What Total Body Water Measurement Should Be Used for Prescribing the Dialysis Dose in Low-Flow Home Daily Dialysis?

<b><i>Introduction:</i></b> In low-flow home daily dialysis (HDD), the dialysis dose is evaluated from the total body water (TBW). TBW can be estimated by anthropometric methods or bioimpedance spectroscopy. <b><i>Methods:</i></b> A multicentric cross-sectional study of patients in HDD for &#x3e;3 months was conducted to assess the correlation and the difference between the anthropometric estimate of TBW (Watson-TBW) and the bioimpedance estimate (BIS-TBW) and to analyse the impact on the dialysate volume prescribed. <b><i>Results:</i></b> Forty patients from 10 centres were included. The median BIS-TBW and Watson-TBW were 35.1 (29.1–41.4 L) and 36.9 (32–42.4 L), respectively. The 2 methods had a good correlation (<i>r</i> = 0.87, <i>p</i> &#x3c; 0.05). However, Bland-Altman analysis showed an overestimation of TBW with Watson’s formula, with a bias of 2.77 L. For 4, 5, or 6 sessions per week, the use of Watson-TBW increases the dialysate prescription per week by 100 L, 45 L, or 10 L, respectively, over our entire cohort. There is no increase in the volume of dialysate prescribed with the 7 sessions per week schedule. <b><i>Conclusion:</i></b> BIS-TBW and Watson-TBW estimation have a good correlation; however, Watson’s equation overestimates TBW. This overestimation is negligible for a prescription frequency of &#x3e;5 sessions per week.

Elimination of fosfomycin during dialysis with the Genius system in septic patients

To assess fosfomycin (FOS) elimination in patients with sepsis and acute kidney injury (AKI) undergoing slow-extended daily dialysis (SLEDD) with the Genius system in a prospective observational study. After ethics committee approval ten patients with sepsis and AKI stage 3 underwent daily SLEDD sessions of eight hours. FOS was applied i.v. at doses of 3 × 5 g per day. FOS serum levels were measured pre- and post hemofilter before, during, and after SLEDD sessions, and instantaneous clearance was calculated. In five of the patients, we analyzed FOS levels after the first dose, in the other five patients serum levels were measured during ongoing therapy. FOS was eliminated rapidly via the hemofilter. FOS clearance decreased from 152 ± 10 mL/min (start of SLEED session) to 43 ± 38 mL/min (end of SLEDD session). In 3/5 first-dose patients after 4–6 h of SLEDD the FOS serum level fell below the EUCAST breakpoint of 32 mg/L for Enterobacterales and Staphylococcus species. In all patients with ongoing fosfomycin therapy serum levels were high and above the breakpoint at all times. FOS toxicity or adverse effects were not observed. FOS serum concentrations exhibit wide variability in critically ill patients with sepsis and AKI. FOS is eliminated rapidly during SLEDD. A loading dose of 5 g is not sufficient to achieve serum levels above the EUCAST breakpoint for common bacteria in all patients, considering that T > MIC > 70% of the dosing interval indicates sufficient plasma levels. We thus recommend a loading dose of 8 g followed by a maintenance dose of 5 g after a SLEDD session in anuric patients. We strongly recommend therapeutic drug monitoring of FOS levels in critically ill patients with AKI and dialysis therapy.

16 Sustained Low Efficiency Dialysis (SLED) in Burn Patients with Acute Kidney Injury

Introduction Acute Kidney Injury (AKI) is common among patients with major burns and may require treatment with renal replacement therapy (RRT). Although continuous renal replacement therapy (CRRT) modalities are widely used and offer many advantages over traditional intermittent hemodialysis (IHD), CRRT is expensive, labour-intensive, and may not be available in some burn centers. Sustained Low Efficiency Dialysis (SLED) is a moderately efficient alternative to IHD, but its use in burn patients with AKI has not been described. The purpose of this study was to review our experience with SLED. Methods Retrospective review of adult burn patients with AKI treated by SLED between 07/2013 and 03/2020 at an adult regional ABA-verified burn center. Data was obtained from the electronic medical record including daily dialysis forms completed by the nephrology service. Values are shown as mean +/- SD or median (IQR) as appropriate. Results We evaluated 367 distinct SLED sessions provided to 33 patients [age 55.8 +/- 14 yrs., %TBSA burn 33 +/-19, % TBSA full thickness burn 10.5 (0, 35.8), and 54.5% with inhalation injury]. The serum creatinine (sCr) prior to the start of SLED was 2.96 (2.3, 4.17) mg/dL. SLED was initiated 5 (3, 10.8) days (range 0–24 d) post burn, and 7 (3.3, 12.8) sessions (range 1–44) with a duration of 4 (4,6) hours each were given per patient. Heparinization was required in 22 sessions (6%), and 46 sessions (12.5%) were aborted, most commonly due to clotting of the lines or circuit, and rarely (4%) due to hypotension. The net ultrafiltrate removal was 1.2 (0.7–2) L, with a dialysate flow rate of 350 (350, 500) mL/min. Among 208 sessions where patients were not on vasopressors (VPs) Pre-SLED, one or more VPs were required in 19 sessions (9%) during or at the termination of SLED. Among 116 sessions where patients were receiving norepinephrine (NEpi) infusions pre-SLED, the NEpi dose dropped from 7.3 +/- 4.2 µgm/min to 6 +/- 4.5 µgm/min (p=0.03). Pre and Post SLED values for blood pressure, creatinine, and potassium are shown in the table. The mortality rate was 36.4%, hospital length of stay was 42 (20.5, 61.5) days, and among surviving patients, 2 (9.5%) required dialysis post discharge. Conclusions SLED was effective and well tolerated. Hemodynamic instability was infrequently encountered.

Physical Function and Clinical Outcomes in Hemodialysis Patients: China Dialysis Outcomes and Practice Patterns Study

Background: Hemodialysis (HD) patients usually have impaired physical function compared with the general population. Self-reported physical function is a simple method to implement in daily dialysis care. This study aimed to examine the association of self-reported physical function with clinical outcomes of HD patients. Methods: The Dialysis Outcomes and Practice Patterns Study (DOPPS) is a prospective cohort study. Data on 1,427 HD patients in China DOPPS5 were analyzed. Self-reported physical function was characterized by 2 items of “moderate activities limited level” and “climbing stairs limited level.” Demographic data, comorbidities, hospitalization, and death records were collected from patients’ records. Associations between physical function and outcomes were analyzed using COX regression models. Results: Compared to “limited a lot” in moderate activities, “limited a little” and “not limited at all” groups were associated with lower all-cause mortality after adjusted for covariates (HR: 0.652, 95% CI: 0.435–0.977, and HR: 0.472, 95% CI: 0.241–0.927, respectively). And, not limited in moderate activities was associated with lower risk of hospitalization than the “limited a lot” group after adjusted for covariates (HR: 0.747, 95% CI: 0.570–0.978). Meanwhile, compared to “limited a lot” in climbing stairs, “limited a little” and “not limited at all” groups were associated with lower all-cause mortality (HR: 0.574, 95% CI: 0.380–0.865 and HR: 0.472, 95% CI: 0.293–0.762, respectively) but not hospitalization after fully adjusted. Conclusion: Higher limited levels in self-reported physical function were associated with higher risk of all-cause mortality and hospitalization in HD patients.

Comparison of different anticoagulation strategies for renal replacement therapy in critically ill patients with COVID-19: a cohort study

Background Critically ill coronavirus disease 2019 (COVID-19) patients have a high risk of acute kidney injury (AKI) that requires renal replacement therapy (RRT). A state of hypercoagulability reduces circuit life spans. To maintain circuit patency and therapeutic efficiency, an optimized anticoagulation strategy is needed. This study investigates whether alternative anticoagulation strategies for RRT during COVID-19 are superior to administration of unfractionated heparin (UFH). Methods Retrospective cohort study on 71 critically ill COVID-19 patients (≥18 years), admitted to intensive care units at a tertiary health care facility in the southwestern part of Germany between February 26 and May 21, 2020. We collected data on the disease course, AKI, RRT, and thromboembolic events. Four different anticoagulatory regimens were administered. Anticoagulation during continuous veno-venous hemodialysis (CVVHD) was performed with UFH or citrate. Anticoagulation during sustained low-efficiency daily dialysis (SLEDD) was performed with UFH, argatroban, or low molecular weight heparin (LMWH). Primary outcome is the effect of the anticoagulation regimen on mean treatment times of RRT. Results In patients receiving CVVHD, mean treatment time in the UFH group was 21.3 h (SEM: ±5.6 h), in the citrate group 45.6 h (SEM: ±2.7 h). Citrate anticoagulation significantly prolonged treatment times by 24.4 h (P = .001). In patients receiving SLEDD, mean treatment time with UFH was 8.1 h (SEM: ±1.3 h), with argatroban 8.0 h (SEM: ±0.9 h), and with LMWH 11.8 h (SEM: ±0.5 h). LMWH significantly prolonged treatment times by 3.7 h (P = .008) and 3.8 h (P = .002), respectively. Conclusions UFH fails to prevent early clotting events in the dialysis circuit during COVID-19. For patients, who do not require effective systemic anticoagulation, regional citrate dialysis is the most effective strategy. For patients, who require effective systemic anticoagulation, the usage of LMWH results in the longest circuit life spans. The proposed anticoagulatory strategies are safe, can easily be monitored, and allow an individualized treatment. Graphical abstract

Transition between peritoneal dialysis and home hemodialysis in Belgium and France in the RDPLF

A renewed interest in home hemodialysis has emerged in recent years, favored by the availability of new dialysis machines and encouraging publication about daily hemodialysis. Since 2013, the RDPLF has become a home dialysis registry that records the data of patients treated with peritoneal dialysis and those treated with home hemodialysis, all techniques combined. Nine Belgian centers and fifty seven French centers communicate information about their patients treated by hemodialysis at home. In the RDPLF centers, 56% of Belgian home hemodialysis patients are treated with daily hemodialysis, in France 83% of home patients are on daily dialysis. This French difference however is not representative of the whole country but can be explained through recruitment of new centers already involved in peritoneal dialysis and convinced by the interest of continuaous daily treatment. In both countries, 13% of home hemodialysis patients have been previously treated with peritoneal dialysis with an interim period of in-center hemodialysis or transplantation. The median duration of in center hemodialysis is 10 months with extremes ranging from 2 months to 25 years. PD patients treated secondarily in home hemodialysis are mainly young, non-diabetic and independent patients. Early information in patients who have a risk of peritoneal dialysis failure, and the provision of materials allowing both techniques would reduce or abolish a transient transfer to in center hemodialysis and would ensure home care in patients who prefer.

Evaluation of Hemodialysis Arteriovenous Bruit by Deep Learning

Physical findings of auscultation cannot be quantified at the arteriovenous fistula examination site during daily dialysis treatment. Consequently, minute changes over time cannot be recorded based only on subjective observations. In this study, we sought to supplement the daily arteriovenous fistula consultation for hemodialysis patients by recording the sounds made by the arteriovenous fistula and evaluating the sounds using deep learning methods to provide an objective index. We sampled arteriovenous fistula auscultation sounds (192 kHz, 24 bits) recorded over 1 min from 20 patients. We also extracted arteriovenous fistula sounds for each heartbeat without environmental sound by using a convolutional neural network (CNN) model, which was made by comparing these sound patterns with 5000 environmental sounds. The extracted single-heartbeat arteriovenous fistula sounds were sent to a spectrogram and scored using a CNN learning model with bidirectional long short-term memory, in which the degree of arteriovenous fistula stenosis was assigned to one of five sound types (i.e., normal, hard, high, intermittent, and whistling). After 100 training epochs, the method exhibited an accuracy rate of 70–93%. According to the receiver operating characteristic (ROC) curve, the area under the ROC curves (AUC) was 0.75–0.92. The analysis of arteriovenous fistula sound using deep learning has the potential to be used as an objective index in daily medical care.

Superior anticoagulation strategies for renal replacement therapy in critically ill patients with COVID-19: a cohort study

BackgroundCoronavirus disease 2019 (COVID-19) patients who are admitted to intensive care units (ICU) have a high risk of requiring renal replacement therapy (RRT) due to acute kidney injury (AKI). Concomitantly, COVID-19 patients exhibit a state of hypercoagulability that can affect circuit lifespan. An optimal anticoagulation strategy is therefore needed in order to maintain circuit patency and therapeutic efficiency of RRT.MethodsRetrospective single-centre cohort study on 71 critically ill COVID-19 patients at the University of Freiburg Medical Center. Included were all patients aged 18 years and older with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection that were admitted to ICU between February 26 and May 21, 2020. We collected data on the COVID-19 disease course, AKI, RRT, thromboembolic events and anticoagulation. Primary outcome of the study was the effect of different anticoagulation strategies during RRT on extracorporeal circuit lifespans.ResultsAnticoagulation during continuous veno-venous haemodialysis (CVVHD) was performed with unfractionated heparin (UFH) or citrate. Mean treatment time in the UFH group was 21.3h (SEM: ±5.6h). Mean treatment time in the citrate group was 45.6h (SEM: ±2.7h). Citrate anticoagulation prolonged treatment duration significantly by 24.4h (p=0.0014). Anticoagulation during sustained low-efficiency daily dialysis (SLEDD) was performed with UFH, argatroban or low molecular weight heparin (LMWH). Mean dialysis time with UFH was 8.1h (SEM: ±1.3h), argatroban 8.0h (SEM: ±0.9h) and LMWH 11.8h (SEM: ±0.5h). Compared to UFH and argatroban, LMWH significantly prolonged treatment times by 3.7h (p=0.0082) and 3.8h (p=0.0024), respectively.ConclusionsUFH fails to prevent early clotting events in dialysis circuits. For patients, who do not require an effective systemic anticoagulation, regional citrate dialysis is the most effective strategy in our cohort. For patients, who require an effective systemic anticoagulation treatment, the usage of LMWH results in the longest circuit life spans.FundingBerta-Ottenstein-Programme for Clinician Scientists, Faculty of Medicine, University of Freiburg, Germany. Else Kröner-Fresenius-Stiftung, Bad Homburg, Germany. Deutsche Forschungsgemeinschaft, Bonn, Germany.

P0631COMPLICATIONS OF TREATMENT WITH HIGH CUT OFF FILTERS FOR ACUTE KIDNEY INJURY SECONDARY TO MULTIPLE MYELOMA

Background and Aims Acute kidney injury is a frequent complication of MM that can affect 18 to 56% of patients and more than 10% end up needing dialysis. One of the drawbacks associated with the technique is attributed to the albumin loss. The other complications are related with the dialysis technique itself, especially infections, as highlighted by the Eulite study. The objective of the study is to check that there are no more complications in dialysis with High Cut Off filters than in conventional Hemodialysis. Method We are the referral hospital in our community in the treatment of acute kidney injury secondary to myeloma. We have performed 28 treatments of hemodialysis with High cut off filters (HD-HCO). The HD-HCO protocol includes daily dialysis session of 6 hours during the first 6 days to subsequently switch to dialysis every other dayuntil free light chains levels below 500 mg/L, or until the recovery of renal function allows the independence of dialysis. All these patients have a chemotherapy regimen based on Bortezomib (25 of the 28 treatments) and Dexamethasone (28 treatments). A retrospective analysis of the 28 treatments that are performed with HD-HCO after 8 years of experience (July 2011 to May 2019) to demostrate the presence of the same complications as the conventional Hemodialysis. Results Loss of albumin is one of the main drawbacks of the technique. Our patients had no changes in albumin levels due to the fact that our protocol includes the infusion of 2 vials of 20% albumin of 50 ml. at the end of each HD-HCO session. Figure 2 Another concern is intradialytic complications. We have reviewed this topic and our results show that patients in HD-HCO do not present a greater number of complications than those who dialyze with HD-HD or other conventional dialysis. The total number of sessions was 298. 21 patients developed hypotension (7%). The number of sessions in which the patient presented fever was 6 (2%), coagulation of the circuit occurred in 23 sessions (7,7%). The catheter dysfunction (when it does not allow to reach 250 ml/min of blood flow) in 26 times(8.7%) and only 13 times the replacement of the catheter (4.26%) was necessary, consequently, in those who required a greater number of dialysis sessions. In only 1 case (patient who required 27 sessions) to place a permanent Tesio catheter was necessary. Figure 1 In referring to complications of dialysis for AKI secondary to myeloma, few studies consider them. These studies focus on quantifying the reduction of light chains and the efficiency of the treatment, but don’t keep in mind the record of the complications. In the EuLITE study, authors observed a greater number of lung infections in the HD-HCO group (12 vs 3) p = 0.014 and attributed this difference to extended dialysis and albumin loss.We have not observed this problem. The levels of albumin are stable with our infusion protocol of 2 vials of 20% human albumin of 50 ml at the end of each HD-HCO. There’s no more complications than conventional dialysis, even infection ones. 13 febrile episodes occurred in 6 patients (more than 37,5ºC). Blood cultures were collected in all patients, being positive in only 4 patients. Germs found were: Escherichia coli (treated with Amoxicilin/clavulanic), Staphylococcus aureus (treated with Daptomycin), Staphylococcus epidermidis (treated with Meropenem) and Klebsiella pneumoniae (treated with Meropenem too). This 4 patients were the ones who required the replacement of the catheter. Conclusion 1. - Our findings indicate that the HD-HCO has the same safety profile as the conventional Hemodialysis. 2.- There is no serious infectious complications in our patients despite of the fact that all of them are immunosuppressed patients (AKI secondary to Multiple Myeloma in patients treated with chemotherapy)