Effects of normal saline flush on extracorporeal circuit lifespan and solute removal in continuous renal replacement therapy_West China Medical Journal

Authors：

HUANG Xianli ^1,2 , ZHANG Sheng ¹ , LIN Li ¹ , WANG Fang ¹ ,  ZHANG Ling ¹

1. Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;
2. Department of Nephrology, Zigong First People’s Hospital, Zigong, Sichuan 64300, P. R. China;

Corresponding?author：

ZHANG Ling, Email: zhangling_crrt@163.com

Keywords：

Without anticoagulation; continuous renal replacement therapy; continuous veno-venous hemodiafiltration; normal saline flush; extracorporeal circuit lifespan

DOI：

10.7507/1002-0179.202205163

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Objective To investigate the effects of normal saline flushing and its frequency on extracorporeal circuit lifespan and solute removal in continuous renal replacement therapy (CRRT) without anticoagulation. Methods Patients undergoing continuous veno-venous hemodiafiltration (CVVHDF) without anticoagulation between June and September 2021 were prospectively collected. The patients were randomly divided into three groups by envelope method, namely 30 min-flushing group (flushing every 30 minutes for extracorporeal circulation), 2 h-flushing group (flushing every 2 hours for extracorporeal circulation), and non-flushing group (no flushing for extracorporeal circulation during treatment). All patients were treated with Prismaflex V8.0 CRRT machine and matched AN69ST-ST150 extracorporeal circuit, through either femoral or internal jugular venous double-lumen catheter. CVVHDF was adopted, the blood pump rate was 200 mL/min, and the rates of replacement fluid and dialysate were both 1 000 mL/h. The replacement fluid was pre-post dilution. Extracorporeal circuit lifespan, treatment time delayed by flushing, overall treatment time of CRRT, actual treatment time of CRRT, proportion of actual treatment time achieved, delayed daily treatment time, and small molecule solute removal efficiency before and after treatment were recorded. Results A total of 83 patients were included, including 24 in the 30 min-flushing group, 30 in the 2 h-flushing group, and 29 in the non-flushing group. There were significant differences in the indexes of extracorporeal circuit lifespan and various treatment time indicators among the three groups (P<0.05). Compared with the 2 h-flushing group and the non-flushing group, the 30 min-flushing group significantly shortened the extracorporeal circuit lifespan, delayed more treatment time by flushing, and delayed the longest daily treatment time (P<0.05). The proportion of actual treatment time in the non-flushing group was significantly higher than that in the 30 min-flushing group and the 2 h-flushing group (P<0.05), and in the 2 h-flushing group was also higher than that in the 30 min-flushing group (P<0.05). There was no significant difference in the blood urea nitrogen clearance rate among the three groups (P=0.570), but the serum creatinine clearance rate was significantly different among the three groups (P=0.020). Compared with the 30 min-flushing group, the 2 h-flushing group had a higher serum creatinine clearance rate, and there was statistical significance (P<0.05). Twenty-five patients had hypotension during treatment. The frequency of 30 min-flushing caused a higher risk of coagulation during cardiopulmonary bypass (hazard ratio=2.502, P=0.001). Conclusion For CVVHDF without anticoagulation, longer extracorporeal circuit lifespan and longer effective treatment time can be achieved without using normal saline flush.

Citation： HUANG Xianli, ZHANG Sheng, LIN Li, WANG Fang, ZHANG Ling. Effects of normal saline flush on extracorporeal circuit lifespan and solute removal in continuous renal replacement therapy. West China Medical Journal, 2022, 37(9): 1314-1321. doi: 10.7507/1002-0179.202205163 Copy

1.	Brandenburger T, Dimski T, Slowinski T, et al. Renal replacement therapy and anticoagulation. Best Pract Res Clin Anaesthesiol, 2017, 31(3): 387-401.
2.	Davenport A, Will EJ, Davidson AM. Improved cardiovascular stability during continuous modes of renal replacement therapy in critically ill patients with acute hepatic and renal failure. Crit Care Med, 1993, 21(3): 328-338.
3.	Kleger GR, F?ssler E. Can circuit lifetime be a quality indicator in continuous renal replacement therapy in the critically ill?. IntJ Artif Organs, 2010, 33(3): 139-146.
4.	Heise D, Gries D, Moerer O, et al. Predicting restoration of kidney function during CRRT-free intervals. J Cardiothorac Surg, 2012, 7: 6.
5.	Tandukar S, Palevsky PM. Continuous renal replacement therapy: who, when, why, and how. Chest, 2019, 155(3): 626-638.
6.	Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract, 2012, 120(4): c179-c184.
7.	VA/NIH Acute Renal Failure Trial Network, Palevsky PM, Zhang JH, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med, 2008, 359(1): 7-20.
8.	Uchino S, Bellomo R, Morimatsu H, et al. Continuous renal replacement therapy: a worldwide practice survey. The beginning and ending supportive therapy for the kidney (B. E. S. T. kidney) investigators. Intensive Care Med, 2007, 33(9): 1563-1570.
9.	Dirkes S, Wonnacott R. Continuous renal replacement therapy and anticoagulation: what are the options?. Crit Care Nurse, 2016, 36(2): 34-41.
10.	陳香美. 血液凈化標準操作規程(2021 版). 北京: 人民軍醫出版社, 2021: 158-159.
11.	金其莊, 王玉柱, 葉朝陽, 等. 中國血液透析用血管通路專家共識(第 2 版). 中國血液凈化, 2019, 18(6): 365-381.
12.	Panphanpho S, Naowapanich S, Ratanarat R. Use of saline flush to prevent filter clotting in continuous renal replacement therapy without anticoagulant. J Med Assoc Thai, 2011, 94(Suppl 1): S105-S110.
13.	張敏, 段棣飛, 張凌, 等. 2 種不同稀釋方式在連續性靜脈-靜脈血液透析濾過治療中應用效果分析. 中國血液凈化, 2019, 18(12): 822-825.
14.	Ramesh Prasad GV, Palevsky PM, Burr R, et al. Factors affecting system clotting in continuous renal replacement therapy: results of a randomized, controlled trial. Clin Nephrol, 2000, 53(1): 55-60.
15.	Uchino S, Bellomo R, Ronco C. Intermittent versus continuous renal replacement therapy in the ICU: impact on electrolyte and acid-base balance. Intensive Care Med, 2001, 27(6): 1037-1043.
16.	何泳, 張新, 周煥, 等. 不同連續性腎臟替代治療模式溶質清除和體外循環通路抗凝效果的比較. 臨床腎臟病雜志, 2018, 18(4): 211-214.
17.	Brunet S, Leblanc M, Geadah D, et al. Diffusive and convective solute clearances during continuous renal replacement therapy at various dialysate and ultrafiltration flow rates. Am J Kidney Dis, 1999, 34(3): 486-492.
18.	Nakagawa N. Seasonal variation and predictors of intradialytic hypotension. Hypertens Res, 2021, 44(11): 1551-1553.
19.	Akhoundi A, Singh B, Vela M, et al. Incidence of adverse events during continuous renal replacement therapy. Blood Purif, 2015, 39(4): 333-339.
20.	Wand S, Schneider S, Meybohm P, et al. Assessment of hemostatic changes after initiation of continuous venovenous hemodialysis. Clin Lab, 2015, 61(3/4): 379-387.
21.	Fu X, Liang X, Song L, et al. Building and validation of a prognostic model for predicting extracorporeal circuit clotting in patients with continuous renal replacement therapy. Int Urol Nephrol, 2014, 46(4): 801-807.

1. Brandenburger T, Dimski T, Slowinski T, et al. Renal replacement therapy and anticoagulation. Best Pract Res Clin Anaesthesiol, 2017, 31(3): 387-401.
2. Davenport A, Will EJ, Davidson AM. Improved cardiovascular stability during continuous modes of renal replacement therapy in critically ill patients with acute hepatic and renal failure. Crit Care Med, 1993, 21(3): 328-338.
3. Kleger GR, F?ssler E. Can circuit lifetime be a quality indicator in continuous renal replacement therapy in the critically ill?. IntJ Artif Organs, 2010, 33(3): 139-146.
4. Heise D, Gries D, Moerer O, et al. Predicting restoration of kidney function during CRRT-free intervals. J Cardiothorac Surg, 2012, 7: 6.
5. Tandukar S, Palevsky PM. Continuous renal replacement therapy: who, when, why, and how. Chest, 2019, 155(3): 626-638.
6. Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract, 2012, 120(4): c179-c184.
7. VA/NIH Acute Renal Failure Trial Network, Palevsky PM, Zhang JH, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med, 2008, 359(1): 7-20.
8. Uchino S, Bellomo R, Morimatsu H, et al. Continuous renal replacement therapy: a worldwide practice survey. The beginning and ending supportive therapy for the kidney (B. E. S. T. kidney) investigators. Intensive Care Med, 2007, 33(9): 1563-1570.
9. Dirkes S, Wonnacott R. Continuous renal replacement therapy and anticoagulation: what are the options?. Crit Care Nurse, 2016, 36(2): 34-41.
10. 陳香美. 血液凈化標準操作規程(2021 版). 北京: 人民軍醫出版社, 2021: 158-159.
11. 金其莊, 王玉柱, 葉朝陽, 等. 中國血液透析用血管通路專家共識(第 2 版). 中國血液凈化, 2019, 18(6): 365-381.
12. Panphanpho S, Naowapanich S, Ratanarat R. Use of saline flush to prevent filter clotting in continuous renal replacement therapy without anticoagulant. J Med Assoc Thai, 2011, 94(Suppl 1): S105-S110.
13. 張敏, 段棣飛, 張凌, 等. 2 種不同稀釋方式在連續性靜脈-靜脈血液透析濾過治療中應用效果分析. 中國血液凈化, 2019, 18(12): 822-825.
14. Ramesh Prasad GV, Palevsky PM, Burr R, et al. Factors affecting system clotting in continuous renal replacement therapy: results of a randomized, controlled trial. Clin Nephrol, 2000, 53(1): 55-60.
15. Uchino S, Bellomo R, Ronco C. Intermittent versus continuous renal replacement therapy in the ICU: impact on electrolyte and acid-base balance. Intensive Care Med, 2001, 27(6): 1037-1043.
16. 何泳, 張新, 周煥, 等. 不同連續性腎臟替代治療模式溶質清除和體外循環通路抗凝效果的比較. 臨床腎臟病雜志, 2018, 18(4): 211-214.
17. Brunet S, Leblanc M, Geadah D, et al. Diffusive and convective solute clearances during continuous renal replacement therapy at various dialysate and ultrafiltration flow rates. Am J Kidney Dis, 1999, 34(3): 486-492.
18. Nakagawa N. Seasonal variation and predictors of intradialytic hypotension. Hypertens Res, 2021, 44(11): 1551-1553.
19. Akhoundi A, Singh B, Vela M, et al. Incidence of adverse events during continuous renal replacement therapy. Blood Purif, 2015, 39(4): 333-339.
20. Wand S, Schneider S, Meybohm P, et al. Assessment of hemostatic changes after initiation of continuous venovenous hemodialysis. Clin Lab, 2015, 61(3/4): 379-387.
21. Fu X, Liang X, Song L, et al. Building and validation of a prognostic model for predicting extracorporeal circuit clotting in patients with continuous renal replacement therapy. Int Urol Nephrol, 2014, 46(4): 801-807.

West China Medical Journal

Effects of normal saline flush on extracorporeal circuit lifespan and solute removal in continuous renal replacement therapy

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