Higher versus Lower Continuous Renal Replacement Therapy Intensity in Critically ill Patients with Liver Dysfunction

O’Brien, Zachary; Cass, Alan; Cole, Louise; Finfer, Simon; Gallagher, Martin; McArthur, Colin; McGuiness, Shay; Myburgh, John; Bellomo, Rinaldo; Mårtensson, Johan

doi:10.1159/000480224

Cited by 12 publications

(5 citation statements)

References 22 publications

(27 reference statements)

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“…Similar to published data on CRRT in the context of the critically ill, 15,[17][18][19] in our study, patients who underwent CRRT had significantly higher mortality. These patients were sicker, as we offered CRRT to only hemodynamically unstable patients.…”

Section: Discussionsupporting

confidence: 91%

“…In our study, a cut‐off MELD above 35 and serum bilirubin more than 23 mg/dL and patients with AARC grade 3 were associated with higher dialysis requirements in the competing risk analysis. Similar to published data on CRRT in the context of the critically ill, 15,17–19 in our study, patients who underwent CRRT had significantly higher mortality. These patients were sicker, as we offered CRRT to only hemodynamically unstable patients.…”

Section: Discussionsupporting

confidence: 90%

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Natural history, spectrum and outcome of stage 3 AKI in patients with acute‐on‐chronic liver failure

Maiwall

Rastogi

Pasupuleti

et al. 2022

Liver International

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Background and Aim There is limited data on natural course and interventions in stage‐3 acute kidney injury (AKI‐3) in patients with acute‐on‐chronic liver failure (ACLF). We studied the factors of AKI‐3 reversal and outcomes of dialysis in ACLF patients. Methods Consecutive patients with ACLF were prospectively enrolled (n = 1022) and variables determining AKI and its outcomes were analysed. Results At 1 month, 337 (33%) patients had AKI‐3, of which, 131 had AKI‐3 at enrolment and 206 developed AKI‐3 during hospital stay. Of patients with AKI‐3 at enrolment, 18% showed terlipressin response, 21% had AKI resolution and 59% required dialysis. High MELD (≥35) (model 1), serum bilirubin (≥23 mg/dL) (model 2) and AARC score (≥11) (model 3) were independent risk factors for dialysis. Dialysis was associated with worse survival in all AKI patients but improved outcomes in patients with AKI‐3 (p = .022, HR 0.69 [0.50–0.95]). Post‐mortem kidney biopsies (n = 61) revealed cholemic nephropathy (CN) in 54%, acute tubular necrosis (ATN) in 31%, and a combination (CN and ATN) in 15%. Serum bilirubin was significantly higher in patients with CN, CN and ATN compared with ATN respectively ([30.8 ± 12.2] vs. [26.7 ± 12.0] vs. [18.5 ± 9.8]; p = .002). Conclusion AKI‐3 rapidly increases from 13% to 33% within 30 days in ACLF patients. Histopathological data suggested cholemic nephropathy as the predominant cause which correlated with high bilirubin levels. AKI‐3 resolves in only one in five patients. Patients with AARC grade 3 and MELD >35 demand need for early dialysis in AKI‐3 for improved outcomes.

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Section: Discussionsupporting

confidence: 91%

Section: Discussionsupporting

confidence: 90%

Natural history, spectrum and outcome of stage 3 AKI in patients with acute‐on‐chronic liver failure

Maiwall

Rastogi

Pasupuleti

et al. 2022

Liver International

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“…[64][65][66] Several studies have recommended initiating dialysis when the serum ammonia level is three times the upper limit of normal or if the patient displays signs of severe HE. [66][67][68] Due to similar clearance properties of ammonia to urea, continuous venovenous hemofiltration (CVVH) or intermittent hemodialysis (IHD) can be considered. CVVH is recommended over IHD due to lower fluctuations in intracranial pressure (ICP) and improved hemodynamic stability in the setting of acute kidney injury (AKI).…”

Section: Management Of Acute Liver Failure Diagnosis and Management Omentioning

confidence: 99%

“…64,67,113,114 This functional impairment is due to a complex interplay between extrarenal vasodilation and renal arteriolar vasoconstriction coupled with inadequate cardiac output. 68 Early initiation of RRT has been favored by many liver transplant centers. Studies comparing continuous renal replacement therapy (CRRT) versus IHD have noted greater variations in hemodynamic parameters and ICPs with IHD.…”

Section: Coagulopathy In Acute Liver Failurementioning

confidence: 99%

Acute Liver Failure

Rajaram

Subramanian

2018

Semin Respir Crit Care Med

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Acute liver failure (ALF) is a condition that can rapidly progress to multiorgan failure. This article focuses on the diagnosis and management of ALF. We provide a detailed review of the common etiologies of ALF, including acetaminophen overdose, viral hepatitis, drug-induced liver injury, Wilson's disease, and autoimmune hepatitis. The article then addresses how to recognize ALF and reviews the role of common laboratory and imaging tests in establishing this diagnosis. The remainder of the article details the management of hepatic and extrahepatic organ dysfunctions in ALF. The article concludes with a discussion regarding the prognostication of patients with ALF and the criteria for considering liver transplantation.

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“…90 Trials comparing convective flow rates of 40 ml/kg/h have not shown improved patient survival compared to those treated with 25 ml/kg/h. 91…”

Section: Introductionmentioning

confidence: 99%

Continuous renal replacement therapy under special conditions like sepsis, burn, cardiac failure, neurotrauma, and liver failure

Davenport

Honoré

2021

Seminars in Dialysis

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Continuous renal replacement therapy (CRRT) in sepsis does have a role in removing excessive fluid, and also role in removal of mediators although not proven today, and to allow fluid space in order to feed. In these conditions, continuous renal replacement therapy can improve morbidity but never mortality so far. Regarding sepsis, timing has become a more important issue after decades and is currently more discussed than dosing. Rationale of blood purification has evolved a lot in the last years regarding sepsis with the discovery of many types of sorbent allowing ideas from science fiction to become reality in 2021. Undoubtedly, COVID-19 has reactivated the interest of blood purification in sepsis but also in COVID-19. Burn is even more dependent about removal of excessive fluid as compared to sepsis. Regarding cardiac failure, ultrafiltration can improve the quality of life and morbidity when diuretics are becoming inefficient but can never improve mortality. Regarding brain injury, CRRTs have several advantages as compared to intermittent hemodialysis. In liver failure, there have been no randomized controlled trials to examine whether single-pass albumin dialysis offers advantages over standard supportive care, and there is always the cost of albumin.

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Higher versus Lower Continuous Renal Replacement Therapy Intensity in Critically ill Patients with Liver Dysfunction

Cited by 12 publications

References 22 publications

Natural history, spectrum and outcome of stage 3 AKI in patients with acute‐on‐chronic liver failure

Natural history, spectrum and outcome of stage 3 AKI in patients with acute‐on‐chronic liver failure

Acute Liver Failure

Continuous renal replacement therapy under special conditions like sepsis, burn, cardiac failure, neurotrauma, and liver failure

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