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 summarize and analyze the clinical outcomes and experiences of continuous renal replacement therapy(CRRT) in patients with acute renal insufficiency after heart transplantation. Methods There were 39 patients received orthotopic heart transplantation from September 2007 to September 2008 in Fu Wai hospital. Seven cases required the use of PRISMA CRRT machine (Gambro Healthcare,Inc.) because of acute renal insufficiency after heart transplantation, and received continuous venovenous hemodiafiltration(CVVHDF) treatment via M100 blood filter (hemofilters). Activated coagulation time (ACT) was maintained in 160200 s. Results Six survivals with New York Heart Association (NYHA)Ⅰdischarged ，1 case died of multiple system organ failure (MSOF) and severe infection. The time of CRRT was 48658 h, with an average of 252 h. Seven patients were oliguric or anuric during CRRT, but hemodynamics and internal environment were stable. After stopping CRRT, the creatinine level rose to 267.1±68.5 μmol/L， then the creatinine level decreased to normal range with urine increasing gradually. Postoperative glomerular filtration rate (GFR) was 56.5±19.0 ml/min， and there was no statistical significance compared with preoperative GFR（Pgt;0.05）. Six survivals were followed up for 513(9.7±3.8)months，and their creatinine level was in normal range(90.6±26.7 μmol/L). There was no statistical significance compared with the creatinine level at discharge (83.2±26.5 μmol/L, Pgt;0.05）. Conclusion The prognostic outcomes of patients with acute renal insufficiency after heart ransplantation are excellent after using CRRT. No significant renal dysfunction is found.
ObjectiveTo explore the effect of continuous renal replacement therapy (CRRT) to treat sepsis associated acute kidney injury (AKI) in patients aged over 80.MethodsForty-one patients diagnosed with sepsis and AKI were enrolled in geriatric RICU department of Huadong Hospital from January 2013 to July 2018, 38 patients were male and 3 were female. All patients were treated with anti-infection and fluid resuscitation therapy. After comprehensive judgment of the indication of renal replacement, they were divided into two groups by the choices of using CRRT. There were 20 patients in CRRT group and 21 in control group. Clinical data such as age, body mass index, previous diseases, 28-day mortality rate, blood cells, APACHEⅡ as well as SOFA scores were compared between two groups. Blood renal function and inflammatory markers at the first day were also compared to those after 3-day treatment of initial time.ResultsNo statistical difference was observed in sex ratio, age, body mass index and previous diseases between two groups (all P>0.05). There was also no difference in APACHEⅡ score, SOFA score, blood cells, hemoglobin and survival time. The 28-day mortality rate in CRRT group was lower than that in control group (P<0.05). The levels of serum UA and C reactive protein (CRP) in CRRT group decreased after 3-day treatment compared with those at the onset, and the differences were statistically significant (all P<0.05). The level of serum blood urea nitrogen (BUN), creatinine (Cr), uric acid (UA) and cystain C in control group increased after 3 days compared with those at the onset, and the difference were statistically significant (all P<0.05). There was no significant difference in serum BUN, Cr, UA, cystain C, CRP and procalcitonin (PCT) between two groups at the onset (all P>0.05). After 3 days of CRRT, the levels of serum PCT, BUN, Cr and UA in CRRT group were lower than those in the control group (all P<0.05).ConclusionCRRT can improve hyperuricemia, control deterioration of renal function, reduce early systemic inflammatory response and 28-day mortality rate in aged patients with sepsis and AKI.
Objective To investigate the effect of different dilution methods of replacement fluid on cardiopulmonary bypass lifespan and small molecule clearance rate in continuous renal replacement therapy (CRRT) without anticoagulation. Methods Patients who needed to undergo CRRT in West China Hospital of Sichuan University between December 2019 and June 2020 were selected in this prospective cohort study. Continuous veno-venous hemodiafiltration treatment mode was applied, with three different dilution methods, namely pre-dilution, post-dilution, and pre- and post-dilution. The lifespan of cardiopulmonary bypass was recorded, and blood samples were taken to detect creatinine, blood urea nitrogen, etc. Only the lifespan of the first tube of each patient was included. Results A total of 74 patients and pipelines were included, including 18 pre-dilution cases, 34 pre- and post-dilution cases, and 22 post-dilution cases. There was no significant difference in the baseline gender, age, catheterization method, or coagulation function among the three groups of patients (P>0.05). The service life of the circulation pipeline was (32.67±17.42) h in the pre-dilution group and (30.32±16.77) h in the post-dilution group, respectively, and the difference was not statistically significant (P<0.05); the service life of the circulation pipeline was (44.15±21.48) h in the pre- and post-dilution group, which was statistically different from those in the other two groups (P<0.05). There was no statistically significant difference in the decrease of blood urea nitrogen or serum creatinine among the three groups when treated with the three different dilution methods (P>0.05). Conclusion On the premise of not affecting the clearance rate of small molecules, compared with pre-dilution and post-dilution, pre- and post-dilution can prolong the service life of extracorporeal circulation pipelines and filters, and has certain promotion value in clinical practice.
Objective To explore the risk factors affecting the prognosis of patients with acute kidney injury (AKI) after extracorporeal circulation surgery who receive continuous renal replacement therapy (CRRT). Methods Patients who developed AKI and underwent CRRT treatment after extracorporeal circulation surgery at the First Affiliated Hospital of Chongqing Medical University between May 2019 and May 2024 were retrospectively selected. According to the prognosis, patients were divided into the good prognosis group and the poor prognosis group. Basic information, duration of extracorporeal circulation during surgery, aortic occlusion time, timing and duration of CRRT initiation therapy, relevant laboratory indicators before surgery, during CRRT intervention, and upon discharge or death were collected. The risk factors affecting the prognosis of such patients were analyzed. Results A total of 45 patients were included. Among them, there were 20 cases in the good prognosis group and 25 cases in the poor prognosis group. There was no statistically significant difference in the basic information between the two groups (P>0.05). Compared with the poor prognosis group, the good prognosis group had decreased preoperative urea nitrogen and increased hemoglobin levels, reduced levels of alanine aminotransferase and aspartate aminotransferase during the initiation of CRRT treatment, and reduced levels of white blood cell count, neutrophil percentage, alanine aminotransferase and aspartate aminotransferase and elevated platelet count before discharge or death (P<0.05). The results of multivariate logistic regression analysis showed that the total duration of CRRT treatment [odds ratio (OR)=1.007, 95% confidence interval (CI) (1.000, 1.015), P=0.046], white blood cell count before discharge or death [OR=1.541, 95%CI (1.011, 2.349), P=0.044], and platelet count before discharge or death [OR=0.964, 95%CI (0.937, 0.991), P=0.010] could affect patient prognosis. Conclusions In patients with AKI after extracorporeal circulation surgery, if combined with renal dysfuction and anemia before surgery, liver function damage and secondary infection during CRRT initiation therapy may be related to poor patient prognosis. The longer the duration of CRRT treatment, the higher the white blood cells before discharge or death, and the lower the platelet count are independent risk factors for poor prognosis in patients.
ObjectiveTo explore the hemodynamic effects of inhaled nitric oxide (iNO) on postoperative hemodynamic in patients with cyanotic congenital heart disease (CHD) combined with decreased pulmonary blood flow.MethodsFrom 2014 to 2018, there were 1 764 patients who received corrective repair of cyanotic CHD with decreased pulmonary blood flow in the Department of Pediatric Cardiac Surgery of Fuwai Hospital. We included 61 patients with the ratio of right ventricular systolic pressure to systolic blood pressure (SBP) ≥75% after weaning from cardiopulmonary bypass. There were 41 males and 20 females, with the age of 20.5 (9.0, 39.0) months and weight of 12.5±7.8 kg. The patients were divided into two groups: a conventional group (33 patients, conventional therapy only) and a combined therapy group (28 patients, iNO combined with conventional therapy). The hemodynamics during the first 24 hours after iNO therapy and the in-hospital outcomes of the two groups were investigated and compared.ResultsThere was no statistical difference between the two groups in demographic characteristics and surgical parameters (P>0.05). The hemodynamic effects of iNO within 24 hours included the decrease in the vasoactive inotropic score (VIS, 21.6±6.6 vs. 17.3±7.2, P=0.020) along with the increase in blood pressure (SBP: 73.7±9.7 mm Hg vs. 90.8±9.1 mm Hg, P<0.001) , the decrease in central venous pressure (10.0±3.1 mm Hg vs. 7.9±2.1 mm Hg, P=0.020), the decrease in lactate (2.2±1.7 mmol/L vs. 1.2±0.5 mmol/L, P<0.001) and increase in urine output [2.8±1.7 mL/(kg·h) vs. 4.9±2.2 mL/(kg·h), P<0.001]. The decrease of VIS at 24 h after the surgery in the conventional therapy group was not statistically significant (22.1±7.9 vs. 20.0±8.5, P=0.232). Besides, we discovered that the need for renal replacement therapy (RRT) was less in the combined therapy group than that in the conventional therapy group, especially in the moderate complicated surgery [risk adjustment in congenital heart surgery (RACHS-1) ≤3] subgroup (9.5% vs. 40.7%, P=0.016).ConclusionIn pediatric patients after corrective repair of cyanotic and pulmonary blood follow decreased CHD with increased pulmonary vascular resistance, iNO combined with conventional therapy can improve the hemodynamics effectively. Compared with the conventional therapy, the combined therapy with iNO can decrease the VIS and the need for RRT, which is beneficial to the postoperative recovery of patients.
Objective To investigate the therapeutic effect of continuous renal replacement therapy (CRRT) plus hemoperfusion (HP) on patients with diabetes and uremic encephalopathy. Methods Fifty-five patients with diabetes and uremic encephalopathy from January 2010 to December 2017 were retrospectively collected in this study and divided into CRRT plus HP (CRRT+HP) group (n=28) and hemodialysis (HD) plus HP (HD+HP) group (n=27). The changes of vital signs, related biochemical indicators before and after treatment and curative effects were compared between the two groups. Results The two groups were comparable in general. No significant differences were found in blood pressure or heart rate before and after treatment between the two groups (P>0.05). The incidence of hypotension events in CRRT+HP group was significantly lower than that in HD+HP group (P<0.05), and the effective rate of cardiac function improvement in CRRT+HP group was significantly higher than that in HD+HP group (P<0.05). After treatment, the blood urea nitrogen, creatinine, parathyroid hormone, β2-microglobulin, phosphorus, C-reactive protein and brain natriuretic peptide in the two groups were significantly decreased than those before treatment (P<0.05). Parathyroid hormone, β2-microglobulin, C-reactive protein and brain natriuretic peptide were significantly decreased in CRRT+HP group as compared with those in HD+HP group (P<0.05). The remission rate of uremic encephalopathy in CRRT+HP group was significantly higher than that in HD+HP group (P<0.05). Conclusions As compared with HD+HP pattern, CRRT+HP pattern is more stable in the hemodynamics, and more effective in the improvement of heart failure and the clearance of inflammatory mediators, middle molecular and macromolecular substances associated with uremic encephalopathy. CRRT+HP pattern is suitable for the treatment of patients with diabetes and uremic encephalopathy.
Acute kidney injury (AKI) presents as a sharp decline in renal function caused by a variety of reasons. It is a severe clinical challenge affecting multiple organs and multiple systems, with high mortality. Continuous renal replacement therapy (CRRT) plays an important role in the treatment of AKI. Limited by the lack of evidence, the timing of CRRT for AKI remains ambiguous. This article reviews the definition and grading of AKI, the indication and the timing of initiation/termination of CRRT for AKI .
Objective To investigate the safety and efficacy of two different anticoagulation regimens of fondaparinux and low molecular weight heparin (LMWH) in continuous renal replacement therapy (CRRT). Methods The clinical data of patients undergoing CRRT in West China Hospital of Sichuan University between October 2021 and April 2022 were retrospectively analyzed. The patients were divided into fondaparinux sodium group and LMWH group according to anticoagulation with fondaparinux or LMWH during CRRT. The general condition, life expectancy of cardiopulmonary bypass, coagulation events, bleeding events, hemoglobin, and coagulation function-related indicators were compared between the two groups. Results A total of 78 patients were finally included, including 38 in the LMWH group and 40 in the fondaparinux group. The age of the patients in the LMWH group was older than that in the fondaparinux group [76.0 (57.0, 85.0) vs. 63.0 (52.3, 76.0) years, P=0.016]. There was no significant difference in other clinical baseline conditions (including gender, vascular access site, and treatment indications) between the two groups (P≥0.05). The cardiopulmonary bypass life of patients in the fondaparinux group was better than that in the LMWH group [67.1 (35.0, 72.0) vs. 42.0 (20.0, 55.3) h, P=0.003]. The survival rate of cardiopulmonary bypass in the fondaparinux group at 24, 48, and 72 h were higher than that in the LMWH group (87.5% vs. 65.8%, P=0.023; 67.5% vs. 36.8%, P=0.007; 42.5% vs. 13.2%, P=0.004). The incidence of blood filter coagulation events in the fondaparinux group was lower than that in the LMWH group (50.0% vs. 84.2%, P=0.001). There was no significant difference in the incidence of coagulation events and mild bleeding events between the two groups (P>0.05). There was no significant difference in hemoglobin and coagulation function-related indicators between the two groups before and after CRRT (P>0.05). Conclusion The continuity of maintenance therapy with fondaparinux is better than that of LMWH, and the safety of both in the course of CRRT treatment is comparable.
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.