Two-tier replication based on Eager Group – Lazy Master model

А scheme of two-tier replication based on Eager Group and Lazy Master models is presented. Initial transactions used permit remote nodes to read and update database. The algorithm of optimisation and commitment of initial transactions into form of base transaction are realised by initial transactions manager of master node.Предложена двухуровневая схема репликации данных, основанная на моделях Eager Group и Lazy Master. Нижний уровень (асинхронный) предназначен для мобильных клиентов и реализует модель Lazy Master. Верхний уровень (синхронный) предназначен для согласования серверов, содержащих реплики баз данных и реализует модель Eager Group. Рассмотрен алгоритм оптимизации входных транзакций на этих уровнях.Запропоновано дворівневу схему реплікації даних, що заснована на моделях Eager Group і Lazy Master. Нижній рівень (асинхронний) призначений для мобільних клієнтів і реалізує модель Lazy Master. Верхній рівень (синхронний) призначений для узгодження серверів, що містять репліки баз даних і реалізує модель Eager Group. Розглянуто алгоритм оптимізації вхідних транзакцій на цих рівнях

Recurrent early filter clotting during continuous veno-venous hemodialysis with regional citrate anticoagulation is linked to systemic thrombin generation and heparin induced thrombocytopenia type II: a retrospective analysis

OBJECTIVE: Regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) is widely used and leads to an excellent clottingfree filter survival. Despite strict adherence to protocols, in some cases recurrent early filter-clotting occurs. The aim of this observational study was to evaluate the underlying causes and the efficacy of interventions in patients with early recurrent filter-clotting during RCA. METHODS: In a retrospective analysis of a cohort of 1183 patients treated with RCA-CRRT we detected 12 patients with early filter-clotting unrelated to protocol violation or any obvious technical or medical reason. RESULTS: All patients were systemically anticoagulated with low molecular weight or unfractionated heparin for at least 24h before initiation of Continuous Veno-Venous Hemodialysis with RCA (RCA-CVVHD). During RCA, all postfilter ionized calcium concentrations were in the target range (mean 0.33±0.05 mmol/L). At the time of the first clotting event, thrombocyte counts were 168±66/ nL. After the clotting events, the systemic anticoagulation was switched to argatroban in all patients. With systemic anticoagulation using argatroban filter lifetime of RCA-CVVHD increased significantly (p<0.001) and clotting-events decreased from 0.61 to 0.10 per 24h. All patients were tested for HIT and 5/12 (42%) had a positive test for hep-PF4-antibodies. Application of argatroban significantly reduced early filter-clotting both in HIT-positive patients as well as in HIT-negative patients. At the time of the first clotting event, no patient had clinical signs of thrombosis or thromboembolism. However, during follow up a thromboembolic event occurred in three patients. CONCLUSION: In patients with recurrent early filter-clotting despite strict adherence to the citrate protocol undetected HIT or other causes of thrombin activation may be present. Therefore, patients with recurrent early filter clotting in RCA-CVVHD should be screened for HIT or other conditions that may activate thrombin. A significant improvement of filter run-time can be achieved by systemic administration of a thrombin inhibitor both in patients with and without HIT

AKI-Alerts

In Anbetracht der hohen Inzidenz und Mortalität von AKI (Acute Kidney Injury) sowie der unzureichenden Erkennung von AKI-Episoden im klinischen Alltag, sind AKI-Frühwarnsysteme ein einfacher und naheliegender Ansatz, um die Versorgung von AKI-Patienten zu verbessern. Obwohl AKI-Alerts in prospektiven Studien bisher keine konsistenten Effekte auf die Krankenhausmortalität zeigten, gibt es deutliche Hinweise, dass sie klinische Prozesse sowie Surrogat-Endpunkte verbessern und somit zur Qualitätsverbesserung im Krankenhaus beitragen. Dabei scheint insbesondere eine Kopplung des Alarmsystems an standardisierte klinische Prozesse entscheidend zu sein. Da diese Prozesse krankenhaus- und abteilungsspezifische Besonderheiten aufweisen und sich derzeit in der Abwesenheit einer überzeugenden Studienlage nicht universell definieren lassen, sollten Kliniken, die AKI-Alert-Systeme implementieren, die Effektivität dieser Maßnahme systematisch evaluieren

The incidence of acute kidney injury and associated hospital mortality: a retrospective cohort study of over 100 000 patients at Berlin's Charité Hospital

BACKGROUND: Studies from multiple countries have shown that acute kidney injury (AKI) in hospitalized patients is associated with mortality and morbidity. There are no reliable data at present on the incidence and mortality of AKI episodes among hospitalized patients in Germany. The utility of administrative codings of AKI for the identification of AKI episodes is also unclear. METHODS: In an exploratory approach, we retrospectively analyzed all episodes of AKI over a period of 3.5 years (2014-2017) on the basis of routinely obtained serum creatinine measurements in 103 161 patients whose creatinine had been measured at least twice and who had been in the hospital for at least two days. We used the "Kidney Disease: Improving Global Outcomes" (KDIGO) criteria for AKI. In parallel, we assessed the administrative coding of discharge diagnoses of the same patients with codes from the International Classification of Diseases (ICD-10-GM). RESULTS: Among 185 760 hospitalizations, stage 1 AKI occurred in 25 417 cases (13.7%), stage 2 in 8503 cases (4.6%), and stage 3 in 5881 cases (3.1%). AKI cases were associated with length of hospital stay, renal morbidity, and overall mortality, and this association was stage-dependent. The in-hospital mortality was 5.1% for patients with stage 1 AKI, 13.7% for patients with stage 2 AKI, and 24.8% for patients with stage 3 AKI. An administrative coding for acute kidney injury (N17) was present in only 28.8% (11 481) of the AKI cases that were identified by creatinine criteria. Like the AKI cases overall, those that were identified by creatinine criteria but were not coded as AKI had significantly higher mortality, and this association was stage-dependent. CONCLUSION: AKI episodes are common among hospitalized patients and are associated with considerable morbidity and mortality, yet they are inadequately documented and probably often escape the attention of the treating physicians