Timing of Continuous Renal Replacement Therapy Initiation in Sepsis-Associated Acute Kidney Injury: A Comprehensive Review and Future Directions

This review examines the application of continuous renal replacement therapy(CRRT)in patients with sepsis-associated acute kidney injury(S-AKI),with a particular focus on the timing of CRRT initiation.This review addresses the controversy surrounding initiation timing and proposes future research directions.Through a systematic review of recent literature on CRRT for S-AKI,working principles,therapeutic mechanisms,initiation timing of CRRT,and related meta-analyses were summarized.Current studies indicate that the optimal timing for CRRT initiation in S-AKI patients remains inconclusive,with ongoing debate regarding whether early initiation significantly improves patient survival and renal function.This lack of consensus reflects the heterogeneity of the S-AKI patient population and the limitations of existing research methodologies.Future studies should focus on advancing the application of precision medicine in S-AKI and developing individualized treatment strategies by integrating multidimensional information to optimize CRRT utilization and improve patient outcomes.

Management of regional citrate anticoagulation for continuous renal replacement therapy:guideline recommendations from Chinese emergency medical doctor consensus

Continuous renal replacement therapy(CRRT)is widely used for treating critically-ill patients in the emergency department in China.Anticoagulant therapy is needed to prevent clotting in the extracorporeal circulation during CRRT.Regional citrate anticoagulation(RCA)has been shown to potentially be safer and more effective,and is now recommended as the preferred anticoagulant method for CRRT.However,there is still a lack of unified standards for RCA management in the world,and there are many problems in using this method in clinical practice.The Emergency Medical Doctor Branch of the Chinese Medical Doctor Association(CMDA)organized a panel of domestic emergency medicine experts and international experts of CRRT to discuss RCA-related issues,including the advantages and disadvantages of RCA in CRRT anticoagulation,the principle of RCA,parameter settings for RCA,monitoring of RCA(mainly metabolic acid-base disorders),and special issues during RCA.Based on the latest available research evidence as well as the paneled experts'clinical experience,considering the generalizability,suitability,and potential resource utilization,while also balancing clinical advantages and disadvantages,a total of 16 guideline recommendations were formed from the experts'consensus.

Eff ects of continuous renal replacement therapy on infl ammation-related anemia, iron metabolism and prognosis in sepsis patients with acute kidney injury

BACKGROUND:This study aims to evaluate the eff ect of continuous renal replacement therapy(CRRT)on inflammation-related anemia,iron metabolism,and the prognosis in sepsis patients with acute kidney injury(AKI).METHODS:Sepsis patients with AKI were prospectively enrolled and randomized into the CRRT and control groups.The clinical and laboratory data on days 1,3 and 7 after intensive care unit(ICU)admission were collected.The serum interleukin(IL)-6,hepcidin,erythropoietin,ferritin,and soluble transferrin receptor(sTfR)were determined by enzyme-linked immunosorbent assay.The Sequential Organ Failure Assessment(SOFA)score and 28-day mortality were recorded.Data were analyzed using Pearson’s Chi-square test or Fisher’s exact test(categorical variables),and Mann-Whitney U-test or t-test(continuous variables).RESULTS:The hemoglobin and serum erythropoietin levels did not signifi cantly diff er between the CRRT and control groups though gradually decreased within the first week of ICU admission.On days 3 and 7,the serum IL-6,hepcidin,ferritin,and red blood cell distribution width significantly decreased in the CRRT group compared to the control group(all P<0.05).On day 7,the serum iron was significantly elevated in the CRRT group compared to the control group(P<0.05).However,the serum sTfR did not signifi cantly diff er between the groups over time.In addition,the SOFA scores were signifi cantly lower in the CRRT group compared to the control group on day 7.The 28-day mortality did not signifi cantly diff er between the control and CRRT groups(38.0%vs.28.2%,P=0.332).CONCLUSION:CRRT might have beneficial effects on the improvement in inflammationrelated iron metabolism and disease severity during the fi rst week of ICU admission but not anemia and 28-day mortality in sepsis patients with AKI.

Effects of plasma exchange combined with continuous renal replacement therapy on acute fatty liver of pregnancy

BACKGROUND: Acute fatty liver of pregnancy (AFLP) in the third trimester or early postpartum period can lead to fatal liver damage. Its traditional therapy is not very effective in facilitating hepatic recovery. The safety and effect of plasma exchange (PE)in combination with continuous renal replacement therapy(CRRT) (PE+CRRT) for AFLP still needs evaluation.METHODS: Five AFLP patients with hepatic encephalopathy and renal failure were subjected to PE+CRRT in our department from 2007 to 2012. Their symptoms, physical signs and results were observed, and all relevant laboratory tests were compared before and after PE+CRRT.RESULTS: All the 5 patients were well tolerated to the therapy. Four of them responded to the treatment and showed improvement in clinical symptoms/signs and laboratory results and they were cured and discharged home after the treatment One patient succeeded in bridging to transplantation for slowing down hepatic failure and its complications process after2 treatment sessions. Intensive care unit stay and hospital stay were 9.4 (range 5-18) and 25.0 days (range 11-42), respectively.CONCLUSION: PE+CRRT is safe and effective and should be used immediately at the onset of hepatic encephalopathy and/or renal failure in patients with AFLP.

Therapeutic plasma exchange and continuous renal replacement therapy for severe hyperthyroidism and multi-organ failure:A case report

BACKGROUND Severe hyperthyroidism is a life-threatening exacerbation of thyrotoxicosis,characterized by high fever and multiorgan failure. The most common medical treatments are administration of antithyroid drugs and radioactive iodine, and thyroidectomy. In some patients, antithyroid therapy is limited due to serious adverse effects or failure to control disease progression. In some extreme cases,such as thyroid storm, conventional therapy alone does not yield effective and rapid improvement before the development of multiorgan failure.CASE SUMMARY This report describes a Chinese patient with severe hyperthyroidism accompanied by multiorgan failure, who was transferred to the medical intensive care unit of our hospital. The patient presented with palpitations, vomiting,diarrhea, and shortness of breath for a week. Laboratory tests showed elevation of thyroid hormones. Hepatic failure occurred with high aminotransferase levels and jaundice. Given her abnormal liver function and medication history, we could not exclude diagnosis of propylthiouracil-induced hepatic failure.Moreover, she also suffered from heart failure. Therapeutic plasma exchange(commonly known as TPE) and continuous renal replacement therapy(commonly known as CRRT) were used as life-saving therapy, which resulted in notable improvement of clinical symptoms and laboratory tests.CONCLUSION Combined TPE and CRRT are safe and effective for patients with hyperthyroidism and multiorgan failure.

Effects of prostaglandin E combined with continuous renal replacement therapy on septic acute kidney injury

BACKGROUND The effects of prostaglandin E(PGE)combined with continuous renal replacement therapy(CRRT)on renal function and inflammatory responses in patients with septic acute kidney injury(SAKI)remain unclear.AIM To investigate the effects of PGE combined with CRRT on urinary augmenter of liver regeneration(ALR),urinary Na+/H+exchanger 3(NHE3),and serum inflammatory cytokines in patients with SAKI.METHODS The clinical data of 114 patients with SAKI admitted to Yichang Second People's Hospital from May 2017 to January 2019 were collected.Fifty-three cases treated by CRRT alone were included in a control group,while the other 61 cases treated with PGE combined with CRRT were included in an experimental group.Their urinary ALR,urinary NHE3,serum inflammatory cytokines,renal function indices,and immune function indices were detected.Changes in disease recovery and the incidence of adverse reactions were observed.The 28-d survival curve was plotted.RESULTS Before treatment,urinary ALR,urinary NHE3,blood urea nitrogen(BUN),serum creatinine(SCr),CD3+T lymphocytes,CD4+T lymphocytes,and CD4+/CD8+T lymphocyte ratio in the control and experimental groups were approximately the same.After treatment,urinary ALR and NHE3 decreased,while BUN,SCr,CD3+T lymphocytes,CD4+T lymphocytes,and CD4+/CD8+T lymphocyte ratio increased in all subjects.Urinary ALR,urinary NHE3,BUN,and SCr in the experimental group were significantly lower than those in the control group,while CD3+T lymphocytes,CD4+T lymphocytes,and CD4+/CD8+T lymphocyte ratio were significantly higher than those in the control group(P<0.05).After treatment,the levels of tumor necrosis factor-α,interleukin-18,and high sensitivity C-reactive protein in the experimental group were significantly lower than those in the control group(P<0.05).The time for urine volume recovery and intensive care unit treatment in the experimental group was significantly shorter than that in the control group(P<0.05),although there was no statistically significant difference in hospital stays between the two groups.The total incidence of adverse reactions did not differ statistically between the two groups.The 28-d survival rate in the experimental group(80.33%)was significantly higher than that in the control group(66.04%).CONCLUSION PGE combined with CRRT is clinically effective for treating SAKI,and the combination therapy can significantly improve renal function and reduce inflammatory responses.

Optimal indicator for changing the filter during the continuous renal replacement therapy in intensive care unit patients with acute kidney injury:A crossover randomized trial

BACKGROUND:The study aims to investigate an optimal indicator for changing the filter during the continuous renal replacement therapy(CRRT)in intensive care unit(ICU)patients with acute kidney injury(AKI).METHODS:Patients with AKI requiring CRRT in an ICU were randomly divided into two groups for crossover trial,i.e.,groups A and B.Patients in the group A were firstly treated with continuous veno-venous hemofiltration(CVVH),followed by continuous veno-venous hemodiafiltration(CVVHDF).Patients in the group B were firstly treated with CVVHDF followed by CVVH.Delivered doses of solutes with different molecular weights at the indicated time points between groups were compared.A correlation analysis between the delivered dose and pre-filter pressure(P_(PRE))and transmembrane pressure(P_(TM))was performed.Receiver operating characteristic(ROC)curves were constructed to evaluate the accuracy of P_(TM) as an indicator for filter replacement.RESULTS:A total of 50 cases were analyzed,27 in the group A and 23 in the group B.Delivered doses of different molecular-weight solutes significantly decreased before changing the filter in both modalities,compared with those at the initiation of treatment(all P<0.05).In the late stage of CRRT,the possible rebound of serum medium-molecular-weight solute concentration was observed.P_(TM) was negatively correlated with the delivered dose of medium-molecular-weight solute in both modalities.The threshold for predicting the rebound of serum concentration of medium-molecularweight solute by P_(TM) was 146.5 mm Hg(1 mm Hg=0.133 k Pa).CONCLUSIONS:The filter can be used as long as possible within the manufacturer’s safe use time limits to remove small-molecular-weight solutes.P_(TM) of 146.5 mm Hg may be an optimal indicator for changing the filter in CRRT therapies to remove medium-molecular-weight solutes.

Evaluation of the Pharmacokinetics of Nafamostat Mesylate during Continuous Renal Replacement Therapy

Continuous renal replacement therapy (CRRT) is the preferred dialysis modality in critical care settings for patients with hemodynamic instability. Nafamostat mesylate (NM) is an anticoagulant commonly used (mainly in Japan) during CRRT in patients with high bleeding risk. In this study, we evaluated the pharmacokinetics of NM during CRRT. Patients undergoing CRRT therapy and using NM as the anticoagulant in the intensive care unit were enrolled in the study. Blood was collected from the CRRT circuit just after blood removal, just before and after the membrane for CRRT, and from the filtrates after the membrane. NM concentrations were measured using high-performance liquid chromatography. NM was detected in the intracorporeal circulation during CRRT in some cases, and liver enzymes were severely elevated in almost all of the cases. Coagulation time was prolonged even before the initiation of NM administration in these cases and may be associated with liver damage. This study suggests that NM dosage should take into account liver damage assessed by elevated liver enzymes.

Study and observation of ultrasound on hemorheology of continuous renal replacement therapy in ICU

Objective: To observe the influence of bedside ultrasound on Hemodynamics of Continuous Renal Replacement Therapy,and explore the clinical value of bedside ultrasound technique in acute kidney injury (AKI) Patients with continuous renal replacement therapy (CRRT) and capacity management. Methods 311 cases of AKI patients with CRRT were divided randomly into Observe group and Control group. the observe group was used bedside ultrasound technique, by monitoring tricuspid annular plane systolic excursion (TAPSE), internal diameter of inferior vena cava (IVC), respiratory variation index of the inferior vena cava internal diameter (RVI) and left vertical Tei index changes. Meanwhile, each parameter change was mediated by ultrasound detection from before, to 30min, 6h, 12h, 36h, 48h after of CRRT to sustain liquid balance in observe group, however, central venous pressure (CVP) change was modulated in control group. The difference of kidney length in pre-CRRT were examined to exclude, and of renal aortic diameter, renal resistance index (RRI)and renal blood flow in post-48h of CRRT were compared in two groups. Results Renal length, Renal parenchyma thickness and Echo strength of renal parenchyma weren't different statistically in pre-CRRT of two groups(P>0.05). In observe group, the RVI level was started to increase significantly and IVC internal diameter to decrease at 6h, which would tend to stable at 36h(F=27.746 and 15.446 respectively);the TAPSE level was gradual ascending and Tei index was descending at 12h with a stable tendency at 24h of CRRT(F=36.213 and 17.127 respectively), and there was difference statistical among time of obvious change in TAPSE, IVC internal diameter, RVI and Tei index(P<0.05);In control group, there was no difference statistical among each time in CVP(F=2.189, P>0.05). Compared with control group, renal aortic diameter and renal blood flow were increased significantly(t=2.356 and 2.075), RRI was decreased obviously in observe group(t=2.244), which was different in statistics (P<0.05). Conclusion the application of bedside ultrasound technique in AKI patient's capacity management with CRRT was more effective and evaluated the kidney perfusion.

Efficacy of Ulinastatin Combined with Continuous Renal Replacement Therapy in the Treatment of Sepsis Acute Kidney Injury and Its Effects on Systemic Inflammation, Immune Function and miRAN Expression

Objective: To research the effectiveness of ulinastatin in combination with continuous renal replacement therapy in treating sepsis acute kidney injury and its effect on systemic inflammation, immune function and miRAN expression. Methods: The 84 patients who were diagnosed with sepsis complicated by acute kidney injury in our hospital between May 2020 and June 2022 were chosen and randomly assigned to the study group (n = 42) and the control group (n = 42). Ulinastatin in combination with continuous renal replacement therapy was administered to the study group, whereas the control group was administered with continuous renal replacement therapy alone. Both groups’ clinical effects were observed. The levels of blood urea nitrogen (BUN), serum creatinine (SCr), tumor necrosis factor-α (TNF-α), high sensitivity Creactive protein (hs-CRP), vascular cell adhesion molecule-1 (VCAM-1), IgG, IgA, IgM, expression levels of miR-233 and miR-10a were compared among both the groups, pre-, and post-treatment. Results: The study group’s overall effectiveness rate was higher that is 95.24%, in comparison to the control group’s 78.57%, and this difference was statistically significant (P α, hs-CRP, VCAM-1, and miR-233 and miR-10a expression levels in both the study and control groups were decreased, however, the study group had reduced levels in comparison to the control group, with statistically significant differences (P P Conclusion: Ulinastatin in combination with continuous renal replacement therapy for treating sepsis acute kidney injury exhibits a positive effect and can significantly improve the systemic inflammation and immune function in patients.

Effect of Xuebijing combined with early continuous renal replacement therapy on systemic inflammatory response and renal impairment in patients with heat stroke

Objective: To study the effect of Xuebijing combined with early continuous renal replacement therapy on systemic inflammatory response and renal impairment in patients with heat stroke. Methods: A total of 24 patients with heat shock who were treated in Qidong People's Hospital between June 2015 and August 2017 were selected an9d randomly divided into two groups, Xuebijing group received Xuebijing combined with early continuous renal replacement therapy, and control group received early continuous renal replacement therapy. Serum levels of inflammatory response cytokines, coagulation-related cytokines and renal function indicators of two groups of patients were detected before treatment as well as 3 d and 6 d after treatment. Results: Serum TNF-α, IL-6, IL-17, hs-CRP, TF, sTM, sE-selectin, BUN, Scr, β2-MG and Cys-C levels of both groups 3 d and 6 d after treatment were significantly lower than those before treatment, and serum TNF-α, IL-6, IL-17, hs-CRP, TF, sTM, sE-selectin, BUN, Scr, β2-MG and Cys-C levels of Xuebijing group 3 d and 6 d after treatment were significantly lower than those of control group. Conclusion: Xuebijing combined with early continuous renal replacement therapy can reduce the degree of systemic inflammatory response and renal impairment in patients with heat stroke.

A Liquid Chromatography Assay for the Simultaneous Quantification of Piperacillin and Ciprofloxacin in Human Plasma and Dialysate in Critically Ill Patients Undergoing Continuous Renal Replacement Therapy

Piperacillin/tazobactam and ciprofloxacin are often used in combination as initial empiric anti-biotic therapy in critical ill patients. Especially in patients undergoing continuous renal replacement therapy (CRRT) the pharmacokinetics of antimicrobial agents can be highly variable. In order to avoid under- or overdosage of antibiotics therapeutic drug monitoring (TDM) is highly re-commendable. Based on two known HPLC assays for piperacillin a new method in combination with solid phase extraction (SPE) for the simultaneous determination of piperacillin and ciprofloxacin was developed. Method validation was performed according to the EMA guideline on validation of bioanalytical methods. The HPLC column used was a Perfect Bond ODS-HD C18 analytical column (100 mm × 4.6 mm i.d., particle size 5 μm), equipped with a guard column (10 mm × 4.6 mm, particle size 5 μm) containing the same packing material. Detection wavelength was set at 228 nm for piperacillin and benzylpenicillin was used as internal standard (IS). Ciprofloxacin was determined at two wavelengths (280 nm, 315 nm). This newly developed HPLC method in combination with SPE-extraction allows an accurate, precise, specific and efficient determination of piperacillin and ciprofloxacin in biological matrices. Results allow the calculation of all relevant pharmacokinetic data for critically ill patients undergoing CRRT and the optimization of dosing and TDM.

An integrative risk assessment approach to enhancing patient safety in Continuous Renal Replacement Therapy(CRRT)

Continuous Renal Replacement Therapy(CRRT)serves as an intervention strategy for the management of acute kidney injury(AKl)in critically ill patients.However,owing to its complex nature and the potential for com-plications,the implementation of CRRT demands continuous monitoring to prevent patient safety risks.This study aims to identify and validate prevalent risks linked to CRRT within a real-world clinical setting,intending to propose preventive measures grounded in expert insights.To systematically categorize and visually depict the risks,their consequences,preventive measures,and recovery controls,our study employed the Bowtie method in conjunction with the Systems Engineering Initiative for Patient Safety(SEIPS)model.In addition to considering patient-related factors that exhibit variability among critically ill individuals,our key findings showed that the most influential risks impacting the effective delivery of CRRT are incidents of clotted filters,bleeding risks arising from the necessity of anticoagulation for filter efficacy,vascular catheter-related bloodstream infections,variations in proficiency levels among healthcare professionals regarding CRRT modalities,especially in oper-ating the CRRT machines,high nursing workload,frequent nursing turnover,occurrences of hypophosphatemia,variability in CRRT prescribing patterns,and issues related to communication among stakeholders.This research sheds light on the primary risks associated with CRRT and provides practical and viable strategies for effective management.Furthermore,the Bowtie diagram developed as part of this study serves as a valuable tool for visually representing the healthcare system and facilitating the identification of system-related risks within healthcare settings.

Early plasma exchange and continuous renal replacement therapy improve puerperal prognosis in hepatitis B virus-related acute-on-chronic liver failure in pregnancy

Background and aim:Hepatitis B virus(HBV)-related gestational acute-on-chronic liver failure(ACLF)is a severe condition with limited treatment options.This study aimed to evaluate the efficacy and ideal timing of plasma exchange and continuous renal replacement therapy(CRRT)in managing pregnant women with HBV-related ACLF.Methods:This study retrospectively analyzed 51 eligible patients with HBV-related gestational ACLF between 2009 and 2020.Patients admitted to the study were divided into a conventional treatment group and a new treatment group according to whether they received the new management protocol,which included more aggressive plasma exchange(PE)and CRRT strategies.All 19 pregnant women with hepatic encephalopathy(HE)were divided into an early treatment group and a non-early treatment group according to whether PE therapy was initiated within three days.Our study had two primary objectives.Firstly,we aimed to evaluate the impact of PE and CRRT on puerperal survival.Secondly,we sought to assess the effects of early PE and CRRT regimens on puerperal survival in women with HE.Results:The levels of total bilirubin on the second day postpartum(D3),the third day postpartum(D4),and the fifth day postpartum(D6)were significantly lower in the new treatment group compared to the conventional treatment group(P=0.02,0.01,and 0.02,respectively).The ALT of D3 was significantly elevated in the new treatment group compared to the conventional treatment group(P=0.02).The incidence of HE overall increased from prenatal to postpartum D4,peaked on D4,and then gradually decreased from the fourth day postpartum(D5)(P=0.027).The first week after delivery revealed a significant difference in survival rate between the two groups,the conventional treatment group had statistically higher mortality rates compared to the new treatment group(P=0.002).Similarly,the entire puerperal period mortality rate of the conventional treatment group was statistically higher than the new treatment group(P=0.002).Moreover,among all patients with HE,the non-early treatment group showed significantly higher puerperal mortality rates compared to the early treatment group(P=0.006).Conclusions:Early PE and CRRT conducted within three days post-childbirth,enhance puerperal prog-nosis for HBV-related gestational ACLF.

A Retrospective Study of Continuous Renal Therapy and Anticoagulation in Patients with Hemorrhagic Fever with Renal Syndrome

Objective To observe the application of continuous renal replacement therapy(CRRT) and heparin anticoagulation in patients with HFRS, and to explore a more suitable anticoagulant strategy. Methods Eighty-five severe-type patients(severe group) and 71 critical-type patients(critical group) were enrolled in this study. The frequency of CRRT was compared between the two groups; the frequency of CRRT treated with and without heparin anticoagulation and the frequency of hemorrhage and channel blood clotting induced by the two anticoagulant strategies were observed. Results The frequency of CRRT in the critical group was higher than that in the severe group(P < 0.001). The frequency of CRRT initiated during the overlapping phases in the critical group was significantly higher than that of the severe group(P = 0.032). The total times of CRRT was 103, and 70 of them were treated with heparin anticoagulation. The frequencies of hemorrhage induced by heparin anticoagulation and no heparinization were 16 and 0, respectively, and the frequencies of channel blood clotting were 2 and 4, respectively. Conclusions CRRT has been used extensively in the critical-type patients with HFRS. The heparin anticoagulation and no anticoagulant strategies should be used more rationally in patients treated with CRRT, according to the clinical characteristics of the disease.

影响慢性肾衰竭CRRT患者细菌感染发生的独立危险因素分析

目的 探讨影响慢性肾衰竭连续肾脏替代疗法(CRRT)患者发生细菌感染的独立危险因素。方法 回顾性分析2019年12月~2022年12月在运城市中心医院进行CRRT治疗的1 000例慢性肾衰竭患者。记录发生细菌感染的患者例数,分析细菌感染病原菌分布状况。将细菌感染患者267例设为观察组,余下未感染患者733例设为对照组,比较两组基线资料,并将有差异的指标纳入二元logistic回归分析,得到影响慢性肾衰竭CRRT患者出现细菌感染的独立危险因素。结果 1 000例慢性肾衰竭CRRT治疗患者,共发生细菌感染267例(观察组),发生率为26.70%;未发生细菌感染733例(对照组)。两组患者年龄、治疗时间、体质量指数(BMI)、合并糖尿病、糖尿病肾病、合并心力衰竭、留置静脉导管、血红蛋白(Hb)及血清白蛋白差异比较具有统计学意义(χ^(2)=8.123、5.463、8.631、5.043、8.898、8.052、4.861、8.658、4.803,P<0.05)。多因素logistic回归分析结果显示,≥65岁、≥1年治疗时间、BMI <20 kg/m2、合并糖尿病、合并心力衰竭、留置静脉导管、糖尿病肾病、Hb <70 g/L及血清白蛋白<30 g/L为影响慢性肾衰竭患者CRRT治疗过程中出现细菌感染的独立危险因素(P<0.05)。结论 慢性肾衰竭CRRT患者年龄、治疗时间、BMI、合并糖尿病与心力衰竭、留置静脉导管、糖尿病肾病、Hb及血清白蛋白均可影响细菌感染的发生,临床应针对上述危险因素构建干预方案,预防细菌感染。

Metabolic and nutritional aspects in continuous renal replacement therapy

Nutrition is one of the foundations for supporting and treating critically ill patients.Nutritional support providescalories,protein,electrolytes,vitamins,and trace elements via the enteral or parenteral route.Acute kidneyinjury(AKI)is a common and devastating problem in critically ill patients and has significant metabolic andnutritional consequences.Moreover,renal replacement therapy(RRT),whatever the modality used,also profoundly impacts metabolism.RRT and of the extracorporeal circuit impede‘effect the evaluation of a patient’senergy requirements by clinicians.Substrates added and removed within the extracorporeal treatment are notalways taken into consideration,making treatment even more challenging.Furthermore,evidence on nutritionalsupport during continuous renal replacement therapy(CRRT)is scarce,and there are no clinical guidelines fornutrition adaptations during CRRT in critically ill patients.Most recommendations are based on expert opinions.This review discusses the complex interaction between nutritional support and CRRT and presents somemilestones for nutritional support in critically ill patients on CRRT.

伴高乳酸血症的重症患者行局部CRA-CRRT治疗的有效性和安全性研究

目的研究伴高乳酸血症的重症患者行局部枸橼酸抗凝(CRA)-连续性肾脏替代(CRRT)治疗的有效性和安全性。方法收集2021年10月-2023年3月于新疆医科大学第一附属医院呼吸重症监护室进行RCA-CRRT治疗的67例伴高乳酸血症(2 mmol/L<乳酸值<10 mmol/L)的重症患者临床资料,按局部抗凝方式分为对照组(低分子肝素抗凝)20例和CRA组(枸橼酸抗凝)47例。收集患者一般资料及CRRT治疗前及治疗24 h患者乳酸值、pH值、碳酸氢根离子(HCO_(3)^(-))、滤器后血清离子钙(iCa^(2+))、体内iCa^(2+)、血清总钙、血钠离子(Na+)、镁离子(Mg^(2+));统计滤器结局、血液制品输注情况、出血事件发生率及死亡率,记录CRA相关并发症发生情况。结果两组一般资料比较,差异均无统计学意义(P>0.05);与本组治疗前比较,CRRT治疗24 h两组乳酸值水平均降低,iCa^(2+)、pH、HCO3-水平升高(P<0.05);CRRT治疗24 h后,两组患者总钙、总钙/iCa^(2+)比值、Na+、Mg^(2+)水平比较,差异均无统计学意义(P>0.05)。与对照组比较,CRA组滤器平均使用寿命延长,差异有统计学意义(P<0.05),两组治疗期间出血事件发生率、血液制品输注情况、死亡率差异均无统计学意义(P>0.05);两组患者治疗24 h滤器或管路凝血发生率等级分布比较,差异有统计学意义(P<0.05),且CRA组Ⅱ/Ⅲ级凝血发生率低于对照组(P<0.05);两组患者枸橼酸蓄积、代谢性酸中毒、代谢性碱中毒发生率及总并发症发生率比较,差异无统计学意义(P>0.05)。结论伴高乳酸血症的重症患者行CRA-CRRT治疗有助于降低血乳酸水平,纠正酸中毒,减少凝血和出血风险,延长滤器寿命,枸橼酸蓄积风险低。

采用自配碳酸氢盐置换液行CRRT治疗流行性出血热合并急性肾功能衰竭1例回顾性分析

目的总结1例流行性出血热(EHF)合并急性肾功能衰竭(ARF)患者采用自配碳酸氢盐置换液行连续性肾脏替代治疗(CRRT)的经验,以期为同类病例的治疗提供参考。方法对2021年4月兰州大学第一医院东岗院区综合内科收治的1例EHF合并ARF患者行内科综合治疗,同时采用自配碳酸氢盐置换液行CRRT,依据动态监测血气分析、电解质、肾功能及凝血指标水平调整自配置换液配方及抗凝剂剂量。结果患者住院治疗14 d出院,出院后30 d复查随访,各项指标均恢复正常。结论在内科综合治疗的同时及时采用自配碳酸氢盐置换液行CRRT是治疗EHF合并ARF的有效方法。

注射用甲磺酸萘莫司他在急性肾损伤CRRT治疗中的应用效果

目的 研究注射用甲磺酸萘莫司他(NM)在急性肾损伤连续肾脏替代治疗(CRRT)治疗中的应用效果。方法 选择本院2023年1月至2024年1月收治的76例AKI患者,按照随机数字表法分为对照组(n=38)与研究组(n=38),对照组采用局部枸橼酸抗凝(RCA),研究组采用注射用NM抗凝,比较两组CRRT治疗前和治疗后3 d的肾功能指标(尿酸、尿素氮、血肌酐),凝血指标(血小板计数、纤维蛋白原、凝血酶原时间、活化部分凝血酶原时间),血清钾、钙及钠离子水平;评估CRRT治疗期间的不良反应和过滤器的平均使用寿命时间。结果 两组治疗前肾功能指标、凝血指标、血清钾、钙及钠离子水平差异无统计学意义(P>0.05);两组治疗后肾功能指标、血小板计数均较治疗前下降(P<0.05),纤维蛋白原、凝血酶原时间、活化部分凝血酶原时间均较治疗前上升(P<0.05),组间差异无统计学意义(P>0.05);研究组治疗后血清钾、钙、钠离子浓度与治疗前差异无统计学意义(P>0.05),对照组治疗后血清钙较治疗前下降(P<0.05),血清钠较治疗前上升(P<0.05)。研究组不良反应总发生率较对照组低(P<0.05)。对照组与研究组过滤器使用寿命时间分别为(23.08±3.29)h比(23.43±3.04)h(P>0.05)。结论 注射用NM在急性肾损伤CRRT治疗中对患者凝血功能、钾钙钠离子的影响较小,可促进患者肾功能恢复,与RCA比较未能延长过滤器使用寿命,但注射用NM的安全性更高。