scholarly journals The interactive effects of input and output on managing fluid balance in patients with acute kidney injury requiring continuous renal replacement therapy

Critical Care ◽  
2019 ◽  
Vol 23 (1) ◽  
Author(s):  
Jong Hyun Jhee ◽  
Hye Ah Lee ◽  
Seonmi Kim ◽  
Youn Kyung Kee ◽  
Ji Eun Lee ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Fluid Balance ◽  
Interactive Effect ◽  
Kidney Injury ◽  
Input And Output ◽  
The Impact ◽  
Cumulative Fluid Balance

Abstract Background The interactive effect of cumulative input and output on achieving optimal fluid balance has not been well elucidated in patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). This study evaluated the interrelation of fluid components with mortality in patients with AKI requiring CRRT. Methods This is a retrospective observational study conducted with a total of 258 patients who were treated with CRRT due to AKI between 2016 and 2018 in the intensive care unit of Ewha Womans University Mokdong Hospital. The amounts of fluid input and output were assessed at 24-h and 72-h from the initiation of CRRT. The study endpoints were 7- and 28-day all-cause mortality. Results The mean patient age was 64.7 ± 15.8 years, and 165 (64.0%) patients were male. During the follow-up, 7- and 28-day mortalities were observed in 120 (46.5%) and 157 (60.9%) cases. The patients were stratified into two groups (28-day survivors vs. non-survivors), and the cumulative fluid balances (CFBs) at 24 h and 72 h were significantly higher in the 28-day non-survivors compared with the survivors. The increase in 24-h and 72-h CFB was significantly associated with an increase in 7- and 28-day mortality risks. To examine the interactive effect of cumulative input or output on the impact of CFB on mortality, we also stratified patients into three groups based on the tertile of 24-h and 72-h cumulative input or output. The increases in 24-h and 72-h CFBs were still significantly related to the increases in 7-day and 28-day mortality, irrespective of the cumulative input. However, we did not find significant associations between increase in 24-h and 72-h CFB and increase in mortality risk in the groups according to cumulative output tertile. Conclusions The impact of cumulative fluid balance on mortality might be more dependent on cumulative output. The physicians need to decrease the cumulative fluid balance of CRRT patients as much as possible and consider increasing patient removal.

scholarly journals Net ultrafiltration rate and its impact on mortality in patients with acute kidney injury receiving continuous renal replacement therapy

2019 ◽  
Author(s):  
Shahrzad Tehranian ◽  
Khaled Shawwa ◽  
Kianoush B Kashani
Keyword(s):  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
High Intensity ◽  
Kidney Injury ◽  
Ultrafiltration Rate ◽  
Baseline Serum ◽  
Fluid Removal ◽  
The Impact

Abstract Background Fluid overload, a critical consequence of acute kidney injury (AKI), is associated with worse outcomes. The optimal fluid removal rate per day during continuous renal replacement therapy (CRRT) is unknown. The purpose of this study is to evaluate the impact of the ultrafiltration rate on mortality in critically ill patients with AKI receiving CRRT. Methods This was a retrospective cohort study where we reviewed 1398 patients with AKI who received CRRT between December 2006 and November 2015 at the Mayo Clinic, Rochester, MN, USA. The net ultrafiltration rate (UFNET) was categorized into low- and high-intensity groups (<35 and ≥35 mL/kg/day, respectively). The impact of different UFNET intensities on 30-day mortality was assessed using logistic regression after adjusting for age, sex, body mass index, fluid balance from intensive care unit (ICU) admission to CRRT initiation, Acute Physiologic Assessment and Chronic Health Evaluation III and sequential organ failure assessment scores, baseline serum creatinine, ICU day at CRRT initiation, Charlson comorbidity index, CRRT duration and need of mechanical ventilation. Results The mean ± SD age was 62 ± 15 years, and 827 (59%) were male. There were 696 patients (49.7%) in the low- and 702 (50.2%) in the high-intensity group. Thirty-day mortality was 755 (54%). There were 420 (60%) deaths in the low-, and 335 (48%) in the high-intensity group (P < 0.001). UFNET ≥35 mL/kg/day remained independently associated with lower 30-day mortality (adjusted odds ratio = 0.47, 95% confidence interval 0.37–0.59; P < 0.001) compared with <35 mL/kg/day. Conclusions More intensive fluid removal, UFNET ≥35 mL/kg/day, among AKI patients receiving CRRT is associated with lower mortality. Future prospective studies are required to confirm this finding.

The Impact of Hemodynamic Transesophageal Echocardiography on the Use of Continuous Renal Replacement Therapy in Trauma

2017 ◽  
Vol 83 (8) ◽  
pp. 855-859 ◽  
Author(s):  
Madison Griffin ◽  
Brett Howard ◽  
Sam Devictor ◽  
Josh Ferenczy ◽  
Frances Cobb ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Transesophageal Echocardiography ◽  
Replacement Therapy ◽  
Kidney Injury ◽  
Volume Overload ◽  
P Value ◽  
Trauma Patients ◽  
The Impact

Post-traumatic fluid management is a widely debated topic. No best-practice consensus exists. Adverse outcomes such as acute kidney injury or volume overload are common. Continuous renal replacement therapy (CRRT) is an adjunct therapy for severe acute renal failure and volume overload, but is costly and not without risk. Hemodynamic transesophageal echocardiography (hTEE) is widely accepted as a reliable way to monitor volume status of intensive care unit (ICU) patients. Although data exist evaluating hTEE and CRRT independently, there is a lack of research mutually inclusive of the two. We hypothesized that the use of hTEE is associated with less need for CRRT. Retrospective review of a level I trauma center from 2009 to 2015 identified patients that required CRRT. In 2013, we implemented a protocol using hTEE in trauma patients with significant resuscitation needs. We compared CRRTuse before and after implementation of the protocol (pre- and post-hTEE). Multivariate analysis using two sample t tests and χ2 test of the odds ratio (O.R.) was completed on variables such as injury severity score (ISS), acute kidney injury network (AKIN), days of CRRT, ICU length of stay (LOS), and hospital LOS. A total of 5037 and 6699 trauma patients were evaluated in the pre- and post-hTEE groups, respectively. Mean ISS was 22 and 28 for pre- and post-hTEE, respectively (P value 0.19). Mean AKIN was 2.7 for both groups. Mean days on CRRT was eight before hTEE and seven after hTEE (P value 0.7); 23 patients required CRRT pre-hTEE, and 15 required CRRT post-hTEE (P value 0.01 O.R. 2.4). Given, the odds of CRRT pre-hTEE are more than twice that of CRRT post-hTEE; we conclude that the use of hTEE is associated with a reduction of CRRT.

The Impact of Hemodynamic Transesophageal Echocardiography on Acute Kidney Injury Management and Use of Continuous Renal Replacement Therapy in Trauma

2020 ◽  
Vol 86 (3) ◽  
pp. 190-194
Author(s):  
Alex Sapp ◽  
Andrew Drahos ◽  
Madison Lashley ◽  
Amy Christie ◽  
D. Benjamin Christie
Keyword(s):  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Transesophageal Echocardiography ◽  
Replacement Therapy ◽  
Hospital Costs ◽  
Kidney Injury ◽  
Acute Kidney Injury Network ◽  
Trauma Patients ◽  
The Impact

Resuscitation of critically ill trauma patients can be precarious, and errors can cause acute kidney injuries. If renal failure develops, continuous renal replacement therapy (CRRT) may be necessary, but adds expense. Hemodynamic transesophageal echocardiography (hTEE) provides objective data to guide resuscitation. We hypothesized that hTEE use improved acute kidney injury (AKI) management, reserved CRRT use for more severe AKIs, and decreased cost and resource utilization. We retrospectively reviewed 2413 trauma patients admitted to a Level I trauma center's ICU between 2009 and 2015. Twenty-three patients required CRRT before standard hTEE use and 11 required CRRTafter; these are the “CRRT” and “CRRT/hTEE” groups, respectively. The hTEE group comprised 83 patients evaluated with hTEE, with AKI managed without CRRT. We compared the average creatinine, change in creatinine, and Acute Kidney Injury Network (AKIN) of “CRRT” with “CRRT/hTEE” and “hTEE.” We also analyzed several quality measures including ICU length of stay and cost. “CRRT” had a lower AKIN score (1.6) than “CRRT/hTEE” (2.9) ( P = 0.0003). “hTEE” had an AKIN score of 2.1 ( P = 0.0387). “CRRT” also had increased ICU days (25.1) compared with “CRRT/hTEE” (20.2) ( P = 0.014) and “hTEE” (16.8) ( P = 0.003). “CRRT” accrued on average $198,695.81 per patient compared with “CRRT/ hTEE” ($167,534.19) and “hTEE” ($53,929.01). hTEE provides valuable information to tailor resuscitation. At our institution, hTEE utilization reserved CRRT for worse AKIs and decreased hospital costs.

Characterization of a Low Extracorporeal Volume, High Accuracy Pediatric Continuous Renal Replacement Therapy Device

2012 ◽  
Author(s):  
Arvind Santhanakrishnan ◽  
Trent Nestle ◽  
Brian Moore ◽  
Ajit P. Yoganathan ◽  
Matthew L. Paden
Keyword(s):  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Fluid Balance ◽  
Pediatric Patients ◽  
Kidney Injury ◽  
High Accuracy ◽  
Critically Ill Children

The incidence of acute kidney injury (AKI) is commonly seen in critically ill children, the origins of which may be traced to a wide range of conditions such as inborn errors of metabolism, sepsis, congenital heart defects, bone marrow and organ transplantation, and to a lesser extent from multiple organ dysfunction syndrome (MODS) [1]. It is vital to provide a form of fluid and electrolyte clearance in these patients until native renal function improves. Nearly 3,600 critically ill children per year with acute kidney injury receive life-saving continuous renal replacement therapy (CRRT) in the United States. However, there is no CRRT device approved by the Food and Drug Administration for use in pediatric patients. Thus, clinicians unsafely adapt adult CRRT devices for use in the pediatric patients due to lack of safer alternatives. Complications observed with using adult adapted CRRT devices in children include hypotension, hemorrhage, thrombosis, temperature instability, inaccurate fluid balance between ultrafiltrate (UF) removed from and replacement fluid (RF) delivered to the patient, electrolyte disorders, and alteration of drug clearance. This research addresses this unmet clinical need through the design, mechanical and biological characterization of a pediatric specific Kidney Injury and Dysfunction Support (KIDS) CRRT device that provides high accuracy in fluid balance, reduces extracorporeal blood volume, and eliminates other problems associated with using adapted adult CRRT devices in children.

MO837IMPACT OF DOWNTIME ON CLINICAL OUTCOMES IN CRITICALLY ILL PATIENTS WITH ACUTE KIDNEY INJURY RECEIVING CONTINUOUS RENAL REPLACEMENT THERAPY: A RETROSPECTIVE STUDY USING PROPENSITY SCORE-MATCHED ANALYSIS

2021 ◽  
Vol 36 (Supplement_1) ◽  
Author(s):  
Jungho Shin ◽  
Hyun Chul Song ◽  
Jin Ho Hwang ◽  
Su Hyun Kim
Keyword(s):  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Propensity Score ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Critically Ill ◽  
Fluid Balance ◽  
Critically Ill Patients ◽  
Quality Indicator ◽  
Kidney Injury

Abstract Background and Aims Continuous renal replacement therapy (CRRT) is essential in treating critically ill patients with acute kidney injury, and circuit downtime is considered a quality indicator. However, it remains uncertain whether CRRT downtime affects outcomes such as mortality and renal recovery. This study investigated the impact of downtime on various clinical outcomes in critically ill patients undergoing CRRT. Method A total of 216 patients who underwent CRRT were retrospectively recruited. Downtime was calculated over 4 days from CRRT initiation, and patients were classified as downtime <20% or ≥20% of potential operative time. Patients with ≥20% downtime were matched to those with <20% downtime using 1:2 propensity score matching, adjusting for age, sex, comorbidity index, and severity score. Results There were 88 patients with <20% downtime and 44 patients with ≥20% downtime. The cumulative volume and median flow rate of effluent in patients with ≥20% downtime were lower than those in patients with <20% downtime (P<0.001 and 0.062, respectively). Daily fluid balance differed on days 2 and 3 (P=0.046 and 0.031, respectively), and the difference in levels of urea and creatinine widened over time (P=0.004 and <0.001, day 4). The levels of total carbon dioxide were lower in those with ≥20% downtime (P=0.038 and 0.020 at days 2 and 3). Based on our results, ≥20% downtime was not associated with increased 28-day mortality (P=0.944). On the other hand, a subgroup analysis showed the interaction between downtime and daily fluid balance on mortality (P=0.004). In this study, downtime was not related to renal recovery. Conclusion Increased downtime could impair fluid and uremic control and acidosis management in patients undergoing CRRT. Moreover, the adverse effect of downtime on fluid control may increase mortality rate. Further studies are needed to verify the value of downtime as a quality indicator and its impact on outcomes in critically ill patients requiring CRRT.

scholarly journals Continuous Renal Replacement Therapy among Patients with COVID-19 and Acute Kidney Injury

2021 ◽  
pp. 1-8
Author(s):  
Ryann Sohaney ◽  
Salma Shaikhouni ◽  
John Travis Ludwig ◽  
Anca Tilea ◽  
Markus Bitzer ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Fluid Balance ◽  
Repeated Measures ◽  
Kidney Injury ◽  
Regional Citrate Anticoagulation ◽  
Respiratory Parameters ◽  
The Relationship

<b><i>Background and Objectives:</i></b> Acute kidney injury (AKI) is a common complication among patients with COVID-19 and acute respiratory distress syndrome. Reports suggest that COVID-19 confers a pro-thrombotic state, which presents challenges in maintaining hemofilter patency and delivering continuous renal replacement therapy (CRRT). We present our initial experience with CRRT in critically ill patients with COVID-19, emphasizing circuit patency and the association between fluid balance during CRRT and respiratory parameters. <b><i>Design, Setting, Participants, and Measurements:</i></b> Retrospective chart review of 32 consecutive patients with COVID-19 and AKI managed with continuous venovenous hemodiafiltration with regional citrate anticoagulation (CVVHDF-RCA) according to the University of Michigan protocol. Primary outcome was mean CRRT circuit life per patient during the first 7 days of CRRT. We used simple linear regression to assess the relationship between patient characteristics and filter life. We also explored the relationship between fluid balance on CRRT and respiratory parameters using repeated measures modeling. <b><i>Results:</i></b> Patients’ mean age was 54.8 years and majority were Black (75%). Comorbidities included hypertension (90.6%), obesity (70.9%) diabetes (56.2%), and chronic kidney disease (40.6%). Median CRRT circuit life was 53.5 [interquartile range 39.1–77.6] hours. There was no association between circuit life and inflammatory or pro-thrombotic laboratory values (ferritin <i>p</i> = 0.92, C-reactive protein <i>p</i> = 0.29, D-dimer <i>p</i> = 0.24), or with systemic anticoagulation (<i>p</i> = 0.37). Net daily fluid removal during the first 7 days of CRRT was not associated with daily (closest recorded values to 20:00) PaO<sub>2</sub>/FIO<sub>2</sub> ratio (<i>p</i> = 0.21) or positive end-expiratory pressure requirements (<i>p</i> = 0.47). <b><i>Conclusions:</i></b> We achieved adequate CRRT circuit life in COVID-19 patients using an established CVVHDF-RCA protocol. During the first 7 days of CRRT therapy, cumulative fluid balance was not associated with improvements in respiratory parameters, even after accounting for baseline fluid balance.

scholarly journals Impact of Cumulative Fluid Balance During Continuous Renal Replacement Therapy on Mortality in Patients With Septic Acute Kidney Injury: A Retrospective Cohort Study

2021 ◽  
Vol 8 ◽  
Author(s):  
Jin Lin ◽  
Hai Zhou Zhuang ◽  
De Yuan Zhi ◽  
Zhili Qi ◽  
Jing Bai ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Fluid Balance ◽  
Kidney Injury ◽  
Septic Acute Kidney Injury ◽  
Increased Risk ◽  
Tertiary Teaching ◽  
All Cause Mortality

Background: The clinicians often use continuous renal replacement therapy (CRRT) for the fluid management of patients with septic acute kidney injury (AKI). However, there is limited knowledge of the effects of changes in fluid balance (FB) on CRRT and its association with outcomes in patients with septic AKI.Objective: This study aimed to determine the association of cumulative FB (CFB) during treatment with 28-day all-cause mortality in the patients with septic AKI who require CRRT.Methods: This retrospective observational study examined patients who received CRRT due to septic AKI in a mixed intensive care unit (ICU) of a tertiary teaching hospital between January 2015 and December 2018. The patients were divided into three groups—negative FB, even FB, and positive FB—based on the CFB during CRRT. The primary outcome was 28-day all-cause mortality.Results: We examined 227 eligible patients and the mean age was 62.4 ± 18.3 years. The even FB group had a significantly lower 28-day mortality (43.0%, p = 0.007) than the positive FB group (72.7%) and the negative FB group (54.8%). The unadjusted and adjusted Cox regression models indicated that the positive FB group had an increased risk for 28-day all-cause mortality relative to the even FB group. A restricted cubic splines model indicated a J-shaped association between the CFB and 28-day all-cause mortality in the unadjusted model.Conclusion: Among the critically ill patients with septic AKI who require CRRT, those with positive FB had a higher mortality rate than those with even FB.

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