Development and First Clinical Use of an Extracorporeal Artificial Multiorgan System in Acute-on-Chronic Liver Failure Patients.

Multiple organ failure (MOF) is a common and deadly condition. Patients with liver cirrhosis with acute-on-chronic liver failure (AOCLF) are particularly susceptible. Excess fluid accumulation in tissues makes routine hemodialysis generally ineffective because of cardiovascular instability. Patients with three or more organ failures face a mortality rate of more than 90%. Many cannot survive liver transplantation. Extracorporeal support systems like MARS (Baxter, Deerfield, IL) and Prometheus (Bad Homburg, Germany) have shown promise but fall short in bridging patients to transplantation. A novel Artificial Multi-organ Replacement System (AMOR) was developed at the University of Washington Medical Center. AMOR removes protein-bound toxins through a combination of albumin dialysis, a charcoal sorbent column, and a novel rinsing method to prevent sorbent column saturation. It removes excess fluid through hemodialysis. Ten AOCLF patients with over three organ failures were treated by the AMOR system. All patients showed significant clinical improvement. Fifty percent of the cohort received liver transplants or recovered liver function. AMOR was successful in removing large amounts of excess body fluid, which regular hemodialysis could not. AMOR is cost-effective and user-friendly. It removes excess fluid, supporting the other vital organs such as liver, kidneys, lungs, and heart. This pilot study's results encourage further exploration of AMOR for treating MOF patients.

An Innovative Approach to Integrating Nephrology Nursing into Acute and Critical Care.

There is a growing number of individuals living with chronic kidney disease in the United States and worldwide. There is also a nursing shortage and increased need for nurses, particularly in specialties like nephrology. Meeting these growing demands and improving conditions for nurses will take multiple approaches and broadening of current systems. An area of focus is the training and expansion of the nephrology nursing workforce. This article discusses a dialysis training program for acute and critical care nurses who are able to provide both bedside care and kidney replacement therapy in the hospital setting.

Nephrology Nurses' Perspectives for the Designs of Mobile Hemodialysis Devices: A Human Factors Engineering Approach.

The goal of this study was to guide the early conceptual designs of two devices intended to improve the quality of life for patients on hemodialysis: a portable hemodialysis device and a wearable hemodialysis device. Thirty-two nephrology nurses were interviewed using a mixed approach of open-ended, rating, and rank-order questions. Results show most nurses try to persuade patients to try a modality of treatment that offers them the best clinical outcome and highest quality of life. Many nurses, however, indicate that patients are often not given the opportunity to choose their preferred modality of treatment, and that current hemodialysis treatments are one-size-fits-all and should be more individualized. Nurses also believe high-frequency home-based, portable, or wearable hemodialysis treatments are better for patients than in-center treatments, and patients can learn to safely connect and disconnect a hemodialysis device to their catheter. Using content analysis, we identified six categories of potential benefits a patient may experience using either a portable or a wearable hemodialysis device. We also identified six categories of potential barriers that may hinder nephrology nurses in recommending either a portable or a wearable hemodialysis device to their patients and seven categories of ideal features for the designs of the devices. Statistical analysis of rank-order questions shows nephrology nurses prefer a wearable hemodialysis device in the form of a belt compared to other designs (p < 0.05). Findings from this study provide valuable information guiding the design process of mobile hemodialysis devices that nephrology nurses will feel comfortable recommending to their patients.

Standing on the Shoulders of Giants: Innovations in Dialysis.

Prior to the 1960s, chronic hemodialysis was limited by vascular access. Pioneers in dialysis technology created the first artificial kidney, chronic vascular access for hemodialysis, and peritoneal dialysis access. Now it is estimated that 600,000 people in the United States and over 2 million people worldwide receive renal replacement therapy. Unfortunately, there has been limited growth in dialysis technology and fairly stagnant outcomes. As a growing body of literature supports improved outcomes and symptoms management with longer dialysis treatments, innovations in wearable and implantable devices are being developed, as well as new options for creating and maintaining vascular access. As the nephrology community stands on the shoulders of the inventors who came before us, we continue to reach for a future with infinite possibilities to improve kidney care. This article discusses some of the new technology for dialysis care and systems that are supporting innovation in this field.

A wearable artificial kidney for patients with end-stage renal disease.

BACKGROUND: Stationary hemodialysis machines hinder mobility and limit activities of daily life during dialysis treatments. New hemodialysis technologies are needed to improve patient autonomy and enhance quality of life. METHODS: We conducted a FDA-approved human trial of a wearable artificial kidney, a miniaturized, wearable hemodialysis machine, based on dialysate-regenerating sorbent technology. We aimed to determine the efficacy of the wearable artificial kidney in achieving solute, electrolyte, and volume homeostasis in up to 10 subjects over 24 hours. RESULTS: During the study, all subjects remained hemodynamically stable, and there were no serious adverse events. Serum electrolytes and hemoglobin remained stable over the treatment period for all subjects. Fluid removal was consistent with prescribed ultrafiltration rates. Mean blood flow was 42 ± 24 ml/min, and mean dialysate flow was 43 ± 20 ml/min. Mean urea, creatinine, and phosphorus clearances over 24 hours were 17 ± 10, 16 ± 8, and 15 ± 9 ml/min, respectively. Mean ß2-microglobulin clearance was 5 ± 4 ml/min. Of 7 enrolled subjects, 5 completed the planned 24 hours of study treatment. The trial was stopped after the seventh subject due to device-related technical problems, including excessive carbon dioxide bubbles in the dialysate circuit and variable blood and dialysate flows. CONCLUSION: Treatment with the wearable artificial kidney was well tolerated and resulted in effective uremic solute clearance and maintenance of electrolyte and fluid homeostasis. These results serve as proof of concept that, after redesign to overcome observed technical problems, a wearable artificial kidney can be developed as a viable novel alternative dialysis technology. TRIAL REGISTRATION: ClinicalTrials.gov NCT02280005. FUNDING: The Wearable Artificial Kidney Foundation and Blood Purification Technologies Inc.

Prevention of hemodialysis central line-associated bloodstream infections in acutely ill individuals.

An arteriovenous access is preferred for hemodialysis, but the use of tunneled, cuffed catheters may be necessary in the inpatient setting with acute kidney injury when immediate hemodialysis is required and fistula immaturity or access complications are present. Care of the dialysis central venous catheter is paramount in the prevention of central line-associated bloodstream infections in acutely ill individuals. One institution's approach to hemodialysis central venous catheter care and a quality improvement projectfor selecting tunneled catheters will highlight their changing practice.