Tandem Therapeutic Plasma Exchange Reduces Continuous Renal Replacement Therapy Downtime

2021 ◽  
pp. 1-8
Author(s):  
Matthew J. Foglia ◽  
Jonathan H. Pelletier ◽  
Hülya Bayir ◽  
Annette Fleck ◽  
Leslie Konyk ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Plasma Exchange ◽  
Treatment Time ◽  
Kidney Injury ◽  
Therapeutic Plasma Exchange ◽  
Factors Associated ◽  
Multivariable Logistic Regression

<b><i>Introduction:</i></b> Continuous renal replacement therapy (CRRT) has become a primary treatment of severe acute kidney injury in children admitted to the intensive care unit. CRRT “downtime” (when the circuit is not active) can represent a significant portion of the prescribed treatment time and adversely affects clearance. The objective of this study was to evaluate factors associated with CRRT “downtime” and to determine whether instituting a tandem therapeutic plasma exchange (TPE) protocol could significantly and robustly decrease circuit downtime in patients receiving both therapies. <b><i>Methods:</i></b> This is a retrospective cohort study of 116 patients undergoing CRRT in the pediatric, neonatal, or cardiac ICU at UPMC Children’s Hospital of Pittsburgh from January 2014 to July 2020. We performed multivariable logistic regression to determine factors associated with CRRT downtime. We instituted a tandem TPE protocol whereby TPE and CRRT could run in parallel without pausing CRRT in April 2018. We analyzed the effect of the protocol change by plotting downtime for patients undergoing CRRT and TPE on a run chart. The effect of initiating tandem TPE on downtime was assessed by special cause variation. <b><i>Results:</i></b> For 108/139 (77.7%) sessions with downtime data available, the median (IQR) percentage of downtime was 6.2% (1.7–12.7%). Multivariable logistic regression showed that TPE was significantly associated with CRRT downtime (<i>p</i> = 0.003), and that age, sex, race, catheter size, and anticoagulation were not. For patients undergoing TPE, the median (IQR) percentage of downtime was 14.7% (10.5–26%) and 3.4% (1.3–4.9%) before and after initiation of tandem TPE, respectively (<i>p</i> &#x3c; 0.001). The difference in downtime percentage met criteria for special cause variation. <b><i>Conclusions:</i></b> Interruptions for TPE increase CRRT downtime. Tandem TPE significantly reduces CRRT downtime in patients undergoing both procedures concomitantly.

scholarly journals Evaluation of Continuous Renal Replacement Therapy and Therapeutic Plasma Exchange, in Severe Sepsis or Septic Shock in Critically Ill Children

Medicina ◽  
2019 ◽  
Vol 55 (7) ◽  
pp. 350
Author(s):  
Fatih Aygün ◽  
Fatih Varol ◽  
Cansu Durak ◽  
Mey Talip Petmezci ◽  
Alper Kacar ◽  
...  
Keyword(s):  
Septic Shock ◽  
Severe Sepsis ◽  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Plasma Exchange ◽  
Critically Ill ◽  
Demographic Data ◽  
Therapeutic Plasma Exchange ◽  
Critically Ill Children

Background and objective: Severe sepsis and septic shock are life-threatening organ dysfunctions and causes of death in critically ill patients. The therapeutic goal of the management of sepsis is restoring balance to the immune system and fluid balance. Continuous renal replacement therapy (CRRT) is recommended in septic patients, and it may improve outcomes in patients with severe sepsis or septic shock. Therapeutic plasma exchange (TPE) is another extracorporeal procedure that can improve organ function by decreasing inflammatory and anti-fibrinolytic mediators and correcting haemostasis by replenishing anticoagulant proteins. However, research about sepsis and CRRT and TPE in children has been insufficient and incomplete. Therefore, we investigated the reliability and efficacy of extracorporeal therapies in paediatric patients with severe sepsis or septic shock. Materials and methods: We performed a multicentre retrospective study using data from all patients aged <18 years who were admitted to two paediatric intensive care units. Demographic data and reason for hospitalization were recorded. In addition, vital signs, haemogram parameters, and biochemistry results were recorded at 0 h and after 24 h of CRRT. Patients were compared according to whether they underwent CRRT or TPE; mortality between the two treatment groups was also compared. Results: Between January 2014 and April 2019, 168 septic patients were enrolled in the present study. Of them, 47 (27.9%) patients underwent CRRT and 24 underwent TPE. In patients with severe sepsis, the requirement for CRRT was statistically associated with mortality (p < 0.001). In contrast, the requirement for TPE was not associated with mortality (p = 0.124). Conclusion: Our findings revealed that the requirement for CRRT in patients with severe sepsis is predictive of increased mortality. CRRT and TPE can be useful techniques in critically ill children with severe sepsis. However, our results did not show a decrease of mortality with CRRT and TPE.

scholarly journals Intra-dialytic hypotension following the transition from continuous to intermittent renal replacement therapy

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
William Beaubien-Souligny ◽  
Yifan Yang ◽  
Karen E. A. Burns ◽  
Jan O. Friedrich ◽  
Alejandro Meraz-Muñoz ◽  
...  
Keyword(s):  
Renal Replacement Therapy ◽  
Hospital Mortality ◽  
Replacement Therapy ◽  
Kidney Injury ◽  
Hemodynamic Instability ◽  
Factors Associated ◽  
Definition Of ◽  
Vasopressor Use ◽  
Cumulative Fluid Balance ◽  
Intermittent Renal Replacement Therapy

Abstract Background Transition from continuous renal replacement therapy (CRRT) to intermittent renal replacement therapy (IRRT) can be associated with intra-dialytic hypotension (IDH) although data to inform the definition of IDH, its incidence and clinical implications, are lacking. We aimed to describe the incidence and factors associated with IDH during the first IRRT session following transition from CRRT and its association with hospital mortality. This was a retrospective single-center cohort study in patients with acute kidney injury for whom at least one CRRT-to-IRRT transition occurred while in intensive care. We assessed associations between multiple candidate definitions of IDH and hospital mortality. We then evaluated the factors associated with IDH. Results We evaluated 231 CRRT-to-IRRT transitions in 213 critically ill patients with AKI. Hospital mortality was 43.7% (n = 93). We defined IDH during the first IRRT session as 1) discontinuation of IRRT for hemodynamic instability; 2) any initiation or increase in vasopressor/inotropic agents or 3) a nadir systolic blood pressure of < 90 mmHg. IDH during the first IRRT session occurred in 50.2% of CRRT-to-IRRT transitions and was independently associated with hospital mortality (adjusted odds ratio [OR]: 2.71; CI 1.51–4.84, p < 0.001). Clinical variables at the time of CRRT discontinuation associated with IDH included vasopressor use, higher cumulative fluid balance, and lower urine output. Conclusions IDH events during CRRT-to-IRRT transition occurred in nearly half of patients and were independently associated with hospital mortality. We identified several characteristics that anticipate the development of IDH following the initiation of IRRT.

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