Renal Replacement Therapy for Acute Kidney Injury in French Intensive Care Units: A Nationwide Survey of Practices

<b><i>Background:</i></b> The frequency of acute kidney injury (AKI) can be as high as 50% in the intensive care unit (ICU). Despite the publication of national guidelines in France in 2015 for the use of RRT, there are no data describing the implementation of these recommendations in real-life. <b><i>Methods:</i></b> We performed a nationwide survey of practices from November 15, 2019, to January 24, 2020, in France. An electronic questionnaire based on the items recommended in the national guidelines was sent using an online survey platform, to the chiefs of all ICUs in France. The questionnaire comprised a section for the Department Chief about local organization and facilities, and a second section destined for individual physicians about their personal practices. <b><i>Results:</i></b> We contacted the Department Chief in 356 eligible ICUs, of whom 88 (24.7%) responded regarding their ICU organization. From these 88 ICUs, 232/285 physicians (82%) completed the questionnaire regarding individual practices. The practices reported by respondent physicians were as follows: intermittent RRT was first-line choice in &#x3e;75% in a patient with single organ (kidney) failure at the acute phase, whereas continuous RRT was predominant (&#x3e;75%) in patients with septic shock or multi-organ failure. Blood and dialysate flow for intermittent RRT were 200–300 mL/min and 400–600 mL/min, respectively. The dose of dialysis for continuous RRT was 25–35 mL/kg/h (65%). Insertion of the dialysis catheter was mainly performed by the resident under echographic guidance, in the right internal jugular vein. The most commonly used catheter lock was citrate (53%). The most frequently cited criterion for weaning from RRT was diuresis, followed by a drop in urinary markers (urea and creatinine). <b><i>Conclusion:</i></b> This study shows a satisfactory level of reported compliance with French guidelines and recent scientific evidence among ICU physicians regarding initiation of RRT for AKI in the ICU.

Imipenem/Relebactam Ex Vivo Clearance during Continuous Renal Replacement Therapy

(1) Purpose of this study: determination of adsorption and transmembrane clearances (CLTM) of imipenem and relebactam in ex vivo continuous hemofiltration (CH) and continuous hemodialysis (CHD) models. These clearances were incorporated into a Monte Carlo Simulation (MCS), to develop drug dosing recommendations for critically ill patients requiring continuous renal replacement therapy (CRRT); (2) Methods: A validated ex vivo bovine blood CH and CHD model using two hemodiafilters. Imipenem/relebactam and urea CLTM at different ultrafiltrate/dialysate flow rates were evaluated in both CH and CHD. MCS was performed to determine dose recommendations for patients receiving CRRT; (3) Results: Neither imipenem nor relebactam adsorbed to the CRRT apparatus. The CLTM of imipenem, relebactam, and urea approximated the effluent rates (ultrafiltrate/dialysate flow rates). The types of hemodiafilter and effluent rates did not influence CLTM except in a dialysis flow rate of 1 L/h and 6 L/h in the CHD with relebactam (p < 0.05). Imipenem and relebactam 200 mg/100 mg every 6 h were sufficient to meet the standard time above the MIC pharmacodynamic targets in the modeled CRRT regimen of 25 kg/mL/h. (4) Conclusions: Imipenem and relebactam are not removed by adsorption to the CRRT apparatus, but readily cross the hemodiafilter membrane in CH and CHD. Dosage adjustment of imipenem/relebactam is likely required for critically ill patients receiving CRRT.

Extracorporeal Albumin Dialysis in Liver Failure with MARS and SPAD: A Randomized Crossover Trial

<b><i>Introduction:</i></b> Liver failure is associated with hepatic and extrahepatic organ failure leading to a high short-term mortality rate. Extracorporeal albumin dialysis (ECAD) aims to reduce albumin-bound toxins accumulated during liver failure. ECAD detoxifies blood using albumin dialysis through an artificial semipermeable membrane with recirculation (molecular adsorbent recirculating system, MARS) or without (single-pass albumin dialysis, SPAD). <b><i>Methods:</i></b> We performed a randomized crossover open trial in a surgical intensive care unit. The primary outcome of the study was total bilirubin reduction during MARS and during SPAD therapies. The secondary outcomes were conjugated bilirubin and bile acid level reduction during MARS and SPAD sessions and tolerance of dialysis system devices. Inclusion criteria were adult patients presenting liver failure with factor V activity &#x3c;50% associated with bilirubin ≥250 μmol/L and a complication (either hepatic encephalopathy, severe pruritus, or hepatorenal syndrome). For MARS and SPAD, the dialysis flow rate was equal to 1,000 mL/h. <b><i>Results:</i></b> Twenty crossovers have been performed. Baseline biochemical characteristics (bilirubin, ammonia, bile acids, creatinine, and urea) were not statistically different between MARS and SPAD. Both ECAD have led to a significant reduction in total bilirubin (−83 ± 67 μmol/L after MARS; −122 ± 118 μmol/L after SPAD session), conjugated bilirubin (−82 ± 61 μmol/L after MARS; −105 ± 96 μmol/L after SPAD session), and bile acid levels (−64 ± 75 μmol/L after MARS; −56 ± 56 μmol/L after SPAD session), all nondifferent comparing MARS to SPAD. <b><i>Conclusion:</i></b> A simple-to-perform SPAD therapy with equal to MARS dialysate flow parameters provides the same efficacy in bilirubin and bile acid removal. However, clinically relevant endpoints have to be evaluated in randomized trials to compare MARS and SPAD therapies and to define the place of SPAD in the liver failure care program.

Effect of increased blood flow rate on renal anemia and hepcidin concentration in hemodialysis patients

Background Increasing the blood flow rate (BFR) is a useful method for increasing Kt/V and the clearance for low molecular solutes. Hemodialysis patients are often anemic due to hypoerythropoiesis and their chronic inflammatory state. Hepcidin, a hormone that regulates iron homeostasis, is considered as an indicator of iron deficiency in patients with end-stage renal disease. This study aimed to investigate the effects of an increased BFR during hemodialysis on serum hepcidin levels and anemia. Methods Between April 2014 and March 2016, 22 chronic dialysis patients (11 men [50.0 %]; mean [± standard deviation] age, 72 ± 12 years) undergoing maintenance hemodialysis treatment, thrice weekly, were enrolled and followed prospectively for 24 months. In April 2014, the BFR was 200 mL/min; in April 2015 this was increased to 400 mL/min, which was within acceptable limits. The dialysate flow rate remained stable at; 500mlL/min. Blood samples were collected in March 2015 and 2016. The primary endpoint was the comparison of the amounts of erythropoiesis-stimulating agent (ESA) required. Results The increased BFR increased the Kt/V and contributed to significantly decreased urea nitrogen (UN) (p = 0.015) and creatinine (Cr) (p = 0.005) levels. The dialysis efficiency was improved by increasing the BFR. Ferritin (p = 0.038), hepcidin (p = 0.041) and high-sensitivity interleukin-6 (p = 0.038) levels were also significantly reduced. The ESA administered was significantly reduced (p = 0.004) and the Erythropoietin Resistant Index (ERI) significantly improved (p = 0.031). The reduction rates in UN (p < 0.001), Cr (p < 0.001), and beta-2 microglobulin (p = 0.017) levels were significantly greater post the BFR increase compared to those prior to the BFR increase. However, hepcidin was not affected by the BFR change. Conclusions Increasing BFR was associated with hemodialysis efficiency, and led to reduce inflammatory cytokine interleukin-6, but did not contribute to reduce C-reactive protein. This reduced hepcidin levels, ESA dosage and ERI. Hepcidin levels were significantly correlated with ferritin levels, and it remains to be seen whether reducing hepcidin leads to improve ESA and iron availability during anemia management.

A material stress test study on occurrence of leakage and material failure of peritoneal dialysis (PD) catheters

Peritonitis is a common complication of peritoneal dialysis (PD). Our root cause analysis allowed to attribute some cases to leakage of the PD catheter. Accordingly, a clinically based stress test study on potential material damage issues of PD catheters was performed, focusing on material damage caused by cleaning, de- and attachment procedures during dialysate changes and on the individual storage methods of PD catheters between dialysate changes. PD catheters were exposed to both chemical stress by repeating dialysate-flow and physical stress simulating de- and connecting, fixation, pressure, flexing, folding etc.—simulating standard clinical daily routine of 8–10 years PD catheter usage. Potentially by normal usage caused damages should be then detected by intraluminal pressure, light- and electron microscopy. The multi-step visual control showed no obvious damages on PD catheters nor any leakage or barrier indulgence. Our tests simulating daily routine usage of PD catheters for several years could not detect any material defects under chemical or physical stress. Hence, we presume that most PD catheter damages, as identified cause for peritonitis in some of our patients, may be due to accidental, unnoticed external damage (e.g. through scissors, while changing dressings) or neglecting PD catheter handling specifications.

FC 134WATER SAVING COMPARISON AT DIFFERENT DIALYSATE FLOWS IN EXPANDED HEMODIALYSIS

Background and Aims Expanded hemodialysis (HDx) improves clearance of middle molecules as a target for uremia treatment. According to previously published results, high cut off filters have high enough clearance to allow diminishing of dialysate flow (Qd) without detrimental in HD adequacy outcomes with less water waste. According to World Health Organization (WHO), globally, almost 800 million people lack access to safe water and 2.5 billion lack access to optimal sanitation. Is our duty to search for ways to avoid water waste. Our aim is to describe the differences in water use between HDX patients receiving Qd 400 mL/min (Group 1) vs 500 ml/min (group 2) in HD patients from 10 renal clinics in Colombia as an alternative to reduce water waste in chronic HD as a strategy from Blue Planet Dialysis initiatives. Method We performed a Sub-analysis of CORHEX Study: We calculated water use at different Qd from our database: prospective, multicentre, observational cohort study of 992 adult patients undergoing chronic HD from 12 renal clinics in Colombia who were switched from high-flux HD to MCO therapy and observed for 12 months. All patients were prescribed with HDX three times a week for a minimum of 4 hours. We analysed patients with weight lower than 70 Kg at different Qd prescriptions to calculate water use at different Qd prescriptions and performed a prediction analysis, adjusting to Qd 400 mL/min, the whole potential population with weight lower than 70 Kg. Results 462 patients with weight lower than 70 Kg were analysed, 127 patients received Qd 400 mL/min. When diminishing Qd from 500 to 400 mL/min, 24 litres were saved per session per patient without detriment of middle molecule clearance. There were no differences in adequacy HD parameters between Qd prescriptions (Table 1 and 2). Conclusion HDX allows lowering of Qd to 400 mL/min without harm for patients and with remarkable savings of potable water: 24 Litres were saved in each session per patient that can be translated in almost 3500 Litres of water each year by patient which is enough for one year for 47 adults. (Based on the WHO minimum for basic health protection of at least 20 L per person/day) (2). We consider our results especially relevant since the World Health Organization estimates that within the next 5 years, over 50% of world population could reside in geographies lacking sufficient access to water. We hope that our results from the Blue Planet dialysis research group, alongside with Dr. Agar`s and Dr. Barraclough`s green nephrology initiatives, can help educate the nephrology community on the ecological impact of dialysis and can present an innovative solution to offer HD therapy even in countries suffering from limited access to potable water.

MO1052GREEN DIALYSIS: FROM MITH TO FUTURE

Background and Aims Over 2 million persons of the 7.8 billion world population undergo hemodialysis (HD). The need is underestimated because dialysis is not available free of charge for more of half of the word population. HD is costly process and produces a large quantity of medical waste. Reducing the environmental burden should be addressed as part of implementation dialysis programs. While collaboration between physicians and several different professionals is needed to design and develop projects in this direction, these are lingering and the literature is still scant. We overviewed literature to frame what is in progress and find clues for development. Method We conducted a systematic review of the literature from 2000 searching in PubMed, Scopus, Web of Science, and Google Scholar using search keywords including dialysis, green, recycling, ecology. We retrieved 41 publications in medical and technological fields. The results were summarized in a narrative review. Results Facilities: the points on which attention is focused are the design of new buildings, whose project should encompass green solutions, including solar power and water conservation, to reduce long-term expenses and ensure an eco-friendly development. Water: water consumption remains high, and the essential targets to improve efficiency are the optimization of the reverse osmosis system, and of the dialysate flow rate, and the waste-water management. The current idea is to substitute standard reverse osmosis, which have a high percent of waste-water, with recirculating systems. Likewise, lowering of dialysate flow rate could spare water consumption with no significant difference in term of efficiency. Moreover, different solutions have been proposed to reuse reject water: local sanitation, laundry departments, sterilization units within health facilities using redirected water, landscaping and irrigation. Power: electricity needed per dialysis session is twice the average daily consumption of a family of four people. Use of renewable energies, as solar or wind power, has been proposed, and are occasionally applied to home HD. To date just one attempt has been made to recycling energy by using hydroturbine. Disposable materials: most of dialysis disposables is made of plastic, over half of which is labeled as “potentially hazardous”. Only a minimal part of the plastic used in dialysis disposables is recyclable, both because of its composition and its assembly which makes in fact impossible the segregation of the different components. Present research regards bioplastics, new assembling techniques, alternative technologies of incineration, microwave treatment, alkaline hydrolysis, biological treatment and the new steam sterilize-then-shred system. Dialysis machines: at the best of our knowledge there are no studies available about dialysis machine recycling. Personnel education: the role of dialysis staff is essential in recycling and reusing materials as well as in correctly dividing contaminated and non-contaminated waste. Conclusion The development of sustainable buildings, devices and procedures requires a multidisciplinary approach: medical, chemical, biological, engineering; in addition producers contribution and government regulation are needed. Talking about these issues, involving specialists, spreading the concepts of planet friendly treatments, gives the opportunity to share ideas, experiences and turn them into relevant innovations. A good starting point could be data collection to identify critical issues and outline pragmatic operational possibilities to reduce consumption, increase reuse and recycle, involve and instruct health care personnel, integrate dialysis facilities in the environment they are built in.

FC 093EFFICACY OF EXPANDED HEMODIALYSIS AT DIFFERENT DIALYSATE FLOWS

Background and Aims Expanded hemodialysis (HDx) is based on hollow fibre dialyzer focused on improving the clearance of middle molecules as a target for uremia treatment. According to in vitro and in vivo results, High cut off filters have high enough clearance to allow diminishing of dialysate flow. Our aim is to compare clearance of middle molecules at different dialysate flow (Qd) in HDx with TheranovaMR membranes. Our aim was to Evaluate efficacy of MCO dialyzer in terms of Kt/V and phosphorus levels at different prescribed dialysate flows (Qd) 400 vs 500 ml/min in HD patients from 10 renal clinics in Colombia. Method We performed a Prospective, observational, multicenter cohort study. Prevalent adult HD patients (&gt;90 days), with weight lower or equal to 70 Kg, were included between September to November 2017 and prospectively followed for one year with routine monthly blood tests for HD adequacy and registered at both Qd groups at 1, 3, 6, 9 and 12 months. A mixed-model repeated measures analysis (MMRM) was performed to identify statistical differences over time. Socio-demographic and clinical characteristics of all patients were summarized descriptively by Qd. Results 462 patients were included: 127 with Qd 400 mL/min. We did not find statistically significative differences in serum levels of albumin, hemoglobin, calcium or phosphorus when comparing Qd 400ml/min vs 500 ml/min. We found statistically higher Kt/V in Qd 400 mL/min patients. (Table 2). In a sustainability analysis, part of Blue Planet dialysis research group, we calculated important savings in water waste in Qd 400 mL/min group. Conclusion MCO dialyzers are at least as effective in reaching HD adequacy parameters (Kt/V, PO4) at Qd 400 as 500 mL/min with interesting savings of potable water: 24 Liters were saved in each session per patient.

Safety of a Novel Dialyzer Containing a Fluorinated Polyurethane Surface-Modifying Macromolecule in Patients with End-Stage Kidney Disease

<b><i>Background:</i></b> By inhibiting the adsorption of protein and platelets, surface-modifying macromolecules (SMMs) may improve the hemocompatibility of hemodialyzers. This trial aims to assess the performance and safety of a novel dialyzer with a fluorinated polyurethane SMM, Endexo™. <b><i>Methods:</i></b> This prospective, sequential, multicenter, open-label study (NCT03536663) was designed to meet regulatory requirements for clinical testing of new hemodialyzers, including assessment of the in vivo ultrafiltration coefficient (Kuf). Adults prescribed thrice-weekly hemodialysis were eligible for enrollment. After completing 12 hemodialysis sessions with an Optiflux® F160NR dialyzer, patients received 38 sessions with the dialyzer with Endexo. Evaluated parameters included the in vivo Kuf of the dialyzer with Endexo extent of removal of urea, albumin, and β2-microglobulin (β2M), as well as complement activation. <b><i>Results:</i></b> Twenty-three patients received 268 hemodialysis treatments during the Optiflux period, and 18 patients received 664 hemodialysis treatments during the Endexo period. Three serious adverse events were reported, and none of them were considered device related. No overt complement activation was observed with either dialyzer. Both dialyzers were associated with comparable mean increases in serum albumin levels from pre- to posthemodialysis (Optiflux: 7.9%; Endexo: 8.0%). These increases can be viewed in the context of a mean increase in hemoglobin of approximately 5% and a mean ultrafiltration volume removed of approximately 2.2 L. The corrected mean β2M removal rate was 47% higher during the Endexo period (67.73%). Mean treatment times (208 vs. 205 min), blood flow rates (447.7 vs. 447.5 mL/min), dialysate flow rates (698.5 vs. 698.0 mL/min), urea reduction ratio (82 vs. 81%), and spKt/V (2.1 vs. 1.9) were comparable for the Endexo and Optiflux periods, respectively. The mean (SD) Kuf was 15.85 (10.33) mL/h/mm Hg during the first use of the dialyzer with Endexo (primary endpoint) and 16.36 (9.92) mL/h/mm Hg across the Endexo period. <b><i>Conclusions:</i></b> The safety of the novel dialyzer with Endexo was generally comparable to the Optiflux dialyzer, while exhibiting a higher β2M removal rate.

Novel use of premixed dialysate bags during water supply interruption in acute hospital setting

Dialysis patients are exposed to large amounts of water during conventional intermittent hemodialysis (IHD) hence strict regulations exist for 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 dialysis dependent inpatients is essential both from ultrafiltration and clearance standpoint. At our hospital, an unforeseen water disruption occurred and we were able to continue to provide renal replacement therapy with pre-made bagged dialysate to mitigate the impact on our dialysis patients. This is a novel method in utilizing available machines and dialysate, which we normally stock for continuous renal replacement therapy, 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. As this situation occurred in the midst of the Sars CoV2 pandemic we had to be mindful of dialysate volumes as well as staffing time. Here we present our investigation into the cause of 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 it was successful as implemented and tailored with adjustments for patients requiring higher clearance for specific indication such as severe hyperkalemia.