Severe acute kidney injury usually requires renal replacement therapy. Intermittent hemodialysis, peritoneal dialysis, continuous renal replacement therapy, and prolonged intermittent renal replacement therapy are the four common modalities of renal replacement therapy. Whether one modality of renal replacement therapy is superior to another in clinical practice remains controversial. The impact of the choice of renal replacement therapy modality on the short-term and long-term prognosis of patients needs to be further explored in large-scale randomized controlled studies and a longer follow-up time. This article will discuss the development history of renal replacement therapy for acute kidney injury, the current status of its application, and the comparison of the four treatment modalities, in order to help clinicians have a deeper understanding of how to design individualized renal replacement therapy programs for patients with acute kidney injury under the guidance of the concept of precision medicine.
Patients with severe acute kidney injury (AKI) often need renal replacement therapy (RRT）with a high morbidity and mortality. For patients with chronic renal failure, the aim of blood purification is renal replacement; but for patients with AKI, although customarily called RRT, the aim of blood purification is not “renal replacement”, but extracorporeal “renal support and protection”, that is, supporting and protecting temporally failed kidney, removing damage factors, avoiding renal reinjury and looking forward to restore renal function. This article provides a detailed explanation of the differences between renal replacement and renal support from the perspective of organ protection, as well as the key links of RRT and extracorporeal multiple organ support for patients with severe AKI.
Because existing anticoagulants may have contraindications and side effects, continuous renal replacement therapy (CRRT) without anticoagulants is nevertheless widely used. Although it does not produce major adverse effects without anticoagulant CRRT, it can raise the risk of clotting, which can lead to treatment cessation. Extracorporeal circulation lines with saline flush are frequently utilized as a non-pharmaceutical anticoagulation strategy. However, in the absence of anticoagulant CRRT, its clinical efficacy remains debatable. Therefore, this article reviews the specific procedures, flushing frequency, flushing effect, and adverse events of flushing extracorporeal circulation lines with normal saline when CRRT is free anticoagulant, generating fresh ideas for future research.
Objective To assess the relationship between the change in fluid overload at 48 h after initiation of continuous renal replacement therapy (CRRT) and 28-day mortality in critically ill patients with acute kidney injury (AKI). Methods A retrospective cohort study was performed using data from the MIMIC-IV database from 2008 to 2019. Patients who received CRRT for AKI for more than 24 h within 14 d of admission to the intensive care unit were included. The exposure variable was the proportion of change of fluid overload (ΔFO%, defined as the difference between body weight normalized fluid input and output) at 48 h after CRRT initiation, and the endpoint was 28-day mortality. Generalized additive linear regression models and logistic regression models were used to determine the relationship between the exposure and endpoint. Results A total of 911 patients were included in the study, with a median (lower quartile, upper quartile) ΔFO% of −3.27% (−6.03%, 0.01%) and a 28-day mortality of 40.1%. Generalized additive linear regression model showed that the ΔFO% at 48 h after CRRT initiation was associated with a J-shaped curve with 28-day mortality. After adjusting for other variables, as compared with the second quartile of ΔFO% group, the first quartile group [odds ratio (OR)=1.23, 95% confidence interval (CI) (0.81, 1.87), P=0.338] was not associated with higher risk of 28-day mortality, while the third quartile group [OR=1.54, 95%CI (1.01, 2.35), P=0.046] and the fourth quartile group [OR=2.05, 95%CI (1.32, 3.18), P=0.001] were significantly associated with higher risk of 28-day mortality. There was no significant relationship between ΔFO% groups and 28-day mortality in the first 24-hour after CRRT initiation (P>0.05), but there was a linear relationship between ΔFO% and 28-day mortality in the second 24-hour after CRRT initiation, the larger the ΔFO%, the higher the mortality rate [OR=1.10, 95%CI (1.04 1.16), P<0.001 for per 1% increase]. ConclusionIn critically ill patients with AKI, the ΔFO% greater than −3.27% within 48 h after CRRT initiation is independently associated with an increased risk of 28-day mortality, and the goals of CRRT fluid management may be dynamical.
Continuous renal replacement therapy (CRRT) is the treatment of choice for critically ill patients with hemodynamic instability who require renal replacement therapy. This review summarizes the impact of CRRT treatment on nutritional support in critically ill patients, including: energy increase caused by citrate-based anticoagulants, energy loss caused by glucose-free replacement fluid and dialysate, a large amount of amino acids loss in the effluent, and the influences on the way of lipid emulsion administration, capacity, electrolyte, vitamins, and trace elements. It is hoped that the intensive care unit doctors, nephrologists, and nutritionists can fully cooperate to determine the CRRT prescription and the nutritional support prescription.
Most patients with coronavirus disease 2019 (COVID-19) have a good prognosis, but a certain proportion of the elderly and people with underlying diseases are still prone to develop into severe and critical COVID-19. Kidney is one of the common target organs of COVID-19. Acute kidney injury (AKI) is a common complication of severe COVID-19 patients, especially critical COVID-19 patients admitted to intensive care units. AKI associated with COVID-19 is also an independent risk factor for poor prognosis in patients. This article mainly focuses on the epidemiological data, possible pathogenesis, diagnostic criteria, and prevention and treatment based on the 5R principle of AKI associated with COVID-19. It summarizes the existing evidence to explore standardized management strategies for AKI associated with COVID-19.
Objective To identify risk factors for death in patients with rhabdomyolysis-induced acute kidney injury (RI-AKI) treated with continuous renal replacement therapy (CRRT), then to develop and validate the efficacy of prediction models based on these risk factors. Methods Clinical data and prognostic information of patients with RI-AKI requiring CRRT from 2008 to 2019 were extracted from the MIMIC-IV 2.2 database. The enrolled patients were divided into a training set and a test set at a ratio of 7∶3. LASSO regression, random forest (RF) and extreme gradient boosting (XGBoost) were used to identify the risk factors affecting patients’ 28-day survival in the training set, then to develop logistic model, RF model, support vector machine (SVM) model and XGBoost model. The accuracy of above prediction models and the area under the receiver operating characteristic curve (AUC) were calculated in the test set. Results A total of 175 patients were included. Lactic acid, age, Acute Physiology Score Ⅲ, hemoglobin, mean arterial pressure and body mass index measured at intensive care unit admission were identified as the six risk factors affecting 28-day survival of enrolled patients by LASSO regression, RF and XGBoost. The accuracy of the logistic model, RF model, SVM model and XGBoost model in the test set was 0.75, 0.79, 0.79 and 0.81, with the AUC of 0.82, 0.85, 0.87 and 0.87, respectively. Conclusion The XGBoost model, incorporating six risk factors including lactic acid, age, Acute Physiology Score Ⅲ, hemoglobin, mean arterial pressure, and body mass index assessed at the time of admission to the intensive care unit, demonstrates superior clinical predictive performance, thereby enhancing the clinical decision-making process for healthcare professionals.
Rhabdomyolysis-induced acute kidney injury (RIAKI) is a serious clinical disease in intensive care unit, characterized by high mortality and low cure rate. Continuous renal replacement therapy (CRRT) is a common form of treatment for RIAKI. There are currently no guidelines to guide the application of CRRT in RIAKI. To solve this problem, this article reviews the advantages and limitations of CRRT in the treatment of RIAKI, as well as new viewpoints and research progress in the selection of treatment timing, treatment mode, treatment dose and filtration membrane, with the aim of providing theoretical guidance for the treatment of CRRT in RIAKI patients.
ObjectiveTo explore the application effect of information-based circuit teaching mode for training refresher nurses in continuous renal replacement therapy (CRRT).MethodsCRRT refresher nurses studied in West China Hospital of Sichuan University from January 2016 to December 2019 were selected. The CRRT refresher nurses who were selected as the control group (studied from January 2016 to December 2017) accepted the conventional teaching method. The CRRT refresher nurses who were selected as the test group (studied from January 2018 to December 2019) accept the information-based combined with circuit teaching mode for teaching and training. After 6 months of training, the theoretical performance, operation performance, teaching satisfaction and the incidence of adverse events were compared between the two groups.ResultsA total of 112 CRRT refresher nurses were enrolled. Among them, there were 52 nurses in the control group and 60 in the test group. The scores of theory achievement (t=−2.421, P=0.017), operation achievement (t=−2.305, P=0.023) and teaching satisfaction [including teaching effect (t=−4.067, P<0.001), operation skill (t=−5.013, P<0.001), teaching mode (t=−5.589, P<0.001) and teaching content (t=−2.586, P<0.001)] of refresher nurses in the test group were higher than those in the control group. There was no significant difference between the control group (4 cases) and the test group (1 case) in the occurrence of adverse nursing events (adjusted χ2=1.169, P=0.280).ConclusionThe information-based circuit teaching mode has achieved good results in the teaching of CRRT refresher nurses, which is conducive to improving the post competency of CRRT refresher nurses.
With the deepening of current study and the innovation of perioperative management concept, there have been great advances in lung transplantation in recent years. The prognosis of patients has been significantly improved. At the same time, the role of various types of blood purification in the clinical monitoring and treatment of lung transplant patients is becoming increasingly prominent. This review aims to summarize the application and latest progress of in vitro blood purification such as renal replacement therapy, plasmapheresis and hemadsorption in the perioperative period of lung transplantation, and to provide a basis for further study.