Continuous Renal Replacement Therapy Might Mask Immobilization-Induced Hypercalcemia in Critically Ill Patients.

Immobilization and prolonged bed rest are harmful to the skeleton, which suffers increased resorption, and contribute to reducing survival rates among patients in critical care units. We report a patient who presented hypercalcemia 10 days after continuous venovenous hemofiltration has ended. Investigative tests showed an increase of serum C-terminal telopeptide of type I collagen (CTx), with suppressed parathormone and calcitriol. Denosumab was administered with a significant response, decreasing ionized calcium and CTx levels. The calcium infusion rate during dialysis procedures, used for citrate anticoagulation compensation, has progressively decreased, suggesting that endogenous calcium was taking part in the citrate chelation. In this report, we highlight the challenges in early diagnosis of immobilization-induced hypercalcemia among patients who are on continuous renal replacement therapy undergoing citrate anticoagulation.

Use of regional citrate anticoagulation for continuous venovenous hemodialysis in critically ill cancer patients with acute kidney injury.

PURPOSE: This study aimed to evaluate the safety and efficacy of a regional citrate anticoagulation (RCA) protocol for continuous venovenous hemodialysis (CVVHD) in cancer patients with acute kidney injury (AKI) in the intensive care unit (ICU) setting. MATERIAL AND METHODS: One hundred twenty two consecutive ICU cancer patients with AKI treated with citrate-based CVVHD were prospectively evaluated in this prospective observational study. RESULTS: A total of 7198 h of CVVHD therapy (250 filters) were performed. Patients were 61.3 ±â€¯15.7 years old, 78% had solid cancer and the main AKI cause was sepsis (50%). The in-hospital mortality was 78.7%. Systemic ionized calcium (SCai) was 4.35 (4.10-4.60) mg/dL, severe hypocalcemia (SCai <3.6 mg/dL) was observed in 4.3% of procedures and post-filter ionized calcium was 1.60 (1.40-1.80) mg/dL. Median filter patency was 24.8 (11-43) hours. Factors related to filter clotting were: no tumor evidence (OR 0.44, CI 0.18-0.99); genitourinary tumor (OR 1.83, CI 1.18-2.81); platelets number (each 10,000/mm3) (OR 1.02, CI 1.00-1.04); International Normatized Ratio (INR) (OR 0.59, CI 0.41-0.85) and citrate dose (each 10 mL/h) (OR 0.88, CI 0.82-0.95). CONCLUSION: Filter patency was relatively short and clotting was associated with active cancer disease, genitourinary tumor, lower citrate dose and lower INR.

Evaluation of Intermittent Hemodialysis in Critically Ill Cancer Patients with Acute Kidney Injury Using Single-Pass Batch Equipment.

BACKGROUND: Data on renal replacement therapy (RRT) in cancer patients with acute kidney injury (AKI) in the intensive care unit (ICU) is scarce. The aim of this study was to assess the safety and the adequacy of intermittent hemodialysis (IHD) in critically ill cancer patients with AKI. METHODS AND FINDINGS: In this observational prospective cohort study, 149 ICU cancer patients with AKI were treated with 448 single-pass batch IHD procedures and evaluated from June 2010 to June 2012. Primary outcomes were IHD complications (hypotension and clotting) and adequacy. A multiple logistic regression was performed in order to identify factors associated with IHD complications (hypotension and clotting). Patients were 62.2 ± 14.3 years old, 86.6% had a solid cancer, sepsis was the main AKI cause (51%) and in-hospital mortality was 59.7%. RRT session time was 240 (180-300) min, blood/dialysate flow was 250 (200-300) mL/min and UF was 1000 (0-2000) ml. Hypotension occurred in 25% of the sessions. Independent risk factors (RF) for hypotension were dialysate conductivity (each ms/cm, OR 0.81, CI 0.69-0.95), initial mean arterial pressure (each 10 mmHg, OR 0.49, CI 0.40-0.61) and SOFA score (OR 1.16, CI 1.03-1.30). Clotting and malfunctioning catheters (MC) occurred in 23.8% and 29.2% of the procedures, respectively. Independent RF for clotting were heparin use (OR 0.57, CI 0.33-0.99), MC (OR 3.59, CI 2.24-5.77) and RRT system pressure increase over 25% (OR 2.15, CI 1.61-4.17). Post RRT blood tests were urea 71 (49-104) mg/dL, creatinine 2.71 (2.10-3.8) mg/dL, bicarbonate 24.1 (22.5-25.5) mEq/L and K 3.8 (3.5-4.1) mEq/L. CONCLUSION: IHD for critically ill patients with cancer and AKI offered acceptable hemodynamic stability and provided adequate metabolic control.

Rejection-triggered haemophagocytic syndrome in renal transplantation successfully treated with intravenous immunoglobulin.

Haemophagocytic syndrome (HPS) is a rare and potentially lethal condition characterized by pancytopoenia, fever, organomegaly and widespread proliferation of macrophages phagocytosing blood elements. Among the triggers of this syndrome, excessive immunosuppression in a context of acute rejection has been rarely reported, although it might be underdiagnosed. Here, we report the case of a kidney transplant recipient with allograft dysfunction due to chronic antibody-mediated rejection treated with antithymocyte globulin and plasmapheresis. The patient developed high fever, pancytopoenia, diarrhoea and respiratory symptoms with no apparent infectious or neoplastic cause, despite an extensive work-up. Haemophagocytosis was found in bone marrow examination, along with hyperferritinaemia and hypertriglyceridaemia. The clinical profile improved after treatment with intravenous immunoglobulin and reduction of the basal immunosuppression.