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Background Current continuous kidney replacement therapy (CKRT) protocols ignore physiological renal compensation for hypercapnia. This study aimed to explore feasibility, safety, and clinical benefits of pCO2-adapted CKRT for hypercapnic acute respiratory distress syndrome (ARDS) patients with indication for CKRT. Methods We enrolled mechanically ventilated hypercapnic ARDS patients (pCO2 > 7.33 kPa) receiving regional citrate anticoagulation (RCA) based CKRT in a prospective, randomized-controlled pilot-study across five intensive care units at the Charité—Universitätsmedizin Berlin, Germany. Patients were randomly assigned 1:1 to the control group with bicarbonate targeted to 24 mmol/l or pCO 2 -adapted-CKRT with target bicarbonate corresponding to physiological renal compensation. Study duration was six days. Primary outcome was bicarbonate after 72 h. Secondary endpoints included safety and clinical endpoints. Endpoints were assessed in all patients receiving treatment. Results From September 2021 to May 2023 40 patients (80% male) were enrolled. 19 patients were randomized to the control group, 21 patients were randomized to pCO 2 -adapted-CKRT. Five patients were excluded before receiving treatment: three in the control group (consent withdrawal, lack of inclusion criteria fulfillment (n = 2)) and two in the intervention group (lack of inclusion criteria fulfillment, sudden unexpected death) and were therefore not included in the analysis. Median plasma bicarbonate 72 h after randomization was significantly higher in the intervention group (30.70 mmol/l (IQR 29.48; 31.93)) than in the control group (26.40 mmol/l (IQR 25.63; 26.88); p  < 0.0001). More patients in the intervention group received lung protective ventilation defined as tidal volume < 8 ml/kg predicted body weight. Thirty-day mortality was 10/16 (63%) in the control group vs. 8/19 (42%) in the intervention group ( p  = 0.26). Conclusion Tailoring CKRT to physiological renal compensation of respiratory acidosis appears feasible and safe with the potential to improve patient care in hypercapnic ARDS. Trial registration The trial was registered in the German Clinical Trials Register (DRKS00026177) on September 9, 2021 and is now closed.

Optimal strategy for volume control and the clinical implication of achieved volume control are unknown in patients with sepsis-associated acute kidney injury (AKI) receiving continuous renal replacement therapy (CRRT). This randomized controlled trial aimed to compare the survival according to conventional or bioelectrical impedance analysis (BIA)-guided volume control strategy in patients with sepsis-associated AKI receiving CRRT. We also compared patient survival according to achieved volume accumulation rate ([cumulative fluid balance during 3 days × 100]/fluid overload measured by BIA at enrollment) as a post-hoc analysis. We randomly assigned patients to conventional volume control strategy (n = 39) or to BIA-guided volume control strategy (n = 34). There were no differences in 28-day mortality (HR, 1.19; 95% CI, 0.63–2.23) or 90-day mortality (HR, 0.99; 95% CI 0.57–1.75) between conventional and BIA-guided volume control group. In the secondary analysis, achieved volume accumulation rate was significantly associated with patient survival. Compared with the achieved volume accumulation rate of ≤  − 50%, the HRs (95% CIs) for the risk of 90-day mortality were 1.21 (0.29–5.01), 0.55 (0.12–2.48), and 7.18 (1.58–32.51) in that of  − 50–0%, 1–50%, and > 50%, respectively. Hence, BIA-guided volume control in patients with sepsis-associated AKI receiving CRRT did not improve patient outcomes. In the secondary analysis, achieved volume accumulation rate was associated with patient survival.

IntroductionThe only supportive therapy for patients with severe acute kidney injury (AKI), a common complication among the critically ill, is dialysis. Based on the literature and current guidelines, continuous renal replacement therapy (CRRT) with a total effluent dose of 20–25 mL/kg/hour and adjustments to ensure such dose is delivered despite down time (eg, due to surgical procedures) is recommended. However, experimental and clinical studies suggest that azotaemia, which can be induced by lowering the effluent dose, may accelerate renal recovery. This clinical study investigates whether a lower effluent dose (10–15 mL/kg/hour) for a maximum of 7 days or until successful (>24 hours) liberation of CRRT in critically ill patients with a dialysis-dependent AKI accelerates renal recovery and reduces time on CRRT compared with guideline-directed standard dose (25–30 mL/kg/hour).Methods and analysisThe Ketzerei trial is an international, multicentre randomised, controlled trial, designed to investigate if a lower effluent dose (10–15 mL/kg/hour) accelerates renal recovery and reduces the time on CRRT compared with the guideline directed standard effluent dose (25–30 mL/kg/hour). The study aims to enrol 150 critically ill patients with a dialysis-dependent AKI. Eligible patients will be randomised to receive either a standard effluent dose (control group, 25–30 mL/kg/hour) or lower effluent dose (interventional group, 10–15 mL/kg/hour). The primary endpoint is the number of days free from CRRT and alive (from randomisation through day 28). Key secondary endpoints include the number of (serious) adverse events due to potential uremia, the duration of RRT and intensive care unit survival.Ethics and disseminationThe Ketzerei trial has been approved by the Ethics Committee of the Chamber of Physicians Westfalen-Lippe (2023–343 f-s), the University of Muenster and subsequently by the corresponding Ethics Committee of the participating sites. Results will be disseminated widely and published in peer-reviewed journals, presented at conferences and will guide patient care and further research.Trial registration numberclinicaltrials.gov (NCT06021288).

Background Rhabdomyolysis is frequently associated with acute kidney injury (AKI). Due to the nephrotoxic properties of myoglobin, its rapid removal is relevant. If kidney replacement therapy (KRT) is necessary for AKI, a procedure with effective myoglobin elimination should be preferred. This pilot trial was designed to compare different KRT modes that enable myoglobin elimination. Methods In this prospective randomized single-center study, 15 patients with rhabdomyolysis and severe AKI requiring KRT were randomized 1:1:1 into three groups: continuous veno-venous hemofiltration (CVVH), continuous veno-venous hemodialysis (CVVHD) using a high cut-off dialyzer (CVVHD-HCO), or CVVHD using a high-flux dialyzer in combination with the adsorber CytoSorb (CVVHD-CS). Concentrations of serum myoglobin, urea, creatinine, β2-microglobulin, interleukin-6, and albumin were measured before and after the dialyzer 1, 6, 12, and 24 h after initiating KRT. Results There was no significant difference in the median myoglobin clearance between the KRT modes during the 24-h study period. Nevertheless, the CVVHD-CS group showed a significantly higher myoglobin elimination compared to the other modes in the first hours of treatment. However, as a greater decline in clearance performance was observed over time, no better performance was detected over the whole study period. Simulation of different device combinations showed the highest myoglobin clearance for CVVHD-HCO combined with CS with a 12-hourly adsorber exchange interval. Conclusions All tested modes showed an effective myoglobin elimination capacity. The time-dependent elimination performance could be further increased by combining KRT with more frequent adsorber exchange. Trial registration German Clinical Trials Registry ( DRKS00023998 ); date of registration 03/03/2021.

This study aimed to investigate the effectiveness of continuous renal replacement therapy and hemoperfusion in acute severe organophosphorus pesticide poisoning patients. Fifty-eight acute severe organophosphorus pesticide poisoning patients who accepted therapy in Nangjing First Hospital, Nangjing Medical University from January 2018 to December 2022 were chosen as the study participants. They were randomly divided into a control group and a research group. Both groups received conventional treatment, while the research group received continuous renal replacement therapy combined with hemoperfusion therapy. Relative to the control group, the research group had higher total effectiveness rate, shorter coma time, cholinase recovery time, reduced stay in intensive care unit, less atropine dosage, lower levels of inflammatory factors and lower sequential organ failure assessment scores. Our study suggests that continuous renal replacement therapy combined with hemoperfusion can improve the clinical therapeutic effect in patients with acute severe organophosphorus pesticide poisoning, effectively control the inflammatory response, and shorten the clinical rescue and treatment time of patients. Cette étude visait à évaluer l'efficacité de la suppléance rénale continue et de l'hémoperfusion chez les patients atteints d'intoxication aiguë sévère aux pesticides organophosphorés. Cinquante-huit patients atteints d'intoxication aiguë sévère aux pesticides organophosphorés, admis au traitement au Nangjing First Hospital de l'Université de médecine de Nangjing entre janvier 2018 et décembre 2022, ont été sélectionnés comme participants à l'étude. Ils ont été répartis aléatoirement en un groupe témoin et un groupe de recherche. Les deux groupes ont reçu un traitement conventionnel, tandis que le groupe de recherche a reçu une suppléance rénale continue associée à une hémoperfusion. Par rapport au groupe témoin, le groupe de recherche présentait un taux d'efficacité globale plus élevé, une durée de coma plus courte, un temps de récupération de la cholinase plus court, une durée d'hospitalisation réduite en unité de soins intensifs, une dose d'atropine plus faible, des taux de facteurs inflammatoires plus faibles et des scores d'évaluation de la défaillance organique séquentielle plus faibles. Notre étude suggère que la suppléance rénale continue associée à l'hémoperfusion peut améliorer l'effet thérapeutique clinique chez les patients atteints d'intoxication aiguë sévère aux pesticides organophosphorés, contrôler efficacement la réponse inflammatoire et raccourcir la durée de la prise en charge et du traitement.

Introduction Acute kidney injury (AKI) is a common complication of acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS) in patients receiving extracorporeal membrane oxygenation (ECMO) support, leading to requirement of continuous renal replacement therapy (CRRT) in 70% of ECMO patients. Parallel arrangement of CRRT and ECMO circuits is common in adult patients. However, CRRT may also be integrated directly into the ECMO circuit. This study compares the safety of both approaches. Methods This retrospective analysis included 105 patients treated with continuous veno-venous haemodiafiltration and veno-venous ECMO (Cardiohelp©) for COVID-19-induced ARDS between April 2020 and December 2021. Of these, 48 patients received a parallel connected CRRT running independently from ECMO (parallel approach), while in 57 patients, CRRT was integrated into the ECMO circuit (integrated approach) by connecting the CRRT access line to the post-oxygenator port and the CRRT return line to the pre-oxygenator position. Local protocol for risk assessment of this device combination mandated a maximum return line pressure below 250 mmHg in the CRRT system. Results At CRRT initiation, the integrated group had significantly higher median pressures in CRRT lines compared to the parallel approach group (access line 110 mmHg vs. -25 mmHg, return line 170 mmHg vs. 50 mmHg; p  < 0.01). However, median transmembrane pressures were similar between both groups (20 mmHg vs. 20 mmHg, p  = 0.16). In-hospital mortality ( p  = 0.99), catheter associated infections ( p  = 0.47), bacteraemia ( p  = 0.96), filter clotting ( p  = 0.58) and unplanned CRRT system changes ( p  = 0.45) within the first 72 h of CRRT were comparable between both groups. The integrated group exhibited higher rates of bleeding events (37% vs. 23%; p  = 0.08). Thromboembolism occurred in four cases in the integrated group, while one pneumothorax was observed in the parallel group. No cases of air embolism, device associated haemolysis or blood leakage was documented. Conclusions Despite higher pressures in CRRT lines, the integrated approach provided comparable safety to the parallel approach. In case of hygienically challenging settings (such as the COVID-19 pandemic), the minimization of extracorporeal accesses and the streamlining of alarm management are decisive factors in providing intensive care medicine. Therefore, the integrated configuration of CRRT into the ECMO circuit can be advantageous in daily intensive care medicine.

Background To explore the feasibility and effectiveness of a segmented sodium citrate solution anticoagulation strategy in patients receiving CRRT. Methods A prospective, randomized controlled study was conducted. Results According to the inclusion and exclusion criteria, 80 patients were included and randomly divided into two groups. Moreover, coagulation indices, liver function indices, renal function indices, and SOFA and APACHE II scores did not significantly differ between the two groups ( P  > 0.05). The coagulation grade of the venous ports in the experimental group was lower than that in the control group and the two groups of filters, but the difference was not statistically significant ( P  = 0.337). Both sodium citrate solution infusion methods maintained a low blood calcium concentration (0.25–0.45 mmol/L) in the peripheral circulation pathway, and no patient developed hypocalcaemia (< 1.0 mmol/L). The lifespans of the extracorporeal circulation tube in the experimental group and the control group were 69.43 ± 1.49 h and 49.39 ± 2.44 h, respectively ( t  = 13.316, P  = 0.001). Conclusion The segmented citrate solution anticoagulation strategy could extend the lifespan of the extracorporeal circulation tube and improve CRRT efficacy. Trial registration The Chinese Clinical Trial Registry number is ChiCTR2200057272. Registered on March 5, 2022.

Background The KDIGO recommendation in acute kidney injury (AKI) patients requiring kidney replacement therapy is to deliver a Urea Kt/V of 1.3 for intermittent thrice weekly hemodialysis, and an effluent volume of 20–25 ml/kg/hour when using continuous renal replacement therapy (CRRT). Considering that prior studies have suggested equivalent outcomes when using CRRT-prolonged intermittent renal replacement therapy (PIRRT) effluent doses below 20 mL/kg/h, our group investigated the possible benefits of low effluent volume CRRT-PIRRT (12.5 ml/Kg/hour). Methods Thirty-six AKI patients that had been treated in the previous 12 months by CRRT-PIRRT with low effluent volume were included in the present retrospective observational study. The total effluent volume, derived from the formula [25 (or 12.5 ml) × kg body weight × 24], was administered over 24 h in CRRT and over 10 h in daily PIRRT. The control group consisted of the last 36 AKI patients previously treated with standard effluent volume CRRT (25 ml/kg/hour). Mortality within 90 days, shift from low effluent volume to standard effluent volume due to dialysis inadequacy, and remission of AKI were the end points. The two groups were homogeneous for age, sex, and sequential organ failure assessment (SOFA) score. Patients with AKI caused by metformin-induced lactic acidosis were excluded because they were treated with standard effluent volume CRRT until the lactic acidosis was corrected by subsequently reducing the effluent volume to 12.5 ml/kg/hour. Results The two groups were homogeneous as for baseline features. The UKt/V in the low effluent volume group was 0.51 ± 0.04 in CRRT and 0.50 ± 0.07 in PIRRT per session (Table 3 ). The UKt/V in the standard effluent volume group was 1.00 ± 0.02 in CRRT and 0.95 ± 0.05 in PIRRT per session. No differences were observed between the 2 groups regarding death from any cause at 90 days, and recovery of renal function. No patient was switched from low effluent volume to standard effluent volume due to inadequate control of uremic toxins. Serum creatinine at discharge from the hospital in patients with no KRT dependence was 2.1 ± 0.6 mg/dl in standard effluent volume and 1.9 ± 0.5 in low effluent volume ( p  = 0.37). All low effluent volume patients showed adequate metabolic, electrolyte, and acid–base profile control. In the low effluent volume group, the incidence of hypophosphatemia was lower than in the standard effluent volume group (5 vs 15, p  = 0.003). Conclusions In this single-center retrospective study, low effluent volume CRRT-PIRRT was associated with similar outcomes to standard effluent volume CRRT-PIRRT, which is consistent with the results of prior observational studies. Randomized controlled studies comparing low effluent volume with standard effluent volume are needed. Graphical abstract

The aim of this study is to describe the incidence of Acute Kidney Injury (AKI) amongst patients admitted to the Intensive Care Unit (ICU) with COVID-19. In addition we aim to detail the range of Renal Replacement Therapy (RRT) modalities offered to these patients (including peritoneal dialysis - PD - and intermittent haemodialysis - IHD) in order to meet demand during pandemic conditions. Single-centre retrospective case note review of adult patients with confirmed COVID-19 admitted to ICU. Amongst 136 patients without a prior history of End Stage Kidney Disease (ESKD), 108 (79%) developed AKI and 63% of admitted patients received RRT. Due to resource limitations the range of RRT options were expanded from solely Continuous Veno-Venous HaemoDiaFiltration (CVVHDF - our usual standard of care) to include PD (in 35 patients) and IHD (in 15 patients). During the study period the proportion of RRT provided within ICU as CVVHDF fell from 100% to a nadir of 39%. There were no significant complications of either PD or IHD. During periods of resource limitations PD and IHD can safely be used to reduce dependence on CVVHDF in select patients with AKI secondary to COVID-19. •AKI frequently complicates COVID-19 in patients admitted to ICU.•Large numbers of patients and high rates of AKI leads to great demand for RRT.•In selected patients PD and IHD can supplement CRRT in meeting this demand.•PD and IHD can be implemented rapidly and safely through a collaborative approach.

Endotoxin induces an inflammatory response, with secondary release of cytokines, which can progress to shock and multiple organ failure. We explored whether continuous renal replacement therapy (CRRT) using a modified membrane (oXiris) capable of adsorption could reduce endotoxin and cytokine levels in septic patients. Sixteen patients requiring CRRT for septic shock-associated acute renal failure and who had endotoxin levels >0.03 EU/ml were prospectively randomized in a crossover double-blind design to receive CRRT with an oXiris filter or with a standard filter. Endotoxin and cytokine levels were measured at baseline and 1, 3, 8, 16 and 24 hours after the start of CRRT. Norepinephrine infusion rate and blood lactate levels were monitored. During the first filter treatment period, endotoxin levels decreased in 7 of 9 (77.8%) oXiris filter patients, but in only 1 of 6 (16.7%) standard filter patients (P = 0.02). Levels of tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-8 and interferon (IFN)γ decreased more with the oXiris filter than with the standard filter. Lactate concentration decreased with oXiris (-1.3[-2.2 to -1.1] mmol/l, P = 0.02), but not with the standard filter (+0.15[-0.95 to 0.6]). The norepinephrine infusion rate was reduced during oXiris CRRT, but not during standard filter CRRT. In the second filter treatment period, there was no significant reduction in endotoxin or cytokine levels in either group. CRRT with the oXiris filter seemed to allow effective removal of endotoxin and TNF-α, IL-6, IL-8 and IFNγ in patients with septic shock-associated acute renal failure. This may be associated with beneficial hemodynamic effects.