Objective To explore the application of regional citrate anticoagulation (RCA) in continuous renal replacement therapy (CRRT) for patients with sepsis and hyperlactacidemia, and to provide a basis for the clinical application of RCA in such patients. Methods Sepsis patients who underwent RCA-CRRT at West China Hospital of Sichuan University between May 2021 and May 2023 were retrospectively included. Patients were divided into a normal lactate group (≤2.0 mmol/L) and a hyperlactacidemia group (>2.0 mmol/L) based on their initial lactate levels before CRRT, and subgroup analysis was performed on patients with moderate hyperlactacidemia (2 mmol/L<lactate level<4 mmol/L) and severe hyperlactacidemia (≥4.0 mmol/L). Propensity score matching (PSM) was used, and baseline characteristics and outcome measures of different groups of patients were compared. Results A total of 441 patients were included, with 228 in the normal lactate group and 213 in the hyperlactacidemia group. Before PSM, there were statistically significant differences in the proportion of liver failure, proportion of chronic kidney disease, mean arterial pressure, bicarbonate, total bilirubin, creatinine, activated partial thromboplastin time, international standardized ratio, procalcitonin, and interleukin-6 between the normal lactate group and the hyperlactacidemia group (P<0.05). After PSM, there were 162 patients in both the normal lactate group and the hyperlactacidemia group. There was no statistically significant difference in baseline characteristics between the two groups of patients (P>0.05). The incidence of citric acid accumulation in the normal lactate group and the hyperlactacidemia group was 13.0% and 25.9%, respectively (P<0.05). There was no statistically significant difference in the incidence of metabolic acidosis, metabolic alkalosis, hypernatremia, filter coagulation events, or in-hospital mortality between the two groups (P>0.05). Kaplan-Meier survival analysis showed that there was no statistically significant difference in the first extracorporeal circulation lifespan between the normal lactate group and the hyperlactacidemia group (P>0.05). Among 213 patients with hyperlactacidemia, 186 had moderate hyperlactacidemia and 27 had severe hyperlactacidemia. Before PSM, there were statistically significant differences in the proportion of male, proportion of diabetes, albumin level, international standardized ratio, and interleukin-6 between moderate and severe hyperlactacidemia groups (P<0.05). After PSM, there were 22 patients in both the moderate and severe hyperlactacidemia groups. There was no statistically significant difference in baseline characteristics between the two groups of patients (P>0.05). The incidence of citric acid accumulation was 18.2% and 50.0% in the moderate and severe hyperlactacidemia groups, respectively (P<0.05). There was no statistically significant difference in the incidence of metabolic acidosis, metabolic alkalosis, hypernatremia, filter coagulation events, or in-hospital mortality between the two groups (P>0.05). Kaplan-Meier survival analysis showed that there was no statistically significant difference in the first extracorporeal circulation lifespan between the moderate and severe hyperlactacidemia groups (P>0.05). Conclusion When RCA is used for CRRT anticoagulation in patients with sepsis and hyperlactacidemia, the incidence of citric acid accumulation is high (especially in patients with severe hyperlactacidemia), and should be closely monitored.
Acute kidney injury (AKI) is common in hospitalized individuals, associated with adverse outcomes and increased cost. Continuous renal replacement therapy (CRRT) is used to treat critically ill patients with AKI, of which the cost in acute phase is higher than that of intermittent renal replacement therapy (IRRT). However, if treatment for subsequent chronic kidney disease or dialysis dependency following AKI is also considered, CRRT might be more cost-effective than IRRT. In this editorial, the cost and health economic evaluation of CRRT for critically ill patients is discussed.
ObjectiveTo explore the application effect of information-based circuit teaching mode for training refresher nurses in continuous renal replacement therapy (CRRT).MethodsCRRT refresher nurses studied in West China Hospital of Sichuan University from January 2016 to December 2019 were selected. The CRRT refresher nurses who were selected as the control group (studied from January 2016 to December 2017) accepted the conventional teaching method. The CRRT refresher nurses who were selected as the test group (studied from January 2018 to December 2019) accept the information-based combined with circuit teaching mode for teaching and training. After 6 months of training, the theoretical performance, operation performance, teaching satisfaction and the incidence of adverse events were compared between the two groups.ResultsA total of 112 CRRT refresher nurses were enrolled. Among them, there were 52 nurses in the control group and 60 in the test group. The scores of theory achievement (t=?2.421, P=0.017), operation achievement (t=?2.305, P=0.023) and teaching satisfaction [including teaching effect (t=?4.067, P<0.001), operation skill (t=?5.013, P<0.001), teaching mode (t=?5.589, P<0.001) and teaching content (t=?2.586, P<0.001)] of refresher nurses in the test group were higher than those in the control group. There was no significant difference between the control group (4 cases) and the test group (1 case) in the occurrence of adverse nursing events (adjusted χ2=1.169, P=0.280).ConclusionThe information-based circuit teaching mode has achieved good results in the teaching of CRRT refresher nurses, which is conducive to improving the post competency of CRRT refresher nurses.
Objective To estimate the cost of continuous renal replacement therapy (CRRT) in public hospitals and analyze the main influencing factors of the cost, in order to provide evidence for the optimal application of CRRT technology. Methods In March 2021, activity-based costing was used to estimate and analyze the cost of CRRT, the data of which were collected from 5 hospitals in Jiangsu, Zhejiang, Henan, Sichuan and Xinjiang, and single factor sensitivity analysis was used to find the main influencing factors of the cost. Results The hourly treatment costs of CRRT in the 5 hospitals ranged from 265.30 to 474.44 yuan, with an average of 376.81 yuan. The costs of manpower and filters accounted for the top two largest proportions, the manpower cost of continuous veno-venous hemofiltration and continuous veno-venous hemodiafiltration accounted for 22.90% and 21.51%, respectively, and the filters cost of the two types of CRRT accounted for 15.07% and 17.73%, respectively. The unit cost and cost composition varied greatly between hospitals. There were four factors affecting the unit cost, namely clinical operation, efficiency, price and patient, among which clinical operation difference was the primary factor leading to cost difference. Conclusions The application cost of CRRT technology varies greatly among hospitals, and there are many factors affecting the cost. Public hospitals face great pressure in cost control. It is necessary to strengthen the internal control operation management of public hospitals, establish CRRT clinical operation standards, and improve the quality of medical services in public hospitals.
ObjectiveTo observe the effect of continuous renal replacement therapy (CRRT) on serum phosphate level in patients after cardiac surgery.
MethodA single-center retrospective observational study was conducted on 30 patients received CRRT after cardiac surgery. There were 14 males and 16 females with mean age of 57.0±10.8 years (ranged 37-79 years). A total of 16 patients underwent CRRT with continuous veno-venous hemofiltration (CVVH), and 14 patients with continuous veno-venous hemodiafiltration (CVVHDF). The serum phosphate level was measured before treatment, at 24 h, and 48 h during therapy and 24 h after phosphate salt supplementation.
ResultsThe level of serum phosphate at 24 h and 48 h during CRRT was decreased (0.6±0.4 mmol/L vs. 0.4±0.2 mmol/L vs. 1.1±0.3 mmol/L, P<0.01). After intravenous phosphate salt supplementation, serum phosphate level got increased (0.6±0.3 mmol/L, P<0.01). There was no statistical difference in serum phosphate level between CVVH and CVVHDF (P>0.05).
ConclusionHypophosphatemia occurs frequently during CRRT, particularly with long treatment time. Phosphate salt supplementation is necessary. The dosage of the supplementation should be adjusted personally based on the regularly monitoring results of serum phosphate tests.
Objective To identify risk factors for death in patients with rhabdomyolysis-induced acute kidney injury (RI-AKI) treated with continuous renal replacement therapy (CRRT), then to develop and validate the efficacy of prediction models based on these risk factors. Methods Clinical data and prognostic information of patients with RI-AKI requiring CRRT from 2008 to 2019 were extracted from the MIMIC-IV 2.2 database. The enrolled patients were divided into a training set and a test set at a ratio of 7∶3. LASSO regression, random forest (RF) and extreme gradient boosting (XGBoost) were used to identify the risk factors affecting patients’ 28-day survival in the training set, then to develop logistic model, RF model, support vector machine (SVM) model and XGBoost model. The accuracy of above prediction models and the area under the receiver operating characteristic curve (AUC) were calculated in the test set. Results A total of 175 patients were included. Lactic acid, age, Acute Physiology Score Ⅲ, hemoglobin, mean arterial pressure and body mass index measured at intensive care unit admission were identified as the six risk factors affecting 28-day survival of enrolled patients by LASSO regression, RF and XGBoost. The accuracy of the logistic model, RF model, SVM model and XGBoost model in the test set was 0.75, 0.79, 0.79 and 0.81, with the AUC of 0.82, 0.85, 0.87 and 0.87, respectively. Conclusion The XGBoost model, incorporating six risk factors including lactic acid, age, Acute Physiology Score Ⅲ, hemoglobin, mean arterial pressure, and body mass index assessed at the time of admission to the intensive care unit, demonstrates superior clinical predictive performance, thereby enhancing the clinical decision-making process for healthcare professionals.
ObjectiveTo evaluate the efficacy of the continuous renal replacement therapy (CRRT) for acute kidney injury (AKI) after the surgery of type A aortic dissection.
MethodsWe retrospectively analyzed 58 hemodialysis patients with AKI after type A aortic dissection surgery in our hospital between January 2003 and January 2014.The 58 patients were divided into two groups including a bedside intermittent hemodialysis (IHD) group and a CRRT group based on the methods of hemodialysis. There were 38 patients with 29 males and 9 females at average age of 49.8± 13.7 years in the CRRT group. There were 20 patients in the IHD group with 14 males and 6 females at average age of 52.6± 11.0 years.
ResultsCompared with IHD, CRRT had significantly greater effect on reducing the simplified acute physiology scoring system (SAPS)Ⅱscore (Ftime=60.964, P=0.000; Ftime * group=3.178, P=0.041). However, there was no significant difference in reducing the acute tubular necrosis individual illness severity index (ATN-ISI) score between the two groups (Ftime=13.803, P=0.000; Ftime * group=0.222, P=0.951). Lower incidences of dialysis-related complications including hypotension (P=0.027) and acute congestive heart failure (P=0.011) were found in the CRRT group. There was no statistical difference in operation time (P=0.367) between the two groups. While statistical differences in duration of hospitalization in intensive care unit (P=0.006), in hospital time (P=0.047), frequency of dialysis (P=0.001), and dialysis time (P=0.039) were found between the two groups. However there were no significant differences in mortality during hospital (P=0.544)and incidences of recovery (P=0.056) between the two groups.
ConclusionCompared with IHD, CRRT had significantly positive effect on patients who suffered from AKI after type A aortic dissection surgery, which can help reduce incidences of dialysis-related complications, duration and cost of hospitalization in ICU.
Objective To analyze the risk factors for death in children with interruption of aortic arch (IAA) and ventricular septal defect (VSD) after one-stage radical surgery. Methods A retrospective analysis was performed on patients with IAA and VSD who underwent one-stage radical treatment in the First Hospital of Hebei Medical University from January 2006 to January 2017. Cox proportional hazards regression model was used to analyze the risk factors for death after the surgery. Results A total of 152 children were enrolled, including 70 males and 82 females. Twenty-two patients died with a mean age of 30.73±9.21 d, and the other 130 patients survived with a mean age of 37.62±11.06 d. The Cox analysis showed that younger age (OR=0.551, 95%CI 0.320-0.984, P=0.004), low body weight (OR=0.632, 95%CI 0.313-0.966, P=0.003), large ratio of VSD diameter/aortic root diameter (VSD/AO, OR=2.547, 95%CI 1.095-7.517, P=0.044), long cardiopulmonary bypass time (OR=1.374, 95%CI 1.000-3.227, P=0.038), left ventricular outflow tract obstruction (LVOTO, OR=3.959, 95%CI 1.123-9.268, P=0.015) were independent risk factors for postoperative death. Conclusion For children with IAA and VSD, younger age, low body weight, large ratio of VSD/AO, long cardiopulmonary bypass time and LVOTO are risk factors for death after one-stage radical surgery.
Continuous renal replacement therapy (CRRT) is the treatment of choice for critically ill patients with hemodynamic instability who require renal replacement therapy. This review summarizes the impact of CRRT treatment on nutritional support in critically ill patients, including: energy increase caused by citrate-based anticoagulants, energy loss caused by glucose-free replacement fluid and dialysate, a large amount of amino acids loss in the effluent, and the influences on the way of lipid emulsion administration, capacity, electrolyte, vitamins, and trace elements. It is hoped that the intensive care unit doctors, nephrologists, and nutritionists can fully cooperate to determine the CRRT prescription and the nutritional support prescription.
Continuous renal replacement therapy (CRRT) is one of the major treatments for critically ill patients. With the development of information technology, the informatization and artificial intelligent of CRRT has received wide attention, which has promoted the optimization of CRRT in terms of workflow, teaching method as well as scientific research. Benefiting from the big data generated, artificial intelligence is expected to be applied in the precision treatment, quality control, timing of intervention, as well as prognosis assessment in severe AKI, so as to ultimately improve the therapeutic effect of CRRT among critically ill patients. This paper summarizes the information construction of CRRT and the research progress of artificial intelligence, which can be used as a reference for practitioners in kidney disease, critical medicine, emergency medicine and other related fields.
