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The epidemiology of acute renal failure (ARF) has recently displayed an increasing shift of cases from the renal ward to the intensive care unit (ICU). Accordingly, two groups of physicians are now highly involved in the care of ARF patients: nephrologists and intensivists. Renal replacement therapy has also evolved a great deal over the last 20 ye...
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Acute renal failure (ARF) is currently more frequently seen as part of a more complex syndrome defined by sepsis and/or multiple organ failure. Evolution in the field of hemodialysis has led to a parallel development of new systems for continuous renal replacement therapy (CRRT) in critically ill patients. The various CRRT modalities differ in the...
Kidney injury, including acute kidney injury (AKI) and chronic kidney disease (CKD), has become very common in critically ill patients treated in ICUs. Many epidemiological studies have revealed significant associations of AKI and CKD with poor outcomes of high mortality and medical costs. Although many basic studies have clarified the possible mec...
Citations
... CKRT is also used in fluid management (especially when the obligate intake is large), burns, sepsis, and heart and liver failure patients (17). The choice of modality has been variable and is based on local ICU practices and the availability of resources (18). CKRT is more costly than IHD. ...
The COVID-19 pandemic resulted in an unprecedented burden on intensive care units (ICUs). With increased demands and limited supply, critical care resources, including dialysis machines, became scarce, leading to the undertaking of value-based cost-effectiveness analyses and the rationing of resources to deliver patient care of the highest quality. A high proportion of COVID-19 patients admitted to the ICU required dialysis, resulting in a major burden on resources such as dialysis machines, nursing staff, technicians, and consumables such as dialysis filters and solutions and anticoagulation medications. Artificial intelligence (AI)-based big data analytics are now being utilized in multiple data-driven healthcare services, including the optimization of healthcare system utilization. Numerous factors can impact dialysis resource allocation to critically ill patients, especially during public health emergencies, but currently, resource allocation is determined using a small number of traditional factors. Smart analytics that take into account all the relevant healthcare information in the hospital system and patient outcomes can lead to improved resource allocation, cost-effectiveness, and quality of care. In this review, we discuss dialysis resource utilization in critical care, the impact of the COVID-19 pandemic, and how AI can improve resource utilization in future public health emergencies. Research in this area should be an important priority.
... Approximately half of all intensive care unit (ICU) patients will go through at least one episode of AKI during hospitalization [3]. In critically ill patients, renal replacement therapy (RRT) is used to provide support for AKI or multiple organ dysfunction syndrome (MODS) [4,5]. Various reports have shown broad variability in estimating the use of RRT in ICU patients, from 5-10% to 38% or even 59.2%, with a trend of 10% increase per year in light of the continuous change in the critically ill patient profile [6][7][8][9][10]. ...
Objectives:
Population-based studies regarding renal replacement therapy (RRT) used in critical care populations are useful to understand the trend and impact of medical care interventions. We describe the use of RRT and associated outcomes (mortality and length of intensive care stay) in a level 1 hospital.
Design:
A retrospective descriptive observational study.
Patients:
Critically ill patients admitted to the ICU from 1 January to 31 December 2018.
Interventions:
Age, gender, ward of admission, primary organ dysfunction at admission, length of hospital stay (LOS), mechanical ventilation, APACHE, SOFA and ISS scores, the use of vasopressors, transfusion, RRT and the number of RRT sessions were extracted.
Results:
1703 critically ill patients were divided into two groups: the RRT-group (238 patients) and the non-RRT group (1465 patients). The mean age was 63.58 ± 17.52 (SD) in the final ICU studied patients (64.72 ± 16.64 SD in the RRT-group), 60.5% being male. Patients admitted from general surgery ward needing RRT were 41.4%. The specific scores, the use of vasopressors, transfusions and mortality were higher in the RRT-group. The ICU LOS was superior in the RRT-group, regardless of the primary organ dysfunction.
Conclusions:
RRT was practiced in 13.9% of patients (especially after age of 61), with mortality being the outcome for 66.8% of the RRT-group patients. All analyzed data were higher in the RRT group, especially for multiple trauma and surgical patients, or patients presenting cardiac or renal dysfunctions at admission. We found significant increased ISS scores in the RRT-group, a significant association between the need of vasopressors or transfusion requirement and RRT use, and an association in the number of RRT sessions and LOS (p < 0.001).
... En países desarrollados como los EE.UU., la HD intermitente o la terapia de reemplazo renal continuo (TRRC) son los modos principales de TRR para el tratamiento de la LRA 10 . Sin embargo, en el pico de la enfermedad por coronavirus, la capacidad de diferentes centros médicos para proporcionar HD y TRRC para el tratamiento de LRA se ha visto abrumada debido al aumento en el número de pacientes con LRA que requieren de TRR combinado con escasez de personal relacionada con la enfermedad 11 . ...
La lesión renal aguda se produce en el 4-23% de los casos en pacientes con coronavirus 2 del síndrome respiratorio agudo grave (SARS-CoV-2). La gravedad de la pandemia ha provocado una escasez significativa de suministros médicos, entre ellos la hemodiálisis, sin embargo, el manejo de diálisis peritoneal en esta entidad por enfermedad por coronavirus 2019 (COVID-19) no ha recibido mucha atención, pudiendo ser una solución práctica para los pacientes con lesión renal aguda y enfermedad renal crónica en etapa terminal. Este artículo describimos nuestra experiencia con la implementación de diálisis peritoneal urgente para lesión renal aguda en pacientes con COVID-19.
... Dazu gehörte die Etablierung von Akut-Peritonealdialyse(PD)-Programmen [9,11,31]. Die Akut-PD bei AKI stellt für Nephrologen in Industrieländern zwar Neuland dar, ist aber eine in Entwicklungsländern lange etablierte Methode [26,28]. Eine Reihe von klinischen Studien zeigt, dass Akut-PD auch bei beatmeten Intensivpatient*innen komplikationsarm durchgeführt werden kann [2,14,25]. ...
Acute kidney injury (AKI) is a frequent and severe complication in coronavirus disease 2019 (COVID-19) patients in the intensive care unit. The development of COVID-19 associated AKI is closely linked to the severity of the disease course. The main risk factor for kidney failure requiring kidney replacement therapy is the necessity for invasive ventilation, whereby the onset of renal failure is often closely associated with the timing of intubation. Additionally, the risk factors for a severe course of COVID-19 have been shown to also be risk factors for renal failure. AKI in COVID-19 shows a high mortality and in some patients leads to chronic kidney disease; however, full recovery of kidney function in survivors who need dialysis is not uncommon. With respect to prevention and treatment of renal failure associated with COVID-19, the same recommendations as for AKI from other causes are valid (Kidney Disease: Improving Global Outcomes, KDIGO bundles). Due to the large numbers of patients in the setting of overwhelmed resources, the availability of extracorporeal renal replacement procedures can become critical, especially since hypercoagulation is frequent in COVID‑19. In order to avoid triage situations, in some centers acute peritoneal dialysis was used as an alternative to extracorporeal procedures.
... In developed countries such as the United States, either intermittent hemodialysis (HD) or continuous kidney replacement therapy (CKRT) are the primary modes of KRT for the management of acute kidney injury (AKI). 1 However, at the peak of the coronavirus disease 2019 (COVID-19) pandemic, our medical center's ability to provide intermittent HD and CKRT for the treatment of AKI was overwhelmed due to the surge in the number of patients with AKI requiring KRT combined with personnel shortages related to illness. From March 11, 2020 to April 26, 2020, there were 3,345 patients with confirmed COVID-19 admitted to Montefiore Medical Center (MMC) in The Bronx, NY, of which 438 (13.1%) required intensive care unit (ICU) admission (M. ...
... With adequate PD, solute clearance, ultrafiltration, and correction of metabolic acidosis can improve the morbidity of patients with severe AKI. 4,5,9 However, there is a notable discrepancy in the frequency of use comparing intermittent HD and CKRT with PD as the primary choice for dialysis in patients with AKI stage 3. 1 In an international survey of nephrologists and intensivists, PD use accounted for less than one-third of patients, whereas CKRT modalities were used in almost half. 1 Although there are many reasons for this incongruence, there have been studies that demonstrate the use of urgent PD in AKI settings with success. [3][4][5]17 Gabriel et al 5 (2008) demonstrated that high-volume continuous PD proved to be an effective form of dialysis in patients with AKI with multiple comorbid conditions, including those with a high level of acuity requiring ICU admission. ...
... 4,5,9 However, there is a notable discrepancy in the frequency of use comparing intermittent HD and CKRT with PD as the primary choice for dialysis in patients with AKI stage 3. 1 In an international survey of nephrologists and intensivists, PD use accounted for less than one-third of patients, whereas CKRT modalities were used in almost half. 1 Although there are many reasons for this incongruence, there have been studies that demonstrate the use of urgent PD in AKI settings with success. [3][4][5]17 Gabriel et al 5 (2008) demonstrated that high-volume continuous PD proved to be an effective form of dialysis in patients with AKI with multiple comorbid conditions, including those with a high level of acuity requiring ICU admission. ...
At Montefiore Medical Center, in The Bronx, NY, the first case of coronavirus disease 2019 (COVID-19) was admitted on March 11, 2020. At the height of the pandemic, there were 855 patients with COVID-19 admitted on April 13, 2020. Due to high demand for dialysis and shortages of staff and supplies, we started an urgent peritoneal dialysis (PD) program. From April 1st to April 22nd, 30 patients were started on PD. Of those 30 patients, 14 died during their hospitalization, 8 were discharged, and 8 were still hospitalized as of May 14, 2020. Although the PD program was successful in its ability to provide much-needed kidney replacement therapy (KRT) when hemodialysis was not available, challenges to delivering adequate PD dosage included difficulties in providing nurse training and availability of supplies. Providing adequate clearance and ultrafiltration for patients in intensive care units was especially difficult due to high prevalence of hypercatabolic state, volume overload, and prone positioning. PD was more easily performed in non-critically ill patients outside the intensive care unit. Despite these challenges, we demonstrate that urgent PD is a feasible alternative to hemodialysis in situations with critical resource shortages.
... Mostly nephrologists, followed by specialists in anesthesiology, reanimatology and intensive care and physicians with other specialties, of whom 40.4% have work experience of over 20 years and most of them are employed in tertiary care institutions, participated in our questionnaire.According to the results, slightly more than half of the participants still use the RIFLE criteria to define the AKI, while in terms of representation, the following use the KDIGO criteria, which is different from the results published last year, in which the KDIGO criteria are dominant(5). The higher prevalence of the RIFLE classification has been reported in previous studies, and in our sample it can be explained by the participation of nonnephrological specialty respondents and possibly by a high percentage of physicians with many years of experience who are somewhat skeptic about accepting novelties(6,7). ...
Background / Aim. Absence of clear guidance in the definition, diagnostics and indications for renal replacement treatment (RRT) is present. The aim of this survey is creating a unique strategy for diagnostics and treatment of acute kidney injury (AKI) based on the current clinical practice. Methods. ? Results. We have conducted a multicentric web-survey among nephrologists (46.8%) and other physicians in Serbia. The sample consisted of 119 participants, 78.9% out of which filled out the survey forms correctly, and were, therefore, included in the analysis. Most of them responded that the nephrologist indicates (76.8%) and prescribes (74.5%) of continuous renal replacement therapy (CRRT).The application of KDIGO 2 criterion for ?early? start of CRRT used 74.5% of the respondents, and 91.5% of them started ?late? initiation of CRRT in the presence of complications associated with AKI or poor response to conservative treatment. Regarding clinical experience of the respondents, 74.5% of them marked ?early? start of CRRT within 12 hours whereas 56.4% of them considered the start of CRRT after 48h as ?late?. The most commonly used modality was continuous venous hemodiafiltration (37.6%). Most participants used heparin as anticoagulant (95.7%) with average life span of filters less than 24 hours (71.3%) and 25 ml/kg/h efficiency target dialysis effluent dose (45.2%) during CRRT. The most common complications of CRRT were hypotension (55.3%) and catheter-related infections (29.8%). Conclusion. ?Early? start of CRRT is considered favorite by the majority of the participants. According to the obtained data, standardization of the strategy in the diagnostics and treatment of AKI is necessary.
... is is the standard practice in most ICUs' in the United Kingdom (UK) and the Republic of Ireland [2]. However, limited consensus exists regarding RRT timing, optimum dosing, modality, and therapeutic efficacy beyond AKI management. ...
Renal replacement therapy (RRT) is frequently required to manage critically ill patients with acute kidney injury (AKI). There is limited evidence to support the current practice of RRT in intensive care units (ICUs). Recently published randomized control trials (RCTs) have further questioned our understanding of RRT in critical care. The optimal timing and dosing continues to be debatable; however, current evidence suggests delayed strategy with less intensive dosing when utilising RRT. Various modes of RRT are complementary to each other with no definite benefits to mortality or renal function preservation. Choice of anticoagulation remains regional citrate anticoagulation in continuous renal replacement therapy (CRRT) with lower bleeding risk when compared with heparin. RRT can be used to support resistant cardiac failure, but evolving therapies such as haemoperfusion are currently not recommended in sepsis.
... Approximately 450 participants attended the course; of these, 369 (82%) filled the survey forms correctly, and therefore were included in the present analysis. Although attendees from Europe were the most frequent (71%), participation from the rest of the world (29%) was relevant for the purposes of such survey (Fig. 1) and appeared to increase, compared to previous years [16][17][18]. Specialties were quite evenly distributed, since 56% participants were nephrologists, 25% were intensivists working in medical intensive care units (ICU), 8% worked in mixed medical-surgical ICU, 3% in surgical ICU, 3% in emergency, 2% in cardiac ICU, 1% in pediatric/neonatal ICU, 1% in cardiac surgery ICU, and 1% in neurosurgical ICU. ...
... The group of participants was quite large (n = 450). Participation of the academic and non-academic centers has been dramatically improved from 56 to 63% in comparison to previous years [16][17][18]. Our participants chose different criteria to define AKI in their population. ...
... Most of them defined AKI with an increase in SCr followed by decreased urine output. On comparison with the results of previous published data in 2007 where majority of the participants opted only RIFLE criteria for AKI classification, this year they chose KDIGO criteria, even if apparently RIFLE and AKIN are still widely applied [18]. This is due to the 2012 KDIGO guidelines to improve kidney health and define AKI in most 6 DOI: 10.1159/000493724 of the population worldwide. ...
Introduction:
Definition, prevention, and management of acute kidney injury (AKI) and the optimal prescription and delivery of renal replacement therapy (RRT) are currently matters of ongoing discussion. Due to the lack of definitive published literature, a wide gap might exist between routine clinical practice and available recommendations. The aim of this survey was to explore the clinical approach to AKI and RRT in a broad population of nephrologists and intensivists participating in the 36th International course on AKI and Continuous RRT (CRRT), held in Vicenza in June 2018. The responses of the 369 participants to a questionnaire on several aspects of critical care nephrology were analyzed and detailed.
Results:
Approximately 450 participants attended the course; of these, 369 (82%) correctly filled the survey forms. According to the reported answers, the average incidence of AKI in respondents' intensive care units (ICU) was 26.8% (SD ±15.99) and AKI requiring dialysis was 13% (SD ±29.7). Sixty-four percent of participants defined AKI as an increase in serum creatinine (SCr) up to 0.99 mg/dL (SD ±0.88 mg/dL); 2.4% defined AKI as an increase in urea nitrogen up to 83.6 mg/dL (SD ±36.6 mg/dL); 33.6% defined AKI as decreased urine output to less than 1 mL/kg/h (SD ±0.6 mL/kg/h). The most common answer to classify AKI was Kidney Disease: Improving Global Outcomes (KDIGO; 41%) criteria. Most of the participants (25%) think novel biomarkers should replace SCr on daily routine laboratory screening, and Cystatin C was the most commonly used biomarker (19%). The use of diuretics in AKI patients was high (62%). Continuous RRT (59%) and heparin anticoagulation (42%) appeared to be the most common approaches in ICU.
Conclusions:
KDIGO appeared to be widely applied. The use of novel biomarkers has also emerged in recent years even if some consistent cost-benefit evidence is still lacking. There is a trend of increased awareness about AKI and extracorporeal treatments seem to be increasingly applied, when compared to previous surveys. Educational efforts and AKI management standardization still appear to be a fundamental aspect to harmonize therapeutic approaches and improve patients' outcomes.
... It is characterized by retention of both nitrogenous and non-nitrogenous waste products of metabolism, as well as disordered electrolyte, acid-base and fluid homeostasis. There is evidence that even relatively small acute reductions in kidney function are associated with poorer outcomes, including increase mortality and higher risk of long-term dialysis [2]. AKI categorize to Pre-renal AKI, Intrinsic renal AKI, and Post-renal AKI [3]. ...
... Commencement of renal replacement therapy (RRT) is common among critically ill patients (1), and continuous RRT (CRRT) is the most widely used RRT technique in this popu- lation (2)(3)(4)(5). In clinical practice, CRRT can significantly affect of RRT have been published (16)(17)(18)(19)(20)(21)(22). ...
Objectives
To determine the adsorption and elimination characteristics of meropenem and piperacillin during simulated continuous renal replacement therapy (CRRT), and to compare the observed data from this ex vivo study with previous data from clinical studies.
Method
This was an experimental study utilizing a modified CRRT circuit and polysulfone membrane (1.2 m2), circulated with a blood-crystalloid mixture. Adsorption onto the CRRT circuit was tested over a 4-h period, and clearance was assessed separately using variable continuous hemofiltration settings.
Results
A rapid 9% reduction in circulating meropenem and piperacillin concentrations was observed at approximately 0.5 and 1.0 h for each antibiotic, respectively. The post-dilution setting was associated with a significantly higher sieving coefficient (Sc) and filter clearance (CLfilter) (mean ± SD) (Sc 1.14 ± 0.10 versus 1.06 ± 0.04; CLfilter 19.05 ± 1.63 versus 17.59 ± 0.62 ml/min, P values <0.05) for meropenem. No significant differences were observed for piperacillin pharmacokinetics. Clinically comparable Sc data were observed between data obtained from the ex vivo study and data from previous clinical studies, for both antibiotics.
Conclusions
Meropenem and piperacillin appear to be rapidly adsorbed into the CRRT circuit, and the delivery site of fluid replacement significantly influences meropenem pharmacokinetics. However, these findings are likely to be clinically insignificant and not affect dosing requirements. This ex vivo method could be a surrogate for future clinical pharmacokinetic studies of CRRT. Further research is required to explore the applicability of the ex vivo method to further characterize antibiotic pharmacokinetics during CRRT.
