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INTRODUCTION: In addition to various techniques involved in catheter insertion, catheter placement location, lumen diameter and operation and management during continuous renal replacement therapy (CRRT), the design of the tip and side holes, as well as the position of the tip of the catheter, can also impact catheter function. Side-hole and step-tip catheters are commonly used during CRRT. However, there is insufficient evidence comparing their efficacy for CRRT in critically ill patients. And the optimal position of the tip of catheters is not well studied and remains controversial. This study was conducted to assess whether using a step-tip catheter could reduce the rate of catheter dysfunction compared with a side-hole catheter and whether inserting a longer catheter could reduce the incidence of catheter dysfunction and increase catheter survival time. METHODS AND ANALYSIS: A prospective, open-label, three-arm, parallel-group, single-centre randomised controlled trial will be conducted at West China Hospital of Sichuan University in China. An estimated sample of 378 participants receiving CRRT treatment will be recruited. Eligible patients will be randomly assigned to three groups to receive different dialysis catheters for the initiation of CRRT at a 1:1:1 ratio via a central randomisation system: group A, side-hole catheters (11Fr, 200 mm; GDHK-1120; Baxter International Inc., Deerfield, Illinois); group B, step-tip catheters (13Fr, 200 mm; GDHK-1320; Baxter International Inc.) and group C, step-tip catheters (13Fr, 250 mm; GDHK-1325; Baxter International Inc.). The femoral vein is the only vascular access. All catheters will be inserted under the guidance of ultrasound using the Seldinger method to reduce complications and trauma related to catheter insertion. The primary outcomes are the occurrence of catheter dysfunction and catheter survival time. Outcome assessors and data analysts will be blinded. All data will be analysed according to the group randomly assigned by an intention-to-treat analysis, in which catheters with missing data for the primary outcomes would be excluded. ETHICS AND DISSEMINATION: The trial protocol has been approved by the Biomedical Research Ethics Committee of West China Hospital of Sichuan University (2023.1221). And the results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ChiCTR2300075107.
Assuntos
Terapia de Substituição Renal Contínua , Unidades de Terapia Intensiva , Ensaios Clínicos Controlados Aleatórios como Assunto , Humanos , Terapia de Substituição Renal Contínua/métodos , Terapia de Substituição Renal Contínua/instrumentação , Estudos Prospectivos , China , Masculino , Estado Terminal/terapia , Desenho de Equipamento , Feminino , Cateteres de Demora/efeitos adversosRESUMO
Castleman disease (CD) is a rare lymphoproliferative disorder, with non-specific clinical manifestations, often delayed diagnosis and treatment, which pose a significant challenge in the present times. Patients diagnosed with this disease have poor prognosis due to the limited treatment options. Multicentric CD occurs at multiple lymph node stations and is associated with a proinflammatory response that leads to the development of the so-called 'B symptoms'. IL-6 seems to be a key cytokine involved in various manifestations such as lymphadenopathies, hepatosplenomegaly, and polyclonal hypergammaglobulinemia. Its levels correlate with the activity of the disease. Other consequences of MCD include increased fibrinogen levels leading to deep vein thrombosis and thromboembolic disorders, high hepcidin levels causing anaemia, elevated VEGF levels promoting angiogenesis and vascular permeability, which, along with hypoalbuminemia, induce oedema, ascites, pleural and pericardial effusions, and in severe cases, generalized anasarca. In extreme cases multiple organ failure can occur, often resulting in death. We propose the use of continuous renal replacement therapy (CRRT) in managing severe multicentric CD. Our arguments are based on the principles that CRRT is able to remove IL-6 from circulation thus attenuating the cytokine storm, can influence hepcidin levels, and reduction in oedema, and is often used in multiple organ failure to regain homeostasis control. Therefore, it could be used as a therapy or bridge therapy in severe cases. To sustain our hypothesis with evidence, we have gathered several studies from the literature confirming the successful removal of cytokines, especially IL-6 from circulation, which can be used as a starting point.
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Hiperplasia do Linfonodo Gigante , Terapia de Substituição Renal Contínua , Hiperplasia do Linfonodo Gigante/terapia , Humanos , Terapia de Substituição Renal Contínua/métodos , Interleucina-6/sangue , Interleucina-6/metabolismo , Hepcidinas/metabolismoRESUMO
BACKGROUND AND OBJECTIVE: Because of the pathophysiological changes associated with critical illness and the use of extracorporeal life support (ECLS) such as continuous renal replacement therapy (CRRT) and extracorporeal membrane oxygenation (ECMO), the pharmacokinetics of drugs are often altered. The objective of this study was to develop a physiologically based pharmacokinetic (PBPK) model for anakinra in children that accounts for the physiological changes associated with critical illness and ECLS technology to guide appropriate pharmacotherapy. METHODS: A PBPK model for anakinra was first developed in healthy individuals prior to extrapolating to critically ill children receiving ECLS. To account for the impact of anakinra clearance by the dialysis circuit, a CRRT compartment was added to the pediatric PBPK model and parameterized using data from a previously published ex-vivo study. Additionally, an ECMO compartment was added to the whole-body structure to create the final anakinra ECLS-PBPK model. The final model structure was validated by comparing predicted concentrations with observed patient data. Due to limited information in guiding anakinra dosing in this population, in-silico dose simulations were conducted to provide baseline recommendations. RESULTS: By accounting for changes in physiology and the addition of ECLS compartments, the final ECLS-PBPK model predicted the observed plasma concentrations in an adolescent receiving subcutaneous anakinra. Furthermore, dosing simulations suggest that anakinra exposure in adolescents receiving ECLS is similar to that in healthy counterparts. CONCLUSION: The anakinra ECLS-PBPK model developed in this study is the first to predict plasma concentrations in a population receiving simultaneous CRRT and ECMO. Dosing simulations provided may be used to inform anakinra use in critically ill children and guide future clinical trial planning.
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Estado Terminal , Oxigenação por Membrana Extracorpórea , Proteína Antagonista do Receptor de Interleucina 1 , Modelos Biológicos , Humanos , Proteína Antagonista do Receptor de Interleucina 1/farmacocinética , Proteína Antagonista do Receptor de Interleucina 1/administração & dosagem , Estado Terminal/terapia , Oxigenação por Membrana Extracorpórea/métodos , Criança , Pré-Escolar , Adolescente , Masculino , Feminino , Lactente , Terapia de Substituição Renal Contínua/métodos , Simulação por ComputadorRESUMO
BACKGROUND: Continuous renal replacement therapy (CRRT) is commonly used for the treatment of acute kidney injury (AKI) in critically ill neonates. This study investigated the effectiveness and feasibility of CRRT for AKI in neonates who weigh ≤3 kg. METHODS: Data from 19 neonates with a weight ≤3 kg and AKI who underwent CRRT at two centres between January 2015 and October 2021 were collected retrospectively. Kidney function, circulatory function, complications and clinical outcomes were recorded. Repeated-measures analyses of variance, t-tests and non-parametric tests were conducted. RESULTS: The median patient age at CRRT initiation was 3 days (IQR: 1-7 days). The median patient weight at CRRT initiation was 2.67 kg (IQR: 2.20-2.85 kg). The median CCRT duration was 46 hours (IQR: 32-72 hours). The serum creatinine and blood urea nitrogen levels decreased significantly, and the mean arterial pressure increased significantly after 12 hours of CRRT and at the end of CRRT. The urinary output was significantly increased at the end of CRRT. 11 patients had thrombocytopaenia, 6 had electrolyte disorders and 3 had blocked tubes. Five patients were discharged, six died after their parents chose to discontinue treatment and eight died after active treatment. Weight at CRRT initiation and urinary output at the end of CRRT were significantly lower among patients who died than among patients who survived. CONCLUSIONS: CRRT is feasible and effective for AKI in neonates who weigh ≤3 kg when accompanied by elaborate supportive care. Lower body weight and persistent oliguria may be correlated with an increased risk of poor clinical outcomes.
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Injúria Renal Aguda , Terapia de Substituição Renal Contínua , Estudos de Viabilidade , Humanos , Injúria Renal Aguda/terapia , Recém-Nascido , Estudos Retrospectivos , Masculino , Feminino , Terapia de Substituição Renal Contínua/métodos , Resultado do Tratamento , Estado Terminal/terapia , Peso CorporalRESUMO
Continuous renal replacement therapy (CRRT) used in cardiac surgery-associated acute kidney injury (CSA-AKI) may have different characteristics from other diseases. We reviewed the medical records of patients with CSA-AKI requiring CRRT who underwent cardiac surgery from January 2020 to September 2021. Patients with AKI caused by other reasons who received CRRT during the same period were also evaluated. A total of 28 patients with CSA-AKI and 12 patients with AKI caused by other reasons were enrolled in this study. Compared with AKI patients caused by other reasons, patients with CSA-AKI were found to have lower mean arterial pressure, higher level of bilirubin, higher vasoactive-inotropic score, and larger daily diuretic dosage. The patients with CSA-AKI were prescribed CRRT earlier than the patients with AKI caused by other reasons. There was a significant difference in the CRRT anticoagulation method between patients with CSA-AKI and patients with AKI caused by other reasons. Six patients with CSA-AKI were treated with regional citrate anticoagulation (RCA), and the other 22 patients were treated with low molecular weight heparin or without anticoagulants. The timing of CRRT initiation in patients with CSA-AKI is earlier than that in patients with AKI caused by other reasons. Although RCA is recommended as the preferred anticoagulant for patients without contraindications, patients with CSA-AKI often have circulatory dysfunction and severe liver damage, so the risk of citrate accumulation is greater, whether to use RCA should be determined according to the individual condition of the patient.
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Injúria Renal Aguda , Anticoagulantes , Procedimentos Cirúrgicos Cardíacos , Terapia de Substituição Renal Contínua , Humanos , Masculino , Feminino , Estudos Retrospectivos , Injúria Renal Aguda/terapia , Injúria Renal Aguda/etiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Terapia de Substituição Renal Contínua/métodos , Anticoagulantes/administração & dosagem , Anticoagulantes/uso terapêutico , Pessoa de Meia-Idade , Idoso , Complicações Pós-Operatórias/etiologia , Fatores de TempoRESUMO
INTRODUCTION: Continuous renal replacement therapy (CRRT) is a critical therapeutic intervention for patients with severe acute kidney injury in intensive care. However, premature filter clotting remains a significant challenge during CRRT, impacting treatment efficacy, costs and patient outcomes. Anticoagulation is essential to maintain circuit patency, with regional citrate anticoagulation (RCA) emerging as a preferred strategy due to its favourable bleeding profile. The standard target for post-filter ionised calcium (iCa) concentration during RCA-CRRT is set between 0.25 and 0.35 mmol/L, although evidence supporting this range is limited. We hypothesise that a higher post-filter iCa target (0.35-0.45 mmol/L) can provide comparable circuit patency while potentially reducing adverse effects associated with citrate administration. METHODS AND ANALYSIS: This multicentre randomised controlled non-inferiority trial will compare a low post-filter iCa target (0.25-0.35 mmol/L) with a higher post-filter iCa target (0.35-0.45 mmol/L) in patients undergoing RCA-CRRT in the intensive care unit. A total of 412 CRRT sessions will be randomised with a 1:1 ratio into these two groups. The primary outcome is the incidence of filter clotting. Secondary outcomes include filter lifespan, post-filter iCa levels, citrate infusion rates, the occurrence of metabolic adverse effects, financial costs and blood loss. ETHICS AND DISSEMINATION: The study has obtained approval from the ethics committee (Ethics Committee Est III, Nancy, France) and patients will be included after providing informed consent. The results will be disseminated at academic conferences and in peer-reviewed publications. All procedures were developed in order to assure data protection and confidentiality. TRIAL REGISTRATION NUMBER: NCT05814341.
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Injúria Renal Aguda , Anticoagulantes , Cálcio , Ácido Cítrico , Terapia de Substituição Renal Contínua , Unidades de Terapia Intensiva , Humanos , Terapia de Substituição Renal Contínua/métodos , Anticoagulantes/administração & dosagem , Anticoagulantes/uso terapêutico , Ácido Cítrico/administração & dosagem , Ácido Cítrico/uso terapêutico , Injúria Renal Aguda/terapia , Estudos de Equivalência como AsuntoRESUMO
Estimating glomerular filtration (eGFR) after Continuous Renal Replacement Therapy (CRRT) is important to guide drug dosing and to assess the need to re-initiate CRRT. Standard eGFR equations cannot be applied as these patients neither have steady-state serum creatinine concentration nor average muscle mass. In this study we evaluate the combination of dynamic renal function with CT-scan based correction for aberrant muscle mass to estimate renal function immediately after CRRT cessation. We prospectively included 31 patients admitted to an academic intensive care unit (ICU) with a total of 37 CRRT cessations and measured serum creatinine before cessation (T1), directly (T2) and 5 h (T3) after cessation and the following two days when eGFR stabilized (T4, T5). We used the dynamic creatinine clearance calculation (D3C) equation to calculate eGFR (D3CGFR) and creatinine clearance (D3Ccreat) between T2-T3. D3Ccreat was corrected for aberrant muscle mass when a CT-scan was available using the CRAFT equation. We compared D3CGFR to stabilized CKD-EPI at T5 and D3CCreat to 4-h urinary creatinine clearance (4-h uCrCl) between T2-T3. We retrospectively validated these results in a larger retrospective cohort (NICE database; 1856 patients, 2064 cessations). The D3CGFR was comparable to observed stabilized CKD-EPI at T5 in the prospective cohort (MPE = - 1.6 ml/min/1.73 m2, p30 = 76%) and in the retrospective NICE-database (MPE = 3.2 ml/min/1.73 m2, p30 = 80%). In the prospective cohort, the D3CCreat had poor accuracy compared to 4-h uCrCl (MPE = 17 ml/min/1.73 m2, p30 = 24%). In a subset of patients (n = 13) where CT-scans were available, combination of CRAFT and D3CCreat improved bias and accuracy (MPE = 8 ml/min/1.73 m2, RMSE = 18 ml/min/1.73 m2) versus D3CCreat alone (MPE = 18 ml/min/1.73 m2, RMSE = 32 ml/min/1.73 m2). The D3CGFR improves assessment of eGFR in ICU patients immediately after CRRT cessation. Although the D3CCreat had poor association with underlying creatinine clearance, inclusion of CT derived biometric parameters in the dynamic renal function algorithm further improved the performance, stressing the role of muscle mass integration into renal function equations in critically ill patients.
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Terapia de Substituição Renal Contínua , Creatinina , Taxa de Filtração Glomerular , Unidades de Terapia Intensiva , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Terapia de Substituição Renal Contínua/métodos , Creatinina/sangue , Creatinina/urina , Idoso , Estudos Prospectivos , Rim/fisiopatologia , Rim/diagnóstico por imagem , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Testes de Função Renal/métodos , Terapia de Substituição Renal/métodosRESUMO
CLINICAL RELEVANCE: Awareness of the causes of hypercalcemia is essential for timely diagnosis of calcium disorders and optimal treatment. Citrate is commonly used as an anticoagulant during continuous renal replacement therapy (CRRT). Accumulation of citrate in the systemic circulation during CRRT may induce several metabolic disturbances, including total hypercalcemia and ionized hypocalcemia. The aim of the present study is to increase awareness of citrate accumulation and toxicity as a cause of hypercalcemia by relating three cases and reviewing the pathophysiology and clinical implications. OBSERVATIONS: We utilized electronic health records to examine the clinical cases and outlined key studies to review the consequences of citrate toxicity and general approaches to management. CONCLUSIONS: Citrate toxicity is associated with high mortality. A safe threshold for tolerating hypercalcemia during citrate anticoagulation is not clearly defined, and whether citrate toxicity independently increases mortality has not been resolved. Greater attention to citrate toxicity as a cause of hypercalcemia may lead to earlier detection, help to optimize the management of systemic calcium levels, and foster interest in future clinical studies.
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Anticoagulantes , Ácido Cítrico , Terapia de Substituição Renal Contínua , Hipercalcemia , Humanos , Hipercalcemia/induzido quimicamente , Hipercalcemia/etiologia , Anticoagulantes/efeitos adversos , Anticoagulantes/administração & dosagem , Anticoagulantes/uso terapêutico , Terapia de Substituição Renal Contínua/métodos , Ácido Cítrico/efeitos adversos , Ácido Cítrico/administração & dosagem , Ácido Cítrico/uso terapêutico , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Cálcio/sangueRESUMO
ABSTRACT: Objective: The objective of this study is to assess and compare the efficacy of oXiris with conventional continuous renal replacement therapy (CRRT) in managing severe abdominal infections. Methods: A retrospective analysis encompassing cases from 2017 to 2023 was conducted at the Department of Critical Care Medicine within the First Affiliated Hospital of Fujian Medical University. Parameters including heart rate (HR), mean arterial pressure (MAP), oxygenation index, lactate (Lac), platelet count, neutrophil ratio, procalcitonin, C-reactive protein (CRP), interleukin 6 (IL-6), norepinephrine dosage, Acute Physiology and Chronic Health Evaluation II (APACHE II), and Sequential Organ Failure Assessment (SOFA) were recorded prior to treatment initiation, at 24 h, and 72 h after treatment for both the oXiris and conventional CRRT groups. In addition, the duration of respiratory support, CRRT treatment, length of stay in the intensive care unit (ICU), total hospitalization period, and mortality rates at 14 and 28 days for both groups were recorded. Results: 1) Within the conventional CRRT group, notable enhancement was observed solely in Lac levels at 24 h after treatment compared with pretreatment levels. In addition, at 72 h after treatment, improvements were evident in HR, Lac, CRP, and IL-6 levels. 2) Conversely, the oXiris group exhibited improvements in HR, MAP, Lac, oxygenation index, neutrophil ratio, and IL-6 at 24 h after treatment when compared with baseline values. In addition, reductions were observed in APACHE II and SOFA scores. At 72 h after treatment, all parameters demonstrated enhancement except for platelet count. 3) Analysis of the changes in the indexes (Δ) between the two groups at 24 h after treatment revealed variances in HR, MAP, Lac, norepinephrine dosage, CRP levels, IL-6 levels, APACHE II scores, and SOFA scores. 4) The Δ indexes at 72 h after treatment indicated more significant improvements following oXiris treatment for both groups, except for procalcitonin. 5) The 14-day mortality rate (24.4%) exhibited a significant reduction in the oXiris group when compared with the conventional group (43.6%). However, no significant difference was observed in the 28-day mortality rate between the two groups. 6) Subsequent to multifactorial logistic regression analysis, the results indicated that oXiris treatment correlated with a noteworthy decrease in the 14-day and 28-day mortality rates associated with severe abdominal infections, by 71.3% and 67.6%, respectively. Conclusion: oXiris demonstrates clear advantages over conventional CRRT in the management of severe abdominal infections. Notably, it reduces the fatality rates, thereby establishing itself as a promising and potent therapeutic option.
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Terapia de Substituição Renal Contínua , Choque Séptico , Humanos , Estudos Retrospectivos , Masculino , Feminino , Pessoa de Meia-Idade , Choque Séptico/terapia , Choque Séptico/mortalidade , Choque Séptico/sangue , Idoso , Terapia de Substituição Renal Contínua/métodos , Infecções Intra-Abdominais/terapia , Infecções Intra-Abdominais/mortalidade , APACHE , Adulto , Escores de Disfunção OrgânicaRESUMO
BACKGROUND AND OBJECTIVE: Renal replacement therapy (RRT) plays a critical role in antimicrobial removal, particularly for low-molecular-weight drugs with low plasma protein binding, low distribution volume and hydrophilicity. Medium cut-off (MCO) membranes represent a new generation in dialysis technology, enhancing diffusive modality efficacy and increasing the cut-off from 30 to 45 kDa, crucial for middle molecule removal. This monocentric randomized crossover pilot study aimed to evaluate the impact of continuous haemodialysis with MCO membrane (MCO-CVVHD) on the removal of piperacillin, tazobactam and meropenem compared with continuous veno-venous hemodiafiltration with standard high-flux membrane (HFM-CVVHDF). METHODS: Twenty patients were randomized to undergo MCO-CVVHD followed by HFM-CVVHDF or vice versa. Extraction ratio (ER), effluent clearance (Cleff) and treatment efficiency were assessed at various intervals. Antibiotic nadir plasma levels were measured for both treatment days. RESULTS: HFM-CVVHDF showed greater ER compared with MCO-CVVHD for meropenem (ß = - 8.90 (95% CI - 12.9 to - 4.87), p < 0.001) and tazobactam (ß = - 8.29 (95% CI - 13.5 to - 3.08), p = 0.002) and Cleff for each antibiotic (meropenem ß = - 10,206 (95% CI - 14,787 to - 5787), p = 0.001); tazobactam (ß = - 4551 (95% CI - 7781 to - 1322), p = 0.012); piperacillin (ß = - 3913 (95% CI - 6388 to - 1437), p = 0.002), even if the carryover effect influenced the Cleff for meropenem and tazobactam. No difference was observed in nadir plasma concentrations or efficiency for any antibiotic. Piperacillin (ß = - 38.1 (95% CI - 47.9 to - 28.3), p < 0.001) and tazobactam (ß = - 4.45 (95% CI - 6.17 to - 2.72), p < 0.001) showed lower nadir plasma concentrations the second day compared with the first day, regardless the filter type. CONCLUSION: MCO demonstrated comparable in vivo removal of piperacillin, tazobactam and meropenem to HFM.
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Antibacterianos , Terapia de Substituição Renal Contínua , Estudos Cross-Over , Meropeném , Diálise Renal , Choque Séptico , Humanos , Antibacterianos/farmacocinética , Antibacterianos/uso terapêutico , Antibacterianos/sangue , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Choque Séptico/terapia , Choque Séptico/tratamento farmacológico , Choque Séptico/sangue , Projetos Piloto , Terapia de Substituição Renal Contínua/métodos , Diálise Renal/métodos , Meropeném/uso terapêutico , Meropeném/administração & dosagem , Meropeném/farmacocinética , Tazobactam/uso terapêutico , Tazobactam/farmacocinética , Piperacilina/farmacocinética , Piperacilina/uso terapêutico , Piperacilina/administração & dosagem , Hemodiafiltração/métodosAssuntos
COVID-19 , Dióxido de Carbono , Terapia de Substituição Renal Contínua , Pandemias , SARS-CoV-2 , Uremia , Humanos , COVID-19/complicações , COVID-19/terapia , Masculino , Idoso , Terapia de Substituição Renal Contínua/métodos , Uremia/terapia , Pneumonia Viral/terapia , Pneumonia Viral/complicações , Infecções por Coronavirus/terapia , Infecções por Coronavirus/complicações , BetacoronavirusRESUMO
BACKGROUND: To explore the feasibility and effectiveness of a segmented sodium citrate solution anticoagulation strategy in patients receiving CRRT. METHODS: A prospective, randomized controlled study was conducted. RESULTS: According to the inclusion and exclusion criteria, 80 patients were included and randomly divided into two groups. Moreover, coagulation indices, liver function indices, renal function indices, and SOFA and APACHE II scores did not significantly differ between the two groups (P > 0.05). The coagulation grade of the venous ports in the experimental group was lower than that in the control group and the two groups of filters, but the difference was not statistically significant (P = 0.337). Both sodium citrate solution infusion methods maintained a low blood calcium concentration (0.25-0.45 mmol/L) in the peripheral circulation pathway, and no patient developed hypocalcaemia (< 1.0 mmol/L). The lifespans of the extracorporeal circulation tube in the experimental group and the control group were 69.43 ± 1.49 h and 49.39 ± 2.44 h, respectively (t = 13.316, P = 0.001). CONCLUSION: The segmented citrate solution anticoagulation strategy could extend the lifespan of the extracorporeal circulation tube and improve CRRT efficacy. TRIAL REGISTRATION: The Chinese Clinical Trial Registry number is ChiCTR2200057272. Registered on March 5, 2022.
Assuntos
Anticoagulantes , Estado Terminal , Citrato de Sódio , Humanos , Estudos Prospectivos , Anticoagulantes/administração & dosagem , Citrato de Sódio/administração & dosagem , Masculino , Pessoa de Meia-Idade , Feminino , Idoso , Coagulação Sanguínea/efeitos dos fármacos , Resultado do Tratamento , Terapia de Substituição Renal Contínua/métodos , Estudos de Viabilidade , China , Terapia de Substituição Renal/métodosRESUMO
BACKGROUND: To construct and evaluate a predictive model for in-hospital mortality among critically ill patients with acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT), based on nine machine learning (ML) algorithm. METHODS: The study retrospectively included patients with AKI who underwent CRRT during their initial hospitalization in the United States using the medical information mart for intensive care (MIMIC) database IV (version 2.0), as well as in the intensive care unit (ICU) of Huzhou Central Hospital. Patients from the MIMIC database were used as the training cohort to construct the models (from 2008 to 2019, n = 1068). Patients from Huzhou Central Hospital were utilized as the external validation cohort to evaluate the models (from June 2019 to December 2022, n = 327). In the training cohort, least absolute shrinkage and selection operator (LASSO) regression with cross-validation was employed to select features for constructing the model and subsequently established nine ML predictive models. The performance of these nine models on the external validation cohort dataset was comprehensively evaluated based on the area under the receiver operating characteristic curve (AUROC) and the optimal model was selected. A static nomogram and a web-based dynamic nomogram were presented, with a comprehensive evaluation from the perspectives of discrimination (AUROC), calibration (calibration curve) and clinical practicability (DCA curves). RESULTS: Finally, 1395 eligible patients were enrolled, including 1068 patients in the training cohort and 327 patients in the external validation cohort. In the training cohort, LASSO regression with cross-validation was employed to select features and nine models were individually constructed. Compared to the other eight models, the Lasso regularized logistic regression (Lasso-LR) model exhibited the highest AUROC (0.756) and the optimal calibration curve. The DCA curve suggested a certain clinical utility in predicting in-hospital mortality among critically ill patients with AKI undergoing CRRT. Consequently, the Lasso-LR model was the optimal model and it was visualized as a common nomogram (static nomogram) and a web-based dynamic nomogram (https://chsyh2006.shinyapps.io/dynnomapp/). Discrimination, calibration and DCA curves were employed to assess the performance of the nomogram. The AUROC for the training and external validation cohorts in the nomogram model was 0.771 (95%CI: 0.743, 0.799) and 0.756 (95%CI: 0.702, 0.809), respectively. The calibration slope and Brier score for the training cohort were 1.000 and 0.195, while for the external validation cohort, they were 0.849 and 0.197, respectively. The DCA indicated that the model had a certain clinical application value. CONCLUSIONS: Our study selected the optimal model and visualized it as a static and dynamic nomogram integrating clinical predictors, so that clinicians can personalized predict the in-hospital outcome of critically ill patients with AKI undergoing CRRT upon ICU admission.
Assuntos
Injúria Renal Aguda , Terapia de Substituição Renal Contínua , Mortalidade Hospitalar , Aprendizado de Máquina , Humanos , Injúria Renal Aguda/mortalidade , Injúria Renal Aguda/terapia , Masculino , Feminino , Terapia de Substituição Renal Contínua/métodos , Pessoa de Meia-Idade , Estudos Retrospectivos , Idoso , Estado Terminal/mortalidade , Estado Terminal/terapia , Nomogramas , Algoritmos , Unidades de Terapia Intensiva/estatística & dados numéricos , Curva ROC , Medição de Risco/métodos , Estados Unidos/epidemiologiaRESUMO
Objective: This study aims to evaluate a novel prone position ventilation device designed to enhance patient safety, improve comfort, and reduce adverse events, facilitating prolonged tolerance in critically ill patients. Methods: A randomized controlled trial was conducted on 60 critically ill patients from January 2020 to June 2023. Of which, one self-discharged during treatment and another was terminated due to decreased oxygenation, leaving an effective sample of 58 patients. Patients were allocated to either a control group receiving traditional prone positioning aids (ordinary sponge pads and pillows) or an intervention group using a newly developed adjustable prone positioning device. A subset of patients in each group also received life support technologies such as extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). We assessed prone position ventilation tolerance, oxygen saturation increments postintervention, duration of prone positioning, CRRT filter lifespan, and the incidence of adverse events. Results: The intervention group exhibited significantly longer average tolerance to prone positioning (16.6 hours vs. 8.3 hours, P < 0.001 with a difference of 8.3 (4.4, 12.2) hours), higher increases in oxygen saturation postventilation (9% vs. 6%, P < 0.001 with a difference of 3.0 (1.5, 4.5)), and reduced time required for medical staff to position patients (11.7 min vs. 21.8 min, P < 0.001 with a difference of -10.1 (-11.9, -8.3)). Adverse events, including catheter displacement or blockage, facial edema, pressure injuries, and vomiting or aspiration, were markedly lower in the intervention group, with statistical significance (P < 0.05). In patients receiving combined life support, the intervention group demonstrated improved catheter blood drainage and extended CRRT filter longevity. Conclusion: The newly developed adjustable prone ventilation device significantly improves tolerance to prone positioning, enhances oxygenation, and minimizes adverse events in critically ill patients, thereby also facilitating the effective application of life support technologies.
Assuntos
Estado Terminal , Posicionamento do Paciente , Respiração Artificial , Humanos , Decúbito Ventral , Masculino , Feminino , Pessoa de Meia-Idade , Estado Terminal/terapia , Respiração Artificial/métodos , Respiração Artificial/instrumentação , Posicionamento do Paciente/métodos , Idoso , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/instrumentação , Oxigenação por Membrana Extracorpórea/efeitos adversos , Adulto , Terapia de Substituição Renal Contínua/métodos , Terapia de Substituição Renal Contínua/instrumentação , Desenho de EquipamentoRESUMO
INTRODUCTION: Anticoagulants are used in continuous renal replacement therapy (CRRT) to prolong filter life. There are no prior investigations directly comparing epoprostenol to more commonly used forms of anticoagulation in children. Therefore, the primary aim of this study was to assess the efficacy and safety of epoprostenol as compared to heparin and citrate anticoagulation in a pediatric cohort. METHODS: We performed a retrospective analysis of all patients <18 years of age admitted to an academic quaternary care children's hospital from 2017-2022 who received epoprostenol, heparin, or citrate exclusively for CRRT anticoagulation. Efficacy was evaluated by comparing the hours to the first unintended filter change and the ratio of filters used to CRRT days. Safety was assessed by evaluating changes in platelet count and vasoactive-ionotropic score (VIS). RESULTS: Of 101 patients, 44 received epoprostenol (43.6%), 38 received heparin (37.6%), and 19 received citrate (18.8%). The first filter change was more commonly planned in patients receiving anticoagulation with epoprostenol (43%) as compared to citrate (11%) or heparin (29%) (p = 0.034). Of those patients where the first filter change was unintended (n = 33), there were greater median hours until the filter was replaced in those receiving epoprostenol (29) when compared to citrate (21) (p = 0.002) or heparin (18) (p = 0.003). There was a smaller median ratio of filters used to days on therapy in the patients that received epoprostenol (0.53) when compared to citrate (1) (p = 0.003) or heparin (0.75) (p = 0.001). For those receiving epoprostenol, there was no significant decrease in platelet count when comparing values prior to CRRT initiation through 7 days of therapy. There was no significant difference in VIS when comparing values prior to CRRT initiation through the first 2 days of CRRT. CONCLUSIONS: Epoprostenol-based anticoagulation is effective when compared to other anticoagulation strategies used in pediatric CRRT with a favorable side effect profile.
Assuntos
Anticoagulantes , Ácido Cítrico , Terapia de Substituição Renal Contínua , Epoprostenol , Heparina , Humanos , Anticoagulantes/uso terapêutico , Anticoagulantes/efeitos adversos , Epoprostenol/uso terapêutico , Epoprostenol/efeitos adversos , Heparina/uso terapêutico , Heparina/efeitos adversos , Criança , Estudos Retrospectivos , Feminino , Masculino , Pré-Escolar , Adolescente , Ácido Cítrico/uso terapêutico , Ácido Cítrico/efeitos adversos , Terapia de Substituição Renal Contínua/métodos , Lactente , Coagulação Sanguínea/efeitos dos fármacosRESUMO
INTRODUCTION: Enkephalins, endogenous opioid peptides, are involved in the regulation of renal function. One derived molecule, proenkephalin A, also known as penKid, has been demonstrated to be a reliable biomarker for kidney function and its plasma concentration correlates with measured glomerular filtration rate. penKid is used for prediction and diagnosis of AKI and need of renal replacement therapy (RRT). penKid has also been used to predict the successful weaning from RRT in patients with AKI. Whether the concentration of penKid is affected or not by RRT is a controversial point and there are no studies describing the kinetics of the molecule in such conditions. The low molecular weight (4.5 kDa) would imply free removal by the glomerulus and the dialysis membranes. During RRT, this reduction could not be detected in clinical practice due to the complex kinetics involving either low dialytic clearance or increased production in response to impaired kidney function. The aim of this study was to determine the sieving coefficient and the diffusive clearance of the penKid molecule in conditions of in vitro continuous veno-venous hemofiltration (CVVH) and continuous veno-venous hemodialysis (CVVHD), respectively, and also the penKid removal ratio in conditions of in vitro hemoadsorption (HA) using a synthetic microporous resin. METHODS: Blood spiked with a lyophilized penKid peptide solved in 20 m
Assuntos
Encefalinas , Precursores de Proteínas , Humanos , Encefalinas/sangue , Precursores de Proteínas/sangue , Cinética , Hemofiltração/métodos , Diálise Renal/métodos , Terapia de Substituição Renal Contínua/métodos , Adsorção , Injúria Renal Aguda/terapia , Injúria Renal Aguda/sangue , Fragmentos de Peptídeos/sangueRESUMO
BACKGROUND: Continuous kidney replacement therapy (CKRT) has recently become the preferred kidney replacement modality for children with acute kidney injury (AKI). We hypothesise that CKRT technical parameters and treatment settings in addition to the clinical characteristics of patients may influence the circuit lifetime in children. METHODS: The study involved children included in the EurAKId registry (NCT02960867), who underwent CKRT treatment. We analysed patient characteristics and CKRT parameters. The primary end point was mean circuit lifetime (MCL). Secondary end points were number of elective circuit changes and occurrence of dialysis-related complications. RESULTS: The analysis was composed of 247 children who underwent 37,562 h of CKRT (median 78, IQR 37-165 h per patient). A total of 1357 circuits were utilised (3, IQR 2-6 per patient). MCL was longer in regional citrate anticoagulation (RCA), compared to heparin (HA) and no anticoagulation (NA) (42, IQR 32-58 h; 24, IQR 14-34 h; 18, IQR 12-24 h, respectively, p < 0.001). RCA was associated with longer MCL regardless of the patient's age or dialyser surface. In multivariate analysis, MCL correlated with dialyser surface area (beta = 0.14, p = 0.016), left internal jugular vein vascular access site (beta = -0.37, p = 0.027), and the use of HA (beta = -0.14, p = 0.038) or NA (beta = -0.37, p < 0.001) vs. RCA. RCA was associated with the highest ratio of elective circuit changes and the lowest incidence of complications. CONCLUSION: Anticoagulation modality, dialyser surface, and vascular access site influence MCL. RCA should be considered when choosing first-line anticoagulation for CKRT in children. Further efforts should focus on developing guidelines and clinical practice recommendations for paediatric CKRT.