Considerations in the Critically Ill ESRD Patient

ESRD patients are admitted more frequently to intensive care units (ICUs) and have higher mortality risks than the general population, and the main causes of critical illness among ESRD patients are cardiovascular events, sepsis, and bleeding. Once in the ICU, hemodynamic stabilization and fluid-electrolyte management pose major challenges in oligoanuric patients. Selection of renal replacement therapy (RRT) modality is influenced by the outpatient modality and access, as well as severity of illness, renal provider experience, and ICU logistics. Currently, most patients receive intermittent hemodialysis or continuous RRT with temporary vascular access catheters. Acute peritoneal dialysis (PD) is less frequently utilized, and utility of outpatient PD is reduced after an ICU admission. Thus, preservation of current vascular accesses, while limiting venous system damage for future access creations, is relevant. Also, dosing of small-solute clearance with urea kinetic modeling is difficult and may be supplanted by novel online clearance techniques. Medication dosing, coordinated with delivered RRT, is essential for septic patients treated with antibiotics. A comprehensive, standardized approach by a multidisciplinary team of providers, including critical care specialists, nephrologists, and pharmacists, represents a nexus of care that can reduce readmission rates, morbidity, and mortality of vulnerable ESRD patients. © 2013 National Kidney Foundation, Inc

Treatment of severe hyponatremia in patients with kidney failure: Role of continuous venovenous hemofiltration with low-sodium replacement fluid

Patients with hypervolemic hyponatremia and kidney failure pose a special therapeutic challenge. Hemodialysis to correct volume overload, azotemia, and abnormal electrolyte levels will result in rapid correction of serum sodium concentration and place the patient at risk for osmotic demyelination syndrome. We present a patient with acute kidney injury and severe hypervolemic hypotonic hyponatremia (serum sodium \u3c 100 mEq/L) who was treated successfully with continuous venovenous hemofiltration. This teaching case illustrates the limitations of hemodialysis and demonstrates how to regulate the sodium correction rate by single-pool sodium kinetic modeling during continuous venovenous hemofiltration. Two methods to adjust the replacement fluid to achieve the desired sodium concentration are outlined. © 2014 by the National Kidney Foundation, Inc

Translation of immunomodulatory therapy to treat chronic heart failure: Preclinical studies to first in human

BACKGROUND: Inflammation has been associated with progression and complications of chronic heart failure (HF) but no effective therapy has yet been identified to treat this dysregulated immunologic state. The selective cytopheretic device (SCD) provides extracorporeal autologous cell processing to lessen the burden of inflammatory activity of circulating leukocytes of the innate immunologic system. AIM: The objective of this study was to evaluate the effects of the SCD as an extracorporeal immunomodulatory device on the immune dysregulated state of HF. HF. METHODS AND RESULTS: SCD treatment in a canine model of systolic HF or HF with reduced ejection fraction (HFrEF) diminished leukocyte inflammatory activity and enhanced cardiac performance as measured by left ventricular (LV) ejection fraction and stroke volume (SV) up to 4 weeks after treatment initiation. Translation of these observations in first in human, proof of concept clinical study was evaluated in a patient with severe HFrEFHFrEF ineligible for cardiac transplantation or LV LV assist device (LVAD) due to renal insufficiency and right ventricular dysfunction. Six hour SCD treatments over 6 consecutive days resulted in selective removal of inflammatory neutrophils and monocytes and reduction in key plasma cytokines, including tumor necrosis factor-alpha (TNF-α),), interleukin (IL)-6, IL-8, and monocyte chemoattractant protein (MCP)-1. These immunologic changes were associated with significant improvements in cardiac power output, right ventricular stroke work index, cardiac index and LVSV index…. Stabilization of renal function with progressive volume removal permitted successful LVAD implantation. CONCLUSION: This translational research study demonstrates a promising immunomodulatory approach to improve cardiac performance in HFrEFHFrEF and supports the important role of inflammation in the progression of HFHF

Considerations in the Critically Ill ESRD Patient

ESRD patients are admitted more frequently to intensive care units (ICUs) and have higher mortality risks than the general population, and the main causes of critical illness among ESRD patients are cardiovascular events, sepsis, and bleeding. Once in the ICU, hemodynamic stabilization and fluid-electrolyte management pose major challenges in oligoanuric patients. Selection of renal replacement therapy (RRT) modality is influenced by the outpatient modality and access, as well as severity of illness, renal provider experience, and ICU logistics. Currently, most patients receive intermittent hemodialysis or continuous RRT with temporary vascular access catheters. Acute peritoneal dialysis (PD) is less frequently utilized, and utility of outpatient PD is reduced after an ICU admission. Thus, preservation of current vascular accesses, while limiting venous system damage for future access creations, is relevant. Also, dosing of small-solute clearance with urea kinetic modeling is difficult and may be supplanted by novel online clearance techniques. Medication dosing, coordinated with delivered RRT, is essential for septic patients treated with antibiotics. A comprehensive, standardized approach by a multidisciplinary team of providers, including critical care specialists, nephrologists, and pharmacists, represents a nexus of care that can reduce readmission rates, morbidity, and mortality of vulnerable ESRD patients. © 2013 National Kidney Foundation, Inc

Sensors and hybrid therapies: A new approach with automated citrate anticoagulation

Background: Hybrid therapies use intermittent hemodialysis (IHD) machines adapted to provide prolonged intermittent or continuous renal replacement therapy in the intensive care unit (ICU). Despite the low cost, hybrid therapy use is limited warranting a novel approach. Methods: The literature was reviewed for limitations of hybrid protocols, use of regional citrate anticoagulation (RCA) on hybrid systems and sensors for IHD and hybrid therapy. The novel hybrid program in the authors\u27 institution is presented as a plausible future direction for the modality. Results: Hybrid therapies are limited by access flow and clotting alarms. Technology limitations render many IHD sensors inoperable at low dialysate flow. A synergy with RCA allows a novel, safe approach with low blood flows and high dialysate flows with alarm- and clotting-free operation and all commercial IHD sensors functional. Conclusion: The low cost, ease of use, safety and efficacy of hybrid therapy with near-automated RCA may lead to rapid expansion of this form of ICU renal support. Copyright © 2012 S. Karger AG, Basel

Automated regional citrate anticoagulation: Technological barriers and possible solutions

Background: Large-scale adoption of regional citrate anticoagulation (RCA) is prevented by risks of the technique as practiced traditionally. Safe RCA protocols with automated delivery on customized dialysis systems are needed. Methods: We applied kinetic analysis of solute fluxes during RCA to design a protocol for sustained low-efficiency dialysis (SLED) for critically ill patients. We used a high-flux hemodialyzer, a zero-calcium (Ca) dialysate, a dialysis machine with online clearance and access recirculation monitoring, and a separate optical hematocrit (Hct) sensor. Flow rates were QB = 200 ml/min for blood; QD = 400 ml/min for dialysate, with Na = 140 mmol/l and HCO3 = 32 mmol/l; Qcitrate = 400 ml/h of acid citrate dextrose A; ultrafiltration as indicated. The QCa was infused into the return blood line, adjusted hourly based on online Hct and a \u3c24-hour-old albumin level. Results: Using the SLED-RCA protocol in an anhepatic, ex vivo dialysis system, ionized Ca (iCa) was \u3e1 mmol/l in the blood reservoir and \u3c0.3 mmol/l in the blood circuit after citrate but before Ca infusion (Q Ca) with normal electrolyte composition of the blood returning to the reservoir. Clinically, SLED-RCA completely abrogated clotting, without adverse electrolyte effects. The QCa prediction algorithm maintained normal systemic iCa (0.95-1.4 mmol/l) in all patients. The high citrate extraction on the dialyzer prevented systemic citrate accumulation even in shock liver patients. Safety analysis shows that building a dialysis system for automated SLED-RCA is feasible. Conclusion: Using predictive QCa dosing and integrating control of the infusion pumps with the dialysis machine, SLED-RCA can be near-automated today to provide a user-friendly and safe system. © 2010 S. Karger AG, Basel

Sensors and hybrid therapies: A new approach with automated citrate anticoagulation

Background: Hybrid therapies use intermittent hemodialysis (IHD) machines adapted to provide prolonged intermittent or continuous renal replacement therapy in the intensive care unit (ICU). Despite the low cost, hybrid therapy use is limited warranting a novel approach. Methods: The literature was reviewed for limitations of hybrid protocols, use of regional citrate anticoagulation (RCA) on hybrid systems and sensors for IHD and hybrid therapy. The novel hybrid program in the authors\u27 institution is presented as a plausible future direction for the modality. Results: Hybrid therapies are limited by access flow and clotting alarms. Technology limitations render many IHD sensors inoperable at low dialysate flow. A synergy with RCA allows a novel, safe approach with low blood flows and high dialysate flows with alarm- and clotting-free operation and all commercial IHD sensors functional. Conclusion: The low cost, ease of use, safety and efficacy of hybrid therapy with near-automated RCA may lead to rapid expansion of this form of ICU renal support. Copyright © 2012 S. Karger AG, Basel

Automated regional citrate anticoagulation: Technological barriers and possible solutions

Background: Large-scale adoption of regional citrate anticoagulation (RCA) is prevented by risks of the technique as practiced traditionally. Safe RCA protocols with automated delivery on customized dialysis systems are needed. Methods: We applied kinetic analysis of solute fluxes during RCA to design a protocol for sustained low-efficiency dialysis (SLED) for critically ill patients. We used a high-flux hemodialyzer, a zero-calcium (Ca) dialysate, a dialysis machine with online clearance and access recirculation monitoring, and a separate optical hematocrit (Hct) sensor. Flow rates were QB = 200 ml/min for blood; QD = 400 ml/min for dialysate, with Na = 140 mmol/l and HCO3 = 32 mmol/l; Qcitrate = 400 ml/h of acid citrate dextrose A; ultrafiltration as indicated. The QCa was infused into the return blood line, adjusted hourly based on online Hct and a \u3c24-hour-old albumin level. Results: Using the SLED-RCA protocol in an anhepatic, ex vivo dialysis system, ionized Ca (iCa) was \u3e1 mmol/l in the blood reservoir and \u3c0.3 mmol/l in the blood circuit after citrate but before Ca infusion (Q Ca) with normal electrolyte composition of the blood returning to the reservoir. Clinically, SLED-RCA completely abrogated clotting, without adverse electrolyte effects. The QCa prediction algorithm maintained normal systemic iCa (0.95-1.4 mmol/l) in all patients. The high citrate extraction on the dialyzer prevented systemic citrate accumulation even in shock liver patients. Safety analysis shows that building a dialysis system for automated SLED-RCA is feasible. Conclusion: Using predictive QCa dosing and integrating control of the infusion pumps with the dialysis machine, SLED-RCA can be near-automated today to provide a user-friendly and safe system. © 2010 S. Karger AG, Basel

Management of dysnatremias with continuous renal replacement therapy

Disorders of serum sodium concentration are common in critically ill patients who may have concomitant acute kidney injury, chronic kidney disease, or end‐stage kidney disease. Many of these patients may require customized serum sodium level management with dialysis which, if not strictly controlled, can lead to significant complications. Thus, controlled correction of the serum sodium level is necessary to avoid the development of osmotic demyelination syndrome in hyponatremic patients and dialysis disequilibrium syndrome in hypernatremic patients. Continuous renal replacement therapy offers unique benefits through the ability to slowly and safely correct dysnatremias that can be tailored to specific patient needs and should be considered in select patients.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/170939/1/sdi12983.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/170939/2/sdi12983_am.pd

High sodium continuous veno-venous hemodialysis with regional citrate anticoagulation and online dialysate generation in patients with acute liver failure and cerebral edema

INTRODUCTION: Acute liver failure is associated with a high mortality rate. Induction of plasma hypertonicity with mannitol or hypertonic saline remains the cornerstone in the management of resultant cerebral edema. Significant disadvantages of this approach include poor or unpredictable control of serum sodium concentration and volume expansion, among others. METHODS: We used high sodium continuous veno-venous hemodialysis with regional citrate anticoagulation and online dialysate generation to accurately control the serum sodium in eleven patients with acute liver failure, renal failure, and cerebral edema. We used a Fresenius 2008 K/K2 machine in hemodialysis mode to deliver a blood flow of 60 ml/minute and dialysate flow of 400 ml/minute. Our previously published protocol results in complete removal of infused citrate by the dialyzer. On-line clearance calculations were used to model the time required to reach the target serum sodium. FINDINGS: All patients achieved serum sodium within 2 mEq/L of target without fluctuations or rebound. Nine patients survived without requiring liver transplantation and two died despite reaching the prescribed serum sodium target. We did not encounter any citrate toxicity. DISCUSSION: We describe a novel approach for delivering continuous osmotherapy to patients with acute liver failure, renal failure, and cerebral edema. In comparison to standard therapy, the described modality enables precise titration of serum sodium without undesirable fluctuations in extracellular fluid volume. A particular advantage is zero delivery of citrate to this vulnerable group of patients with acute liver failure