OBJECTIVEContinuous renal replacement therapy (CRRT) is a continuous process of bedside blood purification which is widely used in the treatment of acute kidney injury (AKI) and for fluid management. However, since AKI and fluid overload are often found to be associated with hemodynamic abnormalities, determining the relationship between CRRT and hemodynamics remains a challenge in the treatment of critically ill patients. The aim of this review was to summarize key points in the relationship between CRRT and hemodynamics and to understand and monitor renal hemodynamics in critically ill patients, especially those with AKI.

DATA SOURCESThis review was based on data in articles published in the PubMed databases up to January 30, 2017, with the following keywords: "continuous renal replacement therapy," "Hemodynamics," and "Acute kidney injury."

STUDY SELECTIONOriginal articles and critical reviews on CRRT were selected for this review.

RESULTSCRRT might treat AKI by hemodynamic therapy, and it was an important form of hemodynamic therapy. The targets of hemodynamic therapy should be established when using CRRT. Therefore, hemodynamic management and stability were very important during CRRT. Most studies suggested that renal hemodynamics should be clearly identified.

CONCLUSIONSCRRT is not only a replacement for organ function, but an important form of hemodynamic therapy. Improved hemodynamic management of critically ill patients can be achieved by establishing specific therapeutic hemodynamic targets and maintaining circulatory stability during CRRT. Over the long term, observation of renal hemodynamics will provide greater opportunities for the progression of CRRT hemodynamic therapy.

Acute Kidney Injury ; physiopathology ; therapy ; Animals ; Female ; Hemodynamics ; physiology ; Humans ; Male ; Renal Dialysis ; methods ; Renal Replacement Therapy ; methods

BACKGROUND: Whether high cut-off (HCO) membranes are more effective than high-flux (HF) membranes in patients requiring renal replacement therapy (RRT) remains controversial. The aim of this systematic review was to investigate the efficacy of HCO membranes regarding the clearance of inflammation-related mediators, β2-microglobulin and urea; albumin loss; and all-cause mortality in patients requiring RRT. METHODS: We searched all relevant studies on PubMed, Embase, Web of Science, the Cochrane Library, and China National Knowledge Infrastructure, with no language or publication year restrictions. Two reviewers independently selected studies and extracted data using a prespecified extraction instrument. Only randomized controlled trials (RCTs) were included. Summary estimates of standardized mean differences (SMDs) or weighted mean differences (WMDs) and risk ratios (RRs) were obtained by fixed-effects or random-effects models. Sensitivity analyses and subgroup analyses were performed to determine the source of heterogeneity. RESULTS: Nineteen RCTs involving 710 participants were included in this systematic review. Compared with HF membranes, HCO membranes were more effective in reducing the plasma level of interleukin-6 (IL-6) (SMD -0.25, 95% confidence interval (CI) -0.48 to -0.01, P   =  0.04, I2  = 63.8%); however, no difference was observed in the clearance of tumor necrosis factor-α (TNF-α) (SMD 0.03, 95% CI -0.27 to 0.33, P  = 0.84, I2  = 4.3%), IL-10 (SMD 0.22, 95% CI -0.12 to 0.55, P  = 0.21, I2  = 0.0%), or urea (WMD -0.27, 95% CI -2.77 to 2.23, P  = 0.83, I2  = 19.6%). In addition, a more significant reduction ratio of β 2 -microglobulin (WMD 14.8, 95% CI 3.78 to 25.82, P  = 0.01, I2  = 88.3%) and a more obvious loss of albumin (WMD -0.25, 95% CI -0.35 to -0.16, P  < 0.01, I2  = 40.8%) could be observed with the treatment of HCO membranes. For all-cause mortality, there was no difference between the two groups (risk ratio [RR] 1.10, 95% CI 0.87 to 1.40, P  = 0.43, I2  = 0.0%). CONCLUSIONS Compared with HF membranes, HCO membranes might have additional benefits on the clearance of IL-6 and β 2-microglobulin but not on TNF-α, IL-10, and urea. Albumin loss is more serious with the treatment of HCO membranes. There was no difference in all-cause mortality between HCO and HF membranes. Further larger high-quality RCTs are needed to strengthen the effects of HCO membranes.
Humans ; Albumins ; Interleukin-10 ; Interleukin-6 ; Renal Replacement Therapy/methods* ; Tumor Necrosis Factor-alpha

OBJECTIVETo assess the role of direct thrombin inhibitor argatroban in the renal replacement therapy.

METHODSElectronic databases including Cochrane library, PubMed, EMBASE, Highwire, MEDLINE, CBM, CNKI, and CSJD were searched using keywords including "Argatroban", "hemodialysis", "renal function", "renal failure", and "renal replacement therapy". A meta-analysis of all randomized controlled trials(RCTs)comparing argatroban with controls in renal replacement therapy was performed. Both the study selection and the meta-analysis were conducted according to the Cochrane Handbook for systematic reviews. Data were extracted from these trials and analyzed by RevMan 5.0 software.

RESULTSCompared with the control group, argatroban in renal replacement therapy showed no significant difference in mortality(RR=0.97, 95%CI: 0.48-1.97, P=0.93)and bleeding rate(RR=0.71, 95%CI: 0.37-1.34, P=0.29). Argatroban significantly decreased the incidence of new thrombosis in renal replacement therapy for patients with heparin-induced Thrombocytopenia(RR=0.40, 95%CI: 0.21-0.75, P=0.004). Also, argatroban significantly decreased the clotting events in extracorporeal circuit during the renal replacement therapy(RR=0.06, 95%CI: 0.01-0.23, P<0.0001). CONCLUSION Argatroban applied in renal replacement therapy can decrease the incidences of new thrombosis and clotting events in extracorporeal circuit and meanwhile will not increase the mortality and bleeding.

Antithrombins ; therapeutic use ; Hemorrhage ; epidemiology ; Humans ; Incidence ; Pipecolic Acids ; therapeutic use ; Renal Dialysis ; Renal Insufficiency ; Renal Replacement Therapy ; methods ; Thrombosis ; drug therapy

Tissue engineering is a discipline involving both materials science, engineering and life science. It has found successful application in Bioartificial renal tubule assist device RAD which is still under development. Experiments have proved that RAD can serve as renal tubule to perform its transport, metabolic and endocrine functions in patients with acute or chronic renal failure.
Animals ; Bioartificial Organs ; Cell Transplantation ; Cells, Cultured ; Kidney Tubules ; cytology ; Kidneys, Artificial ; Renal Insufficiency ; therapy ; Renal Replacement Therapy ; instrumentation ; Swine ; Tissue Engineering ; methods

BACKGROUNDUnfractionated heparin is the most commonly used anticoagulant in continuous renal replacement therapy (CRRT), but it can increase the risk of bleeding. Citrate is a promising substitute. Our study was to assess the efficacy and safety of citrate versus unfractionated heparin in CRRT.

METHODSWe searched the MEDLINE, the EMBASE, the Cochrane Central Register of Controlled Trials, and the China National Knowledge Infrastructure Database until up to November 2011 for randomized controlled trials comparing citrate with unfractionated heparin in adult patients with acute kidney injury prescribed CRRT. The primary outcome was mortality and the secondary outcomes included circuit survival, control of uremia, risk of bleeding, transfusion rates, acid-base statuses, and disturbance of sodium and calcium homeostasis.

RESULTSFour trials met the inclusion criteria. Meta-analysis found no significant difference between two anticoagulants on mortality. Less bleeding and more hypocalcemic episodes were with citrate. Citrate was superior or comparable to unfractionated heparin in circuit life.

CONCLUSIONSCitrate anticoagulation in CRRT seems to be superior in reducing bleeding risk and with a longer or similar circuit life, although there is more metabolic derangement. Mortality superiority has not been approved.

Anticoagulants ; therapeutic use ; Citric Acid ; therapeutic use ; Heparin ; therapeutic use ; Humans ; Randomized Controlled Trials as Topic ; Renal Replacement Therapy ; methods

OBJECTIVE: To investigate the effect of continuous renal replacement therapy (CRRT) on patients with emergency and serious diseases. METHODS: The patients were divided into 2 groups: Group A [71 patients with multiple organ dysfunction syndrome (MODS)] were treated by CRRT for 175 times. Group B (30 patients) were treated with common hematodialysis (HD). Blood urea nitrogen (BUN), serum creatinine (Scr), natrem (Na(+)), kalium (K(+)), chlorine (Clj), power of hydrogen (pH), bicarbonate (HCO3-), carbon dioxide partial pressure (PCO(2)), and oxygen pressure (PO(2)) were measured before and after the treatment. RESULTS: After the treatment, all patients' general state of health, water-electrolyte and acid base disorder were improved. The levels of BUN, Scr, K(+) (All P(s)<0.01), and Na(+) (P<0.05 in Group A, P<0.01 in Group B) were all lower and the levels of CO(2)CP (P<0.01 in Group A, P<0.05 in Group B) were higher than that before the pretherapy in both Group A and Group B. There was significant difference on the levels of BUN, Scr, K(+)(All P(s)<0.01), Cl(-) and CO(2)CP (All P(s)<0.05) between Group A and Group B, which indicated the therapeutic effect in Group A was better than that in Group B. Furthermore, the levels of pH, PO(2) and HCO(3)(-) were higher (P<0.01) and PCO(2) was lower (P<0.05) obviously than that before the CRRT in 30 patients with acute respiratory distress syndrome (ARDS) in Group A. Among the 9 patients with poisoning, 7 were alleviated completely and 2 died after the CRRT plus hemoperfusion (HP). The survival time of patients was lengthened in Group A. No blood or bleed aggravation occurred in patients with bleeding inclination or 48 h before the operation after using the method of heparin soaking the blood filter. CONCLUSION CRRT has better curative effect on removing the toxin effectively, rapidly correcting the turbulence of water electrolyte and sour-alkali balance for patients compare with HD. At the same time, it can increase the level of PO(2) and reduce CO(2) retention, improve the lung function and brain edema, and increase the patient's survival rate. Using CRRT as early as possible is very important and it can improve the prognosis of the patients who had MODS or other dangers because the death rate of MODS patients is very high.
Adolescent ; Adult ; Aged ; Aged, 80 and over ; Blood Urea Nitrogen ; Child ; Child, Preschool ; Creatinine ; blood ; Female ; Humans ; Male ; Middle Aged ; Multiple Organ Failure ; therapy ; Renal Replacement Therapy ; methods

Holmium laser lithotripsy (HLL) is one of the common surgical methods for urolithiasis. It causes minor surgical trauma, but complications are not rare. Extracorporeal membrane oxygenation (ECMO) treatment of sepsis is common, but venoarterial (VA)-ECMO treatment of urosepsis has not been reported yet. In this article, we reported a 67-year-old female patient with refractory septic shock caused by HLL under percutaneous nephroscope, involving breathing, heart, kidney and other organs, and organs support treatment was ineffective for the patient. Finally, we successfully treated the patient under VA-ECMO with continuous renal replacement therapy (CRRT). Combined ECMO and CRRT may provide a solution for addressing refractory sepsis. Here we present the case and review relevant literature, so as to provide a treatment strategy for patients with refractory urogenic sepsis and to reduce the mortality rate.
Aged ; Extracorporeal Membrane Oxygenation/methods* ; Female ; Humans ; Lasers, Solid-State/adverse effects* ; Lithotripsy, Laser/methods* ; Postoperative Complications/therapy* ; Renal Replacement Therapy/methods* ; Shock, Septic/therapy* ; Treatment Outcome ; Urinary Tract Infections/therapy* ; Urolithiasis/surgery*

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a lifesaving therapy used in critically ill patients with severe cardiopulmonary dysfunction. Continuous renal replacement therapy (CRRT) is supplemented to treat fluid overload, acute kidney injury, and electrolyte disturbances during ECMO. However, the best time to initiate CRRT is not well-defined. We performed this study to identify the optimal timing of CRRT for ECMO. METHODS: We conducted a multicenter retrospective cohort study of 296 patients over 12 years. Patients received CRRT during ECMO at Seoul National University Hospital, Seoul National University Bundang Hospital, or Yonsei University Hospital. We assigned patients to an early or late CRRT group depending on the CRRT initiation time. We considered early CRRT to be CRRT instituted within 72 hours of ECMO initiation. RESULTS: Among 296 patients, 212 patients (71.6%) received early CRRT. After using a propensity score matching method, 47 patients were included in each group. The time from ECMO initiation to CRRT initiation was 1.1 ± 0.9 days in the early CRRT group and 14.6 ± 18.6 days in the late CRRT group. No difference in patients’ mortality (P = 0.834) or hospital stay (P = 0.627) between the early and late CRRT groups was found. After adjusting all covariables, there was no significant difference in mortality between the early and late CRRT groups (hazard ratio, 0.697; 95% confidence interval, 0.410–1.184; P = 0.182). CONCLUSION: This study showed that early CRRT may not be superior to late CRRT in ECMO patients. Further clinical trials are warranted.
Acute Kidney Injury ; Cohort Studies ; Critical Illness ; Extracorporeal Membrane Oxygenation* ; Humans ; Length of Stay ; Methods ; Mortality ; Propensity Score ; Renal Replacement Therapy* ; Retrospective Studies ; Seoul ; Time-to-Treatment

OBJECTIVETo analyze the preoperative risk factors on liver transplant recipients with acute renal failure(ARF), and to evaluate renal replacement therapy (RRT) as a transitonary therapy before liver transplantation.

METHODSLiver transplant recipients with acute renal failure treated with renal replacement therapy between January 1st, 2001 and January 1st, 2008 in our center were retrospected. Clinical characteristics, the kinds of RRT and prognosis were analyzed; Logistic regression was applied to analyze the parameters that can forecast the motality of the liver transplant recipients with acute renal failure.

RESULTSOf the patients who received RRT, 30% survived to liver transplantation, 67.5% died while waiting for liver transplantation. The dead had a higher multiple organ dysfunction score (MODS), and lower mean arterial pressure than those survived to liver transplantation. There was no significant difference in the duration of RRT between continuous renal replacement therapy (CRRT) patients and hemodialysis patients. CRRT patients had a higher MODS, lower mean arterial pressure, lower serum creatinine than hemodialysis patients. Lower mean arterial pressure was statistically associated with higher risk of mortality.

CONCLUSIONThough mortality was high, RRT helps part (30%) of patients survive to liver transplantation. Therefore, considering the high mortality without transplantation, RRT is acceptable for liver transplant recipients with ARF.

Acute Kidney Injury ; etiology ; mortality ; therapy ; Adult ; Blood Pressure ; Female ; Humans ; Liver Transplantation ; adverse effects ; Liver, Artificial ; Male ; Middle Aged ; Prognosis ; Regression Analysis ; Renal Dialysis ; methods ; Renal Replacement Therapy ; mortality ; Retrospective Studies ; Risk Factors ; Severity of Illness Index ; Survival Analysis

OBJECTIVETo explore the efficacy of Qishen Huoxue Granules (QHG) for auxiliary treatment of critical patients with acute kidney injury (AKI).

METHODSFifty-two AKI patients came from critical care medical department of Beijing Friendship Hospital were randomly assigned to two groups: Group A (25 patients) was treated with QHG (consisted of Radix Astragali, Radix Salviae miltiorrhizae, Radix Paeoniae rubra, Flos Carthami, and Radix Angelicae sinensis, etc., 10 g/bag, administered via gastric perfusion, 3 times per day, 10 g in each time) and continuous renal replacement therapy (CRRT); Group B (27 cases) was treated only by CRRT, all for 14 days. Besides, mechanical ventilation and vasoactive drugs were applied in case of necessary. The time of renal function recovery, days in ICU, 28-day mortality, changes of serum Cystatin C concentration as well as the time of mechanical ventilation (T-V) and vasoactive drugs application (T-D) in patients, who received corresponding treatment were observed.

RESULTSThe renal function recovery time in Group A was markedly earlier than that in Group B (P < 0.05), with concentration of serum Cystatin C began to decrease from day 10. T-V and T-D in Group A were markedly shorter than those in Group B, respectively (P < 0.05). No significantly statistical difference between the two groups for days in ICU and 28-day mortality was found (P > 0.05).

CONCLUSIONQHG shows favorable prospect in treating critical AKI patients, it can significantly accelerate the renal function recovery time, shorten the duration of mechanical ventilation and vasoactive drugs application.

Acute Kidney Injury ; physiopathology ; therapy ; Aged ; Aged, 80 and over ; Combined Modality Therapy ; Critical Care ; Cystatin C ; blood ; Drugs, Chinese Herbal ; therapeutic use ; Female ; Humans ; Kidney ; physiopathology ; Male ; Middle Aged ; Phytotherapy ; Renal Replacement Therapy ; methods