Continuous venovenous hemodiafiltration with a low citrate dose regional anticoagulation protocol and a phosphate-containing solution: effects on acid–base status and phosphate supplementation needs

BACKGROUND: Recent guidelines suggest the adoption of regional citrate anticoagulation (RCA) as first choice CRRT anticoagulation modality in patients without contraindications for citrate. Regardless of the anticoagulation protocol, hypophosphatemia represents a potential drawback of CRRT which could be prevented by the adoption of phosphate-containing CRRT solutions. The aim was to evaluate the effects on acid--base status and phosphate supplementation needs of a new RCA protocol for Continuous Venovenous Hemodiafiltration (CVVHDF) combining the use of citrate with a phosphate-containing CRRT solution. METHODS: To refine our routine RCA-CVVH protocol (12 mmol/l citrate, HCO3- 32 mmol/l replacement fluid) (protocol A) and to prevent CRRT-related hypophosphatemia, we introduced a new RCA-CVVHDF protocol (protocol B) combining an 18 mmol/l citrate solution with a phosphate-containing dialysate/replacement fluid (HCO3- 30 mmol/l, Phosphate 1.2). A low citrate dose (2.5--3 mmol/l) and a higher than usual target circuit-Ca2+ (<=0.5 mmol/l) have been adopted. RESULTS: Two historical groups of heart surgery patients (n = 40) underwent RCA-CRRT with protocol A (n = 20, 102 circuits, total running time 5283 hours) or protocol B (n = 20, 138 circuits, total running time 7308 hours). Despite higher circuit-Ca2+ in protocol B (0.37 vs 0.42 mmol/l, p < 0.001), circuit life was comparable (51.8 +/- 36.5 vs 53 +/- 32.6 hours). Protocol A required additional bicarbonate supplementation (6 +/- 6.4 mmol/h) in 90% of patients while protocol B ensured appropriate acid--base balance without additional interventions: pH 7.43 (7.40--7.46), Bicarbonate 25.3 (23.8--26.6) mmol/l, BE 0.9 (-0.8 to +2.4); median (IQR). No episodes of clinically relevant metabolic alkalosis, requiring modifications of RCA-CRRT settings, were observed. Phosphate supplementation was needed in all group A patients (3.4 +/- 2.4 g/day) and in only 30% of group B patients (0.5 +/- 1.5 g/day). Hypophosphatemia developed in 75% and 30% of group A and group B patients, respectively. Serum phosphate was significantly higher in protocol B patients (P < 0.001) and, differently to protocol A, appeared to be steadily maintained in near normal range (0.97--1.45 mmol/l, IQR)

Does it pay to be sustainable? Looking inside the black box of the relationship between sustainability performance and financial performance

The last three decades have witnessed a huge amount of research exploring the linkage between companies' sustainability performance (SP), sustainability disclosure and financial performance (FP). Researchers have applied various methods and techniques to investigate this relationship, yet the results remain equivocal. In this article, we look inside this black box by considering various manifestations of sustainability practices and investigating their link with FP. We apply a manual content analysis technique to analyse the sustainability reports of the 100 best-performing US firms. Our results reveal that fragmentation in the results is caused by the SP measurement. Additionally, we note that the interlinkages between different SP dimensions and sub-dimensions are weak and somewhat contradictory. The results help draw important policy implications for the development of an SP reporting framework

Macrosocial determinants of population health in the context of globalization

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/55738/1/florey_globalization_2007.pd

A European patient record study on diagnosis and treatment of chemotherapy-induced anaemia

Purpose – Patients with cancer frequently experience chemotherapy‐induced anaemia (CIA) and iron deficiency (ID). Erythropoiesis‐stimulating agents (ESA), iron supplementation and blood transfusions are available therapies. This study evaluated routine practice in CIA management. Methods – Medical oncologists and/or haematologists from nine European countries (n=375) were surveyed on their last five cancer patients treated for CIA (n=1730). Information was collected on tests performed at diagnosis of anaemia, levels of haemoglobin (Hb), serum ferritin and transferrin saturation (TSAT), and applied anaemia therapies. Results – Diagnostic tests and therapies for CIA varied across Europe. Anaemia and iron status were mainly assessed by Hb (94%) and ferritin (48%) measurements. TSAT was only tested in 14%. At anaemia diagnosis, 74% of patients had Hb ≤10g/dL, including 15% with severe (Hb <8g/dL) anaemia. Low iron levels (ferritin ≤100ng/mL) were detected in 42% of evaluated patients. ESA was the most commonly used treatment (63%) and 30% of ESA‐treated patients also received iron supplementation. Most iron‐treated patients (74%) received an oral iron; intravenous iron was administered to 26%. 52% of patients received transfusions and in 76% of these, transfusions formed part of a regular anaemia treatment regimen. Management practices were similar in 2009 and 2011. Conclusion – Management of anaemia and iron status in patients treated for CIA varies substantially across Europe. Iron status is only assessed in half of the patients. In contrast to clinical evidence, iron treatment is underutilised and mainly based on oral iron supplementation. Implementation of guidelines needs to be increased, particularly the minimisation of blood transfusions