Extended daily on-line high-volume haemodiafiltration in septic multiple organ failure: a well-tolerated and feasible procedure

Kron, Joachim; Kron, Susanne; Wenkel, Reinhard; Schuhmacher, H; Thieme, Ulrike; Leimbach, Til; Kern, Hartmut; Neumayer, Hans‐H.; Slowinski, Torsten

doi:10.1093/ndt/gfr269

Cited by 28 publications

(48 citation statements)

References 30 publications

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“…With the use of citrate-based dialysis concentrate (Citrasate), a clotting rate of 15% has been reported for 6-to 8-hour SLED in critically ill patients (Madison et al, unpublished data, 2005). In extended high-volume hemodiafiltration (6-23 hours) in 21 ICU patients (258 sessions with unfractionated heparin and 31 with citrate) with septic multiple organ failure and AKI (8), the reported clotting rate of 15 of 289 sessions (0.51%) was close to the frequency of interruptions due to irreversible clotting in our study (0.5%), but separate data for heparin and citrate were not available in that article. In the most important series of diffusive prolonged intermittent modalities available thus far (45), (117 SLED in 30 patients) circuit clotting never occurred.…”

Section: Discussionsupporting

confidence: 58%

“…Although no extracorporeal circuit clotting has been reported with unfractionated heparin in SLED (9), other series reported clotting in 17%-26% of treatments (11,(22)(23)(24); clotting rates are 29%-46% without any anticoagulation (11,(22)(23)(24). Few data are currently available in the literature on extended RRT modalities with citrate (Table 4) (8,42,44,45). With the use of citrate-based dialysis concentrate (Citrasate), a clotting rate of 15% has been reported for 6-to 8-hour SLED in critically ill patients (Madison et al, unpublished data, 2005).…”

Section: Discussionmentioning

confidence: 99%

“…SLED, usually lasting 8-12 hours, shares most advantages of both the conventional intermittent (4 hours) and the continuous forms of RRT (4,(7)(8)(9)(10)(11).…”

Section: Introductionmentioning

confidence: 99%

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Efficacy and Safety of a Citrate-Based Protocol for Sustained Low-Efficiency Dialysis in AKI Using Standard Dialysis Equipment

Fiaccadori¹,

Regolisti²,

Cademartiri³

et al. 2013

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives A simple anticoagulation protocol was developed for sustained low-efficiency dialysis (SLED) in patients with AKI, based on the use of anticoagulant citrate dextrose solution formulation A (ACD-A) and standard dialysis equipment. Patients' blood recalcification was obtained from calcium backtransport from dialysis fluid.Design, setting, participants, & measurements All patients treated with SLED (8-to 12-hour sessions) for AKI in four intensive care units of a university hospital were studied over a 30-month period, from May 1, 2008 to September 30, 2010. SLED interruptions and their causes, hemorrhagic complications, as well as coagulation parameters, ionized calcium, and blood citrate levels were recorded.Results This study examined 807 SLED sessions in 116 patients (mean age of 69.7 years [SD 12.1]; mean Acute Physiology and Chronic Health Evaluation II score of 23.8 [4.6]). Major bleeding was observed in six patients (5.2% or 0.4 episodes/100 person-days follow-up while patients were on SLED treatment). Citrate accumulation never occurred, even in patients with liver dysfunction. Intravenous calcium for ionized hypocalcemia (, 3.6 mg/dl or , 0.9 mmol/L) was needed in 28 sessions (3.4%); in 8 of these 28 sessions (28.6%), low ionized calcium was already present before SLED start. In 92.6% of treatments, SLED was completed within the scheduled time (median 8 hours). Interruptions of SLED by impending/irreversible clotting were recorded in 19 sessions (2.4%). Blood return was complete in 98% of the cases. In-hospital mortality was 45 of 116 patients (38.8%).Conclusions This study protocol affords efficacious and safe anticoagulation of the SLED circuit, avoiding citrate accumulation and, in most patients, systematic calcium supplementation; it can be implemented with commercial citrate solutions, standard dialysis equipment, on-line produced dialysis fluid, and minimal laboratory monitoring.

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Section: Discussionsupporting

confidence: 58%

Section: Discussionmentioning

confidence: 99%

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Efficacy and Safety of a Citrate-Based Protocol for Sustained Low-Efficiency Dialysis in AKI Using Standard Dialysis Equipment

Fiaccadori¹,

Regolisti²,

Cademartiri³

et al. 2013

Clinical Journal of the American Society of Nephrology

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“…PIRRT is considered a hybrid RRT modality; it combines the main advantages of conventional intermittent forms of RRT (e.g., standard hemodialysis equipment, online-produced dialysate, flexible scheduling, and lower costs) with those of CRRT (e.g., better hemodynamic tolerance, excellent metabolic control, and gentle osmotic fluctuation and fluid removal capacity) (74,(77)(78)(79)(80)(81).…”

Section: Rca In Prolonged Intermittent Rrtmentioning

confidence: 99%

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Morabito

Pistolesi

Tritapepe

et al. 2014

Clinical Journal of the American Society of Nephrology

124

130

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Hemorrhagic complications have been reported in up to 30% of critically ill patients with AKI undergoing RRT with systemic anticoagulation. Because bleeding is associated with significantly increased mortality risk, strategies aimed at reducing hemorrhagic complications while maintaining extracorporeal circulation should be implemented. Among the alternatives to systemic anticoagulation, regional citrate anticoagulation has been shown to prolong circuit life while reducing the incidence of hemorrhagic complications and lowering transfusion needs. For these reasons, the recently published Kidney Disease Improving Global Outcomes Clinical Practice Guidelines for Acute Kidney Injury have recommended regional citrate anticoagulation as the preferred anticoagulation modality for continuous RRT in critically ill patients in whom it is not contraindicated. However, the use of regional citrate anticoagulation is still limited because of concerns related to the risk of metabolic complications, the complexity of the proposed protocols, and the need for customized solutions. The introduction of simplified anticoagulation protocols based on citrate and the development of dialysis monitors with integrated infusion systems and dedicated software could lead to the wider use of regional citrate anticoagulation in upcoming years.

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“…The latter is also less expensive and less time-consuming, leaving time for other activities such as nursing care and technical investigations [7]. The main diffusive solute clearance involved in SLEDD, which may be perceived as a disadvantage regarding the elimination of larger molecules, may be improved by the use of sustained low-efficiency daily diafiltration (SLEDD-f) [8,9,10,11]. Yet, the ideal renal replacement method for intensive care patients remains under scrutiny.…”

mentioning

confidence: 99%

Implementing On-Line Hemodiafiltration as a Renal Replacement Therapy for ICU Acute Renal Failure: A Single-Center Report of Feasibility, Safety and Hemodynamic Tolerance over a Seven-Year Period

Klouche¹,

Amigues²,

Serveaux-Delous³

et al. 2012

Blood Purif

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Background/Aims: On-line hemodiafiltration (HDF) is not yet routinely used in ICUs given the potential risk of microbial contamination of dialysis fluids. We evaluated the safety and the tolerance of its use in our ICU. Methods: A weekly measurement of bacterial growth (CFU/ml) and endotoxin level (endotoxin units/ml) was performed in dialysis fluids over a 7-year period. Intradialytic hypotensive events and pyrogenic reactions were collected during 466 on-line HDF sessions. Results: A bacterial count <0.1 CFU/ml was achieved in 977/978, 288/290, and 278/280, and an endotoxin level <0.03 endotoxin units/ml in 564/576, 330/337 and 318/323 ultrapure water, dialysate, and infusate samples, respectively. Seventy-six intradialytic hypotensive events but no pyrogenic reaction occurred. Conclusion: The great majority of dialysis fluid samples were considered suitable with a 99% compliance rate. Use of on-line HDF, at a large scale of dialysate and infusate flows, is well tolerated and may be safely performed in critically ill.

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Extended daily on-line high-volume haemodiafiltration in septic multiple organ failure: a well-tolerated and feasible procedure

Cited by 28 publications

References 30 publications

Efficacy and Safety of a Citrate-Based Protocol for Sustained Low-Efficiency Dialysis in AKI Using Standard Dialysis Equipment

Efficacy and Safety of a Citrate-Based Protocol for Sustained Low-Efficiency Dialysis in AKI Using Standard Dialysis Equipment

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Implementing On-Line Hemodiafiltration as a Renal Replacement Therapy for ICU Acute Renal Failure: A Single-Center Report of Feasibility, Safety and Hemodynamic Tolerance over a Seven-Year Period

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