Feasibility and safety of combined cytokine adsorption and continuous veno-venous hemodialysis with regional citrate anticoagulation in patients with septic shock

2019 ◽  
Vol 43 (1) ◽  
pp. 10-16
Author(s):  
Thomas Dimski ◽  
Timo Brandenburger ◽  
Torsten Slowinski ◽  
Detlef Kindgen-Milles
Keyword(s):  
Septic Shock ◽  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Kidney Injury ◽  
Regional Citrate Anticoagulation ◽  
Adjunct Treatment ◽  
Citrate Anticoagulation ◽  
Acute Kidney Injury Stage ◽  
Norepinephrine Dose

Introduction: Septic shock is characterized by severe metabolic and hemodynamic alterations. It is often accompanied by acute kidney injury. A new adjunct treatment is hemoadsorption using a cytokine adsorber in line with continuous veno-venous renal replacement therapy. We studied the feasibility, efficacy, and safety of cytokine adsorption with citrate-anticoagulated continuous veno-venous hemodialysis (regional citrate anticoagulation–continuous veno-venous hemodialysis). Methods: In 11 patients with septic shock and acute kidney injury stage 3, we studied 12 cycles of cytokine adsorption and regional citrate anticoagulation–continuous veno-venous hemodialysis. We monitored parameters of citrate anticoagulation, circuit lifetime, laboratory parameters, hemodynamics, and vasopressor demand. Results: Ten out of 12 adsorber/continuous veno-venous hemodialysis circuits reached the target lifetime of 24 h for the adsorber. One system clotted and one was stopped for non-device-related reasons. Nine of the remaining continuous renal replacement therapy circuits reached 72 h lifetime. With default settings for regional citrate anticoagulation, serum ionized calcium and pH were in the normal range. Urea and creatinine were reduced significantly, and norepinephrine dose decreased from 0.47 (±0.09) to 0.16 (±0.04) µg/kg/min ( p = 0.016) after 24 h. Discussion: We show that combined cytokine adsorption/continuous veno-venous hemodialysis is effective to control pH, to reduce urea and creatinine, and to improve hemodynamics by reducing norepinephrine doses in patients with septic shock. It can be applied safely with standard settings of regional citrate anticoagulation rendering sufficiently long filter lifetimes for the adsorber and the continuous veno-venous hemodialysis circuit. Further studies are on the way to investigate whether these effects translate into improved outcomes in septic shock patients.

scholarly journals Monitoring of Enoxaparin during Hemodialysis Covered by Regional Citrate Anticoagulation in Acute Kidney Injury: A Prospective Cohort Study

2021 ◽  
Vol 10 (19) ◽  
pp. 4491
Author(s):  
Marion Wiegele ◽  
Dieter Adelmann ◽  
Christoph Dibiasi ◽  
Andrè Pausch ◽  
Andreas Baierl ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Kidney Injury ◽  
Regional Citrate Anticoagulation ◽  
Low Molecular Weight Heparins ◽  
Rotational Thromboelastometry ◽  
Citrate Anticoagulation ◽  
Trough Levels

Background: Current guidelines recommend the monitoring of anti-factor Xa (anti-Xa) levels to avoid an accumulation of low-molecular-weight heparins in patients with acute kidney injury, but there is no evidence on how to proceed with such monitoring during continuous renal replacement therapy. Against this background, we investigated the potential accumulation of enoxaparin administered subcutaneously for venous thromboembolism prophylaxis in critically ill patients during continuous renal replacement therapy covered by regional citrate anticoagulation. Methods: Anti-Xa levels were measured at baseline (≤12 h before renal replacement therapy) and on three consecutive days (A to C) when enoxaparin had reached trough levels. Supplementary testing included modified assays of rotational thromboelastometry known to be highly sensitive for low-molecular-weight heparins. Results: The 16 men and 13 women included were adults comparable in age, body mass index, thromboembolism risk assessment, and clinical severity of the disease. Throughout the four examinations, the median trough levels of anti-Xa remained below the detection limit of the test (<0.1 IU mL−1), with interquartile ranges of <0.1 to 0.14 IU mL−1 at baseline and <0.1 to 0.16 IU mL−1 on days A/B/C. All rotational thromboelastometry parameters of clot initiation and clot formation dynamics did not significantly change from baseline to day C. Conclusions: Neither anti-Xa levels nor modified assays of rotational thromboelastometry revealed any accumulation of enoxaparin administered for thromboprophylaxis during continuous renal replacement therapy covered by regional citrate anticoagulation. Although generally recommended in patients with acute kidney injury, monitoring of anti-Xa levels should be questioned in this defined setting.

scholarly journals Concentration of meropenem in patients with sepsis and acute kidney injury before and after initiation of continuous renal replacement therapy: a prospective observational trial

2020 ◽  
Vol 72 (1) ◽  
pp. 147-155 ◽  
Author(s):  
Ilona Nowak-Kózka ◽  
Kamil J. Polok ◽  
Jacek Górka ◽  
Jakub Fronczek ◽  
Anna Gielicz ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Kidney Injury ◽  
Regional Citrate Anticoagulation ◽  
High Dose ◽  
Prolonged Infusion ◽  
Time Points ◽  
Drug Concentrations ◽  
Before And After

Abstract Background The effect of renal replacement therapy on drug concentrations in patients with sepsis has not been fully elucidated because the pharmacokinetic properties of many antimicrobials are influenced by both pathophysiological and treatment-related factors. The aim of this study was to determine meropenem concentrations in patients with sepsis before and after the initiation of continuous venovenous hemodialysis with regional citrate anticoagulation (RCA-CVVHD). Methods The study included 15 critically ill patients undergoing RCA-CVVHD due to sepsis-induced acute kidney injury. All participants received 2 g of meropenem every 8 h in a prolonged infusion lasting 3 h. Meropenem concentrations were measured in blood plasma using high-performance liquid chromatography coupled with tandem mass spectrometry. Blood samples were obtained at six-time points prior to and at six-time points after introducing RCA-CVVHD. Results The median APACHE IV and SOFA scores on admission were 118 points (interquartile range [IQR] 97–134 points) and 19.5 points (IQR 18–21 points), respectively. There were no significant differences in the plasma concentrations of meropenem measured directly before RCA-CVVHD and during the first 450 min of the procedure. The drug concentration reached its peak 2 h after initiating the infusion and then steadily declined. Conclusions The concentration of high-dose meropenem (2 g every 8 h) administered in a prolonged infusion was similar before and after the introduction of RCA-CVVHD in patients with sepsis who developed acute kidney injury.

scholarly journals The Current State of Renal Replacement Therapy in the Treatment of Sepsis

2021 ◽  
Vol 18 (4) ◽  
pp. 80-89
Author(s):  
T. G. Kim ◽  
M. А. Magomedov ◽  
D. N. Protsenko ◽  
M. V. Zakharov ◽  
А. V. Marukhov ◽  
...  
Keyword(s):  
Septic Shock ◽  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Kidney Injury ◽  
Results Of Treatment ◽  
Current State ◽  
Sepsis And Septic Shock ◽  
Positive Results ◽  
Organ Dysfunctions

Of all cases of acute kidney injury (AKI), 45-70% are associated with sepsis. Lethality in sepsis-associated AKI requiring renal replacement therapy (RRT) ranges from 40 to 50%, and in AKI combined with other organ dysfunctions - 60-80%. In order to improve the results of treatment of sepsis and septic shock, various methods of extracorporeal detoxification (ECD) have been developed. The effectiveness of these methods is controversial. In the treatment of sepsis, RRT is used not only to replace the impaired detoxification function of kidneys, but also to remove excess cytokines from the systemic bloodstream. The literature describes mainly positive results of the use of dialyzers with an adsorbing membrane, however, these data do not have the necessary degree of evidence. Currently, there are no clear criteria for the initiation of RRT, its duration and doses, the choice of methodology determined by specific clinical and laboratory parameters, and staging of this therapy. All this highlights the need for further research in this field.

scholarly journals Coupled-plasma filtration and adsorption for severe burn patients with septic shock and acute kidney injury treated with renal replacement therapy

Burns ◽  
2020 ◽  
Vol 46 (1) ◽  
pp. 190-198 ◽  
Author(s):  
Filippo Mariano ◽  
Zsuzsanna Hollo’ ◽  
Nadia Depetris ◽  
Valeria Malvasio ◽  
Alberto Mella ◽  
...  
Keyword(s):  
Septic Shock ◽  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Kidney Injury ◽  
Burn Patients ◽  
Severe Burn ◽  
Plasma Filtration
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