Heterogeneity of Effect of Net Ultrafiltration Rate among Critically Ill Adults Receiving Continuous Renal Replacement Therapy

2020 ◽  
pp. 1-11
Author(s):  
Ary Serpa Neto ◽  
Thummaporn Naorungroj ◽  
Raghavan Murugan ◽  
John A. Kellum ◽  
Martin Gallagher ◽  
...  
Keyword(s):  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Sofa Score ◽  
Missing Values ◽  
Secondary Analysis ◽  
Patient Characteristics ◽  
Randomized Evaluation ◽  
Baseline Weight ◽  
Critically Ill Adults

<b><i>Introduction:</i></b> In continuous renal replacement therapy (CRRT)-treated patients, a net ultrafiltration (NUF) rate &#x3e;1.75 mL/kg/h has been associated with increased mortality. However, there may be heterogeneity of effect of NUF rate on mortality, according to patient characteristics. <b><i>Methods:</i></b> To investigate the presence and impact of heterogeneity of effect, we performed a secondary analysis of the “Randomized Evaluation of Normal versus Augmented Level of Renal Replacement Therapy” (RENAL) trial. Exposure was NUF rate (weight-adjusted fluid volume removed per hour) stratified into tertiles (&#x3c;1.01 mL/kg/h; 1.01–1.75 mL/kg/h; or &#x3e;1.75 mL/kg/h). Primary outcome was 90-day mortality. Patients were clustered according to baseline characteristics. Heterogeneity of effect was assessed according to clusters and baseline edema and related to the additional impact of baseline cardiovascular Sequential Organ Failure Assessment (SOFA) score. We excluded patients with missing values for baseline weight and/or treatment duration. <b><i>Results:</i></b> We identified 2 clusters. The largest (cluster 1; <i>n</i> = 941) included more severely ill patients, with more sepsis, more edema, and more vasopressor therapy (all <i>p</i> &#x3c; 0.001). Compared to the middle tertile, the probability of harm was greater with the high tertile of NUF rate in patients in cluster 1 and in patients with baseline edema (probability of harm, cluster 1: 99.9%; edema: 99.1%). Moreover, higher baseline cardiovascular SOFA score also increased mortality risk with both high and low compared to middle NUF rates in cluster 1 patients and in patients with edema. <b><i>Conclusions:</i></b> In CRRT patients, both high and low NUF rates may be harmful, especially in those with edema, sepsis, and greater illness severity. Cardiovascular SOFA scores modulate this association. Additional studies are needed to test these hypotheses, and targeted trials of NUF rates based on risk stratification appear justified. <b><i>Trial Registration:</i></b> ClinicalTrials.gov identifier: NCT00221013.

Platelet Decreases following Continuous Renal Replacement Therapy Initiation as a Novel Risk Factor for Renal Nonrecovery

2021 ◽  
pp. 1-8
Author(s):  
Benjamin R. Griffin ◽  
Patrick Ten Eyck ◽  
Sarah Faubel ◽  
Diana Jalal ◽  
Martin Gallagher ◽  
...  
Keyword(s):  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Clinical Effect ◽  
Secondary Analysis ◽  
Renal Recovery ◽  
Cut Points ◽  
Randomized Evaluation ◽  
Therapy Initiation ◽  
Renal Replacement Therapy Initiation

<b><i>Background:</i></b> Continuous renal replacement therapy (CRRT) is a form of dialysis used in critically ill patients, and has recently been associated with renal nonrecovery. Decreases in platelets following CRRT initiation are common and are associated with mortality, but associations with renal recovery are unclear. Our objective was to determine if platelet nadir or the degree of platelet decrease following CRRT initiation was associated with renal nonrecovery. <b><i>Methods:</i></b> This is a secondary analysis of the Randomized Evaluation of Normal versus Augmented Level (RENAL) trial. Primary predictors were platelet nadir discretized by median value and percent platelet decrease following CRRT initiation, with cut points evaluated by decile from 30 to 60%. The 2 primary outcomes were time to RRT-independence and RRT-free days. Secondary outcomes were 28-day mortality, 90-day mortality, intensive care unit (ICU)-free, and hospital-free days. <b><i>Results:</i></b> Time to RRT independence censored for death was achieved less frequently in patients with low platelet nadir (hazard ratio [HR] 0.77, confidence interval [CI] 0.66–0.91) and in those with &#x3e;50% platelet decrease (HR 0.84, CI 0.72–0.97). RRT-free days were lower in both low platelet nadir (odds ratio [OR] 0.94, CI 0.90–0.97) and &#x3e;50% platelet decrease (OR 0.91, CI 0.88–0.95). These groups also had higher rates of 28- and 90-day mortality and fewer ICU-free and hospital-free days. Thrombocytopenia at CRRT initiation was also associated with renal nonrecovery, although the clinical effect was small. <b><i>Conclusions:</i></b> Platelet nadir &#x3c;100 × 10<sup>3</sup>/µL and platelet decrease by &#x3e;50% following CRRT initiation were both associated with lower rates of renal recovery. Further research is needed to evaluate mechanisms-linking platelet changes and renal nonrecovery in CRRT.

scholarly journals Hyperoncotic Albumin Solution in Continuous Renal Replacement Therapy Patients

2021 ◽  
pp. 1-10
Author(s):  
Zachary O’Brien ◽  
Mark Finnis ◽  
Martin Gallagher ◽  
Rinaldo Bellomo ◽  
Keyword(s):  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Fluid Balance ◽  
Proportional Hazards ◽  
Human Albumin ◽  
Cox Proportional Hazards ◽  
Albumin Solution ◽  
Randomized Evaluation ◽  
Human Albumin Solution

<b><i>Aim:</i></b> The aim of this study was to investigate the association of hyperoncotic (20%) human albumin solution (HAS) with outcomes among critically ill patients receiving continuous renal replacement therapy (RRT). <b><i>Methods:</i></b> Analysis of the Randomized Evaluation of Normal versus Augmented Level (RENAL) RRT trial data. <b><i>Results:</i></b> Of 1,508 patients, 771 (51%) received albumin. Of these, 345 (45%) received 4% HAS only, 155 (20%) received 20% HAS only, and 271 (35%) received both. Patients who received combined 4% and 20% HAS were more severely ill, received more days of RENAL trial therapy and required mechanical ventilation for longer. Mean daily fluid balance was −288 mL (−904 to 261) with 20% HAS only versus 245 mL (−248 to 1,050) with 4% HAS only (<i>p</i> &#x3c; 0.001). On Cox proportional hazards regression, 20% HAS exposure was not associated with greater 90-day mortality (odds ratio 1.12, 95% confidence interval [CI]: 0.77–1.62; <i>p</i> = 0.55) or longer recovery to RRT independence (sub-hazard ratio 1.04, 95% CI: 0.84–1.30; <i>p</i> = 0.70) compared to those who received 4% HAS only. <b><i>Conclusions:</i></b> RENAL trial patients commonly received albumin in varying concentrations. The administration of 20% HAS was associated with a more negative fluid balance but was not independently associated with increased mortality or RRT dependence when compared to 4% HAS only.

Pharmacokinetics of trimethoprim/sulfametrole in critically ill patients on continuous renal replacement therapy

2020 ◽  
Vol 75 (5) ◽  
pp. 1237-1241
Author(s):  
René Welte ◽  
Rudolph Beyer ◽  
Johannes Hotter ◽  
Astrid Broeker ◽  
Sebastian G Wicha ◽  
...  
Keyword(s):  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Critically Ill ◽  
Pharmacokinetic Analysis ◽  
Control Group ◽  
Population Pharmacokinetic ◽  
Significant Difference ◽  
Critically Ill Adults ◽  
Ill Adults

Abstract Objectives We investigated the effect of continuous renal replacement therapy (CRRT) on the pharmacokinetics of trimethoprim and sulfametrole. Patients and methods We enrolled critically ill adults undergoing CRRT and critically ill adults with normal or slightly impaired renal function (plasma creatinine concentration &lt;1.5 mg/dL, control group). All patients received trimethoprim/sulfametrole at standard doses. Pharmacokinetics were determined after the first dose and at steady-state. In addition, a population pharmacokinetic model using plasma data was built. We also assessed the renal clearance (CLR) and the extracorporeal clearance in patients undergoing CRRT. Results Twelve patients were enrolled in the CRRT group and 12 patients in the control group. There was no statistically significant difference in trimethoprim pharmacokinetics between the two groups. In patients on CRRT, total plasma clearance (CLtot) and V of sulfametrole were significantly higher than in the control group. However, sulfametrole exposure was not significantly altered during CRRT. The population pharmacokinetic analysis indicated that neither CRRT intensity nor residual diuresis were significant covariates on trimethoprim or sulfametrole CL. Median CL by continuous venovenous haemofiltration accounted for about one-third of CLtot of trimethoprim and for about one-half of CLtot of sulfametrole. In patients on CRRT, CLR of trimethoprim and sulfametrole were &lt;5% of CLtot. Conclusions During CRRT, standard doses of trimethoprim/sulfametrole appear to be adequate.

Albumin Levels Predict Mortality In Sepsis Patients With Acute Kidney Injury Undergoing Continuous Renal Replacement Therapy: A Secondary Analysis Based On A Retrospective Cohort Study

2021 ◽  
Author(s):  
Song Sheng ◽  
Ye Huang
Keyword(s):  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Proportional Hazards ◽  
Secondary Analysis ◽  
Kidney Injury ◽  
Cox Proportional Hazards ◽  
Negatively Associated ◽  
Risk Of Death

Abstract Background Albumin (ALB) levels are negatively associated with mortality in patients with sepsis. However, among sepsis patients with acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT), there has been no similar study on the correlation between ALB levels and mortality alone. This study tested the hypothesis that ALB levels are negatively associated with mortality among such patients. Methods We conducted a secondary analysis of 794 patients with sepsis who were diagnosed with AKI and underwent CRRT in South Korea. For the Kaplan–Meier survival analysis, Cox proportional hazards models were used to study the hypotheses, with adjustments for the pertinent covariables. Results The ALB level was an independent prognostic factor for death at 28 and 90 days after CRRT initiation (HR=0.75, 95% CI: 0.62–0.90, P=0.0024 for death at 28 days and HR=0.73, 95% CI: 0.63–0.86, P<0.0001 for death at 90 days). A nonlinear association was not identified between ALB levels and the endpoints. Subgroup analyses and tests for interactions indicated that patients with low HCO3 levels (<22 mmol/L) had a higher rate of death at 28 days (P for interaction=0.0235), and there was a significantly increased mortality at 90 days among patients with high CRP levels (P for interaction=0.0195). Conclusion A 1 g/dL increase in ALB levels was independently associated with a 25% and 27% decrease in the risk of death at 28 and 90 days, respectively. It is feasible to predict mortality using ALB levels in sepsis patients with AKI undergoing CRRT.

Sign in / Sign up

Export Citation Format

Share Document