Precision Continuous Renal Replacement Therapy and Solute Control

Bagshaw, Sean M.; Chakravarthi, M Rajasekara; Ricci, Zaccaria; Tolwani, Ashita J.; Neri, Mauro; Rosa, Silvia De; Kellum, John A.; Ronco, Claudio

doi:10.1159/000448507

Cited by 87 publications

(68 citation statements)

References 41 publications

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“…Both studies show a trend toward an increasing awareness of RRT dosing. In our study, the majority of the respondents reported a patient's weight to be considered important when prescribing the CRRT effluent flow rate, which reflects the recommendations of the 17th ADQI International Consensus from 2016 [43] . This is in contrast to another survey in the USA which suggested that monitoring of the delivered dosage of hemodialysis was only infrequently assessed [44] .…”

Section: Discussionsupporting

confidence: 64%

Definition, Management, and Outcomes of Acute Kidney Injury: An International Survey of Nephrologists

et al. 2017

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Background: Acute kidney injury (AKI) is a complex disease burdened by uncertainties of definition, management strategies, and prognosis. This study explores the relationship between demographic characteristics of nephrologists and their perceptions about the definition, management, and follow-up of AKI. Methods: We developed a Web-based survey, the International Survey on Acute Kidney Injury (ISAKI), consisting of 29 items in 4 categories: (1) demographic and practice characteristics, (2) definition of AKI, (3) management of renal replacement therapy (RRT) in AKI, and (4) sequelae of AKI. A multivariable stepwise logistic regression model was used to examine relationships between the dependent variables and the demographic characteristics of the respondents. Results: Responses from 743 nephrologists from 90 countries were analyzed. The majority (60%) of respondents reported using RIFLE and/or AKIN criteria regularly to define AKI, although US nephrologists were less likely to do so (OR: 0.58; 95% CI: 0.42-0.85). The most common initial RRT modality was intermittent hemodialysis (63.5%), followed by continuous RRT (23.8%). Faculty affiliation was associated with a higher likelihood of using a dialysis schedule of ≥4 times a week (OR: 1.75; 95% CI: 1.20-2.55). The respondents believed that a single episode of AKI increases the likelihood of development of chronic kidney disease (CKD) (55%), subsequent AKI (36%), and rapid progression of preexisting CKD (87%). US nephrologists were less likely to recommend follow-up after resolution of AKI (OR: 0.15; 95% CI: 0.07-0.33). Conclusions: Our findings highlight the need for a widely accepted consensus definition of AKI, a uniform approach to management, and improved follow-up after resolution of AKI episodes.

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Section: Discussionsupporting

confidence: 64%

Definition, Management, and Outcomes of Acute Kidney Injury: An International Survey of Nephrologists

et al. 2017

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“…Thus, continuous renal replacement therapies (CRRT) are the choice in hemodynamically instable patients, because they allow a slow and constant fluid removal, targeted to match the plasma refill rate, to ensure patient survival and renal functional recovery. These techniques of renal substitution therapy have allowed the conceptual shift from renal “replacement” to renal “support” therapies [8], and the term “dynamic CRRT” has been proposed to show that any treatment has to be dynamic and adaptable to the constantly changing clinical status of critically ill patients [9]. …”

Section: Acute Hemodynamically Unstable Patients Require a Continuousmentioning

confidence: 99%

Progress in the Development and Challenges for the Use of Artificial Kidneys and Wearable Dialysis Devices

Hueso

Navarro²,

Sandoval

et al. 2018

Kidney Dis

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Background: Renal transplantation is the treatment of choice for chronic kidney disease (CKD) patients, but the shortage of kidneys and the disabling medical conditions these patients suffer from make dialysis essential for most of them. Since dialysis drastically affects the patients’ lifestyle, there are great expectations for the development of wearable artificial kidneys, although their use is currently impeded by major concerns about safety. On the other hand, dialysis patients with hemodynamic instability do not usually tolerate intermittent dialysis therapy because of their inability to adapt to a changing scenario of unforeseen events. Thus, the development of novel wearable dialysis devices and the improvement of clinical tolerance will need contributions from new branches of engineering such as artificial intelligence (AI) and machine learning (ML) for the real-time analysis of equipment alarms, dialysis parameters, and patient-related data with a real-time feedback response. These technologies are endowed with abilities normally associated with human intelligence such as learning, problem solving, human speech understanding, or planning and decision-making. Examples of common applications of AI are visual perception (computer vision), speech recognition, and language translation. In this review, we discuss recent progresses in the area of dialysis and challenges for the use of AI in the development of artificial kidneys. Summary and Key Messages: Emerging technologies derived from AI, ML, electronics, and robotics will offer great opportunities for dialysis therapy, but much innovation is needed before we achieve a smart dialysis machine able to analyze and understand changes in patient homeostasis and to respond appropriately in real time. Great efforts are being made in the fields of tissue engineering and regenerative medicine to provide alternative cell-based approaches for the treatment of renal failure, including bioartificial renal systems and the implantation of bioengineered kidney constructs.

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“…Timing of RRT initiation in critically-ill patients: time for precision medicine Eric Kipnis 1 , Francesco Garzotto 2 , Claudio Ronco consensus group (7)(8)(9)(10)(11) suggesting that precision CRRT should start from a truly personalized prescription of timing of initiation of the extracorporeal therapy. This has been derived from several previous observations and the analysis of the literature (12)(13)(14).…”

Section: Editorialmentioning

confidence: 99%

Timing of RRT initiation in critically-ill patients: time for precision medicine

Kipnis¹,

Garzotto²,

Ronco³

2016

J. Thorac. Dis.

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Recently published randomized controlled trials have brought a focus upon the timing of renal replacement therapy (RRT) initiation in critically-ill patients (1,2). The AKIKI study randomized 620 ICU patients with severe acute kidney injury (AKI) [kidney disease improving global outcomes (KDIGO) classification, stage 3] to either immediate initiation of RRT or delayed initiation according to predetermined mandatory RRT criteria (1). Gaudry et al. found no significant difference in mortality between early and delayed RRT initiation strategies in critically-ill patients results, suggesting that careful monitoring of patients for predetermined mandatory RRT criteria may safely allow delaying RRT in ventilated and/or catecholaminedependent patients with severe AKI. To a more detailed unadjusted subpopulation analyses however, it seems that results may have been influenced by differences in patient outcomes within the delayed-RRT group. Indeed, among patients in the delayed group, those without RRT had a significantly decreased risk of death [hazard ratio =0.71 (0.52;0.97); P=0.031] while those who received delayed RRT had significantly increased risk of death [hazard ratio =1.40 (1.08;1.8); P=0.011]. These results suggest that patients who will never have required RRT probably benefit from not being exposed to potential complications of RRT while patients who definitely required RRT suffer from delayed initiation. The authors mitigate these results by performing an adjustment to baseline severity, after which differences were no longer significant. Given the important implications of the unadjusted subpopulation analysis, adjustment to baseline severity may not have been sufficient to completely describe results and the related phenomena. Rather, studies show that even when adjusting for severity, fluid accumulation remains a major risk factor for death in ICU patients with AKI (3-6). Therefore, adjusting-to or stratifying-by fluid accumulation could have confirmed or accentuated the opposite behaviors observed within the delayed-RRT group. Although no data on fluid accumulation was provided aside from pulmonary edema incidence, increased diuretic use in the delayed-RRT group [4 patients (1.3%) vs. 112 patients (36.5%); P<0.001] shows that fluid accumulation was a major issue nonetheless.Fluid accumulation was among inclusion criteria in the recent ELAIN trial which randomized 231 critically-ill patients with AKI (KDIGO stage 2) to either early (within 8 hours of diagnosis of KDIGO stage 2 AKI; n=112) or delayed (within 12 hours of stage 3 AKI or no initiation; n=119) initiation of RRT (2). The use of biomarkers was also among inclusion criteria in the ELAIN trial: plasma neutrophil gelatinase-associated lipocalin (NGAL) >150 ng/mL. Zarbock et al. found increased survival in early versus delayed-RRT suggesting that "early" RRT-initiation earlier than the in the AKIKI trial (KDIGO stage 2 vs. stage 3) in patients with both fluid accumulation and NGAL-positive AKI is beneficial.Given possible risks to patient subpopul...

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Precision Continuous Renal Replacement Therapy and Solute Control

Cited by 87 publications

References 41 publications

Definition, Management, and Outcomes of Acute Kidney Injury: An International Survey of Nephrologists

Definition, Management, and Outcomes of Acute Kidney Injury: An International Survey of Nephrologists

Progress in the Development and Challenges for the Use of Artificial Kidneys and Wearable Dialysis Devices

Timing of RRT initiation in critically-ill patients: time for precision medicine

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