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Introduction: Super high-flux hemodialysis (SHF-HD) provides comparable effectiveness in terms of middle-molecule and protein-bound uremic toxin removal to online hemodiafiltration in prevalent end-stage kidney disease (ESKD). However, dialysate albumin loss is raised awareness of the long-term using SHF-HD. The study aims to monitor the long-term use of SHF-HD in nutritional status change and the sustained effect of uremic toxin removal. Method(s): The present study was prospectively conducted on the 15 prevalent ESKD patients from a run-in period of standard high-flux hemodialysis (HF-HD) with ELISIO-H21 dialyzer for 4 weeks to thereafter 15 months follow-up with SHF-HD. The patients provided high-efficiency (high blood flow and dialysate flow rate) SHF-HD using PES17D alpha dialyzers for the first three months. After the amendment protocol, SHF-HD was run with the same type of dialyzer;ELISIO-17Hx (Nipro Corporation, Osaka, Japan) due to the COVID-19 pandemic. Nutritional parameters, BCM;body composition monitor (FMC, Bad Homburg, Germany), and uremic toxins were measured at baseline and every three months during SHF-HD. Result(s): Fourteen of 15 patients could complete the study. One patient was early terminated due to undergoing kidney transplantation. After 15 months of SHF-HD treatment compared to HF-HD at baseline, there was not a statistically significant change in clinical and laboratory parameters on nutritional status. The mean serum albumin levels were 4.09 (1.36) versus 4.01 (0.3) g/dL, respectively (p=0.52), and the mean difference (SE) of normalized protein catabolic rate (nPCR) was -0.04 (0.08), 95% confidence interval [CI] -0.19, 0.11. On the other hand, lean tissue mass (LTM) was significantly decreased, and fat mass was significantly increased (mean difference (SE) of -3.66 (1.07) gram, 95% CI -5.76, -1.55, and 1.79 (0.80), 95% CI 0.21, 3.36). SHF-HD sustainably and significantly removed medium to large middle-molecule uremic toxins including pre-dialysis beta-2 microglobulin, kappa-free light chain, and lambda-free light chain. In addition, protein-bound uremic toxin;indoxyl sulfate was significantly reduced during long-term follow-up using SHF-HD. SHF-HD with PES17D alpha dialyzer resulted in more dialysate albumin leaks than a newer type of SHF-HD with ELISIO-Hx17. Conclusion(s): Long-term use of SHF-HD in ESKD patients was associated with nutritional safety and effectiveness in middle-molecule and protein-bound uremic toxin removal. Although serum albumin and BMI were not changed. LTM was significantly reduced with lower levels of nPCR than in other studies but trended to increase over time. The LTM absolute levels are not below the 10 percentiles of the healthy reference range. Increasing protein intake to reach the current recommendation and physical activity was advised with long-term use of SHF-HD to avoid further reduce LTM. [Formula presented] [Formula presented] [Formula presented] No conflict of interestCopyright © 2023
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Due to the high incidence of kidney disease, there is an urgent need to develop wearable artificial kidneys. This need is further exacerbated by the coronavirus disease 2019 pandemic. However, the dialysate regeneration system of the wearable artificial kidney has a low adsorption capacity for urea, which severely limits its application. Therefore, nanomaterials that can effectively remove uremic toxins, especially urea, to regenerate dialysate are required and should be further investigated and developed. Herein, flower-like molybdenum disulphide (MoS2) nanosheets decorated with highly dispersed cerium oxide (CeO2) were prepared (MoS2/CeO2), and their adsorption performances for urea, creatinine, and uric acid were studied in detail. Due to the open interlayer structures and the combination of MoS2 and CeO2, which can provide abundant adsorption active sites, the MoS2/CeO2 nanomaterials present excellent uremic toxin adsorption activities. Further, uremic toxin adsorption capacities were also assessed using a self-made fixed bed device under dynamic conditions, with the aim of developing MoS2/CeO2 for the practical adsorption of uremic toxins. In addition, the biocompatibility of MoS2/CeO2 was systematically analyzed using hemocompatibility and cytotoxicity assays. Our data suggest that MoS2/CeO2 can be safely used for applications requiring close contact with blood. Our findings confirm that novel 2-dimensional nanomaterial adsorbents have significant potential for dialysis fluid regeneration. © 2022
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Background: Intradialytic hypotension (IH) is a relatively common complication in patients with acute kidney injury (AKI) who undergoes Kidney Replacement Therapy (KRT) and it could be the potential factor for non-recovery due to ischemic events. It is known that high ultrafiltration rate (UFR) is associated with worse outcomes, a recent recommendation to limit UFR to less than 13 ml/hr/kg has been widely accepted among nephrologists. Continuous kidney replacement therapy (CKRT) is the modality of choice in critically ill patients with hemodynamic instability;however, during COVID 19 pandemic a shortage of resources was evident and other modalities such as sustained low-efficiency dialysis was used in this population. As of today, there is not a universally accepted definition of IH, accordingly a safe UFR goal in critically ill patients it is still unknown in the different KRT modalities. The aim of this study was to analyze the differences in demographical, clinical and KRT prescriptions among critically ill patients with AKI related COVID-19 who developed intradialytic hypotension. Method(s): A prospective, observational, single-center study was performed between April 2020 and December 2021. Critically ill patients with COVID-19 and AKI who required KRT were included. Blood and dialysate flow rates, dialysate temperature, dialysate sodium, bicarbonate and potassium prescriptions were recorded. Body weight and height were obtained from the medical records. Body mass index (BMI) were calculated and interpretated according to WHO recommendations. Ideal body weight (IBW) was calculated using Hamwi equations. Intradialytic hypotension was defined as KDOQI;drop in SBP >= 20mmHg drop in SBP or > 10mmHg in MAP. Result(s): Two hundred sixty-three patients were included in the study, the majority were male, the average age was 60 years and a third of the population was diabetic. A total of 1,942 sessions were prescribed (289 hemodiafiltration (HDF), 1,455 intermittent hemodialysis (IHD), 198 prolonged intermittent renal replacement therapy (PIRRT)). Development of hypotension were reported in 1,059 sessions (55%). No differences between all modalities of KRT were observed HDF 15% vs 15%, IHD 74% vs 76% and PIRRT 11% vs 9% respectively for hypotension or non-hypotension groups (p = 0.27). Differences were statistically significant for sex (p=<0.001), age (p=0.054), UFR prescription (p=<0.001), norepinephrine use (p=<0.001) and dialysate bicarbonate (p=0.001). Age, gender male, and norepinephrine doses were independently associated with the development of hypotension in multivariate logistic regression. Linear regression for norepinephrine and development of hypotension beta0.61 (95% CI 0.38-0.85, p<0.001). Conclusion(s): In our study, the prevalence of intradialytic hypotension was greater than reported in literature probably associated with an exaggerated inflammatory response and need for mechanical ventilation. KRT modality and UFR were not associated with development IDH, however the main risk factor associated was norepinephrine initial dose. Further prospective studies are needed for assessment of a safe ultrafiltration rate in critically-ill patients.
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Background: ESRD patients with tracheostomy require long-term mechanical ventilation in addition to need for maintenance dialysis. Due to regulations in California, majority of such patients have prolonged acute hospital stays due to lack of availability of a lower level of care facility, capable of providing ventilation care and hemodialysis. Need for these services increased during the COVID 19 pandemic. Kaiser Permanente Northern California (KPNC) is an integrated health care system providing health care for 4.6 million members. Partnering with a large dialysis organization (LDO) and a local Subacute Care facility (SAC), a program has been developed to provide home hemodialysis for patients requiring long-term mechanical ventilation using Low Dialysate Volume Approach (LDVA) machines. Method(s): The program was initiated in Q4 2017. A set of clinical criteria for admission was developed between the LDO, SAC and KPNC. Weekly meetings with physicians, dialysis nurses, and SAC staffs were conducted to review the potential candidates currently hospitalized in one of twenty-one KPNC hospitals. Dialysis has been performed by a HD nurse four times a week (M-T-Th-F) for 3-3.5 hours for each dialysis treatment. Each treatment was conducted using a LDVA machine with standard LDVA prescriptions using a Watson calculator to achieve a weekly Kt/V above 2.1. Result(s): Since the inception of the program, 45 patients have been admitted to the program, 24 female and 21 male patients. The mean age is 65 (+/-13) on the date of admission. The average length of stay per patient at an acute hospital prior to admission was 125 days, and after the admission, the total days in the SAC is 7,498 days, an average of 167 days per person. Total acute hospital re-admission days after admission to the program is 1,071 days, an average of 25 days per patient (range: 0 to 115 days). Nine patients are currently residing in the SAC. Conclusion(s): It is feasible to provide hemodialysis care for patients requiring long term mechanical ventilation at the appropriate level of care. This approach reduces the patient length of stay (LOS) in acute hospitals and burden to critically stretched healthcare system. Further discussion with local regulatory agencies is needed to develop additional models of care to effectively deliver dialysis to patients requiring facility-based long-term care.
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Background: The Covid-19 pandemic has introduced a number of challenges in managing populations with both acute kidney failure and those dependent on chronic dialysis. Due to a shortage of outpatient dialysis supplies, on February 14, 2022, the Dpt. of Veteran's Affairs issued a memorandum to dialysis units requiring a contingency standard of care. This required a universal reduction of dialysate flow rate to 500 cc/min. Prior to this change, the standard prescription at the Lexington, KY VA unit was 750 cc/min. We evaluated the effect of this change on the adequacy of our dialysis population. Method(s): Data was collected for sp Kt/V urea and urea reduction ratio for 17 chronic hemodialysis patients for the two months prior and three months following the reduction of dialysate flow rate to 500 cc/min from the previous standard of 750 cc/min. There was no change of blood flow rate or dialysis time during this 5 month period for all the patients included. Result(s): A trend towards lower clearance values as measured by single-pool Kt/V and urea reduction ratio was noted between January and April of 2022. Table 1 shows the average spKt/V and URR for each month. The majority of patients maintained adequate spKt/V of >1.2 and urea reduction ratio of >65%. However, 4 patients (23.5% of the population) failed to reach Kt/V and URR goal in April 2022. Conclusion(s): Though this represents only 17 patients from one dialysis unit, the data suggests a significant decline in adequacy due to this reduction in dialysis flow rate to 500 cc/min. Until the current dialysis supply shortage has been addressed, adaptive measures such as utilizing higher efficiency dialyzers or increasing blood flow rates may be necessary.
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Due to the high incidence of kidney disease, there is an urgent need to develop wearable artificial kidneys. This need is further exacerbated by the coronavirus disease 2019 pandemic. However, the dialysate regeneration system of the wearable artificial kidney has a low adsorption capacity for urea, which severely limits its application. Therefore, nanomaterials that can effectively remove uremic toxins, especially urea, to regenerate dialysate are required and should be further investigated and developed. Herein, flower-like molybdenum disulphide (MoS2) nanosheets decorated with highly dispersed cerium oxide (CeO2) were prepared (MoS2/CeO2), and their adsorption performances for urea, creatinine, and uric acid were studied in detail. Due to the open interlayer structures and the combination of MoS2 and CeO2, which can provide abundant adsorption active sites, the MoS2/CeO2 nanomaterials present excellent uremic toxin adsorption activities. Further, uremic toxin adsorption capacities were also assessed using a self-made fixed bed device under dynamic conditions, with the aim of developing MoS2/CeO2 for the practical adsorption of uremic toxins. In addition, the biocompatibility of MoS2/CeO2 was systematically analyzed using hemocompatibility and cytotoxicity assays. Our data suggest that MoS2/CeO2 can be safely used for applications requiring close contact with blood. Our findings confirm that novel 2-dimensional nanomaterial adsorbents have significant potential for dialysis fluid regeneration.
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Introduction: Acute kidney injury (AKI) and need for renal replacement therapy (RRT) is a known complication of SARS-Coronovirus-2 (SARS-CoV-2) in critically ill patients. 1 Early evidence suggested SARS-CoV-2 patients have increased incidence of filter cartridge failure on RRT.2,3 Frequent filter changes can lead to reduced therapy delivery, increased cost and anaemia. To mitigate this, our intensive care unit developed a new protocol for patients with SARS-CoV-2 requiring RRT to balance the benefits of preserving filter lifespan and risks of anticoagulation associated bleeding. Objectives: To investigate whether an increased citrate dose and an adjusted RRT prescription would increase the filter lifespan for patients with SARS-CoV-2. Methods: We performed a retrospective observational study looking at all patients admitted to our Level 3 critical care unit since the pandemic in March 2020 to date. Data was collected from Ward Watcher, a Scottish Intensive Care Society Audit Group (SICSAG) database and the CAREVUE electronic patient records. We introduced a modified RRT prescription for continuous venovenous haemodiafiltration (CVVHDF) with a citrate dose of 4mmol/l, increasing the dialysate flow rate to 1500ml/hr to mitigate the risk of increased citrate load. Results: During the period for data collection, the unit had 106 patients with SARS-CoV-2 of whom 15 required RRT. The median duration spent on RRT was 188 hours (range 24-677). Eight patients were managed exclusively on the adjusted protocol. The average lifespan of a filter in SARSCoV-2 patients on the standard protocol was 37 hours compared to 45 (range 6-70) hours using the adjusted protocol. The median number of filters per patient per RRT day on the adjusted protocol was 0.3 (range 0.2 -1). It also allowed more therapy to be delivered with patients spending on average 79% of the day on RRT. There were no adverse bleeding outcomes and no documented evidence of citrate toxicity or acid-base disturbances Conclusion: This small study showed an increase in filter life for patients on an increased citrate dose protocol of CVVHDF without any adverse outcomes. This results in cost savings and more appropriate resource usage during a pandemic without increased bleeding risk. Another suggested measure to reduce frequent filter malfunctions was that centres returned to using heparin anticoagulation, but this is known to have increased bleeding risk.4.
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The proceedings contain 226 papers. The topics discussed include: identification of biomarkers sensitive to pulsatile and continuous flow for identification of promising continuous flow VAD modulation protocols to mitigate non-surgical bleeding events;comprehensive machine learning analysis of pre-implantation risk factors for right heart failure after LVAD implantation;combining VA-ECMO And Impella (EC-Pella) before reperfusion mitigates left ventricular loading and injury due to VA-ECMO in acute myocardial infarction;platelet function at the intersection of the COVID-19 'cytokine storm' and mechanical circulatory support;a dialysate free portable artificial kidney device;durable right heart mechanical support system: a multi-day proof-of-concept study in pulmonary hypertension sheep;a dual-action nitric oxide-releasing slippery surface coating for extracorporeal organ support: first evaluation at clinically relevant blood flow rate for partial lung support;cannula add-on for pressure and flow measurement in VADs;and comparison of interlaboratory CFD simulations of the FDA benchmark blood pump model.
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Hemodialysis (HD) is a life-sustaining treatment of crucial importance in managing end-stage renal disease (ESRD). However, this membrane-based therapy is associated with acute side-effects due to bioincompatibility issues and limitations on the removal of uremic toxins. The present study assessed the influence of hydrodynamic conditions applied during HD treatment on protein-mediated inflammatory and thrombotic responses. The membrane modules considered are commonly used in Canadian hospitals and are comprised of a polymer blend of polyarylether sulfone-polyvinylpyrrolidone (PAES). The membranes morphology and hydrophilicity were assessed using SEM, AFM, BET, and zeta potential. An in vitro study evaluated the adsorptive behavior of fibrinogen (FB) to the membrane under different flow conditions. Lower rates of 200 mL/min promoted slower and significant FB adsorption, leading to more severe inflammatory and thrombotic responses. Hydrodynamic conditions also affected the concentration of all inflammatory biomarkers. Lower flow rates triggered more complement activation as well as coagulation, clotting, and inflammatory responses compared to higher flow rates. At the end of the dialysis session, patients treated with a Qb of 200 mL/min presented a significant increase in the concentration of C5a (232%), properdin (114%), serpin (545%), IL-1α (50%), IL-6 (450%), and vWF (212%). IL-1β and TNF-α concentrations declined by 12.5 and 35.5%, respectively. Male patients experienced more severe inflammatory responses than female patients at the operating conditions considered. Comparing the pre- and post-dialysis levels of female and male patients, female patients experienced significantly higher levels of IL-6 and properdin, while male patients presented higher levels of C5a, IL-1α, and IL-6. The results of this study will help clinical doctors evaluate the impact of HD operating conditions on blood activations before prescribing treatment and inform expectations for outcomes in female and male patients.
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Hydrothorax occurs in approximately 2% of patients on peritoneal dialysis caused by migration of fluid from the peritoneal cavity into the pleural space via pleuroperitoneal fistulas. These diaphragmatic defects are usually congenital and right-sided, explaining the predominance of right-sided effusion.. Thoracocentesis with biochemical analysis of pleural fluid reveals a transudate with a very high glucose concentration. In uncertain cases, or when there is a clinical need to demonstrate the anatomy of the communication, an imaging approach such as peritoneal scintigraphy is required. 66-year-old Hispanic female with past medical history significant for end stage kidney disease on peritoneal dialysis for past 5 months, hypertension ,cerebrovascular accident with no residual deficit, and recent exposure to COVID19 presented with fever, shortness of breath, left eye gaze abnormality and + COVID PCR. She had been having issues with meeting ultrafiltration goals outpatient. On examination she has decreased breath sounds at right lung base, Abdomen non-tender with PD catheter in place with clean dressing, no pedal edema. Laboratory findings were consistent with a transudative effusion;no organisms were cultured and no malignant cells were visualized. CT failed to identify dispersal of contrast material into the right hemithorax. A nuclear isotope scan was subsequently done. Following administration of technetium 99m via the PD catheter, a high volume of radioactive dialysate was detected entering the right hemithorax. No tracer activity was seen in the left hemithorax. PD was stopped and switched to intermittent hemodialysis.Unfortunately she succumbed to covid 19 pneumonia and died few days later. 50% of the cases, a conservative approach allows reinstitution of CAPD Conservative approach with temporary cessation of peritoneal dialysis remains the first-line treatment. 1-4 months has been shown to be adequate cessation time and restarting with low volume PD. If conservative approach fails, Invasive approach with video-assisted thoracoscopic pleurodesis or diaphragmatic repair or both allows most of them to continue with CAPD
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Hydrothorax occurs in approximately 2% of patients on peritoneal dialysis caused by migration of fluid from the peritoneal cavity into the pleural space via pleuroperitoneal fistulas. These diaphragmatic defects are usually congenital and right-sided, explaining the predominance of right-sided effusion.. Thoracocentesis with biochemical analysis of pleural fluid reveals a transudate with a very high glucose concentration. In uncertain cases, or when there is a clinical need to demonstrate the anatomy of the communication, an imaging approach such as peritoneal scintigraphy is required. 66-year-old Hispanic female with past medical history significant for end stage kidney disease on peritoneal dialysis for past 5 months, hypertension ,cerebrovascular accident with no residual deficit, and recent exposure to COVID19 presented with fever, shortness of breath, left eye gaze abnormality and + COVID PCR. She had been having issues with meeting ultrafiltration goals outpatient. On examination she has decreased breath sounds at right lung base, Abdomen non-tender with PD catheter in place with clean dressing, no pedal edema. Laboratory findings were consistent with a transudative effusion;no organisms were cultured and no malignant cells were visualized. CT failed to identify dispersal of contrast material into the right hemithorax. A nuclear isotope scan was subsequently done. Following administration of technetium 99m via the PD catheter, a high volume of radioactive dialysate was detected entering the right hemithorax. No tracer activity was seen in the left hemithorax. PD was stopped and switched to intermittent hemodialysis.Unfortunately she succumbed to covid 19 pneumonia and died few days later. 50% of the cases, a conservative approach allows reinstitution of CAPD Conservative approach with temporary cessation of peritoneal dialysis remains the first-line treatment. 1-4 months has been shown to be adequate cessation time and restarting with low volume PD. If conservative approach fails, Invasive approach with video-assisted thoracoscopic pleurodesis or diaphragmatic repair or both allows most of them to continue with CAPD
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BACKGROUND AND AIMS: The number of patients requiring home dialysis in Japan is increasing due to COVID-19 and the aging of the population. Home haemodialysis has been performed in Japan since the 1960s. However, as of March 2019, there were 720 home haemodialysis patients in Japan, which is only 0.2% of the total number of dialysis patients. The possible causes are as follows. The number of home haemodialysis patients has not increased markedly due to safety concerns as home haemodialysis patients perform dialysis at home, and the out-ofpocket costs are high. In addition, patients and caregivers must be able to manage themselves, and the burden on both patients and caregivers is heavy. Therefore, the Ministry of Health, Labour and Welfare (Japan) has advocated the need for home patients to share information with medical institutions to improve their quality of life, including COVID-19 measures. We have built a system to support home dialysis patients. Here, we have added an exercise therapy function to this system to encourage patients to continue exercising. METHOD: The items recorded/displayed in the patient's home peritoneal dialysis support system included records such as time, blood pressure, blood glucose level, urine volume, meal content, replacement start time, dialysate/plasma ratio, drainage volume, injection volume, water content and water removal and drainage. These inputs were entered via drop-down menus and displayed visually in graphs or by uploading images. The medical staff could see photographs of the affected areas and of meals entered by the patient. Patients could also share their opinions and treatment schedules with the medical staff at the medical institution. In addition, when exercising, the patients used an ergometer that allowed them to sit or lie down. The developed system incorporates records of the patient's exercises. Data were captured directly from the ergometer into the developed system in CSV format and could also be entered manually via drop-down menus. RESULTS: Using the developed system, we were able to enter and view patients' vital data and display photographs showing the color and volume of the drainage pack. By viewing these photographs, the medical staff could confirm the photographs of the affected areas, the color of the packs and the contents of the patients' meals. In addition, displaying the patient's vital records in a graph allowed for visual evaluation over time, which was useful when giving advice to patients. Using the two-way communication function, patients were also able to share their opinions and treatment schedules with the medical staff of the medical institution. Patients can now consult with medical staff, making their homes more like part of the hospital and giving them greater peace of mind. Figure 1 shows an example of the display of the developed system. Figure 2 shows an example of the patient's pedaling exercise results input from the ergometer. The amount of pedal movement performed by the patient was conserved through the dynamo and used to charge mobile devices. This allows the patient to charge their mobile devices while exercising, thus encouraging them to continue exercising. CONCLUSION: We have developed a support system for home haemodialysis patients that allows the input and display of patients' vital records and consultation with medical staff online. We have added a function to the system to encourage home haemodialysis patients to continue exercising. By using the developed system, patients can now perform home dialysis, including continuous exercise safely and with peace of mind, and healthcare professionals can access all medical information of patients, including changes over time. (Figure Presented).
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Patients on dialysis are exposed to large amounts of water during conventional intermittent hemodialysis; hence, there are strict regulations regarding the quality of water used to prepare dialysate. Occasionally, water systems fail due to natural disasters or structural supply issues, such as water-main breaks or unplanned changes in municipal or facility water quality. It is critical to regularly monitor and immediately recognize such a failure and take steps to avoid exposing the patients to contaminants. In addition to the recognition of the problem, the ability to pivot and continue to provide safe treatment to inpatients who are dependent on dialysis is essential, both from an ultrafiltration and a clearance standpoint. At our hospital, an unforeseen water disruption occurred and we were able to continue to provide KRT with premade, bagged dialysate to mitigate the effect on our patients on dialysis. This is a novel method using available machines and dialysate, which we normally stock for continuous KRT, for short dialysis sessions. The methodology is similar to that which has been widely used for short daily home hemodialysis with low dialysate flow rate. Because this situation occurred in the midst of the SARS-CoV-2 pandemic, we had to be mindful of dialysate volumes and staffing time. Here, we present our investigation into the cause of the water-system failure and how we quickly implemented the alternative dialysis method. Short dialysis with low-flow dialysate will not deliver the same Kt/V per session as standard dialysis; however, this method was successfully implemented and tailored with adjustments for patients requiring higher clearance for specific indications, such as severe hyperkalemia.
Subject(s)
COVID-19 , Dialysis Solutions , COVID-19/prevention & control , Dialysis Solutions/chemistry , Female , Hospitals , Humans , Pregnancy , Renal Dialysis/methods , SARS-CoV-2 , Water SupplyABSTRACT
AKI frequently occurs in patients with COVID-19, and kidney injury severe enough to require RRT is a common complication among patients who are critically ill. During the surge of the pandemic, there was a high demand for dialysate for continuous RRT, and this increase in demand, coupled with vulnerabilities in the supply chain, necessitated alternative approaches, including internal production of dialysate. Using a standard hemodialysis machine and off-the-shelf supplies, as per Food and Drug Administration guidelines, we developed a method for on-site dialysate production that is adaptable and can be used to fill multiple bags at once. The use of a central reverse osmosis unit, dedicated hemodialysis machine, sterile bags with separate ports for fill and use, and frequent testing will ensure stability, sterility, and-therefore-safety of the produced dialysate. The dialysate made in house was tested and it showed both stability and sterility for at least 30 hours. This detailed description of our process for generating dialysate can serve as a guide for other programs experiencing similar vulnerabilities in the demand versus supply of dialysate.
Subject(s)
Acute Kidney Injury , COVID-19 , Continuous Renal Replacement Therapy , Acute Kidney Injury/therapy , Dialysis Solutions , Humans , Pandemics , United StatesABSTRACT
Introduction: Interleukin-6 (IL-6) is a pro-inflammatory cytokine secreted by lymphocytes, fibroblasts and macrophages involved in B-cell differentiation and stimulation of acute-phase proteins. IL-6 is associated with high serum levels in viral human infections such as hepatitis B and C virus, influenza virus, herpes simplex virus, HIV and also in coronavirus disease 2019. This cytokine is also produced by a wide array of intraperitoneal cells after the exposition to a local noxa patogena.Icodextrin has been associate with sterile peritonitis in patients on peritoneal dialysis (PD): this type of peritonitis is a cause of cloudy effluent and mild abdominal discomfort that resolved with the discontinuation of icodextrin. The diagnosis of icodextrinassociated peritonitis is critical to avoid unnecessary antibiotic prescription.Here, we described a case report of steril icodextrin-associated peritonitis coupled with elevation of IL-6 on peritoneal dialysate occurred in a male 76 years old undergoing PD. Methods: IL-6 (DXI 800 Beckman Coulter) and leucocyte count were performed on peripheral blood sample and peritoneal dialysate before and after icodextrin rechallenge. Serum reactive C protein (PCR), serum procalcitonin (PCT) and peritoneal effluent colture were performed before and after icodextrin rechallenge. Results: After 48 hours from the start of icodextrin rechallenge, peritoneal effluent became cloudy with a slight increase in leucocyte count (178 cells/microlitro with 11% neutrophil granulocytes, vs 62). Dyalisate colture, serum PCR and PCT resulted negative;leucocyte count in peripheral blood resulted normal (7300/μL). IL-6 level increased steeply in peritoneal effluent when compared to baseline (1124 vs 114 pg/mL) and subsided to baseline levels with the withdrawal of the icodextrin solution without increase in serum IL-6 (15.7 vs 12 pg/mL);likewise leucocyte count on peritoneal dialysate decreased (63 cells/μL). Discussion: IL-6 can be used, along with peritoneal leukocyte count, as a precocious and sensitive marker of local inflammation and, in these cases, to discriminate from non-inflammatory peritonitis.
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The high incidence of kidney disease caused by various factors (such as COVID-19) has triggered an extreme desire for wearable artificial kidney (WAK). Nevertheless, the dialysate regeneration system in WAK presents a very low adsorption capacity of urea, and must rely on the help of urease and zirconium compounds, which make the device too complex and costly, thus limiting their application. In this study, we employ the adsorption activity of defect-rich MoS2 nanosheets with widened interlayer spacing (WDR-MoS2) for the elimination of three crucial uremic toxins (urea, creatinine, and uric acid). The high adsorption performances of WDR-MoS2 are owing to the presence of abundant S atoms between the two MoS2 sheets that can efficiently adsorb uremic toxins through the unique S-N bond. Furthermore, widening the layer spacing of MoS2 is similar to adjusting the aperture of a filter, which can not only speed up the transport of uremic toxins but also prevent the passage of large molecules (such as proteins). Thus, the WDR-MoS2 can neither affect cell viability nor produce hemolysis and coagulation in the blood. Finally, a home-made WDR-MoS2 fixed-bed system without urease and zirconium compounds is used to efficiently remove uremic toxins in the dialysate. WDR-MoS2 is expected to fundamentally solve the materials science challenges in WAK and provide a new design idea for the development of high-performance 2D material-based adsorbents.
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Introduction: Peritonitis is a major complication of Peritoneal Dialysis (PD), inadequate response to treatment, and the inflammatory state inherent in PD patients may result in hospitalization time and mortality. This Study aims to observe prognosis patients who Peritoneal Dialysis-Associated Peritonitis (PDAP) by Neutrophil-to-Lymphocyte Ratio (NLR). Methods: We have performed observation the incidences of peritonitis, causative organisms, clinical outcomes and mortality between patients undergoing Continuous Ambulatory Peritoneal Dialysis (CAPD) during pandemic era from January 2020-September 2021 in Central General Hospital Dr. Sardjito. Outcomes and clinical course of treatment in the selected patients were reviewed. Results: The Latest case, Male, 22 years old,the Peritoneal Equilibration Test (PET) results are Low. Since the end of August 2021 felt pain in the abdomen accompanied by cloudy dialysis fluid and sometimes there is fibrin. From routine blood examination, the results NLR is 2. The patient received Ceftriaxone and Gentamicin with the results of dialysate fluid culture obtained Klebsiella Pneumonia. The symptoms of peritonitis improved but on the 14th day the symptoms started to reappear, the antibiotics were continued and a re-culture was performed on the 15th day, Burkholderia Cepacia bacteria were sensitive to Meropenem, Trimethoprim/Sulfamethoxazole, and Ceftazidime. Next case, male, 71 years old, since 2014 using CAPD with the last evaluation of PET was High Average. Complaints were felt in early October 2020 with same symptoms. The NLR is 21 and the results of culture Staphylococcus Capitis. Patients receiving therapy with Vancomycin and evaluation of culture results negative. But in December 2020 the signs and symptoms appeared again with NLR 25. Because of the weakness condition, the patient was hospitalized with the culture results Pseudomonas Aeruginosa, sensitive to Ciprofloxacin, because of improvement, the patient was allowed outpatient. The results of the culture evaluation showed the bacteria were the same as sensitive to the same antibiotic group as well, but was replaced with Ceftazidim and Fluconazole. After 14 days of administration antibiotics, the complaints improved and the culture results were negative. In March 2021 the patient came back with the same complaints again related to recurrent peritonitis, with culture results showing Pseudomonas Aeruginosa infection and only sensitive to Ciprofloxacin and Gentamicin. The patient received both antibiotic therapy in an outpatient condition but in the course of his illness the patient died because COVID-19 in other hospital. For last case, the patient was 51 years old with PET Low Average results and NLR 6. The patient presented with persistent symptoms peritonitis 3 times continously after the evaluation but the culture results were always negative. In the treatment of the first infection, the patient had received therapy Ceftazidime and Gentamicin, but because the symptoms did not improve, the patient's antibiotics were then replaced with Ciprofloxacin, and the third evaluation was given Vancomycin even though the bacteria did not grow. Due to the condition of recurrent peritonitis infection in this patient, access to CAPD was then withdrawn and back to HD. Conclusions: According to our findings, the incidence of symptomatic PDAP maybe related with NLR, it can be a prognostic factor but still unclear. No conflict of interest
ABSTRACT
RATIONALE & OBJECTIVE: Since 1994, the Nephrology and Hypertension Department at the Cleveland Clinic has prepared and used bicarbonate-based solution for continuous venovenous hemodialysis (CVVHD) using a standard volumetric hemodialysis machine rather than purchasing from a commercial vendor. This report describes the process of producing Cleveland Clinic UltraPure Solution (CCUPS), quality and safety monitoring, economic costs, and clinical outcomes. STUDY DESIGN: Retrospective study. SETTING & PARTICIPANTS: CVVHD experience at Cleveland Clinic, focusing on dialysate production, institutional factors, and patients requiring continuous kidney replacement therapy. Production is shown at www.youtube.com/watch?v=WGQgephMEwA. OUTCOMES: Feasibility, safety , and cost. RESULTS: Of 6,426 patients treated between 2011 and 2019 with continuous kidney replacement therapy, 59% were men, 71% were White, 40% had diabetes mellitus, and 74% presented with acute kidney injury. 98% of patients were treated with CVVHD using CCUPS, while the remaining 2% were treated with either continuous venovenous hemofiltration or continuous venovenous hemodiafiltration using commercial solution. The prescribed and delivered effluent doses were 24.8 (IQR) versus 20.7 mL/kg/h (IQR), respectively. CCUPS was as effective in restoring electrolyte and serum bicarbonate levels and reducing phosphate, creatinine, and serum urea nitrogen levels as compared with packaged commercial solution over a 3-day period following initiation of dialysis, with a comparable effluent dose. Among those with acute kidney injury, mortality was similar to that predicted with the 60-day acute kidney injury predicted mortality score (r = 0.997; CI: 0.989-0.999). At our institution, the cost of production for 1 L of CCUPS is $0.67, which is considerably less than the cost of commercially purchased fluid. LIMITATIONS: Observational design without a rigorous control group. CONCLUSIONS: CVVHD using locally generated dialysate is safe and cost-effective.
ABSTRACT
The COVID-19 pandemic has become a major worldwide crisis. Although respiratory symptoms are a key feature of the disease, many people who are hospitalized with COVID-19 also suffer acute kidney injury, a condition that exacerbates patient mortality and may have to be treated through renal replacement therapy. Much of the focus on hospital capacity during the pandemic has centered on the availability of ventilators. However, supplies for dialysis treatment, including dialysate, have also run dangerously low in hospitals at the epicenter of the pandemic. Therefore, there is an urgent need to develop materials that can efficiently and rapidly regenerate dialysate, removing toxins and restoring electrolyte concentrations so that this vital resource remains readily available. In this work, Ti3C2Tx, a two-dimensional transition-metal carbide (MXene) that is known to efficiently adsorb urea, was used to remove creatinine and uric acid from an aqueous solution and dialysate, with a maximum adsorption capacity of 45.7 and 17.0 mg/g, respectively. We systematically analyzed and modeled the adsorption kinetics, isotherms, and thermodynamics, thus determining the rate-limiting step and adsorption mechanism. A fixed-bed column loaded with Ti3C2Tx was designed to further evaluate the adsorption performance under continuous fluid-flow conditions, mirroring conditions of continuous renal replacement therapy modalities. The maximum capacity and 50% breakthrough volume were calculated to further approach the practical application of Ti3C2Tx for removal of uremic toxins. Our findings suggest that Ti3C2Tx has the potential to be used as an efficient sorbent for the regeneration of dialysate, allowing for accelerated dialysate regeneration by removing filtered toxins and leading to more portable dialysis devices.