Sensors and Hybrid Therapies: A New Approach with Automated Citrate Anticoagulation

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Abstract

Background: Hybrid therapies use intermittent hemodialysis (IHD) machines adapted to provide prolonged intermittent or continuous renal replacement therapy in the intensive care unit (ICU). Despite the low cost, hybrid therapy use is limited warranting a novel approach. Methods: The literature was reviewed for limitations of hybrid protocols, use of regional citrate anticoagulation (RCA) on hybrid systems and sensors for IHD and hybrid therapy. The novel hybrid program in the authors’ institution is presented as a plausible future direction for the modality. Results: Hybrid therapies are limited by access flow and clotting alarms. Technology limitations render many IHD sensors inoperable at low dialysate flow. A synergy with RCA allows a novel, safe approach with low blood flows and high dialysate flows with alarm- and clotting-free operation and all commercial IHD sensors functional. Conclusion: The low cost, ease of use, safety and efficacy of hybrid therapy with near-automated RCA may lead to rapid expansion of this form of ICU renal support.

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Most cited references 31

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Innovations in optical microfluidic technologies for point-of-care diagnostics.

L. Lee, Monica Myers (2008)

Despite a growing focus from the academic community, the field of microfluidics has yet to produce many commercial devices for point-of-care (POC) diagnostics. One of the main reasons for this is the difficulty in producing low-cost, sensitive, and portable optical detection systems. Although electrochemical methods work well for certain applications, optical detection is generally regarded as superior and is the method most widely employed in laboratory clinical chemistry. Conventional optical systems, however, are costly, require careful alignment, and do not translate well to POC devices. Furthermore, many optical detection paradigms such as absorbance and fluorescence suffer at smaller geometries because the optical path length through the sample is shortened. This review examines the innovative techniques which have recently been developed to address these issues. We highlight microfluidic diagnostic systems which demonstrate practical integration of sample preparation, analyte enrichment, and optical detection. We also examine several emerging detection paradigms involving nanoengineered materials which do not suffer from the same miniaturization disadvantages as conventional measurements.

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Practice patterns in the management of acute renal failure in the critically ill patient: an international survey.

Zaccaria Ricci, Claudio Ronco, Giuseppe D'Amico … (2006)

Several controversies have developed over acute renal failure (ARF) definition and treatment: which approach to patient care is most desirable and which form of renal replacement therapy (RRT) should be applied is an everyday matter of debate. There is also disagreement on clinical practice for RRT including the best timing to start, vascular access, anti-coagulation, membranes, equipment and finally, if continuous or intermittent techniques should be preferred. In this lack of harmony, the epidemiology of ARF has recently displayed an outbreak of cases in the intensive care units and nephrologists and intensivists are now called to work together in the case of such a syndrome. We report on the responses of 560 contributors, mostly coming from Europe, to a questionnaire submitted during the third International Course on Critical Care Nephrology held in Vicenza, Italy in June 2004. The questionnaire was divided into several sections concerning demographic and medical information, definition of ARF, practice of RRT, current opinions about clinical advantages and problems related to different RRTs and modalities, and beliefs on alternative indications to extracorporeal treatments. More then 200 different definitions of ARF and about 90 RRT start criteria were reported. Oliguria and RIFLE (an acronym classifying ARF in different levels of severity: Risk of renal dysfunction; Injury to the kidney; Failure of kidney function; Loss of kidney function; End-stage kidney disease.) were the most frequent criteria used to define ARF. In 10% of centres all forms of renal replacement techniques are available, and in 70% of cases two or more different techniques are available: absolute analysis of different techniques showed that continuous renal replacement therapies are utilized by 511 specialists (91%), intermittent haemodialysis by 387 (69%) and sustained low efficiency dialysis by 136 (24%). Treatment prescription showed significant differences among specialists, 60% of intensivists being uncertain on RRT dose prescription compared to 40% of nephrologists (P = 0.002). The most frequently selected dosage was '35 ml/kg/h' for urea (25%) and creatinine targets (26%), and '2-3 l/h' for the septic dose (25%). Of the participants, 90% said that they used RRT for non-renal indications, 60% although responders admitted the lack of scientific evidence as a limiting factor to its use. New classifications such as RIFLE criteria might improve well-known uncertainty about ARF definition. Different RRT techniques are available in most centres, but a general lack of treatment dose standardization is noted by our survey. Non-renal indications to RRT still need to find a definitive role in routine practice.

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Sustained low-efficiency dialysis in the ICU: cost, anticoagulation, and solute removal.

Jason R. Richardson, A Berbece (2006)

Hemodialysis (HD) for critically ill patients with acute renal failure has been provided as intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT). IHD is often complicated by hypotension and inadequate fluid removal, and CRRT by high cost of solutions and problems with anticoagulation. Sustained low-efficiency daily dialysis (SLED) has been suggested as an alternative treatment. This is an observational, prospective pilot study describing the introduction of SLED at our institution. We compared SLED (23 patients, 165 treatments) with CRRT (11 patients, 209 days), focusing on cost, anticoagulation, and small solute removal. SLED consisted of 8 h of HD 6 days a week, with blood flow of 200 ml/min, dialysate flows of 350 ml/min, and hemofiltration with 1 l of saline/h. CRRT patients were anticoagulated with either heparin or citrate, and SLED patients with either heparin or saline flushes. The weekly costs to the hospital were $1431 for SLED, $2607 for CRRT with heparin, and $3089 for CRRT with citrate. Sixty-five percent of SLED treatments were heparin-free; filter clotting occurred in 18% of heparin treatments and 29% of heparin-free treatments (NS). Weekly Kt/V was significantly higher for SLED (8.4+/-1.8) and time-averaged serum creatinine was lower; equivalent renal clearance (EKRjc) was 29+/-6 ml/min for SLED, similar to that for CRRT. In summary, SLED may be routinely performed without anticoagulation; it provides solute removal equivalent to CRRT at significantly lower cost.

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Author and article information

Journal

Journal ID (publisher-id): BPU

Journal ID (nlm-ta): Blood Purif

Journal ID (doi): 10.1159/issn.0253-5068

Title: Blood Purification

Publisher: S. Karger AG

ISBN: 978-3-318-02240-7

ISBN: 978-3-318-02241-4

ISSN (Print): 0253-5068

ISSN (Electronic): 1421-9735

Publication date Subscription-year: 2012

Publication date (Print): October 2012

Publication date (Electronic): 24 October 2012

Volume: 34

Issue: 2

Pages: 80-87

Affiliations

Division of Nephrology and Hypertension, Henry Ford Health System, Detroit, Mich., USA

Author notes

*Balazs Szamosfalvi, MD, Henry Ford Hospital, CFP-509, 2799 W. Grand Blvd, Detroit, MI 48202 (USA), Tel. +1 313 916 2702, E-Mail bszamos1@hfhs.org

Article

Publisher ID: 341644 Other ID: Blood Purif 2012;34:80–87

DOI: 10.1159/000341644

PubMed ID: 23095406

SO-VID: c5a54594-fe97-46df-aa7e-fc0f7265b7e8

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Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

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Sensors and Hybrid Therapies: A New Approach with Automated Citrate Anticoagulation

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Abstract

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Karger: Nephrology

Most cited references 31

Innovations in optical microfluidic technologies for point-of-care diagnostics.

Practice patterns in the management of acute renal failure in the critically ill patient: an international survey.

Sustained low-efficiency dialysis in the ICU: cost, anticoagulation, and solute removal.

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