in analgo-sedative drugs have been described. CONCLUSIONS CKRT showed a significant impact on hemodynamics and ventilation in the first 24 h of treatment. We observed a significant rise in the inotropic/vasoactive support required after 1 h of treatment in the overall population, and an improvement in the ventilation parameters at 24 h only in survivors.
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Affiliation(s)
- Simona Imberti
- Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Rosanna Comoretto
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Giovanni Ceschia
- Department of Women's and Children's Health, University of Padua, Padua, Italy
- Pediatric Nephrology, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Germana Longo
- Pediatric Nephrology, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Elisa Benetti
- Pediatric Nephrology, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Marco Daverio
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy.
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Raina R, Nair N, Pelletier J, Nied M, Whitham T, Doshi K, Beck T, Dantes G, Sethi SK, Kim YH, Bunchman T, Alhasan K, Lima L, Guzzo I, Fuhrman D, Paden M. Concurrent use of continuous kidney replacement therapy during extracorporeal membrane oxygenation: what pediatric nephrologists need to know-PCRRT-ICONIC practice points. Pediatr Nephrol 2024:10.1007/s00467-024-06311-x. [PMID: 38386072 DOI: 10.1007/s00467-024-06311-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/15/2024] [Accepted: 01/27/2024] [Indexed: 02/23/2024]
Abstract
Extracorporeal membrane oxygenation (ECMO) provides temporary cardiorespiratory support for neonatal, pediatric, and adult patients when traditional management has failed. This lifesaving therapy has intrinsic risks, including the development of a robust inflammatory response, acute kidney injury (AKI), fluid overload (FO), and blood loss via consumption and coagulopathy. Continuous kidney replacement therapy (CKRT) has been proposed to reduce these side effects by mitigating the host inflammatory response and controlling FO, improving outcomes in patients requiring ECMO. The Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup and the International Collaboration of Nephrologists and Intensivists for Critical Care Children (ICONIC) met to highlight current practice standards for ECMO use within the pediatric population. This review discusses ECMO modalities, the pathophysiology of inflammation during an ECMO run, its adverse effects, various anticoagulation strategies, and the technical aspects and outcomes of implementing CKRT during ECMO in neonatal and pediatric populations. Consensus practice points and guidelines are summarized. ECMO should be utilized in patients with severe acute respiratory failure despite the use of conventional treatment modalities. The Extracorporeal Life Support Organization (ELSO) offers guidelines for ECMO initiation and management while maintaining a clinical registry of over 195,000 patients to assess outcomes and complications. Monitoring and preventing fluid overload during ECMO and CKRT are imperative to reduce mortality risk. Clinical evidence, resources, and experience of the nephrologist and healthcare team should guide the selection of ECMO circuit.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA.
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
| | - Nikhil Nair
- Case Western University School of Medicine, Cleveland, OH, USA
| | - Jonathan Pelletier
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH, USA
- Department of Pediatrics, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Matthew Nied
- Department of Internal Medicine, Case Western Reserve / University Hospitals, Cleveland, OH, USA
| | - Tarik Whitham
- Department of Pediatrics, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Kush Doshi
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Tara Beck
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital, Pittsburgh, PA, USA
| | - Goeto Dantes
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Sidharth Kumar Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Yap Hui Kim
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Timothy Bunchman
- Department of Pediatric Nephrology, Children's Hospital of Richmond, Richmond, VA, USA
| | - Kahild Alhasan
- Pediatric Nephrology, King Saud University, Riyadh, Saudi Arabia
| | - Lisa Lima
- Department of Pediatric Critical Care, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Dana Fuhrman
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital, Pittsburgh, PA, USA
| | - Matthew Paden
- Department of Pediatric Critical Care, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Parolin M, Ceschia G, Vidal E. New perspectives in pediatric dialysis technologies: the case for neonates and infants with acute kidney injury. Pediatr Nephrol 2024; 39:115-123. [PMID: 37014528 PMCID: PMC10673994 DOI: 10.1007/s00467-023-05933-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 04/05/2023]
Abstract
Advancements in pediatric dialysis generally rely on adaptation of technology originally developed for adults. However, in the last decade, particular attention has been paid to neonatal extracorporeal therapies for acute kidney care, an area in which technology has made giant strides in recent years. Peritoneal dialysis (PD) is the kidney replacement therapy (KRT) of choice in the youngest age group because of its simplicity and effectiveness. However, extracorporeal blood purification provides more rapid clearance of solutes and faster fluid removal. Hemodialysis (HD) and continuous KRT (CKRT) are thus the most used dialysis modalities for pediatric acute kidney injury (AKI) in developed countries. The utilization of extracorporeal dialysis for small children is associated with a series of clinical and technical challenges which have discouraged the use of CKRT in this population. The revolution in the management of AKI in newborns has started recently with the development of new CKRT machines for small infants. These new devices have a small extracorporeal volume that potentially prevents the use of blood to prime lines and dialyzer, allow a better volume control and the use of small-sized catheter without compromising the blood flow amount. Thanks to the development of new dedicated devices, we are currently dealing with a true "scientific revolution" in the management of neonates and infants who require an acute kidney support.
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Affiliation(s)
- Mattia Parolin
- Pediatric Nephrology Unit, Department for Women's and Children's Health, University-Hospital of Padua, Padua, Italy
| | - Giovanni Ceschia
- Pediatric Nephrology Unit, Department for Women's and Children's Health, University-Hospital of Padua, Padua, Italy
| | - Enrico Vidal
- Pediatric Nephrology Unit, Department for Women's and Children's Health, University-Hospital of Padua, Padua, Italy.
- Department of Medicine (DAME), University of Udine, Udine, Italy.
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Bottari G, Goffredo BM, Marano M, Maccarrone C, Simeoli R, Bianco G, Vallesi L, Beetham JCC, Mazzeo AT, Cappoli A, Cairoli S, Labbadia R, Cecchetti C, Bernaschi P, Corsetti T, Morabito S, Taccone FS, Guzzo I. Impact of Continuous Kidney Replacement Therapy and Hemoadsorption with CytoSorb on Antimicrobial Drug Removal in Critically Ill Children with Septic Shock: A Single-Center Prospective Study on a Pediatric Cohort. Antibiotics (Basel) 2023; 12:1395. [PMID: 37760692 PMCID: PMC10525765 DOI: 10.3390/antibiotics12091395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Background: Extracorporeal therapies (ET) are increasingly used in pediatric settings as adjuvant therapeutic strategies for overwhelming inflammatory conditions. Although these treatments seem to be effective for removing inflammatory mediators, their influence on antimicrobials pharmacokinetic should not be neglected. Methods: A prospective observational study of children admitted to the pediatric intensive care unit (PICU) with a diagnosis of sepsis/septic shock. All critically ill children received hemoadsorption treatment with CytoSorb (CS) in combination with CKRT. Therapeutic drug monitoring has been performed on 10 critically ill children, testing four antimicrobial molecules: meropenem, ceftazidime, amikacin and levofloxacin. In order to evaluate the total and isolated CKRT and CS contributions to antibiotic removal, blood samples at each circuit point (post-hemofilter, post-CS and in the effluent line) were performed. Therefore, the clearance and mass Removal (MR) of the hemofilter and CS were calculated. Results: Our preliminary report describes a different impact of CS on these target drugs removal: CS clearance was low for amikacine (6-12%), moderate for ceftazidime (43%) and moderate to high for levofloxacine (52-72%). Higher MR and clearance were observed with CKRT compared to CS. To the best of our knowledge, this is the first report regarding pharmacokinetic dynamics in critically ill children treated with CKRT and CS for septic shock.
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Affiliation(s)
- Gabriella Bottari
- Pediatric Intensive Care Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.M.); (J.C.C.B.); (C.C.)
| | - Bianca Maria Goffredo
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCSS, 00165 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Marco Marano
- Pediatric Intensive Care Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.M.); (J.C.C.B.); (C.C.)
| | - Cristina Maccarrone
- Anesthesia and Intensive Care Department of Human Pathology, University of Messina, 98158 Messina, Italy; (C.M.); (A.T.M.)
| | - Raffaele Simeoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCSS, 00165 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Giuseppe Bianco
- Hospital Pharmacy Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.B.); (L.V.); (T.C.)
| | - Leonardo Vallesi
- Hospital Pharmacy Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.B.); (L.V.); (T.C.)
| | | | - Anna Teresa Mazzeo
- Anesthesia and Intensive Care Department of Human Pathology, University of Messina, 98158 Messina, Italy; (C.M.); (A.T.M.)
| | - Andrea Cappoli
- Division of Nephrology and Dialysis, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.C.); (R.L.); (I.G.)
| | - Sara Cairoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCSS, 00165 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Raffaella Labbadia
- Division of Nephrology and Dialysis, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.C.); (R.L.); (I.G.)
| | - Corrado Cecchetti
- Pediatric Intensive Care Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.M.); (J.C.C.B.); (C.C.)
| | - Paola Bernaschi
- Microbiology and Diagnostic Immunology Unit, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Tiziana Corsetti
- Hospital Pharmacy Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.B.); (L.V.); (T.C.)
| | - Santo Morabito
- Hemodialysis Unit, Department of Internal Medicine and Medical Specialties, Policlinico Umberto I, 00161 Rome, Italy;
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium;
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.C.); (R.L.); (I.G.)
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Teixeira JP, Saa L, Kaucher KA, Villanueva RD, Shieh M, Baca CR, Harmon B, Owen ZJ, Mendez Majalca I, Schmidt DW, Singh N, Shaffi SK, Xu ZQ, Roha T, Mitchell JA, Demirjian S, Argyropoulos CP. Rapid implementation of an emergency on-site CKRT dialysate production system during the COVID-19 pandemic. BMC Nephrol 2023; 24:245. [PMID: 37608357 PMCID: PMC10463836 DOI: 10.1186/s12882-023-03260-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 06/29/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND On December 29, 2021, during the delta wave of the Coronavirus Disease 2019 (COVID-19) pandemic, the stock of premanufactured solutions used for continuous kidney replacement therapy (CKRT) at the University of New Mexico Hospital (UNMH) was nearly exhausted with no resupply anticipated due to supply chain disruptions. Within hours, a backup plan, devised and tested 18 months prior, to locally produce CKRT dialysate was implemented. This report describes the emergency implementation and outcomes of this on-site CKRT dialysate production system. METHODS This is a single-center retrospective case series and narrative report describing and reporting the outcomes of the implementation of an on-site CKRT dialysate production system. All adults treated with locally produced CKRT dialysate in December 2021 and January 2022 at UNMH were included. CKRT dialysate was produced locally using intermittent hemodialysis machines, hemodialysis concentrate, sterile parenteral nutrition bags, and connectors made of 3-D printed biocompatible rigid material. Outcomes analyzed included dialysate testing for composition and microbiologic contamination, CKRT prescription components, patient mortality, sequential organ failure assessment (SOFA) scores, and catheter-associated bloodstream infections (CLABSIs). RESULTS Over 13 days, 22 patients were treated with 3,645 L of locally produced dialysate with a mean dose of 20.0 mL/kg/h. Fluid sample testing at 48 h revealed appropriate electrolyte composition and endotoxin levels and bacterial colony counts at or below the lower limit of detection. No CLABSIs occurred within 7 days of exposure to locally produced dialysate. In-hospital mortality was 81.8% and 28-day mortality was 68.2%, though illness severity was high, with a mean SOFA score of 14.5. CONCLUSIONS Though producing CKRT fluid with IHD machines is not novel, this report represents the first description of the rapid and successful implementation of a backup plan for local CKRT dialysate production at a large academic medical center in the U.S. during the COVID-19 pandemic. Though conclusions are limited by the retrospective design and limited sample size of our analysis, our experience could serve as a guide for other centers navigating similar severe supply constraints in the future.
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Affiliation(s)
- J Pedro Teixeira
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA.
- Center for Adult Critical Care, UNM Hospital, Albuquerque, NM, USA.
- Acute Dialysis and CRRT Program, UNM Hospital, Albuquerque, NM, USA.
| | - Lisa Saa
- Department of Internal Medicine, UNM School of Medicine, Albuquerque, NM, USA
| | | | | | - Michelle Shieh
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
- Center for Adult Critical Care, UNM Hospital, Albuquerque, NM, USA
| | - Crystal R Baca
- Acute Dialysis and CRRT Program, UNM Hospital, Albuquerque, NM, USA
| | - Brittany Harmon
- Acute Dialysis and CRRT Program, UNM Hospital, Albuquerque, NM, USA
| | - Zanna J Owen
- Acute Dialysis and CRRT Program, UNM Hospital, Albuquerque, NM, USA
| | | | - Darren W Schmidt
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Namita Singh
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Saeed K Shaffi
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Zhi Q Xu
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
- Acute Dialysis and CRRT Program, UNM Hospital, Albuquerque, NM, USA
| | - Thomas Roha
- Center for Adult Critical Care, UNM Hospital, Albuquerque, NM, USA
| | - Jessica A Mitchell
- Center for Adult Critical Care, UNM Hospital, Albuquerque, NM, USA
- Department of Emergency Medicine, UNM School of Medicine, Albuquerque, NM, USA
| | - Sevag Demirjian
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH, USA
| | - Christos P Argyropoulos
- Division of Nephrology, University of New Mexico (UNM) School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
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Anderson A, Shoulders L, James V, Ashcraft E, Cheng C, Ribeiro R, Elbahlawan L. Benefit of continuous kidney replacement therapy for managing tumor lysis syndrome in children with hematologic malignancies. Front Oncol 2023; 13:1234677. [PMID: 37664024 PMCID: PMC10471890 DOI: 10.3389/fonc.2023.1234677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/07/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction Tumor lysis syndrome (TLS) is often diagnosed in children with hematological malignancies and can be life threatening due to metabolic disturbances. Continuous renal replacement therapy (CKRT) can reverse these disturbances relatively quickly when conventional medical management fails. Our objective was to investigate the benefit of CKRT in the management of TLS in children admitted to the intensive care unit with hematologic malignancies. In addition, we sought to assess risk factors for acute kidney injury (AKI) in the setting of TLS. Methods Retrospective review of all children admitted to the intensive care unit with TLS who received CKRT from January 2012 to August 2022. Results Among 222 children hospitalized with TLS from January 2012 to August 2022, 20 (9%) underwent CKRT to manage TLS in the intensive care unit. The patients' median age was 13 years (range 3-17 y), and most were males (18/20). T-cell acute lymphoblastic leukemia was the most common diagnosis (n=10), followed by acute myeloid leukemia (n=4), Burkitt lymphoma (n=4), and B-cell acute lymphoblastic leukemia (n=2). Five patients required mechanical ventilation, and 2 required vasopressors. The most common indication for CKRT was hyperphosphatemia, followed by, hyperuricemia, and hyperkalemia. All metabolic abnormalities corrected within 12 h of initiation of CKRT. CKRT courses were brief, with a median duration of 2 days (range 1-7 days). Having higher serum phosphorus levels 12 h preceding CKRT was significantly associated with severe acute kidney injury (AKI). The median phosphorus level was 6.4 mg/dL in children with no/mild AKI and 10.5 mg/dL in children with severe AKI (p=0.0375). Serum uric acid levels before CKRT were not associated with AKI. All children survived to hospital discharge, and the one-year survival rate was 90%. Conclusion CKRT is safe in children with hematologic malignancies with severe TLS and reverses metabolic derangements within 6-12 h. Most patients had AKI at the initiation of CKRT but did not require long-term kidney replacement therapy. Hyperphosphatemia before initiation of CKRT is associated with higher risk of AKI.
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Affiliation(s)
- Ashlea Anderson
- Division of Critical Care Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Laurie Shoulders
- Department of Nursing, Intensive Care Unit, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Vinson James
- Division of Pediatric Nephrology, Department of Pediatrics, LeBonheur Children's Hospital, Memphis, TN, United States
| | - Emily Ashcraft
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Cheng Cheng
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Raul Ribeiro
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Lama Elbahlawan
- Division of Critical Care Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
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8
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Nalesso F, Bettin E, Bogo M, Cacciapuoti M, Cattarin L, Scaparrotta G, Calò LA. Safety of Citrate Anticoagulation in CKRT: Monocentric Experience of a Dynamic Protocol of Calcium Monitoring. J Clin Med 2023; 12:5201. [PMID: 37629242 PMCID: PMC10455350 DOI: 10.3390/jcm12165201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/05/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Regional Citrate Anticoagulation (RCA) is considered the first-line anticoagulation for Continuous Kidney Replacement Therapy (CKRT). The RCA requires strict protocols and trained staff to avoid unsafe use and ensure its benefit. We have analyzed all our CKRT prescriptions from December 2020 to April 2022 anonymously, collecting data on CKRT, lab tests, clinical conditions, and complications of RCA. In addition, in order to better detect citrate accumulation, we have performed an RCA protocol by reducing the CaTot/Ca2+ ratio cut-off from 2.50 to 2.40 and increasing the number of calcium checks according to its trend. Among the 374 patients in CKRT, 104 received RCA prescriptions, of which 11 (10.6%) were discontinued: 4 for the suspicion of citrate accumulation, 1 for the development of metabolic alkalosis, 1 for the shift to a different CKRT procedure due to the need for a higher bicarbonate dose, 4 for the elevation of hepatocytolysis indexes, and 1 due to a preemptive discontinuation following massive post-surgery bleeding. None of the patients have had citrate toxicity as indicated by a CaTot/Ca2+ greater than 2.50, and our protocol has allowed the early identification of patients who might develop clinical citrate toxicity.
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Affiliation(s)
- Federico Nalesso
- Department of Medicine, Nephrology, Dialysis and Transplant, University of Padua, 35128 Padua, Italy (L.A.C.)
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9
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Rewa OG, Ortiz-Soriano V, Lambert J, Kabir S, Heung M, House AA, Monga D, Juncos LA, Secic M, Piazza R, Goldstein SL, Bagshaw SM, Neyra JA. Epidemiology and Outcomes of AKI Treated With Continuous Kidney Replacement Therapy: The Multicenter CRRTnet Study. Kidney Med 2023; 5:100641. [PMID: 37274539 PMCID: PMC10238597 DOI: 10.1016/j.xkme.2023.100641] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
Rationale & Objective Continuous kidney replacement therapy (CKRT) is the predominant form of acute kidney replacement therapy used for critically ill adult patients with acute kidney injury (AKI). Given the variability in CKRT practice, a contemporary understanding of its epidemiology is necessary to improve care delivery. Study Design Multicenter, prospective living registry. Setting & Population 1,106 critically ill adults with AKI requiring CKRT from December 2013 to January 2021 across 5 academic centers and 6 intensive care units. Patients with pre-existing kidney failure and those with coronavirus 2 infection were excluded. Exposure CKRT for more than 24 hours. Outcomes Hospital mortality, kidney recovery, and health care resource utilization. Analytical Approach Data were collected according to preselected timepoints at intensive care unit admission and CKRT initiation and analyzed descriptively. Results Patients' characteristics, contributors to AKI, and CKRT indications differed among centers. Mean (standard deviation) age was 59.3 (13.9) years, 39.7% of patients were women, and median [IQR] APACHE-II (acute physiologic assessment and chronic health evaluation) score was 30 [25-34]. Overall, 41.1% of patients survived to hospital discharge. Patients that died were older (mean age 61 vs. 56.8, P < 0.001), had greater comorbidity (median Charlson score 3 [1-4] vs. 2 [1-3], P < 0.001), and higher acuity of illness (median APACHE-II score 30 [25-35] vs. 29 [24-33], P = 0.003). The most common condition predisposing to AKI was sepsis (42.6%), and the most common CKRT indications were oliguria/anuria (56.2%) and fluid overload (53.9%). Standardized mortality ratios were similar among centers. Limitations The generalizability of these results to CKRT practices in nonacademic centers or low-and middle-income countries is limited. Conclusions In this registry, sepsis was the major contributor to AKI and fluid management was collectively the most common CKRT indication. Significant heterogeneity in patient- and CKRT-specific characteristics was found in current practice. These data highlight the need for establishing benchmarks of CKRT delivery, performance, and patient outcomes. Data from this registry could assist with the design of such studies.
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Affiliation(s)
- Oleksa G. Rewa
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton Alberta Canada
| | - Victor Ortiz-Soriano
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY
| | - Joshua Lambert
- College of Nursing, University of Cincinnati, Cincinnati, OH
| | - Shaowli Kabir
- Department of Biostatistics, University of Kentucky, Lexington, KY
| | - Michael Heung
- Division of Nephrology, University of Michigan, Ann Arbor, MI
| | - Andrew A. House
- Division of Nephrology, Western University and London Health Sciences Centre, London, Canada
| | - Divya Monga
- Division of Nephrology, University of Mississippi, Jackson, MI
| | - Luis A. Juncos
- Central Arkansas Veterans Healthcare System (CAVHS), Little Rock, Arkansas
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Robin Piazza
- Watermark Research Partners, Inc, Indianapolis, IN
| | - Stuart L. Goldstein
- Center for Acute Care Nephrology, Cincinnati Children’s Hospital and Medical Center, University of Cincinnati, Cincinnati, OH
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton Alberta Canada
| | - Javier A. Neyra
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY
- Department of Internal Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
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10
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Ghannoum M, Gosselin S, Hoffman RS, Lavergne V, Mégarbane B, Hassanian-Moghaddam H, Rif M, Kallab S, Bird S, Wood DM, Roberts DM, Anseeuw K, Berling I, Bouchard J, Bunchman TE, Calello DP, Chin PK, Doi K, Galvao T, Goldfarb DS, Hoegberg LCG, Kebede S, Kielstein JT, Lewington A, Li Y, Macedo EM, MacLaren R, Mowry JB, Nolin TD, Ostermann M, Peng A, Roy JP, Shepherd G, Vijayan A, Walsh SJ, Wong A, Yates C. Extracorporeal treatment for ethylene glycol poisoning: systematic review and recommendations from the EXTRIP workgroup. Crit Care 2023; 27:56. [PMID: 36765419 PMCID: PMC9921105 DOI: 10.1186/s13054-022-04227-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/18/2022] [Indexed: 02/12/2023] Open
Abstract
Ethylene glycol (EG) is metabolized into glycolate and oxalate and may cause metabolic acidemia, neurotoxicity, acute kidney injury (AKI), and death. Historically, treatment of EG toxicity included supportive care, correction of acid-base disturbances and antidotes (ethanol or fomepizole), and extracorporeal treatments (ECTRs), such as hemodialysis. With the wider availability of fomepizole, the indications for ECTRs in EG poisoning are debated. We conducted systematic reviews of the literature following published EXTRIP methods to determine the utility of ECTRs in the management of EG toxicity. The quality of the evidence and the strength of recommendations, either strong ("we recommend") or weak/conditional ("we suggest"), were graded according to the GRADE approach. A total of 226 articles met inclusion criteria. EG was assessed as dialyzable by intermittent hemodialysis (level of evidence = B) as was glycolate (Level of evidence = C). Clinical data were available for analysis on 446 patients, in whom overall mortality was 18.7%. In the subgroup of patients with a glycolate concentration ≤ 12 mmol/L (or anion gap ≤ 28 mmol/L), mortality was 3.6%; in this subgroup, outcomes in patients receiving ECTR were not better than in those who did not receive ECTR. The EXTRIP workgroup made the following recommendations for the use of ECTR in addition to supportive care over supportive care alone in the management of EG poisoning (very low quality of evidence for all recommendations): i) Suggest ECTR if fomepizole is used and EG concentration > 50 mmol/L OR osmol gap > 50; or ii) Recommend ECTR if ethanol is used and EG concentration > 50 mmol/L OR osmol gap > 50; or iii) Recommend ECTR if glycolate concentration is > 12 mmol/L or anion gap > 27 mmol/L; or iv) Suggest ECTR if glycolate concentration 8-12 mmol/L or anion gap 23-27 mmol/L; or v) Recommend ECTR if there are severe clinical features (coma, seizures, or AKI). In most settings, the workgroup recommends using intermittent hemodialysis over other ECTRs. If intermittent hemodialysis is not available, CKRT is recommended over other types of ECTR. Cessation of ECTR is recommended once the anion gap is < 18 mmol/L or suggested if EG concentration is < 4 mmol/L. The dosage of antidotes (fomepizole or ethanol) needs to be adjusted during ECTR.
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Affiliation(s)
- Marc Ghannoum
- grid.14848.310000 0001 2292 3357Research Center, CIUSSS du Nord-de-l’île-de-Montréal, University of Montreal, Montreal, QC Canada ,grid.137628.90000 0004 1936 8753Nephrology Division, NYU Langone Health, NYU Grossman School of Medicine, New York, NY USA ,grid.5477.10000000120346234Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sophie Gosselin
- grid.420748.d0000 0000 8994 4657Centre Intégré de Santé et de Services Sociaux (CISSS) de la Montérégie-Centre Emergency Department, Hôpital Charles-Lemoyne, Greenfield Park, QC Canada ,grid.86715.3d0000 0000 9064 6198Faculté de Médecine et Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Canada ,Centre Antipoison du Québec, Quebec, QC Canada
| | - Robert S. Hoffman
- grid.137628.90000 0004 1936 8753Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY USA
| | - Valery Lavergne
- grid.14848.310000 0001 2292 3357Research Center, CIUSSS du Nord-de-l’île-de-Montréal, University of Montreal, Montreal, QC Canada
| | - Bruno Mégarbane
- grid.411296.90000 0000 9725 279XDepartment of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris Cité University, Paris, France
| | - Hossein Hassanian-Moghaddam
- grid.411600.2Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran ,grid.411600.2Department of Clinical Toxicology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Siba Kallab
- grid.411323.60000 0001 2324 5973Department of Internal Medicine-Division of Nephrology, Lebanese American University - School of Medicine, Byblos, Lebanon
| | - Steven Bird
- Department of Emergency Medicine, U Mass Memorial Health, U Mass Chan Medical School, Worcester, MA USA
| | - David M. Wood
- grid.13097.3c0000 0001 2322 6764Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, and Clinical Toxicology, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Darren M. Roberts
- grid.430417.50000 0004 0640 6474New South Wales Poisons Information Centre, Sydney Children’s Hospitals Network, Westmead, NSW Australia ,grid.413249.90000 0004 0385 0051Drug Health Services, Royal Prince Alfred Hospital, Sydney, NSW Australia
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11
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Frisby-Zedan J, Barhight MF, Keswani M, Arzu J, Nelson D. Long-term kidney outcomes in children following continuous kidney replacement therapy. Pediatr Nephrol 2023; 38:565-572. [PMID: 35552525 DOI: 10.1007/s00467-022-05579-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Continuous kidney replacement therapy (CKRT) is a mainstay of therapy for management of severe acute kidney injury (AKI) in critically ill pediatric patients. There is limited data on the risk of chronic kidney disease (CKD) after discharge in this population. METHODS This is a single-center, retrospective cohort study of all pediatric patients ages 0-17 years who received CKRT from 2013 to 2017. The study excluded patients with pre-existing CKD, those who died prior to discharge, and those who had insufficient follow-up data. Patients were followed after hospital discharge and electronic health record data was collected and analyzed to assess for incidence of and risk factors for kidney sequelae. RESULTS A total of 42 patients were followed at a median time of 27 months (IQR 17.2, 39.8). Of these, 26.2% had evidence of CKD and 19% were at risk for CKD. Lower eGFR at hospital discharge was associated with increased odds of kidney sequelae (aOR 0.985; 95% CI 0.972, 0.996). Ages 0- < 1 and 12-17 were not significantly different (aOR 0.235, 95% CI 0.024, 1.718) and had the highest incidence of kidney sequelae (50% and 77%, respectively). Ages 1-5 and 6-11 had a decreased odds of kidney sequelae compared to the 12-17 year age group (aOR 0.098; 95% CI 0.009, 0.703 and aOR 0.035; 95% CI 0.001, 0.39, respectively). Only 54.8% of patients (n = 23) were seen in the nephrology clinic after discharge. CONCLUSIONS Patients who receive CKRT for AKI have a significant risk of CKD, while follow-up with a pediatric nephrologist in these high-risk patients is sub-optimal. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Jeanne Frisby-Zedan
- Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL, 60611, USA.
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Matthew F Barhight
- Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL, 60611, USA
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mahima Keswani
- Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL, 60611, USA
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jennifer Arzu
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Delphine Nelson
- Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL, 60611, USA
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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12
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Shea T, Dixon AM, Wang GS, DeMasellis G, Blanchette E. A toxic ingestion with an elevated osmolal gap: Questions. Pediatr Nephrol 2023; 38:397-8. [PMID: 35695959 DOI: 10.1007/s00467-022-05598-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 01/10/2023]
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13
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Kompotiatis P, Shawwa K, Jentzer JC, Wiley BM, Kashani KB. Echocardiographic parameters and hemodynamic instability at the initiation of continuous kidney replacement therapy. J Nephrol 2023; 36:173-181. [PMID: 35849262 DOI: 10.1007/s40620-022-01400-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/06/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Investigate the association of echocardiographic parameters with hemodynamic instability after initiating continuous kidney replacement therapy (CKRT) in a cohort of intensive care unit (ICU) patients requiring CKRT. METHODS Historical cohort study of consecutive adults admitted to the ICU at a tertiary care hospital from December 2006 through November 2015 who underwent CKRT and had an echocardiogram done within seven days before CKRT initiation. The primary outcome was hypotension within one hour of CKRT initiation. RESULTS We included 980 patients, 804 (82%) with acute kidney injury (AKI) and 176 (18%) with end-stage kidney disease (ESKD). Median patient age was 63 (± 14) years, and median Sequential Organ Failure Assessment (SOFA) score on the day of CKRT initiation was 12 (IQR 10-14). Multivariable analysis showed that Left (OR 2.01, 95% CI 1.04-3.86), and Right (OR 1.5, 95% CI 1.04-2.25) moderate and severe ventricular enlargement, Vasoactive-Inotropic Score (VIS) one hour before CKRT initiation (OR 1.18 per 10 units increase, 95% CI 1.09-1.28) and high bicarbonate fluid replacement (OR 2.52, 95% CI 1.01-6.2) were associated with hypotension after CKRT initiation. CONCLUSION Right and left ventricular enlargement are risk factors associated with hypotension after CKRT initiation.
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Affiliation(s)
- Panagiotis Kompotiatis
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Khaled Shawwa
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brandon M Wiley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
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14
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Beaubien-Souligny W, Trott T, Neyra JA. How to Determine Fluid Management Goals during Continuous Kidney Replacement Therapy in Patients with AKI: Focus on POCUS. Kidney360 2022; 3:1795-1806. [PMID: 36514727 PMCID: PMC9717662 DOI: 10.34067/kid.0002822022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/18/2022] [Indexed: 06/17/2023]
Abstract
The utilization of kidney replacement therapies (KRT) for fluid management of patients who are critically ill has significantly increased over the last years. Clinical studies have suggested that both fluid accumulation and high fluid removal rates are associated with adverse outcomes in the critically ill population receiving KRT. Importantly, the ideal indications and/or fluid management strategies that could favorably affect these patients are unknown; however, differentiating clinical scenarios in which effective fluid removal may provide benefit to the patient by avoiding congestive organ injury, compared with other settings in which this intervention may result in harm, is direly needed in the critical care nephrology field. In this review, we describe observational data related to fluid management with KRT, and examine the role of point-of-care ultrasonography as a potential tool that could provide physiologic insights to better individualize decisions related to fluid management through KRT.
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Affiliation(s)
- William Beaubien-Souligny
- Division of Nephrology, Department of Medicine, University of Montreal Health Center (CHUM), Montreal, Canada
| | - Terren Trott
- Division of Emergency Medicine and Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Javier A. Neyra
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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15
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Mohamed TH, Morgan J, Mottes TA, Askenazi D, Jetton JG, Menon S. Kidney support for babies: building a comprehensive and integrated neonatal kidney support therapy program. Pediatr Nephrol 2022:10.1007/s00467-022-05768-y. [PMID: 36227440 DOI: 10.1007/s00467-022-05768-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/01/2022] [Accepted: 09/08/2022] [Indexed: 11/26/2022]
Abstract
Kidney support therapy (KST), previously referred to as Renal Replacement Therapy, is utilized to treat children and adults with severe acute kidney injury (AKI), fluid overload, inborn errors of metabolism, and kidney failure. Several forms of KST are available including peritoneal dialysis (PD), intermittent hemodialysis (iHD), and continuous kidney support therapy (CKST). Traditionally, extracorporeal KST (CKST and iHD) in neonates has had unique challenges related to small patient size, lack of neonatal-specific devices, and risk of hemodynamic instability due to large extracorporeal circuit volume relative to patient total blood volume. Thus, PD has been the most commonly used modality in infants, followed by CKST and iHD. In recent years, CKST machines designed for small children and novel filters with smaller extracorporeal circuit volumes have emerged and are being used in many centers to provide neonatal KST for toxin removal and to achieve fluid and electrolyte homeostasis, increasing the options available for this unique and vulnerable group. These new treatment options create a dramatic paradigm shift with recalibration of the benefit: risk equation. Renewed focus on the infrastructure required to deliver neonatal KST safely and effectively is essential, especially in programs/units that do not traditionally provide KST to neonates. Building and implementing a neonatal KST program requires an expert multidisciplinary team with strong institutional support. In this review, we first describe the available neonatal KST modalities including newer neonatal and infant-specific platforms. Then, we describe the steps needed to develop and sustain a neonatal KST team, including recommendations for provider and nursing staff training. Finally, we describe how quality improvement initiatives can be integrated into programs.
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Affiliation(s)
- Tahagod H Mohamed
- Division of Nephrology and Hypertension, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA.
- The Kidney and Urinary Tract Center, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH, 430205, USA.
| | - Jolyn Morgan
- The Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Theresa A Mottes
- Division of Nephrology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - David Askenazi
- Pediatric and Infant Center for Acute Nephrology, Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jennifer G Jetton
- Section of Nephrology, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Shina Menon
- Division of Pediatric Nephrology, Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
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16
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Lion RP, Vega MR, Smith EO, Devaraj S, Braun MC, Bryan NS, Desai MS, Coss-Bu JA, Ikizler TA, Akcan Arikan A. The effect of continuous venovenous hemodiafiltration on amino acid delivery, clearance, and removal in children. Pediatr Nephrol 2022; 37:433-441. [PMID: 34386851 DOI: 10.1007/s00467-021-05162-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND In critically ill children with acute kidney injury (AKI), continuous kidney replacement therapy (CKRT) enables nutrition provision. The magnitude of amino acid loss during continuous venovenous hemodiafiltration (CVVHDF) is unknown and needs accurate quantification. We investigated the mass removal and clearance of amino acids in pediatric CVVHDF. METHODS This is a prospective observational cohort study of patients receiving CVVHDF from August 2014 to January 2016 in the pediatric intensive care unit (PICU) of a tertiary children's hospital. RESULTS Fifteen patients (40% male, median age 2.0 (IQR 0.7, 8.0) years) were enrolled. Median PICU and hospital lengths of stay were 20 (9, 59) and 36 (22, 132) days, respectively. Overall survival to discharge was 66.7%. Median daily protein prescription was 2.00 (1.25, 2.80) g/kg/day. Median daily amino acid mass removal was 299.0 (174.9, 452.0) mg/kg body weight, and median daily amino acid mass clearance was 18.2 (13.5, 27.9) ml/min/m2, resulting in a median 14.6 (8.3, 26.7) % protein loss. The rate of amino acid loss increased with increasing dialysis dose and blood flow rate. CONCLUSION CVVHDF prescription and related amino acid loss impact nutrition provision, with 14.6% of the prescribed protein removed. Current recommendations for protein provision for children requiring CVVHDF should be adjusted to compensate for circuit-related loss. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Richard P Lion
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Molly R Vega
- Section of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - E O'Brien Smith
- Department of Pediatrics and Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Sridevi Devaraj
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, USA
| | - Michael C Braun
- Section of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Nathan S Bryan
- Department of Pediatrics and Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Moreshwar S Desai
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Jorge A Coss-Bu
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Talat Alp Ikizler
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ayse Akcan Arikan
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA. .,Section of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA. .,Texas Children's Hospital, 6651 Main Street, Houston, TX, 77030, USA.
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Smith M, Bell C, Vega MW, Tufan Pekkucuksen N, Loftis L, McPherson M, Graf J, Akcan Arikan A. Patient-centered outcomes in pediatric continuous kidney replacement therapy: new morbidity and worsened functional status in survivors. Pediatr Nephrol 2022; 37:189-197. [PMID: 34235579 PMCID: PMC8263014 DOI: 10.1007/s00467-021-05177-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 05/01/2021] [Accepted: 06/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ongoing measures to improve pediatric continuous kidney replacement therapy (CKRT) have lowered mortality rates, shifting the focus to survivor functional status. While septic acute kidney injury generates new morbidity in pediatric critically ill patients, acquired morbidities and functional status of CKRT population are unknown. We predicted that CKRT survivors are at risk for new morbidity and would have worse functional status at PICU discharge compared to baseline, and aimed to describe associated factors. METHODS Retrospective cohort study over 24 months of CKRT patients surviving to PICU discharge in a quaternary children's hospital. Functional outcome was determined by Functional Status Scale (FSS). RESULTS FSS scores were higher at PICU and hospital discharge compared to baseline. Of 45 CKRT survivors, 31 (69%) had worse FSS score at PICU discharge and 51% had new morbidity (≥3 increase in FSS); majority qualified as moderate to severe disability (FSS ≥10). Four patients (9%) had new tracheostomy, 3 (7%) were ventilator dependent, and 10 (22%) were dialysis dependent. Most (23/45, 51%) required outpatient rehabilitation. Cumulative days on sedation, controlled for illness severity, were independently associated with worse FSS at PICU discharge (aOR 25.18 (3.73, 169.92)). In adjusted analyses, duration of sedation was associated with new morbidity, while neurologic comorbidity, percent fluid overload at CKRT start, and nonrenal comorbidity were associated with moderate to severe disability at PICU discharge when controlled for baseline FSS. CONCLUSIONS CKRT survivors, with new morbidity and worse functional outcomes at PICU discharge, are a newly described vulnerable population requiring targeted follow-up. Deliberate decrease of sedation exposure in patients with decreased clearance due to organ dysfunction needs to be studied as a modifiable risk factor.
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Affiliation(s)
- Mallory Smith
- Department of Pediatrics, Critical Care Section, Seattle Children’s Hospital, Seattle, WA USA ,Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
| | - Cynthia Bell
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX USA
| | - Molly Wong Vega
- Department of Pediatrics, Renal Section, Baylor College of Medicine, 6651 Main Street, Houston, TX 77030 USA
| | - Naile Tufan Pekkucuksen
- Department of Pediatrics, Renal Section, Baylor College of Medicine, 6651 Main Street, Houston, TX 77030 USA
| | - Laura Loftis
- Department of Pediatrics, Critical Care Section, Baylor College of Medicine, Houston, TX USA
| | - Mona McPherson
- Department of Pediatrics, Critical Care Section, Baylor College of Medicine, Houston, TX USA
| | - Jeanine Graf
- Department of Pediatrics, Critical Care Section, Baylor College of Medicine, Houston, TX USA
| | - Ayse Akcan Arikan
- Department of Pediatrics, Renal Section, Baylor College of Medicine, 6651 Main Street, Houston, TX, 77030, USA. .,Department of Pediatrics, Critical Care Section, Baylor College of Medicine, Houston, TX, USA.
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18
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Stahl JL, Whelan RS, Symons JM. Dialysis disequilibrium on CKRT: avoiding the steep slippery slope. Pediatr Nephrol 2021; 36:2697-2702. [PMID: 33835264 DOI: 10.1007/s00467-021-05026-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/30/2021] [Accepted: 02/23/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Current guidelines for initiation of kidney replacement do not include specific recommendations for prescription parameters and monitoring. CASE OUTLINE A 16-year-old girl presented with kidney failure with creatinine of 19.8 mg/dL and BUN of 211 mg/dL. She initiated continuous kidney replacement therapy (CKRT) with clearance of 1,300 mL/min/1.73 m2 which was increased to 1,950 mL/min/1.73 m2 at 17 h of stable therapy. COMPLICATIONS At 31 h of therapy, she developed generalized seizure activity. CT imaging was negative for acute intracranial process, and EEG demonstrated diffuse encephalopathy. CKRT was discontinued, and BUN was noted to be 47 mg/dL at that time (a 79% reduction from presenting BUN). KEY MANAGEMENT POINTS • The potential for development of DDS is not isolated to intermittent hemodialysis and may occur later in presentation. • A decreased clearance rate should be considered in those with risk factors for development of dialysis disequilibrium syndrome (DDS). • Frequent monitoring of BUN/serum osmolality is important to allow for adjustment of the KRT prescription following initiation of therapy. • Additional research is needed to guide risk assessment for DDS and therapeutic timing and goals in the early stages of KRT initiation. • Inclusion of more specific guidelines surrounding DDS would assist in providing important support for nephrologists. LIST OF RELEVANT GUIDELINES KDIGO clinical practice guideline for acute kidney injury [1] Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease [2] The Renal Association Clinical Practice Guideline Acute Kidney Injury (AKI) [3] The Japanese Clinical Practice Guideline for Acute Kidney Injury [4].
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Affiliation(s)
- Jessica L Stahl
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Russell S Whelan
- Division of Nephrology, Seattle Children's Hospital, Seattle, WA, USA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Jordan M Symons
- Division of Nephrology, Seattle Children's Hospital, Seattle, WA, USA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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19
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Yessayan L, Sohaney R, Puri V, Wagner B, Riddle A, Dickinson S, Napolitano L, Heung M, Humes D, Szamosfalvi B. Regional citrate anticoagulation "non-shock" protocol with pre-calculated flow settings for patients with at least 6 L/hour liver citrate clearance. BMC Nephrol 2021; 22:244. [PMID: 34215201 PMCID: PMC8249839 DOI: 10.1186/s12882-021-02443-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) for the prevention of clotting of the extracorporeal blood circuit during continuous kidney replacement therapy (CKRT) has been employed in limited fashion because of the complexity and complications associated with certain protocols. Hypertonic citrate infusion to achieve circuit anticoagulation results in variable systemic citrate- and sodium load and increases the risk of citrate accumulation and hypernatremia. The practice of "single starting calcium infusion rate for all patients" puts patients at risk for clinically significant hypocalcemia if filter effluent calcium losses exceed replacement. A fixed citrate to blood flow ratio, personalized effluent and pre-calculated calcium infusion dosing based on tables derived through kinetic analysis enable providers to use continuous veno-venous hemo-diafiltration (CVVHDF)-RCA in patients with liver citrate clearance of at least 6 L/h. METHODS This was a single-center prospective observational study conducted in intensive care unit patients triaged to be treated with the novel pre-calculated CVVHDF-RCA "Non-shock" protocol. RCA efficacy outcomes were time to first hemofilter loss and circuit ionized calcium (iCa) levels. Safety outcomes were surrogate of citrate accumulation (TCa/iCa ratio) and the incidence of acid-base and electrolyte complications. RESULTS Of 53 patients included in the study, 31 (59%) had acute kidney injury and 12 (22.6%) had the diagnosis of cirrhosis at the start of CVVHDF-RCA. The median first hemofilter life censored for causes other than clotting exceeded 70 h. The cumulative incidence of hypernatremia (Na > 148 mM), metabolic alkalosis (HCO3- > 30 mM), hypocalcemia (iCa < 0.9 mM) and hypercalcemia (iCa > 1.5 mM) were 1/47 (1%), 0/50 (0%), 1/53 (2%), 1/53 (2%) respectively and were not clinically significant. The median (25th-75th percentile) of the highest TCa/iCa ratio for every 24-h interval on CKRT was 1.99 (1.91-2.13). CONCLUSIONS The fixed citrate to blood flow ratio, as opposed to a titration approach, achieves adequate circuit iCa (< 0.4 mm/L) for any hematocrit level and plasma flow. The personalized dosing approach for calcium supplementation based on pre-calculated effluent calcium losses as opposed to the practice of "one starting dose for all" reduces the risk of clinically significant hypocalcemia. The fixed flow settings achieve clinically desirable steady state systemic electrolyte levels.
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Affiliation(s)
- Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA.
| | - Ryann Sohaney
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Vidhit Puri
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Benjamin Wagner
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Amy Riddle
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Sharon Dickinson
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Lena Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - David Humes
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Balazs Szamosfalvi
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA.
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20
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Raina R, Agrawal N, Kusumi K, Pandey A, Tibrewal A, Botsch A. A Meta-Analysis of Extracorporeal Anticoagulants in Pediatric Continuous Kidney Replacement Therapy. J Intensive Care Med 2021; 37:577-594. [PMID: 33688766 DOI: 10.1177/0885066621992751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Continuous kidney replacement therapy (CKRT) is the primary therapeutic modality utilized in hemodynamically unstable patients with severe acute kidney injury. As the circuit is extracorporeal, it poses an increased risk of blood clotting and circuit loss; frequent circuit losses affect the provider's ability to provide optimal treatment. The objective of this meta-analysis is to evaluate the safety and efficacy of the extracorporeal anticoagulants in the pediatric CKRT population. DATA SOURCES We conducted a literature search on PubMed/Medline and Embase for relevant citations. STUDY SELECTION Studies were included if they involved patients under the age of 18 years undergoing CKRT, with the use of anticoagulation (heparin, citrate, or prostacyclin) as a part of therapy. Only English articles were included in the study. DATA EXTRACTION Initial search yielded 58 articles and a total of 24 articles were included and reviewed. A meta-analysis was performed focusing on the safety and effectiveness of regional citrate anticoagulation (RCA) vs unfractionated heparin (UFH) anticoagulants in children. DATA SYNTHESIS RCA had statistically significantly longer circuit life of 50.65 hours vs. UFH of 42.10 hours. Two major adverse effects metabolic alkalosis and electrolyte imbalance seen more commonly in RCA compared to UFH. There was not a significant difference in the risk of systemic bleeding when comparing RCA vs. UFH. CONCLUSION RCA is the preferred anticoagulant over UFH due to its significantly longer circuit life, although vigilant circuit monitoring is required due to the increased risk of electrolyte disturbances. Prostacyclin was not included in the meta-analysis due to the lack of data in pediatric patients. Additional studies are needed to strengthen the study results further.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Nirav Agrawal
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.,Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Kirsten Kusumi
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Avisha Pandey
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Abhishek Tibrewal
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Alexander Botsch
- Division of Critical Care Medicine, Summa Health, Akron, OH, USA
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21
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Wang X, Chen X, Tang F, Luo W, Fang J, Qi C, Sun H, Xiao H, Peng X, Shao J. Be aware of acute kidney injury in critically ill children with COVID-19. Pediatr Nephrol 2021; 36:163-169. [PMID: 32844290 PMCID: PMC7447530 DOI: 10.1007/s00467-020-04715-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/19/2020] [Accepted: 07/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication of critically ill adult patients with COVID-19. However, currently, no studies investigate kidney impairment in children with COVID-19. We investigated incidence and treatment of AKI in pediatric patients with COVID-19 in Wuhan Children's Hospital during the early stages of the COVID-19 pandemic and discuss possible mechanisms of AKI related to SARS-CoV-2 infection. METHODS By extracting data from electronic medical records, we conducted a retrospective observational study of kidney involvement in confirmed pediatric COVID-19 cases in Wuhan Children's Hospital during the coronavirus outbreak, from January 24 to March 20, 2020. Clinical presentations, clinical courses, laboratory findings, and medical interventions are described below. RESULTS Among 238 confirmed COVID-19 cases, only three were critically ill and needed intensive care unit (ICU) admission. All three developed AKI, but AKI was not detected in any non-critically ill patients outside the ICU. Two of the three patients with AKI had prodromal gastrointestinal symptoms. Significantly elevated interleukin-6 (IL-6) levels and complement activation were observed in these patients with AKI. The three patients with AKI were treated with plasma exchange (PE) and continuous kidney replacement therapy (CKRT), resulting in one complete recovery, one partial recovery, and one mortality due to critical illness. CONCLUSIONS Critically ill children with COVID-19 may develop AKI, especially following prodromal gastrointestinal symptoms. An inflammatory storm and complement-mediated injury may underlie AKI development in children with COVID-19. Our study supports implantation of PE and CKRT in management of critically ill patients with AKI.
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Affiliation(s)
- Xiaowen Wang
- Department of Nephrology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China
| | - Xingfeng Chen
- Intensive Care Unit, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China
| | - Feng Tang
- Department of Laboratory Medicine, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China
| | - Wanjun Luo
- Hospital Acquired Infection Control Department, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China
| | - Jian Fang
- Department of Nephrology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China
| | - Chang Qi
- Department of Nephrology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China
| | - Hua Sun
- Department of Nephrology, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Han Xiao
- Institute of Maternal and Child Health, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China
| | - Xuehua Peng
- Medical Imaging Center, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China
| | - Jianbo Shao
- Intensive Care Unit, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China.
- Medical Imaging Center, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430000, China.
- Institute of Maternal and Child Health, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), 100# Hongkong Road, Wuhan, 430000, China.
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22
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Neyra JA, Nadkarni GN. Continuous Kidney Replacement Therapy of the Future: Innovations in Information Technology, Data Analytics, and Quality Assurance Systems. Adv Chronic Kidney Dis 2021; 28:13-19. [PMID: 34389132 DOI: 10.1053/j.ackd.2021.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 03/20/2021] [Accepted: 03/24/2021] [Indexed: 11/11/2022]
Abstract
Continuous kidney replacement therapy is commonly used in the critically ill population. Despite the recent development in continuous kidney replacement therapy technology and clinical informatics, many aspects of continuous kidney replacement therapy delivery are still not fully standardized, and quality assurance programs for the provision of continuous kidney replacement therapy are not fully developed. This is in part explained by practice variations, suboptimal integration between machine and clinical data, and the lack of validated continuous kidney replacement therapy quality indicators that are feasible for measurement and monitoring. The further development and sustainable implementation of quality assurance systems that support continuous kidney replacement therapy delivery rely on the collaborative work of the critical care nephrology community and the continuous evolution of clinical informatics. In this article, we describe the present status of information technology and quality assurance systems for continuous kidney replacement therapy delivery and provide a framework for technology development and implementation which is in the pipeline of enhanced continuous kidney replacement therapy delivery.
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23
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Tufan Pekkucuksen N, Sigler KE, Akcan Arikan A, Srivaths P. Tandem plasmapheresis and continuous kidney replacement treatment in pediatric patients. Pediatr Nephrol 2021; 36:1273-1278. [PMID: 33108508 PMCID: PMC7588944 DOI: 10.1007/s00467-020-04769-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 04/15/2020] [Accepted: 04/27/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND The objectives of the study are to describe tandem therapeutic plasma exchange (TPE) and continuous kidney replacement therapy (CKRT) patients' outcomes in a large institution. METHODS We reviewed pediatric patients receiving tandem TPE and CKRT from 2013 to 2016. Over the study period, 63 discrete patients received tandem TPE and CKRT for a total of 378 TPE procedures on 1676 days on CKRT. RESULTS Patient age ranged from newborn to 19 years old with weights ranging from 2.31 to 112.3 kg (17 patients were < 10 kg and less than 1 year old). All procedures were completed in intensive care units (ICU) as CKRT can only be done in this environment. All treatments completed successfully; majority of patients (90%) developed hypocalcemia though none were symptomatic. Case mortality rate was 40%. Disease severity scores at ICU admission were higher and time to TPE and CKRT start was longer in the deceased group. CONCLUSIONS As a conclusion, though complications including hypocalcemia are common with tandem TPE and CKRT in pediatrics, patients remained asymptomatic. Such treatments have to be carefully planned with interdisciplinary teams to address indications, technicalities, and complications.
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Affiliation(s)
- Naile Tufan Pekkucuksen
- Department of Pediatrics, Pediatric Nephrology Division, University of Florida, Gainesville, FL, USA. .,Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, USA.
| | - Katie E. Sigler
- grid.39382.330000 0001 2160 926XDepartment of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX USA
| | - Ayse Akcan Arikan
- grid.39382.330000 0001 2160 926XDepartment of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX USA ,grid.39382.330000 0001 2160 926XDepartment of Pediatrics, Section of Critical Care Medicine Texas Children’s Hospital, Baylor College of Medicine, Houston, TX USA
| | - Poyyapakkam Srivaths
- grid.39382.330000 0001 2160 926XDepartment of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX USA
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24
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Szamosfalvi B, Puri V, Sohaney R, Wagner B, Riddle A, Dickinson S, Napolitano L, Heung M, Humes D, Yessayan L. Regional Citrate Anticoagulation Protocol for Patients with Presumed Absent Citrate Metabolism. Kidney360 2020; 2:192-204. [PMID: 35373034 PMCID: PMC8740983 DOI: 10.34067/kid.0005342020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/18/2020] [Indexed: 02/04/2023]
Abstract
Background Regional citrate anticoagulation (RCA) is not recommended in patients with shock or severe liver failure. We designed a protocol with personalized precalculated flow settings for patients with absent citrate metabolism that abrogates risk of citrate toxicity, and maintains neutral continuous KRT (CKRT) circuit calcium mass balance and normal systemic ionized calcium levels. Methods A single-center prospective cohort study of patients in five adult intensive care units triaged to the CVVHDF-RCA "Shock" protocol. Results Of 31 patients included in the study, 30 (97%) had AKI, 16 (52%) had acute liver failure, and five (16%) had cirrhosis at the start of CKRT. The median lactate was 5 mmol/L (interquartile range [IQR], 3.2-10.7), AST 822 U/L (IQR, 122-2950), ALT 352 U/L (IQR, 41-2238), total bilirubin 2.7 mg/dl (IQR, 1.0-5.1), and INR two (IQR, 1.5-2.6). The median first hemofilter life censored for causes other than clotting exceeded 70 hours. The cumulative incidence of hypernatremia (Na >148 mM), metabolic alkalosis (HCO3- >30 mM), and hypophosphatemia (P<2 mg/dl) were one out of 26 (4%), zero out of 30 (0%), and one out of 30 (3%), respectively, and were not clinically significant. Mild hypocalcemia occurred in the first 4 hours in two out of 31 patients, and corrected by hour 6 with no additional Ca supplementation beyond the per-protocol administered Ca infusion. The maximum systemic total Ca (tCa; mM)/ionized Ca (iCa; mM) ratio never exceeded 2.5. Conclusions The Shock protocol can be used without contraindications and is effective in maintaining circuit patency with a high, fixed ACDA infusion rate to blood flow ratio. Keeping single-pass citrate extraction on the dialyzer >0.75 minimizes the risk of citrate toxicity even in patients with absent citrate metabolism. Precalculated, personalized dosing of the initial Ca-infusion rate from a table on the basis of the patient's albumin level and the filter effluent flow rate maintains neutral CKRT circuit calcium mass balance and a normal systemic iCa level.
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Affiliation(s)
- Balazs Szamosfalvi
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Vidhit Puri
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ryann Sohaney
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Benjamin Wagner
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Amy Riddle
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sharon Dickinson
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Lena Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - David Humes
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
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25
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Munshi R, Lee-Son K, Hackbarth RM, Quigley R, Sutherland SM, Echeverri J, Goldstein SL. Clinical evaluation of the Prismaflex™ HF 20 set and Prismaflex™ system 7.10 for acute continuous kidney replacement therapy ( CKRT) in children. Pediatr Nephrol 2020; 35:2345-2352. [PMID: 32607769 DOI: 10.1007/s00467-020-04664-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 06/07/2020] [Accepted: 06/10/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Continuous kidney replacement therapy (CKRT) is a common modality for treatment of severe acute kidney injury (AKI) in children. Adult technologies routinely utilized to provide this therapy have a large extracorporeal volume. The Prismaflex™ HF20 filter set has a relatively low extracorporeal blood volume of 60 mL, which provides technological benefit for smaller children compared with current filter sets available in the USA. METHODS We conducted a multicenter, open-label single group study to evaluate whether the Prismaflex™ HF20 filter set delivers efficacious and safe CKRT to support patients with AKI, fluid overload, or both in pediatric patients weighing ≥ 8 to 20 kg. RESULTS Twenty-three patients were enrolled between April 24, 2016 and April 8, 2018. The mean reduction in blood urea nitrogen from baseline to 24 h was 58.12 ± 20.08% (95% CI, - 68.45 and - 47.79 (p = 0.0008)). Median cumulative normalized effluent rate at 24 h was 60.8 mL/kg/h (25.9, 83.7). None of the patients participating in the study suffered a serious adverse event; thus, no obvious safety concerns were noted. CONCLUSIONS We suggest that the Prismaflex HF20™ filter set used in conjunction with the Prismaflex™ System Software Version 7.10 or 7.20 is a suitable alternative to larger filter sets for use in pediatric patients weighing less than 20 kg. Graphical abstract.
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Affiliation(s)
| | - Kathy Lee-Son
- University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | | | - Raymond Quigley
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Stuart L Goldstein
- University of Cincinnati College of Medicine and Cincinnati Children's Hospital, Cincinnati, OH, USA
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