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

doi:10.5847/wjem.j.1920-8642.2022.046

Abstract

Abstract:

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-molecular-weight solute by P_TM was 146.5 mmHg (1 mmHg=0.133 kPa).

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 mmHg may be an optimal indicator for changing the filter in CRRT therapies to remove medium-molecular-weight solutes.

Key words: Acute kidney injury, Continuous renal replacement therapy, Solute removal efficiency, Delivered dose

Cheng Hang, Li-jun Liu, Zhao-yun Huang, Jian-liang Zhu, Bao-chun Zhou, Xiao-zhen Li. 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[J]. World Journal of Emergency Medicine, 2022, 13(3): 196-201.

Figures/Tables 3

Figure 1.

Table 1.

Table 2.

References 21

1	Ostermann M, Joannidis M. Acute kidney injury 2016: diagnosis and diagnostic workup. Crit Care. 2016; 20(1):299. doi: 10.1186/s13054-016-1478-z
2	Asanuma H. Early detection of acute kidney injury can further improve the prognosis of acute myocardial infarction. JACC: Asia. 2021; 1(3):382-4. doi: 10.1016/j.jacasi.2021.08.005
3	Goriki Y, Tanaka A, Nishihira K, Kuriyama N, Shibata Y, Node K. A novel prediction model of acute kidney injury based on combined blood variables in STEMI. JACC: Asia. 2021; 1(3):372-81. doi: 10.1016/j.jacasi.2021.07.013
4	Chang CH, Fan PC, Chang MY, Tian YC, Hung CC, Fang JT, et al. Acute kidney injury enhances outcome prediction ability of sequential organ failure assessment score in critically ill patients. PLoS One. 2014; 9(10):e109649. doi: 10.1371/journal.pone.0109649
5	Yang L, Xing GL, Wang L, Wu Y, Li S, Xu G, et al. Acute kidney injury in China: a cross-sectional survey. Lancet. 2015; 386(10002):1465-71. doi: 10.1016/S0140-6736(15)00344-X pmid: 26466051
6	Digvijay K, Neri M, Fan W, Ricci Z, Ronco C. International survey on the management of acute kidney injury and continuous renal replacement therapies: year 2018. Blood Purif. 2019; 47(1-3):113-9. doi: 10.1159/000493724
7	Yang CS, Yang Y, Huang LW, Zhang XW, Liu SQ, Qiu HB. Survey of continuous renal replacement therapy application status. Zhonghua Yi Xue Za Zhi. 2016; 96(39):3151-5.
8	Lan MJ, Zeng F, Jing JY. Reasons for unscheduled filter replacement in continuous renal replacement therapy. Chin J Emerg Med. 2010; 19(4):426-8.
9	Fan YW, Jiang SW, Chen JM, Wang HQ, Liu D, Pan SM, et al. A pulmonary source of infection in patients with sepsis-associated acute kidney injury leads to a worse outcome and poor recovery of kidney function. World J Emerg Med. 2020; 11(1):18-26. doi: 10.5847/wjem.j.1920-8642.2020.01.003
10	Zhang ZH, Ni HY, Fan HZ, Li D, Xu X. Actually delivered dose of continuous renal replacement therapy is underestimated in hemofiltration. ASAIO J. 2013; 59(6):622-6. doi: 10.1097/MAT.0000436713.34635.a8
11	Claure-del Granado R, Macedo E, Chertow GM, Soroko S, Himmelfarb J, Ikizler TA, et al. Effluent volume in continuous renal replacement therapy overestimates the delivered dose of dialysis. Clin J Am Soc Nephrol. 2011; 6(3):467-75. doi: 10.2215/CJN.02500310
12	Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract. 2012; 120(4):c179-84.
13	Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017; 43(3):304-77. doi: 10.1007/s00134-017-4683-6
14	Mills EJ, Chan AW, Wu P, Vail A, Guyatt GH, Altman DG. Design, analysis, and presentation of crossover trials. Trials. 2009; 10:27. doi: 10.1186/1745-6215-10-27
15	Smith JR, Zimmer N, Bell E, Francq BG, McConnachie A, Mactier R. A randomized, single-blind, crossover trial of recovery time in high-flux hemodialysis and hemodiafiltration. Am J Kidney Dis. 2017; 69(6):762-70. doi: 10.1053/j.ajkd.2016.10.025
16	Lyndon WD, Wille KM, Tolwani AJ. Solute clearance in CRRT: prescribed dose versus actual delivered dose. Nephrol Dial Transplant. 2012; 27(3):952-6. doi: 10.1093/ndt/gfr480
17	Neri M, Villa G, Garzotto F, Bagshaw S, Bellomo R, Cerda J, et al. Nomenclature for renal replacement therapy in acute kidney injury: basic principles. Crit Care. 2016; 20(1):318-9. doi: 10.1186/s13054-016-1489-9
18	Duriseti P, Idrees N, Aldairem A, Jaber BL, Balakrishnan VS. Cost analysis of two modalities of continuous renal replacement therapy. Hemodial Int. 2021; 25(2):173-9. doi: 10.1111/hdi.12899
19	Srisawat N, Lawsin L, Uchino S, Bellomo R, Kellum JA; BEST Kidney Investigators. Cost of acute renal replacement therapy in the intensive care unit: results from The Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) study. Crit Care. 2010; 14(2):R46. doi: 10.1186/cc8933
20	Baas MC, Bouman CS, Hoek FJ, Krediet RT, Schultz MJ. Cystatin C in critically ill patients treated with continuous venovenous hemofiltration. Hemodial Int. 2006; 10(Suppl 2):S33-7.
21	Latour-Pérez J. Clinical research in critical care. Difficulties and perspectives. Med Intensiva (Engl Ed). 2018; 42(3):184-95.

Parameters	Group A (n=27)	Group B (n=23)	χ²/Z/t	P
Gender
Male	18 (66.7)	16 (69.6)	χ²=0.118	0.732
Female	9 (33.3)	7 (30.4)	χ²=0.250	0.617
Age, years	62 (38-79)	61 (44-66)	Z= -0.681	0.496
Height, cm	167±8	169±9	t= -0.870	0.388
Body weight, kg	70 (60-75)	70 (57-75)	Z= -0.283	0.777
APACHE II score	19 (13-23)	17 (13-20)	Z= -0.946	0.344
SOFA score	13 (9-16)	11 (8-17)	Z= -0.078	0.938
Primary diagnosis
Septic shock	17 (63.0)	9 (39.1)	χ²=2.462	0.117
Organ failure	1 (3.7)	5 (21.7)	χ²=2.667	0.102
Poisoning of drugs or toxins	6 (22.2)	2 (8.7)	χ²=2.000	0.157
Cardiac arrest	2 (7.4)	3 (13.0)	χ²=0.200	0.655
AKI with unknown causes	1 (3.7)	4 (17.4)	χ²=1.800	0.180
Urea nitrogen before treatment, mmol/L	28.9±17.2	26.3±16.8	t=0.553	0.583
Creatinine before treatment, μmol/L	615±650	437±223	t=1.249	0.218
β₂-microglobulin before treatment, μg/L	7,746.0±3,891.4	7,309.1±4,696.8	t=0.360	0.721
Cystatin C before treatment, mg/L	1.77±0.72	1.86±0.73	t= -0.414	0.681
Duration of mechanical ventilation, h	141±155	214±277	t= -1.130	0.267
ICU stay, h	229±175	350±370	t= -1.436	0.161
Renal function recovery rate	9 (33.3)	10 (43.5)	χ²=0.053	0.819
In-hospital mortality rate	18 (66.7)	13 (56.5)	χ²=0.806	0.369

Time points	β₂-microglobulin		χ²	P	Cystatin C		χ²	P
Time points	CVVH	CVVHDF	χ²	P	CVVH	CVVHDF	χ²	P
0.5 h	1 (2.0)	0	-	0.472 ^a	1 (2.0)	2 (3.5)	0.000	1.000 ^b
12 h	11 (21.6)	12 (21.1)	0.004	0.948	12 (23.5)	11 (19.3)	0.288	0.592
24 h	19 (43.2)	16 (29.1)	2.124	0.145	23 (52.5)	29 (52.7)	0.002	0.964
36 h	11 (50.0)	27 (57.4)	0.336	0.562	14 (63.6)	28 (59.6)	0.104	0.747
48 h	5 (45.5)	19 (59.4)	0.205	0.423	8 (72.7)	24 (75.0)	0.022	0.822
60 h	3 (60.0)	9 (52.9)	-	1.000 ^a	3 (60.0)	10 (58.8)	-	1.000 ^a

[1]	Yi-wen Fan, Shao-wei Jiang, Jia-meng Chen, Hui-qi Wang, Dan Liu, Shu-ming Pan, Cheng-jin Gao. A pulmonary source of infection in patients with sepsis-associated acute kidney injury leads to a worse outcome and poor recovery of kidney function [J]. World Journal of Emergency Medicine, 2020, 11(1): 18-26.
[2]	Xue-zhong Xing, Hai-jun Wang, Chu-lin Huang, Quan-hui Yang, Shi-ning Qu, Hao Zhang, Hao Wang, Yong Gao, Qing-ling Xiao, Ke-lin Sun. Two acute kidney injury risk scores for critically ill cancer patients undergoing non-cardiac surgery [J]. World Journal of Emergency Medicine, 2012, 3(4): 278-281.
[3]	Fei He, Jun Zhang, Zhong-qiu Lu, Qing-ling Gao, Du-juan Sha, Li-gang Pei, Guo-feng Fan. Risk factors and outcomes of acute kidney injury after intracoronary stent implantation [J]. World Journal of Emergency Medicine, 2012, 3(3): 197-201.
[4]	Qiang Li, Jie-yu Fang, Wei-ping Wang, Jiang-hui Liu, Ke-ke Wang. Cystatin C and serum creatinine in estimating acute kidney injury of shock patients [J]. World Journal of Emergency Medicine, 2010, 1(3): 185-189.
[5]	Hai-peng Shi, Dao-miao Xu, Guo-en Wang. Prognostic indicators of patients with acute kidney injury in intensive care unit [J]. World Journal of Emergency Medicine, 2010, 1(3): 209-211.