Blood Purification最新文献

Introduction Delivering requisite anesthesia for endovascular treatment of dysfunctional arteriovenous fistulas (AVFs) under a targeted nerve block can achieve reasonable analgesia. We evaluated the efficacy and safety of ultrasound-guided selective nerve block during percutaneous transluminal angioplasty (PTA) of dysfunctional arteriovenous access. Methods 246 patients with dysfunctional radiocephalic arteriovenous fistula undergoing PTA were enrolled in this prospective, randomized controlled trial at the Department of Nephrology, Haidian Hospital, Peking University Third Hospital from June 1, 2022 to August 31, 2023. The patients were randomized into either the selective nerve block group (SNB group, n=123) or the local anesthesia group (LA group, n=123) . A visual analogue scale(VAS) from no pain (= 0) to worst pain possible (= 10) was used to assess the pain intensity. Patient and operator satisfaction were graded from 0 to 2: 0, not satisfied at all; 1, partially satisfied; 2, satisfied. The arteriovenous fistula patency at 1 and 3 months after PTA was also evaluated. Results Compared with the local anesthesia group, the selective nerve block group had significantly lower VAS scores (Z = -7.193, p < 0.001) and required fewer additional anesthetics during the operation (² = -4.847, p = 0.028). Patient and operator satisfaction were significantly higher in the selective nerve block group (p < 0.05). Eight patients in the selective nerve block group encountered grade 3 motor paralysis after the operation and they all recovered within 60 minutes. There was no significant difference in primary patency rates of the fistula between the two groups either at 1 month or 3 months after the operation (p > 0.05). Conclusion Compared with local anesthesia, ultrasound-guided selective nerve block has advantages over the local anesthesia during endovascular treatment of dysfunctional hemodialysis fistulas. It can provide safe and efficient analgesia with excellent procedural satisfaction in hemodialysis patients.

Introduction: The purpose of this meta-analysis was to assess the association between hypoalbuminemia and the risk of peritoneal dialysis-associated peritonitis (PDAP) in patients receiving peritoneal dialysis (PD).

Methods: By the specified deadline of November 13, 2023, a systematic search across various databases was conducted to identify relevant literature. The databases searched included PubMed, Embase, the Cochrane Library, Web of Science, the China National Knowledge Infrastructure (CNKI), WanFang, and VIP. The effect sizes were quantified using odds ratios (OR) or hazard ratios (HR) and were presented with 95% confidence intervals (CI). The analysis was stratified by the type of PD [continuous ambulatory peritoneal dialysis (CAPD), mixed] and the timing of albumin (ALB) level measurements (at baseline, after initiation of PD, or average over time).

Results: A total of 14 studies encompassing 6,448 PD patients were incorporated in this meta-analysis. The findings revealed a significantly elevated risk of peritonitis in patients with hypoalbuminemia compared to those with an ALB level above 3.5g/dL (OR: 2.70, 95% CI: 1.78 to 4.09, P <0.001). Stratification by PD modality showed consistent results within the CAPD group (OR: 5.79, 95% CI: 3.57 to 9.41, P <0.001). For the timing of ALB measurements, the baseline measurement group maintained these findings (OR: 2.53, 95% CI: 1.40 to 4.58, P =0.002), while the group with post-PD measurements did not show statistical significance (OR: 0.76, 95% CI: 0.49 to 1.17, P =0.212). The HR analysis similarly indicated an increased risk of peritonitis in hypoalbuminemia patients compared to those with higher serum ALB levels (HR: 1.62, 95% CI: 1.44 to 1.82, P <0.001).

Conclusion: Our meta-analysis reveals that hypoalbuminemia raises the risk of peritonitis in PD patients, particularly at baseline. This finding underscores the need for close monitoring to detect peritonitis early. Further research is needed to understand the impact of ALB levels post-PD initiation on peritonitis risk.

This review commemorates the 100th anniversary of the first human hemodialysis, which was performed by Georg Haas in 1924 at University Hospital Giessen. Haas' groundbreaking innovation, which included the development of the first functional artificial kidney, laid the foundation for modern hemodialysis therapies. Despite the technical and clinical challenges of his time, Haas' contributions marked a pivotal moment in the history of nephrology. The review also traces the evolution of dialysis at University Hospital Giessen in the decades following Haas' achievements. Key advancements include the introduction of refined hemodialysis technologies, the establishment of a kidney transplant center, an AV Fistula Center, and a regional peritoneal dialysis competence center. Despite these advancements, significant challenges persist worldwide, including the reduced life expectancy of patients undergoing dialysis and global disparities in access to renal replacement therapy. The growing incidence of chronic kidney disease (CKD), which affects 850 million people worldwide, highlights the urgent need for preventive strategies and early interventions. Emerging pharmacological therapies, such as treatment with sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists, offer promising opportunities to slow CKD progression and mitigate the associated complications.

Introduction: Cholemic nephropathy is an overlooked cause of acute kidney injury (AKI) in patients with advanced cirrhosis and high bilirubin plasma levels (usually above 20mg/dl), due to bilirubin and bile acid deposition in the kidneys. Those deposits have been hypothesized to cause tubular injury. It has no standardized diagnostic criteria or therapeutic strategies.

Methods: We present a series of fifteen patients with cirrhosis and severe cholemic AKI, diagnosed by microscopic urinary cast visualization after excluding and treating other causes of AKI. Bilirubin plasma removal was performed with albumin dialysis (n=3) or plasma exchange (n=12) to treat and prevent further kidney deterioration.

Results: Kidney function improved in most of the patients, five patients also required transient haemodialysis, with only one patient evolving to end stage chronic kidney disease needing liver-kidney transplant. Five patients underwent extended PE sessions as a bridge to liver transplantation. Survival at 30 days and 1 year was 80% and 73%, respectively, with 10 patients undergoing transplantation along this year.

Conclusion: In this highly selected cohort of patients with terminal cirrhosis and severe cholemic AKI extracorporeal plasma removal techniques seem to improve kidney function and overall prognosis. Larger prospective and controlled studies are required to better understand this condition.

Introduction: The lack of peritoneal dialysis (PD) catheters designed explicitly for neonates creates significant challenges in the provision of neonatal PD. High resource settings can circumvent this limitation by resorting to alternative extracorporeal dialysis methods. However, in low-resource settings, PD remains the preferred dialysis modality, and the use of off-label catheters for PD results in complications such as omental wrapping and occlusion. This study introduces a novel catheter design featuring a multi-diameter side port configuration and a helical geometry.

Methods: We employed numerical simulations to identify an optimal multi-diameter side port configuration, to address fluid dynamic issues that lead to catheter occlusion and omental wrapping. Following the simulations, we experimentally evaluated the catheter's performance in a series of benchtop tests designed to simulate physiological conditions encountered in neonatal PD.

Results: Our experimental evaluations demonstrated that the helical catheter outperforms commonly utilized pigtail catheters with same-sized diameter side ports by consistently achieving superior drainage efficiency during fibrin clot occlusion and omental wrapping tests.

Conclusion: The catheter is intended to be placed at the bedside to perform renal replacement therapy for neonates in low-resourced settings.

Background: Patient care informatics are becoming more advanced with digital capacity and server functionality. The intensive care unit (ICU) is becoming paperless for prescribing, charting, and monitoring care. A further challenge is to include all life sustaining therapies in this digital space. Digital modules and options may be available; however, continuous renal replacement therapies (CRRTs) often require custom design for many nuances. Associated with the COVID pandemic and a surge in the paperless and "green" ICU bedside, we gathered a team to design, develop, and implement a CRRT orders, charting-documentation, and monitoring functionality into our existing Cerner (ORACLE Corp., Austin, Texas, USA) software.

Key messages: This included new approaches to the two-dimensional paper documents used prior and a live dashboard with new metrics and data. The design linked to other relevant CRRT pages such as the master patient fluid balance, pathology results, and medication prescribing. The primary views and function are role-related for medical, nursing, and pharmacy with specific and sensitive input. Following the build and implementation, initial evaluation was positive and led to an audit trail or e-history for prescribers use and provision for concurrent therapies. Clinicians use this digital ordering differently with live data available for "handover" and case discussion. There is scope for research and further links to devices such as personal phones and via an app.

Summary: This experience may assist CRRT users design and develop similar prescribing, charting, and monitoring bedside computer opportunities in the desire for digital and green nephrology in the ICU.

Introduction: Anticoagulation for continuous renal replacement therapy (CRRT) can be performed using systemic anticoagulation or regional citrate anticoagulation (RCA). The 2012 Kidney Disease Improving Global Outcomes guidelines support the use of RCA as the first-line strategy in patients requiring CRRT, with and without bleeding risk. Implementing RCA in the intensive care unit (ICU) implies involving all medical and nursing staff. The primary objective of this study was to report and describe the various anticoagulation strategies for CRRT in French ICUs. The secondary objectives were to determine the rate of RCA use and to identify the factors limiting its implementation.

Methods: An online questionnaire containing 40 questions was sent to attending physicians and fellows practicing in French ICUs between May and September 2021. The questionnaire was sent via several networks: mailing list from the French Society of Anesthesia and Intensive Care Medicine and mailing lists of RRT manufacturers.

Results: A total of 597 responses were analyzed. RCA was used by most of the participants for patients with (81%) and without (80%) increased bleeding risk. The preferred CRRT modality of the participants while using RCA was continuous veno-venous hemodialysis (48%). The clinical situations frequently reported as an absolute contraindication to RCA were uncontrolled shock associated with liver failure and drug poisoning impairing citrate metabolism (62% and 52%, respectively). In case of a higher risk of citrate accumulation, most participants claimed to perform closer biological monitoring (57%) or to modify the CRRT protocol (61%). Among the participants who did not prescribe RCA as a first-line strategy, the main factors limiting its implementation were the lack of nurse (50%) or physician (34%) training.

Conclusion: RCA is the main anticoagulation strategy prescribed for CRRT in France. Providing medical and nursing staff easy access to training may facilitate the understanding and use of RCA as the first-line anticoagulation strategy for CRRT.

Introduction: Intermittent hemodialysis (IHD) is a preferable renal replacement therapy (RRT) option in metformin-associated lactic acidosis (MALA) due to rapid correct metabolic acidosis. However, IHD might not be started immediately. Immediate urgent-start peritoneal dialysis (iUSPD) is used as a life-saving dialysis option and then followed by IHD. The outcomes of iUSPD were compared with other extracorporeal dialysis in MALA.

Methods: In two tertiary hospitals in Thailand, the outcomes of patients with MALA who had received three different RRT modalities (iUSPD followed by IHD, IHD, and continuous renal replacement therapy [CRRT]) from January 2015 to December 2019 were compared. The primary outcome was 30-day mortality. The secondary outcomes were door-to-dialysis time and 90-day RRT dependence.

Results: A total of 180 MALA cases that required dialysis were included (20 iUSPD, 120 IHD, and 40 CRRT). Their mean age was 64 years. Most of the patients had severe metabolic acidosis (mean pH 6.91, HCO3 6 mmol/L, and anion gap 40 mmol/L) and were critically ill. The 30-day mortality was 30% in iUSPD, 9.2% in IHD, and 32.5% in CRRT (p = 0.001). The mortality risk in the iUSPD group was not significantly different from those of the IHD and CRRT groups (adjusted HR 2.5, 95% CI: 0.65-9.6, and adjusted HR 0.75, 95% CI: 0.2-2.78, respectively). All dialysis modalities had comparable 90-day dialysis dependence. iUSPD exhibited the shortest door-to-dialysis time.

Conclusion: In MALA, iUSPD followed by IHD might be a viable RRT option to save patient lives if no other dialysis options are available.

Introduction: Patients with end-stage renal disease (ESRD) are known to have reduced structural and functional brain connectivity in the brain regions associated with cognitive function. However, the effect of dialysis on brain connectivity remains unclear. This study aimed to evaluate the effects of dialysis on structural brain connectivity in patients with ESRD.

Methods: This prospective study included 20 patients with ESRD in the pre-dialysis stage and 35 healthy controls. The patients underwent T2-weighted and three-dimensional T1-weighted magnetic resonance imaging before and 3 months after dialysis initiation. Moreover, the cortical thickness was calculated. We applied graph theoretical analysis to calculate the structural covariance network based on cortical thickness. We compared the cortical thickness and structural covariance network of patients with ESRD in the pre-dialysis stage with those of healthy controls and with those of patients with ESRD in the post-dialysis stage.

Results: The mean cortical thickness in both hemispheres was lower in patients with ESRD in the pre-dialysis stage than in healthy controls (2.296 vs. 2.354, p = 0.030; 2.282 vs. 2.362, p = 0.004, respectively) and was higher in patients with ESRD in the post-dialysis stage than in those in the pre-dialysis stage (2.333 vs. 2.296, p = 0.001; 2.322 vs. 2.282, p = 0.002, respectively). Analysis of the structural covariance network revealed that the assortative coefficient was lower in patients with ESRD in the pre-dialysis stage than in healthy controls (-0.062 vs. -0.031, p = 0.029) and was higher in patients with ESRD in the post-dialysis stage than in those in the pre-dialysis stage (-0.002 vs. -0.062, p = 0.042).

Conclusion: We observed differences in the cortical thickness and structural covariance networks before and after dialysis in patients with ESRD. This indicates that dialysis affects structural brain connectivity, contributing to the understanding of the pathophysiological mechanism of cognitive function alterations resulting from dialysis in patients with ESRD.