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Achieving dialysis adequacy: A global perspective

Bharati J, Jha V

Semin Dial, 2020 11;33(6):490-498.
PMID: 33030777 DOI: 10.1111/sdi.12924

Dialysis adequacy is conventionally quantified as net urea clearance. Single pool (sp) Kt/Vurea remains the best studied measure of dialysis adequacy globally. Other measures such as fluid status control, anemia correction, and mineral metabolism are monitored variably. Increasing use of hemodiafiltration across Europe and many parts of Japan and Australia is predicated on studies showing better patient survival with middle molecule clearance. Apart from local clinical practice guidelines, the income level and public health policy of a country determine quality of dialysis services. Among developed nations, small solute clearance adequacy targets are achieved with high frequency. In the United States, dialysis adequacy target is met by focussing on high blood flow rates and large dialyzer size, sometimes at the cost of session time. In Japan, Australia, and Germany, session length is given importance. Dialysis adequacy reporting is restricted and inconsistent in developing nations. The Gulf Cooperation Council countries, Russia and Malaysia, respectively, are close to achieving dialysis adequacy target (spKt/Vurea ≥1.2) universally in their dialysis populations. Patient-reported outcomes are typically measured only in developed countries. Patient survival on dialysis, partly linked to dialysis adequacy, varies greatly around the world, with Japan having the best survival rates. Until the development of better markers of dialysis adequacy, universal consistency in reporting of conventional parameters with a focus on patient-reported measures should be endeavored.

Matched MeSH terms: Hemodiafiltration*
Fulltext Impact of pre-dilution and flushing on continuous renal replacement therapy

Koh KH

Singapore Med J, 2006 Sep;47(9):785-95.
PMID: 16924361

Infusing the replacement solution before the filter (pre-dilution) and regular flushing have not been accounted for in conventional mathematical equations. Their effects on various continuous renal replacement therapy (CRRT) parameters, such as ultrafiltration fraction and urea clearance, have not been well studied. We incorporated these parameters into mathematical equations to help in understanding and prescribing CRRT.

Matched MeSH terms: Hemodiafiltration/instrumentation; Hemodiafiltration/methods*
A Double-Blind Randomized Controlled Trial of High Cutoff Versus Standard Hemofiltration in Critically Ill Patients With Acute Kidney Injury

Atan R, Peck L, Prowle J, Licari E, Eastwood GM, Storr M, et al.

Crit Care Med, 2018 10;46(10):e988-e994.
PMID: 30074491 DOI: 10.1097/CCM.0000000000003350

OBJECTIVES: In critically ill patients with acute kidney injury receiving vasopressors, high cytokine levels may sustain the shock state. High cutoff hemofiltration achieves greater cytokine removal in ex vivo and in animal models and may reduce the duration of shock but may also increase albumin losses.
DESIGN: This was a single-center double-blind randomized controlled trial comparing continuous venovenous hemofiltration-high cutoff to continuous venovenous hemofiltration-standard.
SETTING: Tertiary care hospital in Australia.
PATIENTS: Vasopressor-dependent patients in acute kidney injury who were admitted to the ICU.
INTERVENTIONS: Norepinephrine-free time were calculated in critically ill vasopressor-dependent patients in acute kidney injury, randomized to either continuous venovenous hemofiltration-high cutoff or continuous venovenous hemofiltration-standard.
MEASUREMENT AND MAIN RESULTS: A total of 76 patients were randomized with the following characteristics (continuous venovenous hemofiltration-high cutoff vs continuous venovenous hemofiltration-standard); median age of 65 versus 70 year, percentage of males 47% versus 68%, and median Acute Physiology and Chronic Health Evaluation scores of 25 versus 23.5. The median hours of norepinephrine-free time at day 7 were 32 (0-110.8) for continuous venovenous hemofiltration-high cutoff and 56 hours (0-109.3 hr) (p = 0.520) for continuous venovenous hemofiltration-standard. Inhospital mortality was 55.6% with continuous venovenous hemofiltration-high cutoff versus 34.2% with continuous venovenous hemofiltration-standard (adjusted odds ratio, 2.49; 95% CI, 0.81-7.66; p = 0.191). There was no significant difference in time to cessation of norepinephrine (p = 0.358), time to cessation of hemofiltration (p = 0.563), and filter life (p = 0.21). Serum albumin levels (p = 0.192) were similar and the median dose of IV albumin given was 90 grams (20-212 g) for continuous venovenous hemofiltration-high cutoff and 80 grams (15-132 g) for continuous venovenous hemofiltration-standard (p = 0.252).
CONCLUSIONS: In critically ill patients with acute kidney injury, continuous venovenous hemofiltration-high cutoff did not reduce the duration of vasopressor support or mortality or change albumin levels compared with continuous venovenous hemofiltration-standard.

Matched MeSH terms: Hemodiafiltration/methods; Hemodiafiltration/mortality*
Fulltext A case of urgent colonoscopic hemostasis of a cecal hemorrhagic ulceration in a patient receiving heparin for COVID-19 coagulopathy

Yoshida N, Hirose R, Watanabe M, Yamazaki M, Hashimoto S, Matsubara S, et al.

JGH Open, 2021 Jan;5(1):160-162.
PMID: 33490630 DOI: 10.1002/jgh3.12435

COVID-19 rarely causes lower gastrointestinal bleeding even though its RNA has been detected in patient's stool. Urgent colonoscopy in a COVID-19 patient with massive bloody stool requires various procedural and equipment considerations. Here, we present a case of colonoscopic hemostasis of a cecal hemorrhagic ulceration in a patient on heparin for COVID-19 coagulopathy. We also share various management methods for the prevention of COVID-19 contamination. A 71-year-old man was diagnosed with COVID-19 pneumonia and subsequently underwent hemodiafiltration. Heparin was initiated for COVID-19 coagulopathy. At day 42, the patient experienced 2000 mL of bloody stool. An operator performed urgent colonoscopy with three assistants in a negative-pressure room with full personal protective equipment. A hemorrhagic ulceration was detected at the cecum, and endoscopic hemostasis was performed. Immunohistochemistry was positive for cytomegalovirus. Postprocedure, the endoscopic systems were thoroughly cleaned, and specific measures for endoscope reprocessing and disinfection were performed to prevent contamination with COVID-19.

Matched MeSH terms: Hemodiafiltration