Blood Purification最新文献

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: The use of temporary-left ventricular assist devices (T-LVADs) for circulatory support in cardiogenic shock is increasing along with complications like acute kidney injury requiring kidney replacement therapy (KRT). While KRT is linked to mortality in cardiogenic shock, data on mortality in patients receiving both T-LVAD and KRT are limited.

Methods: We conducted a systematic review and meta-analysis, searching three databases from inception through December 30, 2023, for studies reporting on patients with concurrent T-LVAD and KRT support during cardiogenic shock. We performed random-effects meta-analyses, looking at in-hospital mortality as our primary outcome. Subgroup analysis was performed based on the continent, timing of KRT, and type of T-LVAD. Risk of bias was assessed with the Joanna Briggs Institute checklists and certainty of evidence with the GRADE approach.

Results: We included 35 studies after screening through 89 full-text articles, consisting of 2,277 individuals receiving T-LVAD and 722 (30.9%, 95% CI: 25.8-36.6) receiving concurrent KRT. In-hospital mortality was pooled across 6 studies, with 91 non-survivors (65.5%) among 139 individuals (95% CI: 57.2-72.9). Concurrent KRT and T-LVAD was associated with higher in-hospital (OR 3.48, 95% CI: 2.20-5.49) and overall mortality (OR 2.19, 95% CI: 1.01-4.76) compared to patients not on KRT. The proportion of patients on KRT was significantly (p interaction = 0.0004) larger in Europe (37.2%, 95% CI: 32.2-42.4) than North America (18.2%, 95% CI: 12.0-26.7). Region, type of T-LVAD, and publication year did not significantly impact any of the mortality outcomes.

Conclusion: Patients on concurrent KRT and T-LVAD suffer significantly greater odds of mortality compared to patients not receiving KRT during their hospital admission. A substantial proportion of patients receiving T-LVADs require KRT. Further studies with head-to-head comparisons between KRT and non-KRT treatment arms are warranted to confirm our findings, in addition to identifying at-risk populations that require KRT and potential interventions to improve survival in this subset of patients.

Introduction: Survival is a core outcome of hemodialysis (HD) therapy. Expanded hemodialysis (HDx) enabled by Theranova dialyzer increases clearance of medium-sized molecules and was reported to improve various patient-reported outcomes compared to HD using high-flux membranes, but the impact on survival is unclear. Herein, we evaluated the risk of death for HDx versus high-flux HD over a 4-year follow-up period.

Methods: This is a multicenter, retrospective cohort study in adult prevalent chronic HD at Renal Care Services - Colombia starting between September 1, 2017, and November 30, 2017, with follow-up for up to 4 years. The sociodemographic and clinical characteristics of all patients were summarized descriptively. The Fine-Gray subdistribution hazard model was employed to evaluate the sub-hazard ratio of factors associated with time to death from causes other than COVID-19; death attributable to COVID-19 was considered as a competing risk. Sensitivity analyses included Cox proportional hazards model, extended Cox regression, and Cox regression after adjusting for imbalances between cohorts using the inverse probability of treatment weighting method.

Results: We evaluated 1,092 patients, 559 in HDx cohort and 533 in high-flux HD cohort; the mean age 61 years; 42% had diabetes, and 19% had cardiovascular disease. HDx using the Theranova dialyzer had a protective effect with reduction of mortality risk when controlling for confounding variables, SHR = 0.79 [95% CI: 0.62-0.98, p = 0.035]. Sensitivity analyses also showed a statistically significant beneficial effect of HDx versus high-flux HD.

Conclusions: HDx enabled by Theranova dialyzer was associated with an approximately 21% reduction in mortality risk compared to treatment with high-flux HD in patients followed for up to 4 years. It would be desirable for these very promising results to be corroborated by a randomized controlled trial, with sufficient follow-up time to investigate the effect described in this study.

Background: Hemodialysis is a water-intense procedure, needing large quantities of water for preparation of small volumes of dialyzate. The resulting large volumes of reject water are usually discarded. With the rising water crisis both in the USA and the world, it is essential to understand water utilization and identify ways to minimize its utilization and maximize the use of the reject water.

Summary: Unfortunately, water from the city sources cannot be used to produce dialyzate unless it undergoes further purification. This results in a large amount of reject water, which can be from 50 to 70% of total water use, resulting in an enormous waste of resources. A review of solutions for water sustainability is broadly classified into solutions that decrease water utilization and solutions for increased reject water utilization. Those that are aimed at decreasing water utilization were mainly based in innovations in technology - examples are NxStage PureFlow™SL, Aquaboss by Braun and AquaBPlus by Fresenius, and those that focused on increased reuse of RO reject water rely on data that it can be safely utilized for various purposes such as irrigation and flushing toilets. These strategies can be cost-effective. Although the need for sustainability has been recognized, there needs to be further awareness and participation among nephrologists to further this cause. In addition, there need to be policies put forward by the government that could encourage sustainability.

Key messages: Hemodialysis continues to heavily tax the environment. Although the need for sustainability has been recognized, there still remains a lot of work that needs to be done. Further buy-in is needed from all participating entities - nephrologists, dialysis manufacturers and organizations, and the government in order to safeguard our limited resources.

Selected Abstracts from the 43rd Vicenza Course AKI-CRRT-EBPT and Critical Care Nephrology.

Introduction: Dialysis-related amyloidosis (DRA) is a refractory complication of long-term dialysis caused by β2-microglobulin (β2MG) deposition. While β2MG adsorption columns remove β2MG, their impact on preventing re-surgery remains unclear.

Methods: This a noninterventional, population-based cohort study used a large-scale medical claims database. This study included patients with chronic kidney disease undergoing maintenance hemodialysis (HD) and diagnosed with DRA. The exposure group received β2MG adsorption column therapy, while the control group was divided into online hemodiafiltration (OHDF) and HD subgroups. The primary endpoint was carpal tunnel or trigger finger release.

Results: Among 3,946 eligible patients, 212 patients in the β2MG adsorption column group, 139 in the OHDF group, and 237 in the HD group were included; the primary endpoint occurred in 28 (13.2%), 21 (15.1%), and 37 (15.6%) patients, respectively. Although there was a trend toward a lower incidence in the β2MG adsorption column group, no significant difference was observed (p = 0.43). The adjusted hazard ratio for the β2MG adsorption column group (HD group as reference) tended to be low (0.68, 95% CI: 0.41-1.13), but this difference was not significant.

Conclusions: Although there was no statistically significant difference, the findings suggest that the β2MG adsorption column may help slow DRA progression.

Introduction: The use of hemoadsorption devices is increasingly gaining impact as an adjunct therapy for various critical conditions in ICU patients, including systemic hyperinflammation, cytokine release syndrome, sepsis, and more. A key concern in this therapy is its impact on the plasma levels of concurrently administered drugs, which could potentially be reduced to subtherapeutic levels, affecting patient care. The present study investigates the adsorption behavior of various drugs in an in vitro hemoadsorption model using human whole blood, aiming to provide insights for optimizing drug dosing during hemoadsorption therapy.

Methods: The study assessed the removal rates and clearances of several drugs, namely, apixaban, argatroban, carbamazepine, oxcarbazepine, lamotrigine, phenytoin, valproate, levosimendan, methylene blue, and metformin, by circulating the blood through CytoSorb adsorbers in an in vitro setup.

Results: Significant removal (75 to 100% of the initial concentration) and high initial plasma clearances (approximately 10-25 mL/min) were observed for most of the tested drugs within the first 30-60 min of recirculation. Lower removal rates and clearances were noted for valproate (approximately 40% and 5 mL/min) and metformin (approximately 15% and 1 mL/min).

Conclusion: The findings indicate considerable differences in the adsorption of the tested drugs and should be confirmed by additional in vivo studies with careful monitoring of drug levels throughout the course of therapy. Understanding the in vivo dynamics is crucial for adjusting dosages appropriately during hemoadsorption use to ensure therapeutic efficacy and patient safety.