A Nomogram to Predict the 28-day Mortality of Critically Ill Patients With Acute Kidney Injury and Treated With Continuous Renal Replacement Therapy.

BACKGROUND: Acute kidney injury (AKI) is a severe and common complication in critically ill patients and is associated with increased morbidity and mortality. At present, there is not a tool to predict the prognosis of critically ill patients with AKI and treated with continuous renal replacement therapy (CRRT). METHODS: A retrospective cohort study was to construct a prediction model for the 28-day mortality of patients with AKI and treated with CRRT. From January 2009 to September 2016, A total of 846 cases were included in our study. RESULTS: A total of five variables selected by multi-factor Cox regression analysis were used to constructed three predictive models and adopted bootstrapping for internal validation. Finally, we get five sets of models (three sets of construction models and two sets of internal verification models) with similar predictive value. The stepwise model, which including four variables (CCI score, Alb, Phosphate (24h) and SOFA score), was the simplest model, so we chose it as our final predictive model and constructed a nomogram based on it. The area under the ROC curve (AUC) of the stepwise model and the stepwise bootstrap model (BS stepwise) were respectively 0.78(0.75,0.82) and 0.78 (0.75,0.82). The AUC of the stepwise model and the BS stepwise in patients with sepsis were 0.77 (0.73,0.81) and 0.77 (0.73,0.81). The AUC of the stepwise model and the BS stepwise in patients without sepsis were 0.83 (0.78,0.89) and 0.83 (0.78,0.89). CONCLUSIONS: We developed a four-marker-based prognostic tool that could effectively predict each individual's 28-day mortality for patients with AKI and treated with CRRT.

The effectiveness of a specialized team intervention on prognosis in patients undergoing continuous renal replacement therapy: A retrospective cohort study.

AIMS: Limited evidence is available regarding the effectiveness of a specialized continuous renal replacement therapy (CRRT) team approach. Hence, we aimed to evaluate the effectiveness of a specialized CRRT team intervention in a Japanese hospital. MATERIALS AND METHODS: We retrospectively identified adult patients who underwent CRRT in the intensive care unit (ICU) from July 2015 to June 2019 and divided them into two groups based on whether or not they received CRRT team intervention. We extracted data from the electronic medical record database. The concurrent effects of various factors on study outcomes were analyzed by multivariate analysis using a generalized linear model. RESULTS: A total of 540 patients were included. Baseline characteristics were similar in the two groups. In univariate analysis, no significant differences were found in in-hospital mortality (34.0 vs. 30.8%; risk difference, -3.2%; 95% confidence interval, -12.6 to 6.1), total duration of ICU stay, total CRRT time, and the proportion of patients starting maintenance hemodialysis during hospitalization between both groups. Multivariate analysis also indicated no significant differences. CONCLUSION: In this study, no significant difference was found in patient outcomes between both groups. The results suggest that the CRRT team should have integrated protocols and play a core role in CRRT management.

Creatinine-Cystatin C Ratio and Mortality in Patients Receiving Intensive Care and Continuous Kidney Replacement Therapy: A Retrospective Cohort Study.

RATIONALE & OBJECTIVE: Studies have suggested associations between lower ratios of serum creatinine to cystatin C with both lower muscle mass and adverse clinical outcomes in multiple disease conditions. Identifying risk factors for mortality among patients with acute kidney injury (AKI) undergoing continuous kidney replacement therapy (CKRT) may improve assessment of prognosis. We sought to evaluate the association of creatinine-cystatin C ratio with outcomes in patients with AKI undergoing CKRT. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 1,588 patients treated with intensive care and CKRT for AKI at a tertiary Korean medical center. PREDICTOR: Baseline serum creatinine-cystatin C ratio at the time of CKRT initiation. OUTCOMES: Age- and sex-adjusted 90-day mortality after CKRT initiation. ANALYTICAL APPROACH: Cox proportional hazard models to estimate the association between creatinine-cystatin C ratio and outcome. RESULTS: Mean age was 64.7 ± 14.5 years and 635 patients (40.0%) were women. The range of creatinine-cystatin C ratios was 0.08 to 10.48. The 30- and 90-day mortality rates were significantly lower for the higher creatinine-cystatin C ratio groups. Multivariable Cox proportional hazards regression analyses revealed that mortality risk became successively lower across quartiles of greater creatinine-cystatin C ratio. When creatinine-cystatin C ratio was evaluated using cubic spline analyses, risks for both 30- and 90-day mortality were lower with higher creatinine-cystatin C ratios. These associations remained significant even after adjustment for confounding variables. LIMITATIONS: Retrospective analysis, serum creatinine and cystatin C may not be in steady state in the setting of AKI. CONCLUSIONS: Higher serum creatinine-cystatin C ratios were associated with better survival in patients receiving intensive care and CKRT.

Early Treatment with Human Albumin Solution in Continuous Renal Replacement Patients.

AIMS: To study the impact of early human albumin solution (HAS) in continuous renal replacement therapy (RRT) patients. METHODS: Analysis of Randomized Evaluation of Normal versus Augmented Level (RENAL) RRT trial data. RESULTS: Of 1,464 patients, 500 (34%) received early albumin. These patients had higher illness severity scores, greater use of mechanical ventilation, and 90-day mortality (51 vs. 41%; p < 0.001). However, early albumin carried similar RRT dependence risk among survivors at day 90 (4.9 vs. 5.8%; p = 0.62). On Cox proportional hazards regression, with standardized inverse probability of treatment weighting, early albumin was not associated with increased mortality (hazard ratio [HR]: 1.23, 95% CI: 0.97-1.55; p = 0.09) or recovery to RRT independence (HR: 0.92, 95% CI: 0.78-1.10; p = 0.38). CONCLUSIONS: Early albumin was administered to one-third of RENAL trial patients and in those with greater illness severity. Early albumin was not independently associated with mortality risk or rate of recovery to RRT independence.

Pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy.

BACKGROUND: Acute kidney injury (AKI) is a major comorbidity in hospitalised patients. Patients with severe AKI require continuous renal replacement therapy (CRRT) when they are haemodynamically unstable. CRRT is prescribed assuming it is delivered over 24 hours. However, it is interrupted when the extracorporeal circuits clot and the replacement is required. The interruption may impair the solute clearance as it causes under dosing of CRRT. To prevent the circuit clotting, anticoagulation drugs are frequently used. OBJECTIVES: To assess the benefits and harms of pharmacological interventions for preventing clotting in the extracorporeal circuits during CRRT. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 12 September 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: We selected randomised controlled trials (RCTs or cluster RCTs) and quasi-RCTs of pharmacological interventions to prevent clotting of extracorporeal circuits during CRRT. DATA COLLECTION AND ANALYSIS: Data were abstracted and assessed independently by two authors. Dichotomous outcomes were calculated as risk ratio (RR) with 95% confidence intervals (CI). The primary review outcomes were major bleeding, successful prevention of clotting (no need of circuit change in the first 24 hours for any reason), and death. Evidence certainty was determined using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. MAIN RESULTS: A total of 34 completed studies (1960 participants) were included in this review. We identified seven ongoing studies which we plan to assess in a future update of this review. No included studies were free from risk of bias. We rated 30 studies for performance bias and detection bias as high risk of bias. We rated 18 studies for random sequence generation,ààsix studies for the allocation concealment, three studies for performance bias, three studies for detection bias,à nine studies for attrition bias,à14 studies for selective reporting and nine studies for the other potential source of bias, as having low risk of bias. We identified eight studies (581 participants) that compared citrate with unfractionated heparin (UFH). Compared to UFH, citrate probably reduces major bleeding (RR 0.22, 95% CI 0.08 to 0.62; moderate certainty evidence) and probably increases successful prevention of clotting (RR 1.44, 95% CI 1.10 to 1.87; moderate certainty evidence). Citrate may have little or no effect on death at 28 days (RR 1.06, 95% CI 0.86 to 1.30, moderate certainty evidence). Citrate versus UFH may reduce the number of participants who drop out of treatment due to adverse events (RR 0.47, 95% CI 0.15 to 1.49; low certainty evidence). Compared to UFH, citrate may make little or no difference to the recovery of kidney function (RR 1.04, 95% CI 0.89 to 1.21; low certainty evidence). Compared to UFH, citrate may reduceàthrombocytopenia (RR 0.39, 95% CI 0.14 to 1.03; low certainty evidence). It was uncertain whether citrate reduces a cost to health care services because of inadequate data. For low molecular weight heparin (LMWH) versus UFH, six studies (250 participants) were identified. Compared to LMWH, UFH may reduce major bleeding (0.58, 95% CI 0.13 to 2.58; low certainty evidence). It is uncertain whether UFH versus LMWH reduces death at 28 days or leads to successful prevention of clotting. Compared to LMWH, UFH may reduce the number of patient dropouts from adverse events (RR 0.29, 95% CI 0.02 to 3.53; low certainty evidence). It was uncertain whether UFH versus LMWH leads to the recovery of kidney function because no included studies reported this outcome. It was uncertain whether UFH versus LMWH leads to thrombocytopenia. It was uncertain whether UFH reduces a cost to health care services because of inadequate data. For the comparison of UFH to no anticoagulation, one study (10 participants) was identified. It is uncertain whether UFH compare to no anticoagulation leads to more major bleeding. It is uncertain whether UFH improves successful prevention of clotting in the first 24 hours, death at 28 days, the number of patient dropouts due to adverse events, recovery of kidney function, thrombocytopenia, or cost to health care services because no study reported these outcomes. For the comparison ofàcitrate to no anticoagulation,àno completed study was identified. AUTHORS' CONCLUSIONS: Currently,àavailable evidence does not support the overall superiority of any anticoagulant to another. Compared to UFH, citrate probably reduces major bleeding and prevents clotting and probably has little or no effect on death at 28 days. For other pharmacological anticoagulation methods, there is no available data showing overall superiority to citrate or no pharmacological anticoagulation. Further studies are needed to identify patient populations in which CRRT should commence with no pharmacological anticoagulation or with citrate.

Factors Associated with In-Hospital Mortality after Continuous Renal Replacement Therapy for Critically Ill Patients: A Systematic Review and Meta-Analysis.

Continuous renal replacement therapy (CRRT) is a broadly-accepted treatment for critically ill patients with acute kidney injury to optimize fluid and electrolyte management. Despite intensive dialysis care, there is a high mortality rate among these patients. There is uncertainty regarding the factors associated with in-hospital mortality among patients requiring CRRT. This review evaluates how various risk factors influence the in-hospital mortality of critically ill patients who require CRRT. Five databases were surveyed to gather relevant publications up to 30 June 2020. We identified 752 works, of which we retrieved 38 in full text. Finally, six cohort studies that evaluated 1190 patients were eligible. The in-hospital mortality rate in these studies ranged from 38.6 to 62.4%. Our meta-analysis results showed that older age, lower body mass index, higher APACHE II and SOFA scores, lower systolic and diastolic blood pressure, decreased serum creatinine level, and increased serum sodium level were significantly associated with increased in-hospital mortality in critically ill patients who received CRRT. These results suggest that there are multiple modifiable factors that influence the risk of in-hospital mortality in critically ill patients undergoing CRRT. Further, healthcare professionals should take more care when CRRT is performed on older adults.

Effect of Regional Citrate Anticoagulation vs Systemic Heparin Anticoagulation During Continuous Kidney Replacement Therapy on Dialysis Filter Life Span and Mortality Among Critically Ill Patients With Acute Kidney Injury: A Randomized Clinical Trial.

Importance: Although current guidelines suggest the use of regional citrate anticoagulation (which involves the addition of a citrate solution to the blood before the filter of the extracorporeal dialysis circuit) as first-line treatment for continuous kidney replacement therapy in critically ill patients, the evidence for this recommendation is based on few clinical trials and meta-analyses. Objective: To determine the effect of regional citrate anticoagulation, compared with systemic heparin anticoagulation, on filter life span and mortality. Design, Setting, and Participants: A parallel-group, randomized multicenter clinical trial in 26 centers across Germany was conducted between March 2016 and December 2018 (final date of follow-up, January 21, 2020). The trial was terminated early after 596 critically ill patients with severe acute kidney injury or clinical indications for initiation of kidney replacement therapy had been enrolled. Interventions: Patients were randomized to receive either regional citrate anticoagulation (n = 300), which consisted of a target ionized calcium level of 1.0 to 1.40 mg/dL, or systemic heparin anticoagulation (n = 296), which consisted of a target activated partial thromboplastin time of 45 to 60 seconds, for continuous kidney replacement therapy. Main Outcomes and Measures: Coprimary outcomes were filter life span and 90-day mortality. Secondary end points included bleeding complications and new infections. Results: Among 638 patients randomized, 596 (93.4%) (mean age, 67.5 years; 183 [30.7%] women) completed the trial. In the regional citrate group vs systemic heparin group, median filter life span was 47 hours (interquartile range [IQR], 19-70 hours) vs 26 hours (IQR, 12-51 hours) (difference, 15 hours [95% CI, 11 to 20 hours]; P < .001). Ninety-day all-cause mortality occurred in 150 of 300 patients vs 156 of 296 patients (Kaplan-Meier estimator percentages, 51.2% vs 53.6%; unadjusted difference, -2.4% [95% CI, -10.5% to 5.8%]; unadjusted hazard ratio, 0.91 [95% CI, 0.72 to 1.13]; unadjusted P = .38; adjusted difference, -6.1% [95% CI, -12.6% to 0.4%]; primary adjusted hazard ratio, 0.79 [95% CI, 0.63 to 1.004]; primary adjusted P = .054). Of 38 prespecified secondary end points, 34 showed no significant difference. Compared with the systemic heparin group, the regional citrate group had significantly fewer bleeding complications (15/300 [5.1%] vs 49/296 [16.9%]; difference, -11.8% [95% CI, -16.8% to -6.8%]; P < .001) and significantly more new infections (204/300 [68.0%] vs 164/296 [55.4%]; difference, 12.6% [95% CI, 4.9% to 20.3%]; P = .002). Conclusions and Relevance: Among critically ill patients with acute kidney injury receiving continuous kidney replacement therapy, anticoagulation with regional citrate, compared with systemic heparin anticoagulation, resulted in significantly longer filter life span. The trial was terminated early and was therefore underpowered to reach conclusions about the effect of anticoagulation strategy on mortality. Trial Registration: ClinicalTrials.gov Identifier: NCT02669589.

Mediators of the Impact of Hourly Net Ultrafiltration Rate on Mortality in Critically Ill Patients Receiving Continuous Renal Replacement Therapy.

OBJECTIVES: During continuous renal replacement therapy, a high net ultrafiltration rate has been associated with increased mortality. However, it is unknown what might mediate its putative effect on mortality. In this study, we investigated whether the relationship between early (first 48 hr) net ultrafiltration and mortality is mediated by fluid balance, hemodynamic instability, or low potassium or phosphate blood levels using mediation analysis and the primary outcome was hospital mortality. DESIGN: Retrospective, observational study. SETTING: Mixed medical and surgical ICUs at Austin hospital, Melbourne, Australia. PATIENTS: Critically ill patients treated with continuous renal replacement therapy within 14 days of ICU admission who survived greater than 48 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We studied 347 patients (median [interquartile range] age: 64 yr [53-71 yr] and Acute Physiology and Chronic Health Evaluation III score: 73 (54-90)]. After adjustment for confounders, compared with a net ultrafiltration less than 1.01 mL/kg/hr, a net ultrafiltration rate greater than 1.75 mL/kg/hr was associated with significantly greater mortality (adjusted odds ratio, 1.15; 95% CI, 1.03-1.29; p = 0.011). Adjusted univariable mediation analysis found no suggestion of a causal mediation pathway for this effect by blood pressure, vasopressor therapy, or potassium levels, but identified a possible mediation effect for fluid balance (average causal mediation effect, 0.95; 95% CI, 0.89-1.00; p = 0.060) and percentage of phosphate measurements with hypophosphatemia (average causal mediation effect, 0.96; 95% CI, 0.92-1.00; p = 0.055). However, on multiple mediator analyses, these two variables showed no significant effect. In contrast, a high net ultrafiltration rate had an average direct effect of 1.24 (95% CI, 1.11-1.40; p < 0.001). CONCLUSIONS: An early net ultrafiltration greater than 1.75 mL/kg/hr was independently associated with increased hospital mortality. Its putative effect on mortality was direct and not mediated by a causal pathway that included fluid balance, low blood pressure, vasopressor use, hypokalemia, or hypophosphatemia.

Evaluation of continuous renal replacement therapy and risk factors in the pediatric intensive care unit.

Acute kidney injury (AKI) is one of the most common causes of increased mortality and morbidity in the pediatric intensive care unit (PICU). Continuous renal replacement therapy (CRRT) is the mainstay treatment for AKI in children as it allows continuous and programmed removal of fluids, which is tolerated better hemodynamically. Defining the risk factors of CRRT related to mortality and morbidity will help improve the outcomes of patients in the PICU. In this study, we aimed to determine the prognostic factors and outcomes of patients who received CRRT. This was a single-center, retrospective study on PICU patients requiring CRRT. Patients with a history of chronic renal failure and PICU stay duration of <24 h and those who died on the 1st day of admission were excluded from the study. A total of 447 patients admitted between October 2016 and March 2018 were included in the study. Children who received CRRT for the management of AKI and/or other nonrenal indications, such as metabolic acidosis, poisoning, electrolyte imbalance, and congenital metabolic diseases, were also included in the study. Fifty patients underwent CRRT. There was a statistically significant relationship between CRRT support and prognostic factors, including age (P = 0.012), inotropic drug usage (P = 0.000), concomitant infection (P = 0.010), blood component transfusion (P = 0.005), pediatric risk of mortality score (P = 0.027), and mortality (P = 0.003). The odds ratio for mortality was 5.396 (95% confidence interval: 1.732-16.809). In conclusion, CRRT is associated with increased morbidity and mortality in the PICU.

Continuous Renal Replacement Therapy Dosing in Critically Ill Patients: A Quality Improvement Initiative.

RATIONALE & OBJECTIVE: Clinical practice guidelines recommend delivering a continuous renal replacement therapy (CRRT) dose of 20 to 25mL/kg/h. However, practice patterns nationwide are highly variable; this inconsistent prescribing may lead to errors in medication dosing and increase rates of electrolyte and acid-base abnormalities. We describe an initiative to standardize CRRT practice patterns and reduce dosing variability. STUDY DESIGN: Quality improvement study. SETTING & PARTICIPANTS: Adult patients treated with CRRT at the University of Colorado Hospital between January 2016 and October 2017. QUALITY IMPROVEMENT ACTIVITIES: An assessment of the magnitude of the variability in CRRT dosing and the following specific interventions were implemented during the course of 1 year: (1) modification of the electronic medical record (EMR) to include calculated average 24-hour dose in real time, (2) modification of the CRRT procedure note to include comments on dosing, (3) modification of the CRRT order set to display calculations, and (4) yearly educational sessions for renal fellows outlining CRRT-specific dosing targets. OUTCOMES: The primary outcome was weekly percentage of CRRT treatments with an average delivered daily dose of 20 to 25mL/kg/h. Process and balancing outcomes included CRRT flowsheet accuracy, documentation of rates of delivered dose, and nursing satisfaction. ANALYTICAL APPROACH: Rates of weekly CRRT dosing in compliance with national guidelines were determined and used to create run charts showing compliance rates before and after the quality improvement interventions. RESULTS: Among 837 treatments before the intervention, 279 (33%) daily CRRT sessions achieved an average dose of 20 to 25mL/kg/h. Following implementation of interventions, 631 of 952 (66%) treatments achieved this goal. Week-to-week variation in dosing was significantly reduced. LIMITATIONS: A single-center study generating data that may not be generalizable to institutions with different CRRT nursing models or different EMR systems. CONCLUSIONS: Changes to the EMR and documentation templates and education of CRRT providers about dosing were associated with doubling of the rate of appropriate CRRT dosing and reduction in dosing variability.

Analysis of survival after initiation of continuous renal replacement therapy in patients with extracorporeal membrane oxygenation.

BACKGROUND: No study has specifically investigated the duration of continuous renal replacement therapy (CRRT) in patients who experienced acute kidney injury during extracorporeal membrane oxygenation (ECMO) support. However, there are concerns that prolonged CRRT may be futile. METHODS: We conducted a retrospective population-based cohort study using Taiwan National Health Insurance Research Database data collected between January 1, 2007 and December 31, 2013. Patients who received ECMO and CRRT during the study period were included. We divided patients into three groups based on the duration of CRRT received: ≤ 3 days, 4-6 days, and ≥ 7 days. The outcomes were all-cause mortality, end-stage renal disease, ventilator dependency, and readmission rate. RESULTS: There were 247, 134 and 187 patients who survived the hospitalization in the CRRT for ≤3 days, 4-6 days and > 7 days respectively. Survival after discharge did not differ significantly between CRRT for 4-6 days vs. ≤ 3 days (adjusted hazard ratio [aHR] 1.16, 95% confidence interval [CI] 0.85-1.57), between CRRT for > 7 days vs. ≤ 3 days (aHR 1.001, 95% CI 0.73-1.38) and between CRRT for > 7 days vs. 4-6 days (aHR 0.87, 95% CI 0.62-1.22). The patients who received CRRT for ≥7 days had a higher risk of ESRD than did those who received CRRT for ≤3 days (adjusted hazard ratio [aHR] 3.46, 95% confidence interval [CI] 1.47-8.14) and for 4-6 days (aHR 3.10, 95% CI 1.03-9.29). The incidence of ventilator dependence was higher in the patients with CRRT ≥7 days than in those with ≤3 days (aHR 2.45, 95% CI 1.32-4.54). The CRRT ≥7 days group also exhibited a higher readmission rate than did the 4-6 days and ≤ 3 days groups (aHR 1.43, 95% CI 1.04-1.96 and aHR 1.67, 95% CI 1.13-2.47, respectively). CONCLUSIONS: Our study found similar long-term survival but increased ESRD and ventilator dependency among ECMO patients who underwent CRRT for ≥7 days. These results offer reason to be concerned that this aggressive life support may maintain patient survival but do so at the cost of long-term disabilities and a lower quality of life.

Fluid balance after continuous renal replacement therapy initiation and outcome in paediatric multiple organ failure.

BACKGROUND: Patients with multiple organ failure (MOF) often receive large amounts of resuscitation fluid, making them at high risk of fluid overload (FO). Our main objective was to investigate if the ability to achieve a negative fluid balance during the first 3 continuous renal replacement therapy (CRRT) days was associated with mortality in children with MOF. METHODS: Retrospective cohort study in a tertiary multidisciplinary academic paediatric hospital. The study included 63 patients (age 0-18 years) with 3 or more failing organs receiving CRRT due to acute kidney injury and/or fluid overload. RESULTS: The median age was 4 months, and PICU mortality was 29%. Survivors had significantly lower degree of FO at CRRT initiation, (median 15% (Interquartile range 9-22)) than non-survivors (24% (17%-37%), P = 0.002). On PICU admission, PIM-3 score was significantly higher in non-survivors (P = 0.01), but at CRRT initiation there was no difference in PELOD-2 score (P = 0.98). Mortality in patients achieving a cumulative net negative fluid balance during the first 3 days after CRRT initiation was 12%, compared to 86% in those not achieving this (P < 0.0001). In multivariate analysis, the inability to achieve a net negative fluid balance during 3 days after CRRT initiation (P < 0.0001) and FO >20% at CRRT initiation (P = 0.0019) remained associated with mortality. CONCLUSION: Our results suggest that early fluid removal is associated with improved patient outcome in critically ill children receiving CRRT, and that prompt measures should be taken to prevent fluid overload in critical illness. These results need to be verified in further, prospective studies.

Association of Net Ultrafiltration Rate With Mortality Among Critically Ill Adults With Acute Kidney Injury Receiving Continuous Venovenous Hemodiafiltration: A Secondary Analysis of the Randomized Evaluation of Normal vs Augmented Level (RENAL) of Renal Replacement Therapy Trial.

Importance: Net ultrafiltration (NUF) is frequently used to treat fluid overload among critically ill patients, but whether the rate of NUF affects outcomes is unclear. Objective: To examine the association of NUF with survival among critically ill patients with acute kidney injury being treated with continuous venovenous hemodiafiltration. Design, Setting, and Participants: The Randomized Evaluation of Normal vs Augmented Level (RENAL) of Renal Replacement Therapy trial was conducted between December 30, 2005, and November 28, 2008, at 35 intensive care units in Australia and New Zealand among critically ill adults with acute kidney injury who were being treated with continuous venovenous hemodiafiltration. This secondary analysis began in May 2018 and concluded in January 2019. Exposures: Net ultrafiltration rate, defined as the volume of fluid removed per hour adjusted for patient body weight. Main Outcomes and Measures: Risk-adjusted 90-day survival. Results: Of 1434 patients, the median (interquartile range) age was 67.3 (56.9-76.3) years; 924 participants (64.4%) were male; median (interquartile range) Acute Physiology and Chronic Health Evaluation III score was 100 (84-118); and 634 patients (44.2%) died. Using tertiles, 3 groups were defined: high, NUF rate greater than 1.75 mL/kg/h; middle, NUF rate from 1.01 to 1.75 mL/kg/h; and low, NUF rate less than 1.01 mL/kg/h. The high-tertile group compared with the low-tertile group was not associated with death from day 0 to 6. However, death occurred in 51 patients (14.7%) in the high-tertile group vs 30 patients (8.6%) in the low-tertile group from day 7 to 12 (adjusted hazard ratio [aHR], 1.51; 95% CI, 1.13-2.02); 45 patients (15.3%) in the high-tertile group vs 25 patients (7.9%) in the low-tertile group from day 13 to 26 (aHR, 1.52; 95% CI, 1.11-2.07); and 48 patients (19.2%) in the high-tertile group vs 29 patients (9.9%) in the low-tertile group from day 27 to 90 (aHR, 1.66; 95% CI, 1.16-2.39). Every 0.5-mL/kg/h increase in NUF rate was associated with increased mortality (3-6 days: aHR, 1.05; 95% CI, 1.00-1.11; 7-12 days: aHR, 1.08; 95% CI, 1.02-1.15; 13-26 days: aHR, 1.11; 95% CI, 1.04-1.18; 27-90 days: aHR, 1.13; 95% CI, 1.05-1.22). Using longitudinal analyses, increase in NUF rate was associated with lower survival (ß = .056; P < .001). Hypophosphatemia was more frequent among patients in the high-tertile group compared with patients in the middle-tertile group and patients in the low-tertile group (high: 308 of 477 patients at risk [64.6%]; middle: 293 of 472 patients at risk [62.1%]; low: 247 of 466 patients at risk [53.0%]; P < .001). Cardiac arrhythmias requiring treatment occurred among all groups: high, 176 patients (36.8%); middle: 175 patients (36.5%); and low: 147 patients (30.8%) (P = .08). Conclusions and Relevance: Among critically ill patients, NUF rates greater than 1.75 mL/kg/h compared with NUF rates less than 1.01 mL/kg/h were associated with lower survival. Residual confounding may be present from unmeasured risk factors, and randomized clinical trials are required to confirm these findings. Trial Registration: ClinicalTrials.gov identifier: NCT00221013.

A Report of 7-Year Experience on Pediatric Continuous Renal Replacement Therapy.

BACKGROUND: Continuous renal replacement therapies (CRRTs) either as continuous venovenous hemofiltration (CVVH) or hemodiafiltration (CVVHD) are used frequently in critically ill children. Many clinical variables and technical issues are known to affect the result. The factors that could be modified to increase the survival of renal replacement are sought. As a contribution, we present the data on 104 patients who underwent CRRT within a 7-year period. MATERIALS AND METHOD: A total of 104 patients admitted between 2009 and 2016 were included in the study. The demographic information, admittance pediatric risk of mortality (PRISM) scores, indication for CRRT, presence of fluid overload, CRRT modality, durations of CRRT, and pediatric intensive care unit (PICU) stay were compared between survivors and nonsurvivors. RESULTS: The overall rate of survival was 51%. Patients with fluid overload had significantly increased rate of death, CRRT duration, and PICU stay. Multiorgan dysfunction syndrome as the indication for CRRT was significantly related to decreased survival when compared to acute renal failure and acute attacks of metabolic diseases. The CRRT modality was not different between survivors and nonsurvivors. Standardized mortality ratio of the group was calculated to be 0.8. CONCLUSION: The CRRT in critically ill patients is successful in achieving fluid removal and correction of metabolic imbalances caused by organ failures or attacks of inborn errors of metabolism. It has a positive effect on expected mortality in high-risk PICU patients. To affect the outcome, follow-up should be focused on starting therapy in early stages of fluid overload. Prospective studies defining relative importance of risk factors causing mortality can assist in building up guidelines to affect the outcome.

Intraoperative extracorporeal support during lung transplantation in patients bridged with venovenous extracorporeal membrane oxygenation.

BACKGROUND: Venovenous (VV) extracorporeal membrane oxygenation (ECMO) is the preferred configuration for bridging respiratory failure patients while awaiting lung transplantation. However, there is no consensus on intraoperative extracorporeal cardiopulmonary support during lung transplantation in these patients. METHODS: The configuration of the intraoperative extracorporeal circuit after VV ECMO bridge was reviewed and correlated with clinical outcomes. This retrospective cohort study performed at our university hospital included 34 patients who were successfully bridged solely with VV ECMO to lung transplantation during the period 2007 to 2016. Indications to switch to intraoperative venoarterial (VA) ECMO were hemodynamic compromise (systemic hypotension or mean pulmonary artery pressure >40 mm Hg) or when this scenario was thought to be highly likely. RESULTS: The median duration of bridging was 12 (IQR 7 to 19) days. Intraoperatively, 3 patients (8.8%) required cardiopulmonary bypass. Twenty patients (58.8%) stayed on VV ECMO and 11 (32.3%) were switched to central VA ECMO. Between the 2 types of intraoperative ECMO (VV vs VA), there were no significant differences in post-operative ECMO duration, chest reopening for bleeding, or renal replacement therapy. There was no significant difference in 90-day mortality (0% and 9.0%, p = 0.35) or in long-term survival (p = 0.59). The intraoperative transfusion of red blood cells tended to be higher in the VA group (5 [4 to 9] vs 8 [6 to 13] units, p = 0.06). Use of intraoperative VA ECMO was associated with the use of low-flow VV device bridging and lobar transplantation. CONCLUSIONS: Using the existing VV ECMO bridge intraoperatively during lung transplantation is feasible and provides comparable outcomes to patients converted to central VA ECMO for compromised hemodynamics.