Urea kinetics during sustained low-efficiency dialysis in critically ill patients requiring renal replacement therapy

Marshall, Mark R.; Golper, Thomas A.; Shaver, Mary Jo; Alam, Muhammad G.; Chatoth, Dinesh

doi:10.1053/ajkd.2002.31406

Cited by 113 publications

(65 citation statements)

References 43 publications

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“…Hemodynamic stability was maintained during SLED treatments in both groups. The SLED method has been shown to be a viable alternative to traditional CRRT techniques for critically ill patients (21). In addition, SLED provides solute clearances similar to those obtained with intermittent classic hemodialysis and eliminates the need for expensive CRRT machines, as well as reduces the costs related to anticoagulation, customized solutions, and trained personnel (22).…”

Section: Discussionmentioning

confidence: 99%

Door-to-Dialysis Time and Daily Hemodialysis in Patients with Leptospirosis

Andrade

Cleto

Seguro

2007

Clinical Journal of the American Society of Nephrology

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Background: Leptospirosis is a public health problem, the severe form of which (Weil's disease) includes acute respiratory distress syndrome, typically accompanied by acute kidney injury (AKI), and is associated with high mortality rates. Recent evidence suggests that dialysis dosage affects outcomes in critically ill patients with sepsis-induced AKI. However, this population varies widely in terms of age, gender, and concomitant conditions, making it difficult to determine the appropriate timing (door-to-dialysis time) and dialysis dosage.Design, setting, participants, and measurements: It is logical to assume that increasing the dialysis dosage would minimize uremic complications and improve outcomes in such patients. Patients with Weil's disease constitute a homogeneous population and are typically free of comorbidities, therefore presenting an ideal model in which to test this assumption.Results Conclusions: On the basis of this result, it is believed that alternate-day hemodialysis is no longer appropriate for critically ill patients with Weil's disease.

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Section: Discussionmentioning

confidence: 99%

Door-to-Dialysis Time and Daily Hemodialysis in Patients with Leptospirosis

Andrade

Cleto

Seguro

2007

Clinical Journal of the American Society of Nephrology

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“…The interpretation of studies that use blood flow as a measure of catheter dysfunction are challenging without knowledge of blood pump setting, use of average versus episodic measures of blood flow, percentage of recirculation, and other dialysis variables. There is an increasing use of long daily, nocturnal dialysis and slow low-efficiency dialysis, all of which use lower blood flows (27,28). Defining dysfunctional catheters by blood flows of Ͻ300 ml/min in this population would lead to unnecessary intervention in the majority of patients.…”

Section: Discussionmentioning

confidence: 99%

Relationship between Blood Flow in Central Venous Catheters and Hemodialysis Adequacy

Moist

Hemmelgarn

Lok

2006

Clinical Journal of the American Society of Nephrology

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Central venous catheter dysfunction is a frequent problem and often is defined as a blood flow <300 ml/min. This prospective, cross-sectional study included 259 patients and examined the relationship between catheter blood flow and dialysis adequacy as measured by urea reduction ratio (URR), single pool urea kinetics, and online effective ionic dialysance clearance. Dialysis adequacy at blood flow rates of <300, <275, and <250 ml/min; sensitivity; specificity; and positive and negative predictive values were calculated. Mean blood flow was 352 ml/min (SD ؎ 48.8). Mean blood flow <300 ml/min occurred in 10.5% of the patients, and only 26% had a URR of <65%. Maximum blood flows <300 ml/min occurred in 6.9% of patients, and only 22.2% had URR <65%. The positive predictive value of mean blood flow of <300 and <275 ml/min to predict a URR <65% was 22 and 40%, respectively. Using receiver operator characteristic curves, the area under the curve was not significantly different for blood flows of 300, 275, or 250 ml/min. This study indicates that mean blood flows <300 ml/min are not commonly associated with dialysis inadequacy. Setting a single blood flow cut point of <300 ml/min to define the need for intervention will result in a significant number of unnecessary interventions. There is a need to reexamine the definition of catheter dysfunction and expand the definition beyond blood flow rates.Clin C uffed, tunneled, dual-lumen central venous catheters (CVC) have become an acceptable form of hemodialysis (HD) vascular access when other permanent vascular accesses are unavailable, despite the associated high complication rates and mortality risk (1-4). In Canada, up to 70% of patients initiate HD with a CVC, and 33% continue to use catheters 90 days after dialysis initiation (5). This is far in excess of the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) recommendation that CVC be used in Ͻ10% of prevalent HD patients (6).A common complication of the CVC is its inability to deliver adequate dialysis as a result of dysfunction. The definition of CVC dysfunction varies across the literature and includes variable rates of blood flow ranging from Ͻ100 to 350 ml/min (7-16). The NKF-DOQI vascular access guideline defines CVC dysfunction as failure to attain and maintain extracorporeal blood flow that is sufficient to perform HD without significantly lengthening the HD treatment and considered insufficient extracorporeal blood flow to be Ͻ300 ml/min (6). This recommendation was opinion based and has been interpreted as the need to maintain blood flows Ͼ300 ml/min to ensure adequate dialysis. As a result of these guidelines, CVC often are run in the reverse configuration, thrombolytic agents such as thromboplastin inhibitor (t-PA) are used, or catheters are rewired when blood flow is reduced to Ͻ300 ml/min. With the increase in CVC prevalence and the corresponding increase in thrombolytic use and subsequent cost consequences, there is a clear need to clarify the relationship between CVC blood flow a...

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“…The volume of blood returned to the patient was defined on the basis of visual inspection of the extracorporeal circuit by the nurses; complete return was defined by a complete rinsing from blood of the lines and the filter at the end of SLED; no blood return was defined by complete occlusion of the air traps by visible clots rendering blood flow not possible; and intermediate conditions were defined as partial return. The urea reduction ratio was calculated according to standard methods (34).…”

Section: Efficacy Measuresmentioning

confidence: 99%

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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Urea kinetics during sustained low-efficiency dialysis in critically ill patients requiring renal replacement therapy

Cited by 113 publications

References 43 publications

Door-to-Dialysis Time and Daily Hemodialysis in Patients with Leptospirosis

Door-to-Dialysis Time and Daily Hemodialysis in Patients with Leptospirosis

Relationship between Blood Flow in Central Venous Catheters and Hemodialysis Adequacy

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

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