AKI was defined according to KDIGO AKI criteria using serum creatinine values [8 ]. CRRT is defined as continuous renal replacement using continuous veno-venous hemodiafiltration or diafiltration, either with Baxter's Prismaflex or Fresenius Multifiltrate platforms. Karolinska University Hospital expanded its ICU capacity four-fold and treated patients at nine established or temporary ICUs at two sites. CRRT was initiated at each physician's discretion guided by KDIGO AKI guidelines for CRRT.
Multifiltrate
Manufactured by Fresenius
Sourced in Germany
The MultiFiltrate is a blood purification device used in renal replacement therapy. It is designed to filter and remove waste, electrolytes, and excess fluid from the blood. The MultiFiltrate utilizes a semi-permeable membrane to selectively filter and control the balance of substances in the bloodstream.
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Lab products found in correlation
16 protocols using multifiltrate
1
Expanded CRRT During COVID-19 ICU
2
CRRT Machine Comparison for Critically Ill
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One of three machines was used for CRRT: Diapact (B. Braun Medical, Inc., Melsungen, Germany), with a 1.0–2.3 m2 polysulfone high-flux filter (Diacap HI; B. Braun Medical, Inc.), for CVVHD or CVVH; Prisma (Gambro, Lund, Sweden), with a 0.9 m2 membrane (AN69 M100 filter set; Gambro) for CVVHDF; or Multifiltrate (Fresenius, Bad Homburg vor der Höhe, Germany), with a 1.8 m2 membrane (AV1000 set; Fresenius), also for CVVHDF. Post-filter ionized calcium (iCa) was measured three times per day.
The decision to start CRRT was based on standard clinical guidelines. In all cases, bicarbonate-buffered solution was used. Filters were routinely changed after 72 h, or sooner if any dysfunction was detected. A prefilter pressure > 270 mmHg was considered indicative of filter clotting. The prescribed dialysis dose was 30 ml/kg of body weight/h. When CVVHDF was performed, the protocol was two-thirds dialysis and one third hemofiltration.
The decision to start CRRT was based on standard clinical guidelines. In all cases, bicarbonate-buffered solution was used. Filters were routinely changed after 72 h, or sooner if any dysfunction was detected. A prefilter pressure > 270 mmHg was considered indicative of filter clotting. The prescribed dialysis dose was 30 ml/kg of body weight/h. When CVVHDF was performed, the protocol was two-thirds dialysis and one third hemofiltration.
3
Initiation of CRRT in Critically Ill ICU Patients
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Upon the development of AKI in ICU patients, nephrologists decided whether or not to initiate CRRT in those who were critically ill. General indications were sustained oliguria, uncontrolled volume overload, intractable hyperkalemia or metabolic acidosis. Patients received continuous veno-venous haemodiafiltration through the internal jugular, subclavian, or femoral vein using the multiFiltrate (Fresenius Medical Care, Bad Homburg, Germany) or the Prismaflex (Baxter International Inc. Lundia AB, Sweden) machine. The applied dialyzers had a surface area of 1.0 to 1.4 m2 with a sieving coefficient for albumin and ß2-microglobulin of 0.001 and 0.58 to 0.65, respectively. CRRT was started at a blood flow rate of 100 mL/min, and this was increased up to 150 mL/min. The total effluent volume as a sum of dialysis and replacement dose was targeted to deliver ≥35 mL∙kg-1∙h-1 in all patients. The mean duration of 1st CRRT was 40 hours.
4
Renal Function Assessment After Surgery
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Patients were divided into two groups, cohort 1 with normal renal function post-surgery and cohort 2 who developed acute kidney injury (AKI) and was subjected to renal replacement therapy (RRT) done by continuous veno-venous hemodialysis (CVVH; multiFiltrate, Fresenius Medical Care, Bad Homburg, Germany). Assessment of renal function after surgery was done by two different criteria: Criterion 1 was based on the “Standard Operating Procedure” (SOP), defined by the Centre for Anaesthesiology, Emergency and Intensive Care Medicine, Göttingen University Hospital:
Pulmonary oedema or impending right ventricular decompensation due to overhydration which cannot be treated by diuretics,
Uraemic complications (encephalopathy, neuropathy, pericarditis, acidosis),
Hyperkalemia (> 6,5 mmol/l).
5
Extracorporeal Hemoperfusion with CytoSorb
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The set-up has been described elsewhere by our group, but in brief: The CytoSorb adsorber was integrated with standard dialysis connectors into an extracorporeal circuit in hemoperfusion mode (multiFiltrate, Fresenius Medical Care, Bad Homburg, Germany) using citrate anticoagulation and was run using standard settings (tubes and hemofilter, Kit Ci-Ca CVVHD 1000, Fresenius Medical Care; dialysate, Ci-Ca Dialysate K2, 2 L/h, Fresenius Medical Care). No ultrafiltration was used. Tubes were connected to a large 12-F, 3-lumen catheter (Arrow International Inc., Reading, PA, USA) and were implanted into the femoral vein of the patient. The blood flow rate of this system was set up to 150 mL/h [12 (link)].
6
MARS Treatment for Acute Liver Failure
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MARS treatment was performed using a double lumen catheter inserted into the internal jugular or femoral vein. A standard continuous renal replacement therapy (MultiFiltrate; Fresenius Medical Care AG, Bad Homburg, Germany) system was used to run the MARS monitor (Baxter, Lund, Sweden). The blood flow on the MultiFiltrate machine was adjusted to 90‐150 mL/minute, and the albumin flow on the MARS monitor was set to 150 mL/minute. Dialysate and replacement fluid flow was set to receive a renal dialysis dose of 35 mL/kg/hour. Anticoagulation was achieved by local anticoagulation of the MARS circuit with citrate as described.23 Every session was planned to last between 6 and 12 hours. Intensive care unit (ICU) treatment was standardized prior to study onset and performed in accordance with the guidelines for treatment of acute liver failure, including renal hemodialysis (continuous veno‐venous hemofiltration) along with MARS treatment, mechanical ventilation, drainage of fluid collections, directed treatment with antibiotics and antifungals, and parenteral nutrition if needed, as reviewed elsewhere.24
7
Anticoagulation Strategies in CRRT
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Patients were randomly assigned to the NM group or the no anticoagulant (NA) group by using a random number table with a randomization ratio, as previously designed. In patients assigned to the NM group, filters were primed with 500 mL of normal saline containing 20 mg of NM (Futhan®, SK chemicals, Seoul, South Korea) dissolved in 1 mL of 5% dextrose water. For maintenance anticoagulation, the initial dose of NM was 20 mg/h, and the NM dose was regulated to 10 to 30 mg/h according to the physicians’ decision. In patients assigned to the NA group, filters were primed with 2 L of normal saline containing 5000 IU of heparin, and then, heparin was washed out using 500 mL of normal saline before use in patients. During CRRT, normal saline (2 mL/h) was infused in the NA group patients.
Continuous renal replacement therapy was performed using multiFiltrate® (Fresenius Medical Care, Bad Homburg, Germany) with a standard polysulfone membrane hemofilter (Ultraflux® AV 600S, Bad Homburg, Germany). Blood flow rates were maintained between 150 and 200 mL/h. The dialysate flow rate, replacement flow rate, and fluid removal rate were modified at the discretion of the attending physician to achieve optimal hemodynamic balance and dialysis.
Continuous renal replacement therapy was performed using multiFiltrate® (Fresenius Medical Care, Bad Homburg, Germany) with a standard polysulfone membrane hemofilter (Ultraflux® AV 600S, Bad Homburg, Germany). Blood flow rates were maintained between 150 and 200 mL/h. The dialysate flow rate, replacement flow rate, and fluid removal rate were modified at the discretion of the attending physician to achieve optimal hemodynamic balance and dialysis.
8
Continuous Veno-Venous Haemofiltration Protocol
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Continuous veno-venous haemofiltration (CVVH) was performed by using Prismaflex (Gambro Co., Ltd.) or multiFiltrate (Fresenius Medical Care GmbH, Bad Homburg, Germany) machines. The anticoagulation regimen consisted of low-molecular-weight heparin or citrate. The blood flow rate was set at 120–200 ml/min.
9
CRRT in Critically Ill ICU Patients
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Upon the development of AKI in ICU patients, nephrologists intervened and decided whether or not to begin CRRT in those who were critically ill. Generally, CRRT was applied in patients with sustained oliguria, uncontrolled volume overload, hyperkalemia or metabolic acidosis. All patients received continuous veno-venous haemodiafiltration by using a Prisma (Gambro Co., Ltd., Hechingen, Germany), Prismaflex (Gambro Co., Ltd), or multiFiltrate (Fresenius Medical Care GmbH, Bad Homburg, Germany) machine, through the internal jugular, subclavian, or femoral vein. CRRT machines were installed, and the system was maintained by trained and educated nurses. Biocompatible polyethersulphone membranes were used in all CRRTs. Pre-filter replacement was loaded with bicarbonate-containing fluid, and a pre-dilution method was applied. CRRT was started at a blood flow rate of 100 mL/min, and this was increased up to 150 mL/min. The total effluent volume as a sum of dialysis and replacement dose was targeted to deliver ≥35 mL⋅kg− 1⋅h− 1 in all patients.
10
Endotoxin Elimination via LPS Adsorber Column
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Endotoxin elimination was performed using an Alteco LPS Adsorber column (Alteco Medical AB, Lund, Sweden). The adsorber is a class IIa medical device for extracorporeal removal of LPS from whole blood. This device contains polyethylene porous plates with a covalently bound peptide with a high affinity for endotoxins. When blood flows through the porous plates of the adsorber, the cationic peptide captures and eliminates negatively charged endotoxin molecules from the bloodstream. Hemoperfusion with the Alteco LPS Adsorber was performed using continuous renal replacement therapy equipment (multiFiltrate, Fresenius Medical Care, Bad Homburg, Germany) with a blood flow of 150 ml/h and unfractionated heparin anticoagulation. A double-lumen dialysis catheter was inserted into a central vein and used for venous access. The procedure was performed a maximum of two times. The first session of endotoxin elimination was completed within 120 min. The second session was performed 24 h after the end of the first session, also for 120 min. The decision to perform a second session was based on a persistently high EA level. For 12 patients, endotoxin elimination was performed simultaneously with renal replacement therapy.
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