Comparable Triglyceride Reduction With Plasma Exchange and Insulin in Acute Pancreatitis - A Randomized Trial.

Background and Aims: Both insulin and plasma exchange (PE) are used in hypertriglyceridemic acute pancreatitis (HTG-AP). Our aim was to compare the efficacy of both treatments. Methods: A randomized, parallel group study performed in a tertiary hospital in 22 HTG-AP patients with non-severe prognosis and triglycerides between 15 and 40 mmol/L. Patients were randomized to daily PE or insulin infusion until triglycerides were <10 mmol/L. Primary outcome was % reduction in triglycerides within 24 h. Secondary outcomes were days needed to lower triglycerides <10 mmol/L, highest CRP and percentage of patients with a severe course of pancreatitis. Results: There was a trend toward a greater decrease in triglycerides within the first 24 h in the PE group (67 ± 17% vs. 53 ± 17%, p = 0.07), but the absolute difference was modest [mean difference of 6 mmol/L (14% of initial value)]. Triglycerides fell below 10 mmol/L in a median (IQR) of 1 (1-2) and 2 (1-2) days, respectively (p = 0.25). Secondary outcomes related to disease severity were also comparable: highest CRP 229 vs. 211 mg/L (p = 0.69) and severe course of pancreatitis in 2/11 cases in both groups (p = 1.0). Regarding treatment complications, there was one mild hypoglycemia and one allergic reaction during PE. Survival was 100% in both groups. Conclusion: There was no significant difference, but only a trend toward a greater decrease in triglycerides with PE, and the clinical course was also comparable. These results do not support universal use of PE in patients with HTG-AP. Clinical Trial Registration: [ClinicalTrials.gov], identifier [NCT02622854].

A national cohort study on hemodialysis arteriovenous fistulas after kidney transplantation - long-term patency, use and complications.

OBJECTIVE: To describe the long-term hemodialysis arteriovenous fistula (AVF) patency, incidence of AVF use, incidence and nature of AVF complications and surgery in patients after kidney transplantation. PATIENTS AND METHODS: We retrospectively analysed the AVF outcome and complications in all adult kidney allograft recipients transplanted between January 1st, 2000 and December 31, 2015 with a functional AVF at the time of transplantation. Follow-up was until December 31, 2019. RESULTS: We included 626 patients. Median AVF follow-up was 4.9 years. One month after kidney transplantation estimated AVF patency rate was 90%, at 1 year it was 82%, at 3 years it was 70% and at 5 years it was 61%; median estimated AVF patency was 7.9 years. The main cause of AVF failure was spontaneous thrombosis occurring in 76% of AVF failure cases, whereas 24% of AVFs were ligated or extirpated. In a Cox multivariate model female sex and grafts were independently associated with more frequent AVF thrombosis. AVF was used in about one third of our patients. AVF-related complications occurred in 29% of patients and included: growing aneurysms, complicated thrombosis, high-flow AVF, signs of distal hypoperfusion, venous hypertension, trauma of the AVF arm, or pain in the AVF/arm. CONCLUSIONS: AVFs remain functional after kidney transplantation in the majority of patients and are often re-used after graft failure. AVF-related complications are common and require proper care.

Regional citrate anticoagulation for continuous renal replacement therapy in newborns and infants: Focus on citrate accumulation.

Continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) in newborns and infants is challenging and accumulation of citrate can occur. There are only a few studies reporting the detailed data on RCA. We aimed to analyze RCA-CRRT at our institution with focus on citrate accumulation. Critically ill newborns and infants up to 11 kg of body weight (BW), treated with RCA-CRRT in the 2011-2016 period were included in this retrospective observational study. Prismaflex(R) and Multifiltrate-CiCa(R) dialysis monitors were used with either automated or manual RCA. Data was collected regarding the circuit lifetime, parameters of RCA, markers of citrate accumulation (total/ionized calcium ratio > 2.5), and metabolic complications. We included 10 children with mean age of 2.6 ± 3.8 months and BW of 4.6 ± 2.7 kg. In-hospital mortality was 60%. RCA-CRRT parameters were: blood flow 46 ± 9 mL/min (12 ± 5 mL/min/kg BW), citrate dose 2.8 ± 0.6 mmol/L of blood resulting in estimated citrate load to the patient of 1.7 ± 0.8 mmol/h/kg BW. In total, 57 dialysis circuits were used with mean filter lifetime of 39 ± 29 h. Citrate accumulation (total/ionized calcium ratio > 2.5) was observed in 7/10 patients and in 14/57 (25%) of circuits; those circuits were performed in children with lower age and BW, had higher relative blood flow and citrate load, while citrate dose was similar. When citrate load to the patient was used to predict citrate accumulation, AUC under the ROC curve was 0.78 and 1.7 mmol/h/kg BW was considered the optimal cutoff value (sensitivity 71% and specificity 72%). CRRT with RCA using equipment, developed for adult population, is feasible in newborns and infants. Signs of citrate accumulation developed relatively often. To prevent it, we suggest avoiding citrate loads above 1.7 mmol/h/kg BW, which can best be achieved by keeping the blood flow below 9 mL/min/kg BW.

Hemodialysis arteriovenous fistula-related complications and surgery in kidney graft recipients.

Arteriovenous fistula (AVF) remains functional after kidney transplantation in many patients. The aim of this historical cohort study was to evaluate the data on AVF-related complications and surgery performed after kidney transplantation in our patients. The study cohort included the recipients of a kidney transplant with AVF complications between January 2006 and April 2012. 74 renal transplant recipients (47% male, mean age 51 ± 10, range 14 to 73 years) with complications related to AVF were analyzed. Among all AVFs, 51 (72%) were located in the forearm, nine (13%) in the upper arm, and 14 (15%) in the elbow. Complications occurred in 12.5% (74/592) of kidney graft recipients who were treated at our Outpatient Transplant Unit during the study period. The most common complication was painful thrombosis with or without thrombophlebitis, which occurred in 32 patients (43.2%). Other complications included growing aneurysms (27%, 20/74), venous hypertension with arm edema (8.1%, 6/74), distal hypoperfusion (8.1%, 6/74), high flow AVF with cardiac failure (8.1%, 6/74), trauma (1.3%, 1/74), and cosmetic appearance (4%, 3/74). Fifty-one surgical interventions were performed in 49 patients (mean age 52 ± 12, range 28 to 73 years). AVF closure was performed in 29/51 (56%) patients. Furthermore, an extirpation of aneurysm was performed in 12/51 (23%) and an extirpation of thrombosed AVF was performed in 1/51 (2%) patients, simple trombectomies were performed in 5/51 (10%) and a thrombectomy with reanastomosis was performed in 4/51 (8%) patients. One patient underwent percutaneous transluminal angioplasty for underlying stenosis after surgery. The most common AVF-related complications in kidney graft recipients are painful thrombosis (often accompanied with thrombophlebitis) and growing aneurysms. Surgical intervention is performed in a significant proportion of patients, mainly AVF closure, aneurysm extirpation, and thrombectomy.