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.
Objective To evaluate the effects of two filtration fraction formulas on extracorporeal circulation life of continuous renal replacement therapy (CRRT) under regional citrate anticoagulation. Methods Patients with acute kidney injury who received CRRT treatment with regional citrate anticoagulation and the estimated CRRT duration was greater than 24 h at West China Hospital of Sichuan University between June 2022 and April 2023 were selected. They were randomly divided into continuous veno-venous hemofiltration (CVVH), continuous veno-venous hemodialysis (CVVHD) and continuous veno-venous hemodiafiltration (CVVHDF) groups using Prismaflex machines. The life of the CRRT extracorporeal circulation in the three groups of patients was compared, and the reasons for replacing the extracorporeal circulation after 72 h were not used, and the filtration fraction score of the three groups was calculated according to the two filtration score calculation formulas (Formula 1 and Formula 2) currently used in the world. The filtration value obtained by the two filtration fraction calculation formulas was taken as the test variable, and whether the median life of the group with the longest extracorporeal circulation life was taken as the state variable, and the receiver operating characteristic curve was drawn, and the area under the curve was calculated. Results A total of 121 patients were included, including 40 patients in the CVVH group, 40 patients in the CVVHD group, and 41 patients in the CVVHDF group. The extracorporeal circulation life of CVVH group, CVVHD group and CVVHDF group was 64 (46, 71) h, 47 (31.5, 54) h and 70 (65, 72) h, respectively, with statistical difference (log-rank P=0.036). A total of 94 cases were replaced due to filter or venous pot clotting after 72 h after the filter was not used, including 30 cases in the CVVH group, 39 cases in the CVVHD group, and 25 cases in the CVVHDF group. The difference between the three groups was statistically significant (χ2=15.83, P<0.001). According to Formula 1, the filtration fraction of CVVH group, CVVHD group and CVVHDF group was 15.8% (15.2%, 17.0%), 1.1% (0.7%, 2.1%) and 16.2% (14.9%, 17.6%), respectively, and the difference among the three groups was statistically significant (H=69.402, P<0.001). According to Formula 2, the filtration fraction of CVVH group, CVVHD group and CVVHDF group was 33.1% (32.4%, 35.7%), 4.0% (3.6%, 4.9%) and 19.1% (17.7%, 20.7%), respectively, and the differences among the three groups and pairwise comparison between groups were statistically significant (P<0.001). The area under the receiver operating characteristic curvec calculated by the Formula 1 and 2 for the influence of filtration fraction on extracorporeal circulation life were 0.539 and 0.668, the sensitivity were 43.18% and 82.22%, and the specificity were 80.65% and 56.25%, respectively. Conclusions When using Prismaflex machine, the filter life of CVVHD is shorter than CVVH and CVVHDF modes. The filtration fraction calculated by Formula 2 is more sensitive but less specific in predicting CRRT extracorporeal circulation life. Filtration fraction as a CRRT extracorporeal circulation risk assessment has limitations, especially for the CVVH model with pre and post replacement.
Continuous renal replacement therapy (CRRT) originated from intermittent hemodialysis. Over the past 40 years, its application scope has gradually expanded from the initial treatment of kidney diseases alone to the support of multi-organ functions. As a safe, adequate, and flexible therapeutic modality, CRRT has become one of the main means of treating critically ill patients. Continuous innovation in technology, biomaterials and other technologies provides important driving force for the sustainable development of CRRT. This paper reviews the technological innovation and development of CRRT devices. With continuous technological updates and iteration, CRRT can better adapt to clinical needs. Biofeedback, portability, and intelligence are several directions of the development of CRRT, which can provide more accurate and personalized treatment for critically ill patients in different scenarios.
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 evaluate the efficacy and safety of nafamostat mesylate as an in vitro anticoagulant in continuous renal replacement therapy (CRRT) using oXiris filters for patients with sepsis-associated acute kidney injury (SA-AKI). Methods SA-AKI patients at high risk of bleeding who received oXiris filter-CRRT at West China Hospital of Sichuan University between November 2021 and January 2023 were included in the study. Patients who received nafamostat mesylate as an anticoagulant were categorized into the nafamostat group, while patients who did not receive any anticoagulant during the same period were categorized into the control group. A comparative analysis was conducted between the two groups regarding general conditions, the lifespan of the first filter in CRRT, the number and percentage of cases with the first filter lasting 24, 48, and 72 h, activated clotting time (ACT) before and during treatment (both pre-filter and post-filter), laboratory test results before and after treatment, incidence of adverse reactions during treatment, and clinical outcomes of the patients. The mean ± standard deviation was used for normal distribution, and the median (lower quartile, upper quartile) was used for non-normal distribution. Results A total of 118 patients were included in the study, with 90 in the control group and 28 in the nafamostat group. There was no statistically significant difference in the general conditions or pre-treatment laboratory test indicators between the two groups (P>0.05). Kaplan-Meier survival analysis showed that the lifespan of the first filter was longer in the nafamostat group compared to the control group (hazard ratio=0.524, P=0.001). The percentage of patients whose first filter lasted 24 h was higher in the nafamostat group than that in the control group (60.7% vs. 25.7%, P=0.001); however, there was no statistically significant difference between the two groups for the first filter lasting 48 h or 72 h (P>0.05). During CRRT treatment, the mean post-filter ACT was longer in the nafamostat group than that in the control group [(216.7±43.2) vs. (181.6±35.5) s, P<0.001], and the mean post-filter ACT was longer than the pre-filter ACT in the nafamostat group [(216.7±43.2) vs. (183.3±37.7) s, P=0.005]. After the treatment, the international normalized ratio [1.5 (1.1, 1.8) vs. 1.7 (1.4, 2.4)], interleukin-6 levels [(235.5±80.9) vs. (500.5±112.7) pg/mL] were lower, and platelet count [48.0 (31.8, 73.0)×109/L vs. 29.0 (11.0, 61.8)×109/L] was higher in the nafamostat group compared to the control group (P<0.05). There was no statistically significant difference in other laboratory test indicators (P>0.05). The clinical outcomes of the patients did not show statistically significant difference between the two groups (P>0.05). Conclusion Nafamostat mesilate may be an effective and safe anticoagulant in SA-AKI patients at high risk of bleeding underwent oXiris filter-CRRT, and its in vitro anticoagulant effect is better than that without anticoagulant.
Objective To evaluate the efficacy and safety of in vitro anticoagulation with nafamostat mesilate in continuous renal replacement therapy (CRRT) in patients with sepsis complicated with acute kidney injury (AKI). Methods The study subjects were sepsis patients with AKI who underwent CRRT in West China Hospital of Sichuan University and were at high risk of bleeding. CRRT patients who received in vitro anticoagulation with nafamostat mesilate between July 2021 and January 2022 were included in the nafamostat group. The medical records of CRRT patients who did not use anticoagulants between January 2020 and December 2020 were retrospectively collected as a control group. The general situation, the lifespan of the first CRRT filter, the number of filters used within 72 hours of treatment, laboratory tests before and after treatment, and the occurrence of adverse reactions during treatment of the two groups of patients were analyzed. Results There were 42 patients in the control group and 21 patients in the nafamostat group. There was no statistically significant difference in age, gender, body mass index, mean arterial pressure, primary disease, Sequential Organ Failure Assessment score, Acute Physiology and Chronic Health Evaluation Ⅱ score, or pre-treatment laboratory test results between the two groups of patients (P>0.05). Kaplan-Meier survival analysis showed that the lifespan of the first filter was longer in the nafamostat group than in the control group (hazard ratio=0.408, P<0.05). The number of filters used by the control group patients after 72 hours of treatment was greater than that of the nafamostat group patients (2.1±0.6 vs. 1.3±0.5, P<0.05). After 72 hours of treatment, serum creatinine levels [(99.4±15.7) vs. (127.6±20.5)] μmol/L], urea nitrogen [(4.5±1.9) vs. (6.8±2.3) mmol/L], cystatin C [(1.0±0.2) vs. (1.2±0.2) mg/L], uric acid [(86.5±15.3) vs. (105.3±20.3) μmol/L] in the nafamostat group were lower than those of the control group (P<0.05), and there was no statistically significant difference in the results of other laboratory tests (P>0.05). There was no statistically significant difference in adverse reactions between the two groups of patients (P>0.05). Conclusion For patients with sepsis complicated with AKI who undergo CRRT and are at high risk of bleeding, nafamostat mesilate may be a safe and effective anticoagulant for in vitro anticoagulation.
Hypernatremia is one of the commonly syndromes in critically ill patients. Severe hypernatremia has a low incidence (0.6%–1.0%) but with a very high mortality (58%–87%). Conventional treatments include the limitation of sodium intake and the supplement of sodium free liquid according to the assessed water lost. The reduction rates of conventional treatments are commonly not effective enough to decrease the serum sodium concentration in severe euvolemic or hypervolemic hypernatremia patients. Continuous renal replacement therapy (CRRT) has been reported to be effective on the reduction of sodium level in severe hypernatremia patients. However, the evidences on the use of CRRT for hypernatremia are limited. Our present review summarizes the current evidences on the prevalence of hypernatremia, the outcome of hypernatremia patients, the conventional treatment of hypernatremia, and the advantages and indications of CRRT for the management of hypernatremia. Additionally, we introduce our experiences on the management of hypernatremia using CRRT as well.
Objective To compare the clinical effect of continuous renal replacement therapy (CRRT) and intermittent hemodialysis (IHD) in the treatment of severe acute renal failure (ARF). Methods A hundred patients with severe ARF treated between May 2011 and December 2014 were chosen to be the study subjects. According to the order of admission, they were divided into control group and observation group with 50 patients in each. Patients of the control group underwent IHD, while those in the observation group underwent CRRT. Serum creatinine (Scr), blood urea nitrogen (BUN), endogenous creatinine clearance rate (Ccr), treatment effective rate and survival rate were compared between the two groups before and after the treatment. Results Scr, BUN and Ccr were all improved after treatment in both the two groups. However, Scr, BUN and Ccr in the observation group [(225.1±162.7) μmol/L, (14.2±9.3) mmol/L, (23.4±10.5) mL/min] were significantly better than those in the control group [(588.4±183.6) μmol/L, (29.1±10.4) mmol/L, (15.9±8.2) mL/min]. The treatment effective rate and patients’ survival rate in the observation group were respectively 60% and 70%, both significantly higher than those in the control group (40% and 52%) All the differences were significant (P<0.05). Conclusion CRRT is superior in the treatment of severe ARF with a higher survival rate of the patients, which is worthy of clinical promotion.
Hypophosphatemia is a common and potentially serious complication during continuous renal replacement therapy (CRRT), which is often underestimated and ignored. This article systematically searched and reviewed the relevant literature on previous CRRT and hypophosphatemia, and summarized the risk factors affecting hypophosphatemia during CRRT, the impact on the body, and the existing phosphorus supplement scheme during CRRT, so as to attract everyone’s attention to hypophosphatemia during CRRT in clinical work.
Patients with severe acute kidney injury (AKI) often need renal replacement therapy (RRT）with a high morbidity and mortality. For patients with chronic renal failure, the aim of blood purification is renal replacement; but for patients with AKI, although customarily called RRT, the aim of blood purification is not “renal replacement”, but extracorporeal “renal support and protection”, that is, supporting and protecting temporally failed kidney, removing damage factors, avoiding renal reinjury and looking forward to restore renal function. This article provides a detailed explanation of the differences between renal replacement and renal support from the perspective of organ protection, as well as the key links of RRT and extracorporeal multiple organ support for patients with severe AKI.