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Membrane pressures predict clotting of pediatric continuous renal replacement therapy circuits

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Abstract

Background

Clotting of continuous renal replacement therapy (CRRT) circuits leads to inadequate clearance, decreased ultrafiltration, and increased resource use. We identified factors associated with premature clotting of circuits during CRRT in children.

Methods

In a retrospective cohort of 26 children (median age 11.8 years) receiving 79 CRRT circuits (51 heparin, 22 citrate, 6 using no anticoagulation), we captured hourly pressure, flow, and fluid removal rates along with all activated clotting time (ACT) and circuit ionized calcium measurements. Cox and logistic regression models were used to examine factors associated with premature circuit clotting before the scheduled 3-day circuit change.

Results

Of the 79 circuits, 51 (64.6%) underwent unplanned filter change due to filter clotting (median duration 18.25 h, interquartile range [IQR] 9.25, 33.5 h), and 28 (35.4%) underwent scheduled change (median duration 66 h, IQR 61.00, 69.00 h). Patient age, catheter size and location, blood flow rate, and the percentage of pre-filter replacement fluid were not associated with premature clotting. Heparin circuits were less likely than citrate circuits to clot prematurely. Each 1-mmHg increase in the transmembrane or filter pressure was independently associated with a 1.5% (95% confidence interval [CI] 1.0–2.0%) and 1.5% (95% CI 1.0–2.0%) higher risk of clotting, respectively. Higher ACTs were associated with lower transmembrane (p = 0.03) and filter (p < 0.001) pressures.

Conclusions

The majority of circuits in our cohort were subject to unplanned filter changes. Elevated transmembrane and filter pressures were associated with clotting. Our results suggest that maintaining higher ACT may decrease the risk of circuit clotting. Larger studies are needed to examine other factors that may prolong the lifespan of the CRRT circuit in this high-risk population.

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Acknowledgments

Dr. Laskin is supported by grant DK101600 and Dr. Denburg by grant DK093556, both K23 Career Development Awards from the National Institutes of Health.

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Authors and Affiliations

  1. Department of Pediatrics, Division of Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA

    Aadil Kakajiwala, Kimberly Windt, Michelle Denburg & Benjamin Laskin

  2. Department of Pediatrics, Division of Pediatric Nephrology, Washington University in St. Louis School of Medicine, Campus Box 8116, 660 Euclid Ave, St. Louis, MO, 63110, USA

    Aadil Kakajiwala

  3. Department of Biostatistics, University of Pennsylvania, Philadelphia, PA, USA

    Thomas Jemielita

  4. Drexel College of Medicine and Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA

    John Z. Hughes

  5. Center for Acute Care Nephrology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

    Stuart L. Goldstein

Authors
  1. Aadil Kakajiwala
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  2. Thomas Jemielita
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  3. John Z. Hughes
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  4. Kimberly Windt
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  5. Michelle Denburg
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  6. Stuart L. Goldstein
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  7. Benjamin Laskin
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Corresponding author

Correspondence to Aadil Kakajiwala.

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The study was reviewed and approved by our Institutional Review Board who waived the requirement for informed consent.

Disclosures

Dr. Goldstein consults for and receives educational and research grant support from Baxter-Gambro Renal.

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Kakajiwala, A., Jemielita, T., Hughes, J.Z. et al. Membrane pressures predict clotting of pediatric continuous renal replacement therapy circuits. Pediatr Nephrol 32, 1251–1261 (2017). https://doi.org/10.1007/s00467-017-3601-z

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  • DOI: https://doi.org/10.1007/s00467-017-3601-z

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