Circuit Lifetime With Citrate Versus Heparin in Pediatric Continuous Venovenous Hemodialysis. (Duke)

Zaoral T, et al. Circuit Lifetime With Citrate Versus Heparin in Pediatric Continuous Venovenous Hemodialysis. Pediatr Crit Care Med. 2016 Sep;17(9):e399-405.

OBJECTIVES: To determine if there is a difference between regional citrate and global heparinized anticoagulation on circuit lifetimes during continuous venovenous hemodialysis in children.

DESIGN: Prospective “cross-over” trial.

SETTING: PICU, Department of Pediatrics, University Hospital Ostrava.

PATIENTS: Children 0-18 years old.

INTERVENTIONS: From 2009 to 2014, 63 eligible children (age, 89.24 ± 62.9 mo; weight, 30.37 ± 20.62 kg) received at least 24 hours of continuous venovenous hemodialysis. Each child received four continuous venovenous hemodialysis circuits with anticoagulants in the following order: heparin, citrate, heparin, citrate. Circuit life ended when transmembrane pressure was greater than or equal to 250 mm Hg for more than 60 minutes.

MEASUREMENTS AND MAIN RESULTS: The total mean circuit lifetime was 39.75 ± 10.73 hours. Citrate had a significantly longer median circuit lifetime (41.0 hr; CI, 37.6-44.4) than heparin (36.0 hr; CI, 35.4-36.6; p = 0.0001). Mortality was 33.33%. Circuit lifetime was significantly correlated to patient age (r = 0.606), weight (r = 0.763), and blood flow rate (r = 0.697). Transfusion rates (units of red cells per circuit of continuous venovenous hemodialysis) were 0.17 (0.0-1.0) with citrate and 0.36 (0.0-2.0) with heparin (p = 0.002).

CONCLUSIONS: We showed in our study that citrate provided significantly longer circuit lifetimes than heparin for continuous venovenous hemodialysis in children. Citrate was superior to heparin for the transfusion requirements. Citrate was feasible and safe in children and infants.

Safety and Efficacy of Combined Extracorporeal CO2 Removal and Renal Replacement Therapy in Patients With Acute Respiratory Distress Syndrome and Acute Kidney Injury. (Betters)

Allardet-Servent J, et al. Safety and Efficacy of Combined Extracorporeal CO2 Removal and Renal Replacement Therapy in Patients With Acute Respiratory Distress Syndrome and Acute Kidney Injury: The Pulmonary and Renal Support in Acute Respiratory Distress Syndrome Study. Crit Care Med. 2015 Dec;43(12):2570-81.

OBJECTIVE: To assess the safety and efficacy of combining extracorporeal CO2 removal with continuous renal replacement therapy in patients presenting with acute respiratory distress syndrome and acute kidney injury.

DESIGN: Prospective human observational study.

SETTINGS: Patients received volume-controlled mechanical ventilation according to the acute respiratory distress syndrome net protocol. Continuous venovenous hemofiltration therapy was titrated to maintain maximum blood flow and an effluent flow of 45 mL/kg/h with 33% predilution.

PATIENTS: Eleven patients presenting with both acute respiratory distress syndrome and acute kidney injury required renal replacement therapy.

INTERVENTIONS: A membrane oxygenator (0.65 m) was inserted within the hemofiltration circuit, either upstream (n = 7) or downstream (n = 5) of the hemofilter. Baseline corresponded to tidal volume 6 mL/kg of predicted body weight without extracorporeal CO2 removal. The primary endpoint was 20% reduction in PaCO2 at 20 minutes after extracorporeal CO2 removal initiation. Tidal volume was subsequently reduced to 4 mL/kg for the remaining 72 hours.

MEASUREMENTS AND MAIN RESULTS: Twelve combined therapies were conducted in the 11 patients. Age was 70 ± 9 years, Simplified Acute Physiology Score II was 69 ± 13, Sequential Organ Failure Assessment score was 14 ± 4, lung injury score was 3 ± 0.5, and PaO2/FIO2 was 135 ± 41. Adding extracorporeal CO2 removal at tidal volume 6 mL/kg decreased PaCO2 by 21% (95% CI, 17-25%), from 47 ± 11 to 37 ± 8 Torr (p < 0.001). Lowering tidal volume to 4 mL/kg reduced minute ventilation from 7.8 ± 1.5 to 5.2 ± 1.1 L/min and plateau pressure from 25 ± 4 to 21 ± 3 cm H2O and raised PaCO2 from 37 ± 8 to 48 ± 10 Torr (all p < 0.001). On an average of both positions, the oxygenator’s blood flow was 410 ± 30 mL/min and the CO2 removal rate was 83 ± 20 mL/min. The oxygenator blood flow (p <0.001) and the CO2 removal rate (p = 0.083) were higher when the membrane oxygenator was placed upstream of the hemofilter. There was no safety concern.

CONCLUSIONS: Combining extracorporeal CO2 removal and continuous venovenous hemofiltration in patients with acute respiratory distress syndrome and acute kidney injury is safe and allows efficient blood purification together with enhanced lung protective ventilation.

High-volume hemofiltration in children with acute liver failure. (Williams)

Chevret L, Durand P, Lambert J, Essouri S, Balu L, Devictor D, Tissieres P. High-volume hemofiltration in children with acute liver failure*. Pediatr Crit Care Med. 2014 Sep;15(7):e300-5.


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OBJECTIVES: High-volume hemofiltration has shown beneficial effects in severe sepsis and multiple organ failure, improving hemodynamics and fluid balance. Recent studies suggest that acute liver failure shares many pathophysiologic similarities with sepsis. Therefore, we assessed the systemic effects of high-volume hemofiltration inchildren with acute liver failure.

DESIGN: Retrospective observational cohort study.

PATIENTS: Twenty-two children.

SETTING: Forty-two-bed multidisciplinary pediatric and neonatal ICUs in a tertiary university hospital.

INTERVENTION: We evaluated high-volume hemofiltration therapy as part of standard management of 22 childrenadmitted in our unit for acute liver failure. Fifteen patients had fulminant hepatic failure, three had acute-on-chronic liver disease, and four had primary nonfunction. High-volume hemofiltration was initiated in patients requiring emergency liver transplantation and when hepatic encephalopathy grade higher than 2 and/or hemodynamic instability requiring vasopressors occurred. High-volume hemofiltration was defined by a flow of ultrafiltrate of more than 80 mL/kg/hr. Clinical and biological variables were assessed before and 24 and 48 hours after initiation of high-volume hemofiltrationtherapy.

MEASUREMENTS AND MAIN RESULTS: High-volume hemofiltration was initiated with a median grade III of hepatic encephalopathy. The median flow of ultrafiltrate was 119 mL/kg/hr (range, 80-384). After 24 hours of high-volumehemofiltration treatment, we observed an increase in mean arterial pressure (p = 0.0002) and a decrease in serum creatinine (p = 0.0002). In half of the patients, the encephalopathy grade decreased. After 48 hours of treatment, mean arterial pressure (p = 0.0005), grade of hepatic encephalopathy (p = 0.04), and serum creatinine (p = 0.0002) improved. Overall mortality was 45.4% (n = 10). Emergency liver transplantation was performed in eight children. Five patients spontaneously recovered liver function.

CONCLUSIONS: High-volume hemofiltration therapy significantly improves hemodynamic stability and neurological status in children with acute liver failure awaiting for emergency liver transplantation.

Renal protective effects of early continuous venovenous hemofiltration in rhabdomyolysis: improved renal mitochondrial dysfunction and inhibited apoptosis. (Paden)

Artif Organs. 2013 Apr;37(4):390-400  PMID: 23441644

Rhabdomyolysis (RM) and subsequent myoglobin (Mb) deposition can lead to acute kidney injury. Continuous venovenous hemofiltration (CVVH) can remove Mb, but direct renal protection is unclear. We hypothesized that CVVH can improve renal mitochondrial dysfunction in its early stage. Twenty-four mongrel dogs were randomly divided into four groups: (A) control; (B) model; (C) model + CVVH (50 mL/kg/h); and (D) model + CVVH (30 mL/kg/h). RM was induced by glycerol via intramuscular injection. The dogs were closely monitored for urine flow and renal function. Mb, plasma tumor necrosis factor-α (TNF-α), and interleukin (IL)-6 were measured by enzyme-linked immunosorbent assay. After 8 h of CVVH, the morphological changes of renal mitochondria were observed and mitochondrial function indicators (reactive oxygen species, malondialdehyde, and respiratory control index) were detected. Western blot analysis was used to detect the expression of Mb, TNF-α, and IL-6 in renal tubules. The terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling assay method and Western blot analysis were used to detect apoptosis and apoptosis-related proteins. In group B, the dog urine output gradually decreased with increased blood creatinine. In groups C and D, the urine output was normal and stable. CVVH effectively eliminated Mb. High-dose CVVH was significantly better for removal efficiency than low-dose CVVH. CVVH significantly reduced the deposition of circulating Mb in the kidney in a dose-dependent manner. The impact of CVVH on TNF-α and IL-6 were not observed. The morphological changes of mitochondria and function indicators were significantly improved in group C compared with groups D and B. Compared with group B, renal apoptosis and apoptosis-related protein expression were inhibited in groups C and D. Group C was significantly better for mitochondrial improvement and apoptosis inhibition than group D. At the cellular and molecular level, CVVH can improve renal mitochondrial function and inhibit cell apoptosis. Early CVVH can protect from RM-caused renal injuries in a dose-dependent manner.

© 2013, Copyright the Authors. Artificial Organs © 2013, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

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