PCRRT Expert Committee ICONIC Position Paper on Prescribing Kidney Replacement Therapy in Critically Sick Children With Acute Liver Failure

Management of acute liver failure (ALF) and acute on chronic liver failure (ACLF) in the pediatric population can be challenging. Kidney manifestations of liver failure, such as hepatorenal syndrome (HRS) and acute kidney injury (AKI), are increasingly prevalent and may portend a poor prognosis. The overall incidence of AKI in children with ALF has not been well-established, partially due to the difficulty of precisely estimating kidney function in these patients. The true incidence of AKI in pediatric patients may still be underestimated due to decreased creatinine production in patients with advanced liver dysfunction and those with critical conditions including shock and cardiovascular compromise with poor kidney perfusion. Current treatment for kidney dysfunction secondary to liver failure include conservative management, intravenous fluids, and kidney replacement therapy (KRT). Despite the paucity of evidence-based recommendations concerning the application of KRT in children with kidney dysfunction in the setting of ALF, expert clinical opinions have been evaluated regarding the optimal modalities and timing of KRT, dialysis/replacement solutions, blood and dialysate flow rates and dialysis dose, and anticoagulation methods

Fuzzy set based decision support system for transactions of electricity in a deregulated environment

In the restructured electricity market environment, the market participants conduct their power transactions with an aim to maximize their profits. Electricity is typically traded either through an auction at an open-access power exchange market or directly between supplier and retailer/consumer through bilateral and/or multilateral contracts. In the power exchange, the balance of supply and demand determines the spot market price. These transactions are purely economic and are subject to the physical constraints of the transmission system. The transmission grid is controlled by an Independent System Operator (ISO), and information about the system operation is restricted and rarely available to the market entrants. The market players generally receive partial information about the system conditions, such as a forecast of the total demand. Hence, the pivotal information in conducting the spot market transactions of electricity is price and demand. In some cases, a direct bilateral contract between suppliers and consumers can provide an attractive alternative to the spot market pricing, where the price can be volatile due to strategic behavior of market participants or tight demand-supply balance. The most likely measure of suitability of a bilateral contract is its comparison with the market price. However, the spot market price tends to be significantly volatile. Therefore, suitable methods for representing the volatile market price are needed. The traditional modeling methods are primarily based on statistical and probabilistic approaches, and it may not be entirely suitable to apply these stochastic methods to model the data generated by human activities such as power exchange markets. Besides, most of the existing models are aimed at stock exchanges, and may not necessarily be applicable to the electricity markets. In this research work, a data representation model based on extended fuzzy regression is developed. The model represents the highly volatile demand-price relations as a range and estimates the possible distribution of the price range for a given value of a demand forecast. The highlight of the model is its capability to preserve the aggregate information contained in the original data set such as the uncertainty. The model was tested using actual data from California Power Exchange and results were found to be promising. Based on the proposed model, a procedure for evaluation of bilateral contracts in an open market environment is developed.Applied Science, Faculty ofElectrical and Computer Engineering, Department ofGraduat

Biosurfactant Production and its Role in Candida albicans Biofilm Inhibition

Biosurfactants are surface active compounds, which may be of microbial, animal or plant origin. They are typically less toxic and less persistent than the synthetically derived surfactants. The current study intended to analyze the biosurfactants production and its antagonistic activity against Candida albicans biofilm formation. Isolation of biosurfactant producing organism was carried out using swab sample of human vagina and from oil contaminated soil samples. Isolates were screened for biosurfactant production by using oil spread assay and the organisms showing higher activity were selected. The Emulsification assay was done and the E24 was found to be 20.83% for cell free extract of growth medium of isolate B1.The selected isolates were further studied for yield of biosurfactant produced by cultivation in MRS broth and extraction by chloroform and methanol (3:1) extraction. The yield of biosurfactant for isolate B1was found to be4.55gl-1.Theextracted biosurfactant was separated by TLC and identified to be a lipopeptide by FTIR spectroscopy. The isolate with maximum yield of biosurfactant was identified as Lactobacillus fermentum using VITEK II Compact System for microbial identification system. The percentage biofilm inhibition activity of the biosurfactant was studied by CFU assay followed by adhesion assay and by pre-coating experiment. On the basis of above studies, it concludes that use of biosurfactant producing organism can be effective weapon against colonizing opportunistic C. albicans and can be applied in medical devices for inhibition of biofilms formation. Microbial adhesion also decreased from 85% to 11% with78.125 to 2500 µg/ml of biosurfactant. The lipopeptide extracted from isolated isolate B1 also showed powerful penetration capacity in the biofilm and killed 91% C. albicans as seen by CFU assay and a highest inhibition at 2500µg/ml and 1250µg/ml concentration as studied by pre-coating experiment

Fluid Overload and Renal Angina Index at Admission Are Associated With Worse Outcomes in Critically Ill Children

Objectives: We investigated the association of fluid overload and oxygenation in critically sick children, and their correlation with various outcomes (duration of ventilation, ICU stay, and mortality). We also assessed whether renal angina index (RAI) at admission can predict mortality or acute kidney injury (AKI) on day 3 after admission.Design and setting: Prospective study, pediatric intensive care in a tertiary hospital.Duration: June 2013-June 2014.Patients: Patients were included if they needed invasive mechanical ventilation for >24 h and had an indwelling arterial catheter. Patients with congenital heart disease or those who received renal replacement therapy (RRT) were excluded.Methods: Oxygenation index, fluid overload percent (daily, cumulative), RAI at admission and pediatric logistic organ dysfunction (PELOD) score were obtained in all critically ill children. KDIGO classification was used to define AKI, using both creatinine and urine output criteria. Admission data for determination of RAI included the use of vasopressors, invasive mechanical ventilation, percent fluid overload, and change in kidney function (estimated creatinine clearance). Univariable and multivariable approaches were used to assess the relations between fluid overload, oxygenation index and clinical outcomes. An RAI cutoff >8 was used to predict AKI on day 3 of admission and mortality.Results: One hundred and two patients were recruited. Fluid overload predicted oxygenation index in all patients, independent of age, gender and PELOD score (p < 0.05). Fluid overload was associated with longer duration of ventilation (p < 0.05), controlled for age, gender, and PELOD score. Day-3 AKI rates were higher in patients with a RAI of 8 or more, and higher areas under the RAI curve had better prediction rates for Day-3 AKI. An RAI <8 had high negative predictive values (80–95%) for Day-3 AKI. RAI was better than traditional markers of pediatric severity of illness (PELOD) score for prediction of AKI on day 3.Conclusions: This study emphasizes that positive fluid balance adversely affects intensive care in critically ill children. Further, the RAI prediction model may help optimize treatment and improve clinical prediction of AKI

Heparin free dialysis in critically sick children using sustained low efficiency dialysis (SLEDD-f): A new hybrid therapy for dialysis in developing world.

In critically sick adults, sustained low efficiency dialysis [SLED] appears to be better tolerated hemodynamically and outcomes seem to be comparable to CRRT. However, there is paucity of data in critically sick children. In children, two recent studies from Taiwan (n = 11) and India (n = 68) showed benefits of SLED in critically sick children.The objective of the study was to look at the feasibility and tolerability of sustained low efficiency daily dialysis-filtration [SLEDD-f] in critically sick pediatric patients.Design: Retrospective study Inclusion criteria: All pediatric patients who had undergone heparin free SLEDD-f from January 2012 to October 2017. Measurements: Data collected included demographic details, vital signs, PRISM III at admission, ventilator parameters (where applicable), number of inotropes, blood gas and electrolytes before, during, and on conclusion of SLED therapy. Technical information was gathered regarding SLEDD-f prescription and complications.Between 2012-2017, a total of 242 sessions of SLEDD-f were performed on 70 patients, out of which 40 children survived. The median age of patients in years was 12 (range 0.8-17 years), and the median weight was 39 kg (range 8.5-66 kg). The mean PRISM score at admission was 8.77±7.22. SLEDD-f sessions were well tolerated, with marked improvement in fluid status and acidosis. Premature terminations had to be done in 23 (9.5%) of the sessions. There were 21 sessions (8.6%) terminated due to hypotension and 2 sessions (0.8%) terminated due to circuit clotting. Post- SLEDD-f hypocalcemia occurred in 15 sessions (6.2%), post- SLEDD-f hypophosphatemia occurred in 1 session (0.4%), and post- SLEDD-f hypokalemia occurred in 17 sessions (7.0%).This study is the largest compiled data on pediatric SLEDD-f use in critically ill patients. Our study confirms the feasibility of heparin free SLEDD-f in a larger pediatric population, and even in children weighing <20 kg on inotropic support

Baseline characteristics.

<p>Baseline characteristics.</p

Post SLEDD-f complications.

<p>Post SLEDD-f complications.</p

Clinical and biochemical characteristics before and after SLEDD-f.

<p>Clinical and biochemical characteristics before and after SLEDD-f.</p