Acute kidney injury is a common complication and is associated with multiple organ dysfunction syndrome among critically ill patients in intensive care unit. Once renal replacement therapy in required, the mortality rate was high. Using slow and uninterrupted clearance of retained fluid and toxins, continuous renal replacement therapy (CRRT) can avoid hemodynamic instability while provide acid-base, electrolytes, and volume homeostasis. For decades, CRRT has become the dominant form of renal replacement therapy as well as multiple organ support in critically ill patient with acute kidney injury. However, there remains wide practice variation in the CRRT care when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice, despite evidences to guide practice. In addition, CRRT is a complex technology that is resource-intensive, costly, and requires specialized training by health providers.Taiwan Society of Critical Care Medicine organized a group of experts in critical care and nephrology to review the recommendations and provide their clinical practice and concerns to write this operational manual. The purpose of this manual is to provide step-by-step instructions on the practice of CRRT and troubleshooting. In addition, it is designed to help the newbies to carry out this complex treatment correctly and efficiently. We hope that this operational manual is of value to improve clinical skills, quality of care, and patient safety.
In continuous renal replacement therapy (CRRT), the combination of medicine and engineering is propelling advancements in therapeutic technology. By enhancing the biocompatibility and specific adsorption capabilities of the blood adsorption materials, the therapeutic efficacy of CRRT is augmented, leading to a reduction in adverse reactions for patients. Moreover, the application of big data and artificial intelligence in CRRT is continually being developed. Utilizing intelligent devices, data analysis, and machine learning, the initiation, monitoring, and formulation of CRRT treatment plans are optimized, providing clinical patients with more efficient and secure therapeutic options, thereby further improving clinical outcomes.
Rhabdomyolysis-induced acute kidney injury (RIAKI) is a serious clinical disease in intensive care unit, characterized by high mortality and low cure rate. Continuous renal replacement therapy (CRRT) is a common form of treatment for RIAKI. There are currently no guidelines to guide the application of CRRT in RIAKI. To solve this problem, this article reviews the advantages and limitations of CRRT in the treatment of RIAKI, as well as new viewpoints and research progress in the selection of treatment timing, treatment mode, treatment dose and filtration membrane, with the aim of providing theoretical guidance for the treatment of CRRT in RIAKI patients.
Acute kidney injury (AKI) is common in hospitalized individuals, associated with adverse outcomes and increased cost. Continuous renal replacement therapy (CRRT) is used to treat critically ill patients with AKI, of which the cost in acute phase is higher than that of intermittent renal replacement therapy (IRRT). However, if treatment for subsequent chronic kidney disease or dialysis dependency following AKI is also considered, CRRT might be more cost-effective than IRRT. In this editorial, the cost and health economic evaluation of CRRT for critically ill patients is discussed.
ObjectiveTo observe the effect of continuous renal replacement therapy (CRRT) on serum phosphate level in patients after cardiac surgery. MethodA single-center retrospective observational study was conducted on 30 patients received CRRT after cardiac surgery. There were 14 males and 16 females with mean age of 57.0±10.8 years (ranged 37-79 years). A total of 16 patients underwent CRRT with continuous veno-venous hemofiltration (CVVH), and 14 patients with continuous veno-venous hemodiafiltration (CVVHDF). The serum phosphate level was measured before treatment, at 24 h, and 48 h during therapy and 24 h after phosphate salt supplementation. ResultsThe level of serum phosphate at 24 h and 48 h during CRRT was decreased (0.6±0.4 mmol/L vs. 0.4±0.2 mmol/L vs. 1.1±0.3 mmol/L, P<0.01). After intravenous phosphate salt supplementation, serum phosphate level got increased (0.6±0.3 mmol/L, P<0.01). There was no statistical difference in serum phosphate level between CVVH and CVVHDF (P>0.05). ConclusionHypophosphatemia occurs frequently during CRRT, particularly with long treatment time. Phosphate salt supplementation is necessary. The dosage of the supplementation should be adjusted personally based on the regularly monitoring results of serum phosphate tests.
Objective To explore the global research status and trends of continuous renal replacement therapy (CRRT) based on knowledge visualization analysis. Methods Based on the Web of Science Core Collection, studies reporting CRRT research that were published between June 2014 and June 2023 were retrieved and collected after manual review. VOSviewer and CiteSpace softwares were used for bibliometric visualization analysis, including publication trends, geographical distribution characteristics, journal distribution characteristics, author contributions, citations, funding source characteristics, and keyword clustering. Results A total of 2708 papers were analyzed, with an increasing trend in the number of articles and citation frequency from 2015 to 2021. The United States was the most prolific country and France was the most influential country. The University of Pittsburgh in the United States had the highest number of publications among research institutions and showed higher motivation for inter-institutional collaboration. The University of Queensland in the Australia had the highest average citation frequency. Professor Rinaldo Bellomo of Australia was the most productive author and Professor Jeffrey Lipman was the most influential. Jason A. Roberts, Jeffrey Lipman and Claudio Ronco were the three authors who had the highest number of collaborations with other authors. Keyword cluster analysis showed that the prognosis of CRRT for renal disease was the focus of research, with hotspots of research being antibiotics, citrate accumulation, plasma replacement, lactate clearance, acute respiratory distress syndrome, and coronavirus disease 2019. Coupling analysis of the literature showed that exploring the indications for CRRT and optimizing treatment prescription were at the forefront of research. Conclusions The present study of CRRT has generally shown an upward trend in the last decade. The management and efficacy of CRRT remains a hot topic of research. Exploring the indications for CRRT and optimizing treatment prescriptions may be a popular research direction and trend in the future.
Objective To explore the feasibility and effect of infusion pump potassium supplementation in continuous renal replacement therapy (CRRT). Methods Patients who underwent CRRT were randomly divided into infusion pump group and traditional way group between March and May 2018. In infusion pump group, 10% potassium chloride was supplemented with infusion pump. In traditional way group, 10% potassium chloride was supplemented in the traditional way, which meant adding potassium in the replacement solution. The peripheral blood potassium level, the potassium well-controlled rate, the incidence of adverse events, the average frequency of replacement liquid bags change, the average pump stopping time, and the delivery dose and potassium supplement dose between the two groups were compared. Results A total of 60 patients were randomly divided into two groups, with 30 cases in each group. The infusion pump group was treated with an average of 6.90 mL/h potassium supplement dose by infusion pump, and in traditional way group, potassium was added to the replacement solution by an average of 9.29 mL/h; there were significant differences between the two groups (P<0.05). When compared with traditional way group, there was no significant differences (P>0.05) in the peripheral blood potassium level and the potassium well-controlled rate of the patients at 0, 2, 8, 12 and 24 hours after CRRT (P>0.05). As for the adverse events rate, average frequency of replacement liquid bags change, average pump stopping time, and potassium supplement dose, there were significant differences between the two groups (P<0.05). Conclusions The application of infusion pump to supply potassium in CRRT is feasible and safe, and is superior to the traditional potassium supplement method. It could be further applied in clinical practice.
Continuous renal replacement therapy (CRRT) is the treatment of choice for critically ill patients with hemodynamic instability who require renal replacement therapy. This review summarizes the impact of CRRT treatment on nutritional support in critically ill patients, including: energy increase caused by citrate-based anticoagulants, energy loss caused by glucose-free replacement fluid and dialysate, a large amount of amino acids loss in the effluent, and the influences on the way of lipid emulsion administration, capacity, electrolyte, vitamins, and trace elements. It is hoped that the intensive care unit doctors, nephrologists, and nutritionists can fully cooperate to determine the CRRT prescription and the nutritional support prescription.
Objective To assess the relationship between the change in fluid overload at 48 h after initiation of continuous renal replacement therapy (CRRT) and 28-day mortality in critically ill patients with acute kidney injury (AKI). Methods A retrospective cohort study was performed using data from the MIMIC-IV database from 2008 to 2019. Patients who received CRRT for AKI for more than 24 h within 14 d of admission to the intensive care unit were included. The exposure variable was the proportion of change of fluid overload (ΔFO%, defined as the difference between body weight normalized fluid input and output) at 48 h after CRRT initiation, and the endpoint was 28-day mortality. Generalized additive linear regression models and logistic regression models were used to determine the relationship between the exposure and endpoint. Results A total of 911 patients were included in the study, with a median (lower quartile, upper quartile) ΔFO% of ?3.27% (?6.03%, 0.01%) and a 28-day mortality of 40.1%. Generalized additive linear regression model showed that the ΔFO% at 48 h after CRRT initiation was associated with a J-shaped curve with 28-day mortality. After adjusting for other variables, as compared with the second quartile of ΔFO% group, the first quartile group [odds ratio (OR)=1.23, 95% confidence interval (CI) (0.81, 1.87), P=0.338] was not associated with higher risk of 28-day mortality, while the third quartile group [OR=1.54, 95%CI (1.01, 2.35), P=0.046] and the fourth quartile group [OR=2.05, 95%CI (1.32, 3.18), P=0.001] were significantly associated with higher risk of 28-day mortality. There was no significant relationship between ΔFO% groups and 28-day mortality in the first 24-hour after CRRT initiation (P>0.05), but there was a linear relationship between ΔFO% and 28-day mortality in the second 24-hour after CRRT initiation, the larger the ΔFO%, the higher the mortality rate [OR=1.10, 95%CI (1.04 1.16), P<0.001 for per 1% increase]. ConclusionIn critically ill patients with AKI, the ΔFO% greater than ?3.27% within 48 h after CRRT initiation is independently associated with an increased risk of 28-day mortality, and the goals of CRRT fluid management may be dynamical.
Objective To observate the influencing factors on circuit life during continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA), so as to provide data support for further optimization of RCA anticoagulation strategy. MethodsPatients who underwent CRRT with RCA in West China Hospital of Sichuan University between March 2021 and April 2022 were retrospectively selected. Analyze the basic information of patients and the impact of relevant indicators before or within 12 hours of treatment on the circuit life. Results A total of 116 patients were included. Among the included patients, a total of 225 cases were treated with CRRT for 11 051.7 hours, the median circuit life was 57.0 (25.4, 72.0) h. 142 cases (63.1%) were terminated due to coagulation, the median circuit life was 30.3 (20.5, 52.8) h. The results of multivariate Cox regression analysis showed that pH value [hazard ratio (HR)=0.002, 95% confidence interval (CI) (0.0001, 0.127), P=0.003], the maximam postfilter ionized calcium [HR=0.039, 95%CI (0.004, 0.437), P=0.008], blood flow [HR=1.051, 95%CI (1.027, 1.075), P<0.001] and catheter dysfunction [HR=5.701, 95%CI (3.777, 8.605), P<0.001] were the four influential factors affected circuit life. Kaplan Meier survival curve showed that RCA had the best effect when the postfilter ionized calcium was in the range of 0.25 ~ 0.35 mmol/L. Conclusions During CRRT treatment of RCA, pH value, postfilter ionized calcium, blood flow and catheter function are the independent influencing factors of circuit life. The above parameters should be carefully monitored and optimized in the treatment process to minimize the risk of coagulation, prolong the circuit life and maintain the continuty of CRRT treatment. The postfilter ionized calcium was recommended to be maitained at 0.25-0.35mmol/L, pH value maintained above 7.38, blood flow no more than 145 mL/min and catheter maitained patency to ensure the adequate anticoagulation.