Control of respiratory drive by extracorporeal CO2 removal in acute exacerbation of COPD breathing on non-invasive NAVA.

BACKGROUND: Veno-venous extracorporeal CO2 removal (vv-ECCO2R) and non-invasive neurally adjusted ventilator assist (NIV-NAVA) are two promising techniques which may prevent complications related to prolonged invasive mechanical ventilation in patients with acute exacerbation of COPD. METHODS: A physiological study of the electrical activity of the diaphragm (Edi) response was conducted with varying degrees of extracorporeal CO2 removal to control the respiratory drive in patients with severe acute exacerbation of COPD breathing on NIV-NAVA. RESULTS: Twenty COPD patients (SAPS II 37 ± 5.6, age 57 ± 9 years) treated with vv-ECCO2R and supported by NIV-NAVA were studied during stepwise weaning of vv-ECCO2R. Based on dyspnea, tolerance, and blood gases, weaning from vv-ECCO2R was successful in 12 and failed in eight patients. Respiratory drive (measured via the Edi) increased to 19 ± 10 µV vs. 56 ± 20 µV in the successful and unsuccessful weaning groups, respectively, resulting in all patients keeping their CO2 and pH values stable. Edi was the best predictor for vv-ECCO2R weaning failure (ROC analysis AUC 0.95), whereas respiratory rate, rapid shallow breathing index, and tidal volume had lower predictive values. Eventually, 19 patients were discharged home, while one patient died. Mortality at 90 days and 180 days was 15 and 25%, respectively. CONCLUSIONS: This study demonstrates for the first time the usefulness of the Edi signal to monitor and guide patients with severe acute exacerbation of COPD on vv-ECCO2R and NIV-NAVA. The Edi during vv-ECCO2R weaning was found to be the best predictor of tolerance to removing vv-ECCO2R.

Patient Demographics and Extracorporeal Membranous Oxygenation (ECMO)-Related Complications Associated With Survival to Discharge or 30-Day Survival in Adult Patients Receiving Venoarterial (VA) and Venovenous (VV) ECMO in a Quaternary Care Urban Center.

OBJECTIVE: Investigate how a multitude of patient demographics and extracorporeal membranous oxygenation (ECMO)-related complications affect 30-day survival or survival to discharge. DESIGN: Retrospective observational study. SETTING: Urban university hospital, quaternary care center. PARTICIPANTS: Patients who underwent ECMO circulatory support from January 2012 to May 2016. INTERVENTIONS: Date-based data extraction, univariate and multivariate regression analysis. MEASUREMENTS AND MAIN RESULTS: The hospital database contained complete data for 235 adult patients who received venoarterial ECMO (74.04 %) and venovenous ECMO (25.96 %); 106 patients (45.11%) survived. The independent predictors significant in the odds of in-hospital mortality in a multiregression model were age (odds ratio [OR] = 1.028, p = 0.008), extracorporeal cardiopulmonary resuscitation (ECPR) after unsuccessful high-quality CPR (OR = 7.93, p =0.002), cardiogenic shock as the primary indication for circulatory support (OR = 2.58, p = 0.02), acute kidney injury (AKI) before ECMO initiation (OR = 7.53, p < 0.001), time spent on ECMO in days (OR = 1.08, p = 0.03), and limb ischemia (OR = 3.18, p = 0.047). CONCLUSION: The most significant findings of advancing age, time spent on ECMO, AKI, ECMO use in the setting of cardiogenic shock, ECPR, and limb ischemia as a complication of ECMO all independently increase the odds of in-hospital and 30-day mortality. To the best of the authors' knowledge, this study is the first to demonstrate a significant relationship between limb ischemia and mortality.

Extracorporeal techniques for the treatment of critically ill patients with sepsis beyond conventional blood purification therapy: the promises and the pitfalls.

Sepsis is one of the leading causes of morbidity and mortality worldwide. It is characterized by a dysregulated immune response to infections that results in life-threatening organ dysfunction and even death. Bacterial cell wall components (endotoxin or lipopolysaccharide), known as pathogen-associated molecular patterns (PAMPs), as well as damage-associated molecular patterns (DAMPs) released by host injured cells, are well-recognized triggers resulting in the elevation of both pro-inflammatory and anti-inflammatory cytokines. Understanding this complex pathophysiology has led to the development of therapeutic strategies aimed at restoring a balanced immune response by eliminating/deactivating these inflammatory mediators. Different extracorporeal techniques have been studied in recent years in the hope of maximizing the effect of renal replacement therapy in modulating the exaggerated host inflammatory response, including the use of high volume hemofiltration (HVHF), high cut-off (HCO) membranes, adsorption alone, and coupled plasma filtration adsorption (CPFA). These strategies are not widely utilized in practice, depending on resources and local expertise. The literature examining their use in septic patients is growing, but the evidence to support their use at this stage is considered of low level. Our aim is to provide a comprehensive overview of the technical aspects, clinical applications, and associated side effects of these techniques.

Rapid calcium loss may cause arrhythmia in hemofiltration with regional citrate anticoagulation: a case report.

BACKGROUND: Renal replacement therapy (RRT) with regional citrate anticoagulation (RCA) is an important therapeutic approach for refractory hypercalcemia complicated with renal failure. However, RCA has the potential to induce arrhythmia caused by rapid calcium loss. We report a case of arrhythmia associated with rapid calcium loss during RCA-RRT. CASE PRESENTATION: A 51-year-old man with hypercalcemia, primary hyperparathyroidism, and acute kidney injury was treated by predilutional-RCA-hemofiltration at a rate of 4.3 L/h. The effect of lowering serum calcium was unsatisfactory despite reducing calcium substitution gradually from 5.3 to 2.2 mmol/h in the first 8-h session of RCA-hemofiltration. New-onset sinus tachycardia with a prolonged QT interval occurred when calcium substitution was infused at rate of 1.1 mmol/h after 15 min of starting the second RCA-hemofiltration session (estimated net calcium loss was 7.54 mmol/h). When the calcium substitution was increased to usual rate of 5.6 mmol/h, the arrhythmia disappeared after 2 min. Arrhythmia did not recur when the calcium substitution rate was 2.2 mmol/h during the third session (estimated net calcium loss was 6.44 mmol/L). After the third RCA-hemofiltration session, the patient underwent parathyroidectomy and serum calcium returned to normal. CONCLUSIONS: This case indicated that rapid calcium loss may cause arrhythmia in RCA-hemofiltration, and the rate of net calcium loss should be limited below a threshold value to prevent similar adverse effect during RCA-RRT.

Effect of Extracorporeal Membrane Oxygenation on the New Vancomycin Dosing Regimen in Critically Ill Patients Receiving Continuous Venovenous Hemofiltration.

BACKGROUND: The optimal dosing regimen of vancomycin for critically ill patients receiving continuous venovenous hemofiltration (CVVH) remains controversial, not to mention those with concurrent use of extracorporeal membrane oxygenation (ECMO). We aimed to determine if a new dosing regimen can achieve the target vancomycin trough concentration (Ctrough) of 10-20 mcg/mL in patients receiving CVVH with or without ECMO. METHODS: We conducted a retrospective study by enrolling patients who received vancomycin while undergoing CVVH. The vancomycin dosing regimen was 15-20 mg/kg as the loading dose and 7.5 mg/kg every 12 hours as the maintenance doses. Serum concentration was determined after at least 4 doses of vancomycin were given. RESULTS: A total of 38 patients were enrolled, of which 21 were also on ECMO. The ultrafiltration rate of CVVH was 30.6 ± 5.5 mL·kg·h with the Ctrough of 14.7 ± 3.5 mcg/mL. Ctrough was within the target range in 82% of patients. All CVVH-only patients achieved the target concentration, whereas only 76.2% of those with concurrent ECMO did (P = 0.031). CONCLUSIONS: All patients receiving CVVH achieved the target Ctrough with this new dosing regimen, but those with concurrent ECMO did not. Ctrough must be more closely monitored in patients using ECMO simultaneously.

Lacosamide Pharmacokinetics in a Critically Ill Patient Receiving Continuous Venovenous Hemofiltration.

Lacosamide is a new-generation antiepileptic drug (AED) that is eliminated by both hepatic and renal mechanisms. Lacosamide elimination by continuous renal replacement therapy (CRRT) has never been studied. The objective of this case report was to describe lacosamide pharmacokinetics in the setting of CRRT. We describe a single patient admitted to the study center with status epilepticus and multiorgan failure. The patient required both continuous venovenous hemofiltration (CVVH) and several AEDs. He was receiving intravenous lacosamide 200 mg twice/day at steady state prior to sampling. Plasma lacosamide concentrations were derived using a validated high-performance liquid chromatography method. Parameters were calculated using Phoenix WinNonlin 7.1 software. The peak concentration at steady state was 7.7 mg/L, the trough concentration was 5.9 mg/L (goal 5-12 mg/L). The volume of distribution was 0.7 L/kg, the elimination half-life was 21 hours, and the sieving coefficient was 0.8 (± 0.06). Lacosamide was cleared by CVVH as demonstrated by the sieving coefficient, but plasma concentrations remained within goal range throughout the dosing interval. These results may suggest that lacosamide 200 mg twice/day is a useful dosing strategy for critically ill patients who require CVVH.

Bleeding Complications Associated With Percutaneous Tracheostomy Insertion in Patients Supported With Venovenous Extracorporeal Membrane Oxygen Support: A 10-Year Institutional Experience.

OBJECTIVES: To evaluate the bleeding complications associated with percutaneous tracheostomy while a patient is receiving venovenous extracorporeal membrane oxygen (VV ECMO) support. DESIGN: Retrospective, observational analysis. SETTING: Single-center, tertiary, academic institution. PARTICIPANTS: All consecutive patients on VV ECMO over a 10 year-period undergoing percutaneous tracheostomy. INTERVENTIONS: Percutaneous tracheostomy. MEASUREMENTS AND MAIN RESULTS: Fifty percutaneous tracheostomies were performed in patients requiring VV ECMO support over the 10-year period. The authors observed a 40% incidence of bleeding, with 32% of these incidences characterized as minor (self-limiting, localized stomal ooze) and 8% characterized as significant (necessitating surgical control and frequent packing or accompanied by a decrease in hemoglobin >20%). CONCLUSIONS: Bleeding is associated with percutaneous tracheostomy and is self-limiting in the majority of patients.

Evaluation of nucleoside reverse transcriptase inhibitor dosing during continuous veno-venous hemofiltration.

Background Unpredictable drug concentrations may lead to suboptimal exposure to nucleoside reverse transcriptase inhibitors (NRTIs) due to inadequate doses administered during continuous veno-venous hemofiltration (CVVH), which in turn may lead to decreased antiretroviral efficacy and possibly further HIV disease progression. Objective To compare administered doses of NRTIs to calculated doses of NRTIs to evaluate if patients were expected to have a favorable pharmacokinetic exposure profile while receiving CVVH. Methods The NRTI dose was compared to a table of recommendations based on a mathematical formula that estimates the amount of drug expected to be removed during CVVH. Results Twelve patients were on 27 NRTIs. Eleven (41%) NRTI doses were expected to provide a favorable pharmacokinetic profile based on pharmacokinetic mathematical calculations. Conclusion The majority of NRTIs were potentially not optimally dosed based on proposed pharmacokinetic calculations.

Caspofungin Population Pharmacokinetics in Critically Ill Patients Undergoing Continuous Veno-Venous Haemofiltration or Haemodiafiltration.

BACKGROUND AND OBJECTIVE: Sepsis and continuous renal replacement therapy (CRRT) can both significantly affect antifungal pharmacokinetics. This study aimed to describe the pharmacokinetics of caspofungin in critically ill patients during different CRRT modes. METHODS: Patients receiving caspofungin and undergoing continuous veno-venous haemofiltration (CVVH) or haemodiafiltration (CVVHDF) were eligible to take part in the study. Blood samples were collected at seven sampling times during a dosing interval. Demographics and clinical data were recorded. Population pharmacokinetic analysis and Monte-Carlo simulation were undertaken using Pmetrics. RESULTS: Twelve pharmacokinetic profiles from nine patients were analysed. The caspofungin CRRT clearance (CL) was 0.048 ± 0.12 L/h for CVVH and 0.042 ± 0.042 L/h for CVVHDF. A two-compartment linear model best described the data. Patient weight was the only covariate affecting drug CL and central volume. The mean (standard deviation) parameter estimates were 0.64 ± 0.12 L/h for CL, 9.35 ± 3.56 L for central volume, 0.25 ± 0.19 per h for the rate constant for drug distribution from central to peripheral compartments and 0.19 ± 0.10 per h from peripheral to central compartments. Based on simulation results, a caspofungin 100 mg loading dose followed by a 50 mg maintenance dose for patients with a total body weight of ≤80 kg best achieved the pharmacokinetic/PD targets whilst a 70 mg maintenance dose was required for patients with a weight of >80 kg. CONCLUSION: No caspofungin dosing adjustment is necessary for patients undergoing either form of CRRT. However, higher than recommended loading doses of caspofungin are required to achieve pharmacokinetic/pharmacodynamic targets in critically ill patients. Registration: ClinicalTrials.gov Identifier NCT01403220.

Severe cefepime-induced status epilepticus treated with haemofiltration / Estatus epiléptico grave inducido por cefepime tratado con hemofiltración

Neurotoxicity caused by cefepime may occur predominantly in patients with impaired renal function. A case of a cefepime-induced non-convulsive status epilepticus (NCSE) is presented. A 65-year-old woman suffered a severe NCSE due to cefepime in the presence of acute renal failure, requiring coma induction with sodium thiopental. A serious interaction between valproic acid (VPA) and meropenem was also produced after changing cefepime to meropenem. Continuous veno-venous haemofiltration was employed to improve cefepime clearance, and the patient progressively regained her previous mental condition. In conclusion, the cefepime dose must be adjusted according to renal function in order to avoid toxicity in patients with renal failure. Electroencephalogram should be considered in cases of acute confusional state in patients receiving cefepime, to achieve early detection of NCSE. Continuous renal replacement therapy may be successfully employed in severe cases in order to accelerate cefepime removal. Likewise, meropenem should not be used concomitantly with VPA (AU)

La neurotoxicidad por cefepime puede producirse principalmente en pacientes con insuficiencia renal. Presentamos un caso de status epiléptico no convulsivo producido por cefepime. Una mujer de 65 años con fracaso renal agudo en tratamiento con cefepime sufrió un episodio grave de status epiléptico no convulsivo que requirió inducción de coma barbitúrico con tiopental sódico. Tras el cambio de cefepime a meropenem se produjo también una interacción grave entre meropenem y ácido valproico. Se utilizó hemofiltración venovenosa continua para acelerar el aclaramiento de cefepime y la paciente recuperó progresivamente su situación neurológica previa. En conclusión, la dosis de cefepime debe ser ajustada a la función renal para evitar toxicidad en pacientes con insuficiencia renal. Debería considerarse la utilización del electroencefalograma en casos de estado confusional agudo en pacientes en tratamiento con cefepime para un diagnóstico precoz del status epiléptico no convulsivo. La terapia continua de reemplazo renal puede ser empleada en casos graves para acelerar la eliminación de cefepime. Además el meropenem no debe de utilizarse concomitantemente con el ácido valproico (AU)

Venovenous Extracorporeal Membrane Oxygenation in Intractable Pulmonary Insufficiency: Practical Issues and Future Directions.

Venovenous extracorporeal membrane oxygenation (vv-ECMO) is a highly invasive method for organ support that is gaining in popularity due to recent technical advances and its successful application in the recent H1N1 epidemic. Although running a vv-ECMO program is potentially feasible for many hospitals, there are many theoretical concepts and practical issues that merit attention and require expertise. In this review, we focus on indications for vv-ECMO, components of the circuit, and management of patients on vv-ECMO. Concepts regarding oxygenation and decarboxylation and how they can be influenced are discussed. Day-to-day management, weaning, and most frequent complications are covered in light of the recent literature.

The influence of high volume hemofiltration on extra vascular lung water and alveolar-arterial oxygen pressure difference in patients with severe sepsis.

OBJECTIVE: To explore the effects of high-volume hemofiltration (HVHF) on the plasma interleukin-6 (IL-6), pro-calcitonin (PCT), extra vascular lung water index (EVLWI) and alveolar-arterial oxygen exchange in patients with septic shock. PATIENTS AND METHODS: 97 cases intensive patients with septic shock were enrolled  from Department of Intensive Care Unit (ICU) of the Provincial Hospital affiliated to Shandong University between January 2011 and December 2014. According to the puting into practice of high-volume hemofiltration (HVHF) or not, all the patients were divided in two groups (NHVHF group, group A, n = 46 cases) and (HVHF group, group B, n = 51 cases). The plasma IL-6, PCT intrathoracic blood volume index (ITBVI), extra-vascular lung water index (EVLWI) and pulmonary vascular permeability index(PVPI) was detected before treatment and after treatment 24h, 72h The Alveolar- arterial oxygen pressure difference P(A-a)DO2 was checked by arterial blood gas analysis (ABGA) at first and after treatment 24 hour, 72 hour, 7 day in two groups. The mortality at 28 day was compared between two groups. RESULTS: After 72h treatment, the plasma IL-6, PCT in group B has a significant decrease. After 72h treatment, the level ITBVI, EVLWI and PVPI in group B had a significant improvement. The levels of P(A-a)DO2 in HVHF group were reduced more significantly than N-HVHF group after 7 day. The EVLWI and P(A-a)DO2 had a significant positive correlation (correlation ratio = 0.712, 95% confident interval [0.617, 0.773], p = 0.001). The mortality at 28 day had a significant decrease between groups (15.22% vs. 34.15% χ2 = 4.242, p = 0.038). CONCLUSIONS: HVHF could decrease plasma inflammatory factors and EVLWI so that it could improve the levels of alveolar-arterial-oxygen exchange in patients with septic shock, so it could improve the survival rate of patients.

Biomedical applications of high gradient magnetic separation: progress towards therapeutic haeomofiltration.

High gradient magnetic separation is a well-established technology in the mineral processing industry, and has been used for decades in the bioprocessing industry. Less well known is the increasing role that high gradient magnetic separation is playing in biomedical applications, for both diagnostic and therapeutic purposes. We review here the state of the art in this emerging field, with a focus on therapeutic haemofiltration, the key enabling technologies relating to the functionalisation of magnetic nanoparticles with target-specific binding agents, and the development of extra-corporeal circuits to enable the in situ filtering of human blood.

Renal failure requiring dialysis complicating slow continuous ultrafiltration in acute heart failure: importance of systolic perfusion pressure.

BACKGROUND: Recent reports have raised concerns regarding renal outcomes in patients with decompensated acute heart failure (HF) treated with slow continuous ultrafiltration (SCUF). The purpose of this study was to identify risk factors for renal failure (RF) requiring dialysis in patients with acute HF initiated on SCUF. METHODS AND RESULTS: We studied 63 consecutive patients with acute HF who required SCUF because of congestion refractory to hemodynamically guided intensive medical therapy. Median serum creatinine at SCUF initiation was higher in patients who developed RF requiring dialysis [2.5 (interquartile range 1.8-3.3) vs 1.6 (1.2-2.3) mg/dL; P < .001]. Weight loss within 48 hours of SCUF initiation was larger in patients who did not progress to RF [-6 (-10 to -2) vs -4 (-6 to -2) kg; P = .03]. Systolic perfusion pressure had a nonlinear association with RF requiring dialysis, with a threshold effect noted at 90 mm Hg. Twelve-month mortality in patients who were moved to dialysis versus those who were not was 95% versus 35%, respectively (P < .001). CONCLUSIONS: In patients with acute HF initiated on SCUF, onset of RF requiring dialysis is associated with high mortality. Systolic perfusion pressure which incorporates both perfusion and venous congestion parameters may present a modifiable risk factor for worsening RF during SCUF in acute HF patients.

Clinical effectiveness of continuous blood purification in combination with ulinastatin in treating thermoplegia.

OBJECTIVE: To explore the clinical effectiveness of continuous blood purification (CBP) in combination with ulinastatin for the treatment of thermoplegia. PATIENTS AND METHODS: Forty patients (28 men and 12 women) with severe heat stroke were admitted to our hospital's ICU department from June 2010 to August 2013. The patients were randomized into a treatment group (n=21; 15 men and six women, with an average age of 32.9 years) and control group (n=19; 13 men and six women, with an average age of 33.1 years). Patients in the control group underwent treatments of oxygen inhalation, dynamic ECG monitoring, physical cooling methods (ice caps or ice application), whereas patients in the treatment group, in addition to this treatment, were further treated with continuous blood purification in combination with ulinastatin. During administration, the content of one vial was dissolved in 100 mL of physiological saline for intravenous dripping for 1.5 hours. RESULTS: There were 18 cured cases, one case of sequelae of mild neurological disorders, and two deaths in the treatment group, with the cure rate of 90.48%. In comparison, there were 12 cured cases, three cases of sequelae of mild neurological disorders, and four deaths in the control group, with the cure rate of 78.95%. The overall response rates of rectal temperature drop were determined to be 95.24% and 73.68% for the treatment group and the control group, respectively. Based on the treatment outcomes data, multiple organ dysfunction syndrome (MODS) recovery, deaths and survival outcomes of patients in the treatment group was more favorable than that of the control group. This difference was statistically significant (p < 0.05). CONCLUSIONS: Continuous blood purification in combination with ulinastatin is effective in treating thermoplegia and warrants further investigation.

The evolution of pediatric continuous renal replacement therapy.

The provision of continuous renal replacement therapies (CRRT) to small children has generally required the adaptation of adult machines and modified operational characteristics. CRRT prescription for younger and smaller children versus adults differs significantly due to problems concerning the extracorporeal blood volume, the need for circuit blood priming, and the adaptation of machines designed for adult-sized patients. Moreover, the provision of renal replacement therapy to infants and neonates presents a unique problem: no more than 10-15% of their blood volume should be removed by the extracorporeal circuit to prevent hypotension and anemia. In 2012, a dedicated machine, i.e. the Cardio-Renal, Pediatric Dialysis Emergency Machine (CARPEDIEM), was developed and launched the 'fitted era' for pediatric CRRT. In this review, we analyze how CRRT techniques have evolved for pediatric application and describe the first in vivo application of the CARPEDIEM for the safe and efficacious provision of CRRT to infants.

The effect of continuous versus intermittent renal replacement therapy on the outcome of critically ill patients with acute renal failure (CONVINT): a prospective randomized controlled trial.

INTRODUCTION: Acute renal failure (ARF) requiring renal replacement therapy (RRT) occurs frequently in ICU patients and significantly affects mortality rates. Previously, few large clinical trials investigated the impact of RRT modalities on patient outcomes. Here we investigated the effect of two major RRT strategies (intermittent hemodialysis (IHD) and continuous veno-venous hemofiltration (CVVH)) on mortality and renal-related outcome measures. METHODS: This single-center prospective randomized controlled trial ("CONVINT") included 252 critically ill patients (159 male; mean age, 61.5 ± 13.9 years; Acute Physiology and Chronic Health Evaluation (APACHE) II score, 28.6 ± 8.8) with dialysis-dependent ARF treated in the ICUs of a tertiary care academic center. Patients were randomized to receive either daily IHD or CVVH. The primary outcome measure was survival at 14 days after the end of RRT. Secondary outcome measures included 30-day-, intensive care unit-, and intrahospital mortality, as well as course of disease severity/biomarkers and need for organ-support therapy. RESULTS: At baseline, no differences in disease severity, distributions of age and gender, or suspected reasons for acute renal failure were observed. Survival rates at 14 days after RRT were 39.5% (IHD) versus 43.9% (CVVH) (odds ratio (OR), 0.84; 95% confidence interval (CI), 0.49 to 1.41; P = 0.50). 14-day-, 30-day, and all-cause intrahospital mortality rates were not different between the two groups (all P > 0.5). No differences were observed in days on RRT, vasopressor days, days on ventilator, or ICU-/intrahospital length of stay. CONCLUSIONS: In a monocentric RCT, we observed no statistically significant differences between the investigated treatment modalities regarding mortality, renal-related outcome measures, or survival at 14 days after RRT. Our findings add to mounting data demonstrating that intermittent and continuous RRTs may be considered equivalent approaches for critically ill patients with dialysis-dependent acute renal failure. TRIAL REGISTRATION: NCT01228123, clinicaltrials.gov.

Worsening renal function in patients with acute decompensated heart failure treated with ultrafiltration: predictors and outcomes.

BACKGROUND: Ultrafiltration (UF) is used to treat patients with diuretic-resistant acute decompensated heart failure. The aim of this study was to identify predictors and the effect of worsening renal failure (WRF) on mortality in patients treated with UF. METHODS AND RESULTS: Based on changes in serum creatinine, 99 patients treated with UF were divided into WRF and control groups. Overall creatinine increased from 1.9 ± 9.7 to 2.2 ± 2.0 mg/dL (P < .001), and WRF developed in 41% of the subjects. The peak UF rate was higher in the WRF group in univariate analysis (174 ± 45 vs 144 ± 42 mL/h; P = .03). Based on multivariate analysis, aldosterone antagonist treatment (odds ratio [OR] 3.38, 95% confidence interval [CI] 1.17-13.46, P = .04), heart rate ≤65 beats/min (OR 6.03, 95% CI 1.48-48.42; P = .03), and E/E' ≥15 (OR 3.78, 95% CI 1.26-17.55; P = .04) at hospital admission were associated with WRF. Patients with baseline glomerular filtration rate (GFR) ≤60 mg/dL who developed WRF during UF had a 75% 1-year mortality rate. CONCLUSIONS: WRF occurred frequently during UF. Increased LV filling pressures, lower heart rate, and treatment with aldosterone antagonist at hospital admission can identify patients at increased risk for WRF. Patients with baseline GFR ≤60 mg/dL and WRF during UF have an extremely high 1-year mortality rate.

Hypophosphatemia during continuous veno-venous hemofiltration is associated with mortality in critically ill patients with acute kidney injury.

INTRODUCTION: The primary aim of this study was to determine whether hypophosphatemia during continuous veno-venous hemofiltration (CVVH) is associated with the global outcome of critically ill patients with acute kidney injury (AKI). METHODS: 760 patients diagnosed with AKI and had received CVVH therapy were retrospectively recruited. Death during the 28-day period and survival at 28 days after initiation of CVVH were used as endpoints. Demographic and clinical data including serum phosphorus levels were recorded along with clinical outcome. Hypophosphatemia was defined according to the colorimetric method as serum phosphorus levels < 0.81 mmol/L (2.5 mg/dL), and severe hypophosphatemia was defined as serum phosphorus levels < 0.32 mmol/L (1 mg/dL). The ratio of CVVH therapy days with hypophosphatemia over total CVVH therapy days was calculated to reflect the persistence of hypophosphatemia. RESULTS: The Cox proportional hazard survival model analysis indicated that the incidence of hypophosphatemia or even severe hypophosphatemia was not associated with 28-day mortality independently (p = 0.700). Further analysis with the sub-cohort of patients who had developed hypophosphatemia during the CVVH therapy period indicated that the mean ratio of CVVH therapy days with hypophosphatemia over total CVVH therapy days was 0.58, and the ratio independently associated with the global outcome. Compared with the patients with low ratio (< 0.58), those with high ratio (≥ 0.58) conferred a 1.451-fold increase in 28-day mortality rate (95% CI 1.103-1.910, p = 0.008). CONCLUSIONS: Hypophosphatemia during CVVH associated with the global clinical outcome of critically ill patients with AKI. The ratio of CVVH therapy days with hypophosphatemia over total CVVH therapy days was independently associated with the 28-day mortality, and high ratio conferred higher mortality rate.