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References:

AlEnezi, F., Alhazzani, W., Ma, J., Alanazi, S., Salib, M., Attia, M., Thabane, L., & Fox-Robichaud, A. (2014). Continuous venovenous hemofiltration versus continuous venovenous hemodiafiltration in critically ill patients: a retrospective cohort study from a Canadian tertiary center. Canadian respiratory journal, 21(3), 176–180. https://doi.org/10.1155/2014/965479

Continuous Renal Replacement Therapy (CRRT), Market Size, Share & Covid-19 Impact Analysis, By Product Type (Systems, and Consumables), By Modality (Slow continuous Ultra Filtration (SCUF), Continuous Venovenous Hemofiltration (CVVF), Continuous Venovenous Hemodialysis (CVVHD) and Continuous Venovenous Hemodiafiltration (CVVHDF), and Regional Forecast, 2020-2027.(2020).  Market Research Report. https://www.fortunebusinessinsights.com/continuous-renal-replacement-therapy-crrt-market-102547

Golper, T. T. (2021). Continuous kidney replacement therapy in acute kidney injury. UpToDate. Retrieved July 9, 2023.

Kim, S. G., Yun, D., Kim, J., Lee, J., Kang, M. W., Kim, Y. C., Kim, D. K., Oh, K. H., Joo, K. W., Koo, H., Kim, Y. S., & Han, S. S. (2023). Risk of ventricular tachycardia and its outcomes in patients undergoing continuous renal replacement therapy due to acute kidney injury. Kidney research and clinical practice, 42(3), 370–378. https://doi.org/10.23876/j.krcp.22.101

Opgenorth, D., Reil, E., Lau, V., Fraser, N., Zuege, D., Wang, X., Bagshaw, S. M., & Rewa, O. (2022). Improving the quality of the performance and delivery of continuous renal replacement therapy (CRRT) to critically ill patients across a healthcare system: QUALITY CRRT: a study protocol. BMJ open, 12(2), e054583. https://doi.org/10.1136/bmjopen-2021-054583

Ruiz, E. F., Ortiz-Soriano, V. M., Talbott, M., Klein, B. A., Thompson Bastin, M. L., Mayer, K. P., Price, E. B., Dorfman, R., Adams, B. N., Fryman, L., Neyra, J. A., & University of Kentucky CRRT Quality Assurance Group (2020). Development, implementation and outcomes of a quality assurance system for the provision of continuous renal replacement therapy in the intensive care unit. Scientific reports, 10(1), 20616. https://doi.org/10.1038/s41598-020-76785-w

Saunders, H. & Saghavi D.K. (2023). Continuous Renal Replacement Therapy. NIH National Library of Medicine StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK556028/

Siddiqui, A. H., Valecha, G., Modi, J., Saqib, A., Weerasinghe, C., Siddiqui, F., & El Sayegh, S. (2020). Predictors of 15-Day Survival for the Intensive Care Unit Patient on Continuous Renal Replacement Therapy: A Retrospective Analysis. Cureus, 12(5), e8175.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237053/

Welbaum, C. (2021). Nurse’s role in continuous renal replacement therapy. American Nurse Official Journal. https://www.myamericannurse.com/crrt-nurses-role-in-continuous-renal-replacement-therapy/

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- The implementation of CRRT on a standardized scale with a framework geared towards decreased mortality, length of stay and hospital cost.

- The creation of a quality assurance program in order to support provisions made for CRRT in order to achieve a proper standardization scale.

- Standardized, routine lab value monitoring, specifically electrolytes and blood gases in order to decrease the risk of VT (ventricular tachycardia) or any other rhythms that could potentiate cardiac arrest.

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What about CRRT? What does the data tell us?

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What about CRRT? What does the data tell us?

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It is so important to review the literature on CRRT and educate ourselves on strategies on improving health outcomes and enhancing care. Very limited statistical data was provided through the CDC, Agency for Healthcare Research and Quality and NYS Health department, however, the significance for this intervention is demonstrated through the below statistics. These statistics were obtained through retrospective studies published over the past 3 years. The links to the studies are provided with the statistics below. This epidemiological data obtained can be analyzed in order to increase one’s education on this intervention as well as to provide strategies for these patients to improve health outcomes.

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What Type of Technology and Equipment is Used with CRRT?

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What Type of Technology and Equipment is Used with CRRT?

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The CRRT is performed with the use of a specialized technology referred to as a CRRT machine. This machine consists of a filtration component, fluid warmer, cartridge and cycler. An anticoagulation component may also plays a role in this process.

The  cycler, AKA,  the blood purification machine is the operational unit of the system. This system utilizes pumps and sensors needed for the actual operation to be performed. The cycler, or hardware of this technology, is serviced by a brand specific representative independent to the hospital. This representative specializes in machine maintenance and  the cycler's software system updates.

Independent to these methods a vascular access site is used to hook the patient up to the machine in order to initiate the process.

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For this intervention to occur  there is a support staff fully involved with the communication surrounding these patients and their CRRT therapy.  This support staff refers to providers, pharmacists, nurses, dietary and the medical machine representatives. This communication technology involves the use of cortex (messaging between providers and nurses), faxing orders to pharmacy  (fluid solute bags are provided by pharmacy) and the continuous updates via phone. Face to face  communication with family regarding the patient’s prognosis and plan of care is always imperative in any healthcare setting.

FUN FACT!!!!

There are four main methods of CRRT that are based on the critical care team and nephrologist orders.

1. Continueous Venovenous Hemofiltration (CVVH)-

2. Continuous Venovenous Hemodialysis (CVVHD)-

3. Continuous Venovenous Hemodiafiltration (CVVHDF)

4. Slow Continuous Ultrafiltration (SCUF)

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Check out the Medtronic's Page with Information on their CRRT Machine!!

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Acute Extracorporeal Therapy Solutions

Provides continuous renal replacement therapy (CRRT) for acute kidney injury and fluid overloaded pediatric patients weighing 2.5 to 10 kgs.

Order Information

Overview

Innovations in Pediatric CRRT

For the first time, infants with acute kidney injury (AKI) and fluid overload (FO) can be treated with a dialysis system designed specifically for them.

A miniaturized, high-precision platform1,

For the Most Fragile Patients

The first of its kind, the Carpediem™ system offers a dedicated extracorporeal CRRT to low weight patients and responds to the needs of the most fragile patient.

CVVH, CVVHD, and SCUF modalities

Low priming volume & pump flow

High-precision scales

Continuous or bolus Heparin pump delivery

View Clinical Summary

When Size and Scale Matter

Neonatal acute kidney injury (AKI) and fluid overload are under-recognized conditions which often lead to morbidity and mortality.

Clinical data from the Carpediem™ system EU Registry demonstrates a 97% survival rate at end of treatment,†

Closely monitor fluid balance:+/- 1 g High-precision scales2

Enable use of small catheter sizes

Reduce blood cell and vessel damage while providing necessary and adequate diffusive clearances: 2-50 mL/min low blood flow rates1,2,

A renewed focus on what is most important

For the first time, there is no need to adapt adult machines and weigh the complexities that have traditionally plagued pCRRT treatments.

Carpediem™ System Details

1. IV pole holder

2. Warning light

3. Control panel

4. Clip for effluent (EFF) pump segment

5. Effluent (EFF) scale

6. Infusion/dialysis (INF/DIA) scale

7. Venous pressure transducer (Dome)

8. Effluent (EFF) pump

9. Heparin pump

10. Filter holder

11. Venous drip chamber holder

12. Clip for the infusion/dialysis (INF/DIA) pump segment

13. Blood leakage detector (BLD)

14. Air sensor

15. Infusion/dialysis (INF/DIA) pump

16. Blood pump

17. Arterial pressure transducer (Dome)

18. Pre-filter pressure transducer (Dome)

19. Venous electroclamp

20. Clip for infusion/dialysis (INF/DIA) line if a warmer is used

21. Clip for venous line

22. Warmer holder

Carpediem™ system support includes:

Tailored training specific to each individual care setting

On-site system installation

On-demand, 24-hour emergency access to experienced, registered Carpediem™ pCRRT nurses

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carpediem™ cardio-renal pediatric dialysis emergency machine

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Carpediem™ Cardio-Renal Pediatric Dialysis Emergency Machine

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Acute Extracorporeal Therapy Solutions Provides continuous renal replacement therapy (CRRT) for acute kidney injury and fluid overloaded pediatric patients weighing 2.5 to 10 kgs. Order Information Innovations in Pediatric CRRT For the first time, infants with acute kidney injury (AKI) and fluid overload (FO) can be treated with a dialysis system designed specifically for them.

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Check out the  Manufacturer Baxter's Page with Information on their CRRT machine!!

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PRISMAX/PRISMAFLEX Systems provide the truly slow continuous treatment that critically ill patients may require

Download White Paper

Easily Switch Between Therapies

PRISMAX and PRISMAFLEX Systems deliver multiple modes of Continuous Renal Replacement Therapy (CRRT) without the need for additional equipment.

CVVHDF: Continuous Veno-Venous Hemodiafiltration

CVVHD: Continuous Veno-Venous Hemodialysis

CVVH: Continuous Veno-Venous Hemofiltration

SCUF: Slow Continuous Ultrafiltration

Simplify Electrolyte Management With Our Comprehensive Portfolio of CRRT Solutions

Ready to use: Premixed solutions may help minimize preparation time, waste, and potential for medication errors1,2

Flexible: Available in a wide range of bicarbonate buffered solutions with various ionic formulations

Self-sealing: All solutions are packaged in two-compartment bags with self-sealing luer lock capability

On-label: A wide range of replacement solutions allow for security of on-label delivery of all CRRT modalities

PHOXILLUM Solution

The ONLY FDA-approved premixed CRRT replacement solution with phosphate, available in 2 formulations

PRISMASOL Solution

Standard replacement solution available in seven formulations

PRISMASATE Solution

Standard dialysate solution available in seven formulations

Pam Waters, RN, explains the uses and benefits of CRRT replacement solutions, and the differences between pre- and post- replacement solutions.

The PRISMAFLEX and PRISMAX Systems are intended for:
Continuous Renal Replacement Therapy (CRRT) for patients weighing 20 kilograms or more with acute renal failure and/or fluid overload.

Therapeutic Plasma Exchange (TPE) therapy for patients weighing 20 kilograms or more with diseases where fluid removal of plasma components is indicated.

Rx Only. For safe and proper use of products mentioned herein refer to the appropriate Instructions for Use or Operator's Manual.
PHOXILLUM and PRISMASOL Renal Replacement Solution Indications and Important Risk Information
Indications and Usage
PRISMASOL and PHOXILLUM solutions are indicated in pediatric and adult patients for use as a replacement solution in Continuous Renal Replacement Therapy (CRRT) to replace plasma volume removed by ultrafiltration and to correct electrolyte and acid-base imbalances. They may also be used in case of drug poisoning when CRRT is used to remove dialyzable substances.

Warnings and Precautions
Electrolyte and Volume Abnormalities
PHOXILLUM and PRISMASOL solutions can affect electrolytes and volume and may result in hyperkalemia or hyperphosphatemia. Monitor hemodynamic status and fluid inputs and outputs, potassium, phosphorous, calcium, other electrolytes and acid-base balance throughout the procedure. Abnormalities may be corrected by changing the formulation of replacement solution and/or dialysate, supplementation, or adjusting flow rates appropriately. PHOXILLUM replacement solutions contain hydrogen phosphate, a weak acid that may increase the risk of metabolic acidosis.

Blood Glucose Abnormalities
The use of PRISMASOL and PHOXILLUM replacement solutions can affect blood glucose levels resulting in hypo- or hyper-glycemia depending upon the dextrose content of the replacement solution. Monitor blood glucose levels regularly. Patients may require initiation of or modification of antidiabetic therapy or other corrective measures during treatment.

Please see PHOXILLUM and PRISMASOL Solutions full Prescribing Information.

MARS is indicated for the treatment of drug overdose and poisonings. The only requirement is that the drug or chemical be dialyzable (in unbound form) and bound by charcoal and/or ion exchange resins.

MARS is not indicated for the treatment of chronic liver disease conditions or as a bridge to liver transplant. Safety and efficacy has not been demonstrated for those indications in controlled, randomized clinical trials. The effectiveness of the MARS device in patients that are sedated could not be established in clinical studies and therefore cannot be predicted in sedated patients.

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PRISMAX/PRISMAFLEX Systems provide the truly slow continuous treatment that critically ill patients require.

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March 24, 2023 - The FDA has finalized two guidances: Transition Plan for Medical Devices That Fall Within Enforcement Policies Issued During the Coronavirus Disease 2019 (COVID-19) Public Health Emergency and Transition Plan for Medical Devices Issued Emergency Use Authorizations (EUAs) Related to Coronavirus Disease 2019 (COVID-19). The guidances outline the FDA's general recommendations to transition from certain policies adopted and operations implemented during the COVID-19 pandemic to normal operations, including the FDA's recommendations for:

Developing a transition implementation plan,

Submitting a marketing submission, and

Taking other actions with respect to these devices.

The FDA encourages stakeholders to review the two final guidances, attend the webinar, and reach out to the FDA if they have questions or concerns. In particular, for manufacturers planning to seek marketing authorization for their devices, the FDA recommends beginning work on a marketing submission, including a transition implementation plan, as described in the guidances.

Additional Resources:

Continuous renal replacement therapy (CRRT) devices are used to filter and clean the blood when kidneys are damaged or not functioning normally. Based on published data, it has been noted that SARS-CoV-2, the virus that causes COVID-19, has led to an increased population with critical illness and multiple organ failure, including acute kidney injury, increasing the need for CRRT. Devices authorized by these EUAs include the hemodialyzer/hemofilter, delivery unit, bloodlines and tubing, and dialysate solution.

The table below lists the authorization information for the use of specific CRRT and hemodialysis devices during the COVID-19 public health emergency.

Templates for these EUA submissions are available to help facilitate the preparation, submission, and authorization of an EUA.

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Continuous Renal Replacement Therapy and Hemodialysis Devices EUAs

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Continuous Renal Replacement Therapy and Hemodialysis Devices EUAs

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Guidelines from the UK Kidney association created for patients during the COVID-19 pandemic. 

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We use this every day to contact MDs, APPs, other RNs, the Sterile Processing Department and even our dietary department. Click the link to to watch!!

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cortex imprevia medical commercial - Google Search

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"The global continuous renal replacement therapy (CRRT) market size was valued at $986.4 Mn in 2019 & is projected to reach $1,811.5 Mn by 2027, at a CAGR of 8.0%."

This demonstrates the increase in this therapy throughout the years.

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The global continuous renal replacement therapy (CRRT) market size was valued at USD 986.4 million in 2019 and is projected to reach USD 1,811.5 million by 2027, exhibiting a CAGR of 8.0% during the forecast period.

Continuous renal replacement therapy (CRRT) is a popular choice of therapy usually used for renal support in critically ill patients with acute kidney injury (AKI), mainly in hemodynamically unstable patients. It includes the solute removal from blood through the process of hemodialysis or hemofiltration or a combination of both methods. The CRRT therapy is generally carried for about 24 hours in an ICU, making it different from other kinds of conventional renal replacement therapies such as intermittent hemodialysis (IHD) that lasts for about 4 to 6 hours or even less.

For improved dialysis care, key strategies such as technological advancement are adopted by major acute therapy manufacturers. For Example, in 2019, Baxter international Inc., cleared its PrisMax system and the integrated TherMax blood warmer for Continuous renal replacement therapy and therapeutic plasma exchange (TPE). Factors such as the growing prevalence of acute kidney injury worldwide, rising incidence of sepsis, a mounting number of ICU patients, and significant technological advancements would boost the market.

However, stringent regulatory guidelines, coupled with the high CRRT procedural cost in North America, is likely to hamper the market growth. But, the FDA has regulated specific laws on manufacturers that certify the accessibility of advanced quality CRRT devices in intensive care units, thus creating growth opportunities for CRRT industry in the near future.
Impact of COVID-19 Pandemic on the CRRT Market
Despite the COVID-19 outbreak challenges, the market for Continuous renal replacement therapy has witnessed a rise in financial incentives and regulatory supports from various governments worldwide. The market continues to progress and develop in terms of the number of products, companies, and applications. Among the COVID-19 infected people, quite a few have developed acute kidney injury (AKI), a condition which can upsurge mortality. For example, according to the recent report by the International Society of Nephrology (ISN), about 25-50% of the people infected with COVID-19, were diagnosed with kidney abnormalities. Although it is generally observed that COVID-19 virus involves respiratory systems mainly lungs, but a research study and evidence shows that it also includes the kidneys infections either directly or intervened by excessive immune response seen in severe COVID-19 patients.

Besides, as per previous reports of SARS and MERS-CoV infections, acute kidney injury (AKI) has developed in 5 to 15 per cent cases and it brings very high mortality. Considering the ongoing scenario and the increasing rate of kidney infections due to COVID-19, such extra-corporeal therapies may play an important role in the treatment of severely ill patients. Moreover, to support this Ministry of Health & Family Welfare (Government of India) in 2020, released guidelines for dialysis in COVID-19 patients. Right treatment by the experts at the right time can save the lives of the infected people who are battling between life and death. Thus, the aforementioned factors contribute to the positive growth of CRRT market during the forecast period.

LATEST TRENDS

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Technological Advancements in the Market to Boost Kidney Disease Management
The use of CRRT for the management of AKI in critically ill patients has significantly benefited from technological advances in equipment design, a developed understanding of the dose of RRT, timing, and the application of new, more complex modalities. Such advancements have momentously expanded the field of extracorporeal therapies in the ICU. Furthermore, software integration is likely to become a new tool for advanced equipment to perform CRRT treatments efficiently and more safely. The treatment delivery and online hemodynamic stability will be affected by integrating bioimpedance and online hematocrit measurements. Integrating thermal energy balance will help in monitoring the patient's blood temperature. This allows a specific energy balance to be achieved by altering the dialysate based on temperature sensors placed on blood and dialysate lines.

Indeed, such integrated care must be supported by information technologies, for integrated assistance, data collection, delivery of a personalized recommendation, and measurement of results. Consequently, the implementation of advanced software solutions will help in improving treatment for acute kidney injury and organ dysfunction in critically ill patients.

DRIVING FACTORS
Increasing Incidence of Acute Kidney Injury and Chronic Kidney Disease is driving the Market
Diabetes, hypertension, and aging population are the primary risk factors for acute kidney injury. Globally, the prevalence of diabetes is increasing at a rapid pace. According to an article published by the International Diabetes Federation (DFU) in 2019, an estimated 463 million people were living with diabetes, and the number is expected to rise to 578 million by 2030. Accordingly, with the increase in the incidences of diabetes, the number of patients with acute kidney injury is also increasing. Rising awareness by health care providers might reduce its occurrence and improve the management of the underlying diseases amongst the aged population.

Moreover, according to the Centers for Disease Control and Prevention (CDC) in 2019, around 37 million people in U.S are estimated to have chronic kidney disease. This disease, if left untreated, may lead to renal failure or kidney injury and can also result in end-stage renal disease, thereby leading to rise in demand for renal replacement therapy. Hence, the growing prevalence of acute and chronic kidney diseases is likely to propel the growth of the Market.
Growing R&D Expenditures by Industry Players for Developing Innovative CRRT Devices to Boost the Market Growth
The investments in research and development activities by prominent industry players, such as Baxter International Inc., Fresenius Kabi, and Medtronic, aimed at improving CRRT systems are driven to impact business growth. For example, Baxter has developed the PRISMAFLEX system for critical care. PRISMAFLEX system is a flexible platform that offers customized therapies according to the patient's ease and suitability. The system is integrated with advanced technology that enables accurate CRRT in patients suffering from acute kidney injuries. Besides this, the Diapact CRRT system developed by B. Braun is unified with advanced technology that allows effective treatment of acute kidney injuries and diseases. The critical blood filtration process is carried out precisely without any obstructions ensuring rapid recovery of the patients. Such improvements in the CRRT systems, coupled with innovation will result in higher adoption of CRRT systems and is likely to amplify the growth in the near future.

RESTRAINING FACTORS
Stringent Regulatory Guidelines for CRRT in North America to Hinder the Market Growth
Continuous renal replacement therapy product companies in North America experience several regulatory barriers owing to complex regulations set by the FDA, thus adversely impacting the demand for these products. For example, in Europe, CRRT is approved for several indications such as cardiac failure, liver support, intoxication, elevated Intracranial Pressure (ICP), rhabdomyolysis, and post-cardiac surgery. On the other hand, in North America, no CRRT machine is approved by the FDA for the treatment of multiple indications. Likewise, no anticoagulating agent for blood infusion during a CRRT procedure is approved by the FDA till date, though it has been approved in Europe. Owing to these stringent regulatory barriers, several CRRT products approved in other countries are yet to receive approval from the FDA in North America.

The U.S. is holding a substantial Continuous Renal Replacement Therapy Market share in the global market due to its huge AKI population base. Accordingly, the presence of stringent and regulatory policies for the approval of new CRRT product launches in this region is hampering the growth of the market.

SEGMENTATION

By Product Type Analysis

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Consumables Segment to Dominate the CRRT Market Owing to its Low Cost
Based on type, the continuous renal replacement therapy (CRRT) market is segmented into systems and consumables. Though consumable products are low-priced due to repeated use, the market for this segment is comparatively the largest. Besides this, the consumables segment market is predicted to grow massively during the forecast period, owing to the increasing application of charcoal filters, hemofilter, fluids, and other consumables in CRRT procedures.

The systems segment is likely to grow moderately, owing to an increase in the prevalence of acute kidney injury cases. According to an article published by the National Center for Biotechnology Information, the prevalence of acute kidney injury treated with CRRT is approximately 200-300 per million people per year, worldwide. Henceforth, with the increasing prevalence of acute kidney injury, the use of these systems will grow continually.

By Modality Analysis
CVVH to Dominate Owing to the Rising Cases of Fluid Overload in AKI Patients.
Based on modality, the market is segmented into slow continuous ultra-filtration (SCUF), continuous venovenous hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), and continuous venovenous hemodiafiltration (CVVHDF). Among them, the continuous venovenous hemofiltration (CVVH) segment is predicted to dominate the market. The dominance is attributable to the growing incidence of fluid overload cases, which is recurrently found in patients affected by acute kidney injury in critical care units. Additionally, according to an article issued by Elsevier, congestive heart failure is responsible for approximately 5% of all-cause mortality in dialysis patients, which is linked closely with fluid overload, and will consequently increase the application of CVVH treatment procedure. Thus, the increase in dialysis procedures are driving the growth of the segment.

The continuous venovenous hemodiafiltration (CVVHDF) segment is estimated to grow at the highest rate during the forecast period. This treatment modality results in comprehensive removal and replacement of solutes and fluids within the blood. It also includes principles of diffusion and convection, i.e., hemofiltration and hemodialysis using a competent hemodiafilter to remove both solute and fluid, hence propelling the growth of the market.

REGIONAL INSIGHTS

North America Continuous Renal Replacement Therapy Market Size, 2019 (USD Million)

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Growing Demand for CRRT Procedures and Upsurge in Kidney Diseases to Aid North America 's Dominance
The continuous renal replacement therapy market in North America generated a revenue of USD 354.3 million in 2019. The growing demand for CRRT procedures and radical innovation of the machines and systems are factors responsible for the growth of this market in North America. Besides this, the growing prevalence of kidney diseases in the U.S. is projected to spur market growth over the forecast period. According to the data published by the Centers for Disease Control and Prevention (CDC), in 2020, about 34.2 million people in the U.S. are diagnosed with diabetes. Thus, it proposes a large base of kidney-affected target populace for the CRRT market in this region.

On the other hand, Asia Pacific is expected to showcase the fastest growth during the forecast period on account of technological advancement and substantial healthcare expenditure. Moreover, the governments of several Asian countries are actively investing on improving the healthcare centers and services for providing better healthcare facilities to its patient population. Hence, all the aforementioned dynamics are expected to foster growth of this region.

KEY INDUSTRY PLAYERS
Innovation and Geographical Expansion of Key Players to Assist Market Growth
The competitive landscape of the global market represents a monopolistic nature as it is dominated by Baxter International Inc. The presence of a diversified product portfolio of unique Continuous renal replacement therapy technology in critical care, along with constant innovations by the company leading to new device introductions, is the key factor responsible for the dominance of this company.

However, the regional and domestic players such as B. Braun Melsungen AG, Fresenius Medical Care AG & Co. KGaA, Asahi Kasei Corporation, NxStage Medical, Inc., Toray Medical Co., NIPRO Corporation, Ltd, Medtronic plc, and others have entered the market with innovative technology devices. They are focusing on making a positive impact on the market, thereby gaining a significant position in the market share.

LIST OF KEY COMPANIES PROFILED:

Baxter International Inc. (Illinois, United States)

B. Braun Medical Inc. (Pennsylvania, United States)

Fresenius Medical Care AG & Co. KGaA (Bad Homburg, Germany)

Asahi Kasei Corporation (Tokyo, Japan)

NIPRO Corporation (Osaka, Japan)

Toray Medical Co., Ltd (Tokyo, Japan)

NxStage Medical, Inc., (Massachusetts, United States)

Medtronic Plc

Other key Players

KEY INDUSTRY DEVELOPMENTS:

February 2021 - DaVita accomplished its first position by including a secure telehealth platform, DaVita Care Connect, into its home dialysis program. It is one of the various connective technologies in its suite of services designed to improve outcomes and the care experience for patients deciding to treat at home.

December 2020 - Medtronic plc announced the launch of the Carpediem Cardio-Renal Pediatric Dialysis Emergency Machine. This technique is indicated to be used in acute kidney injury or fluid overloaded patients that need hemodialysis. It is planned to supply continuous renal replacement therapy (CRRT) to patients weighing between 2.5 & 10 kg.

April 2020 - Fresenius Medical Care, a worldwide provider of dialysis products and services, has announced the release of an advisory that calls for clinical care principles for patients with advanced chronic kidney during the pandemic crisis. The advisory states that patients who need renal replacement therapy during the COVID-19 crisis should still be offered the treatment decided in consultation with their physicians.

April 2020 - Baxter International Inc. announced that the company had increased its supply of critically needed dialysis products around the world. The company has seen an extreme demand of up to five times greater than previous levels for multiple acute dialysis products due to the rise in COVID-19 patients who require access to continuous renal replacement therapy (CRRT). The company is collaborating with governments worldwide to help assist these challenges.

REPORT COVERAGE

An Infographic Representation of Continuous Renal Replacement Therapy (CRRT) Market

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The Continuous renal replacement therapy market research report provides a detailed analysis of the market and focuses on key aspects such as leading companies, product types, and leading modality types. Besides this, the report offers insights into the market, current trends and highlights the key industry developments. In addition to the aforementioned factors, the report encompasses several factors that have contributed to the growth of the market over recent years.

Report Scope & Segmentation

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Continuous Renal Replacement Therapy (CRRT) Market Size | Report, 2030

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The global continuous renal replacement therapy (CRRT) market size was valued at $986.4 Mn in 2019 & is projected to reach $1,811.5 Mn by 2027, at a CAGR of 8.0%

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Siddiqui et al., (2020) found that:

CRRT has become the choice of RRT for the treatment of AKI in patients admitted to ICUs. In this single-center retrospective review, the overall in-hospital mortality of patients undergoing CRRT in ICU was found to be 84.2%, with only 24.8% of patients surviving the 15-day post-CRRT mark. The reported mortality in patients undergoing CRRT in the ICU ranges from 37% to 75% .

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Predictors of 15-Day Survival for the Intensive Care Unit Patient on Continuous Renal Replacement Therapy: A Retrospective Analysis

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PurposeIn the intensive care unit (ICU), acute renal failure is mostly part of multiple organ dysfunction syndromes with mortality ranging from 28%-90%, continuous renal replacement therapy (CRRT) is the predominant mode of RRT used in ICU. The…

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CRRT is a continuous, 24 hour dialysis therapy that is used in the ICU setting commonly set up and run by the bedside nurse. It is a medical intervention to provide kidney support to hemodynamically unstable, critical patients who would not tolerate hemodialysis (HD). Similar to HD, CRRT acts as a renal replacement therapy. It has the potential to remove plasma water (fluid) and solutes (wastes) from a patient’s blood; however, with CRRT this is accomplished slowly. This is done with the attempt of decreasing fluid and electrolyte shifts  with the goal of maintaining a patient's hemodynamics.

Examples of patients requiring this therapy are a diagnosis of a AKI (acute kidney injury), electrolyte dysfunction, sepsis, metabolic acidosis, fluid overload, heart failure, rhabdomyolysis, multisystem organ dysfunction and inflammatory disorders.

The for-mentioned examples are the health related issues that have benefited from the use of  the intervention CRRT.

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Opgenorth et al, (2022) demonstrated that:

The factors predicting in-hospital mortality in critically ill patients who require CRRT have not been established. Critical care teams should be aware that certain risk factors should be considered in the triage of ICU patients receiving CRRT.

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Affiliations

¹ Division of Renal Diseases and Hypertension/Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO. Electronic address: benjamin.griffin@cuanschutz.edu.

² University of Colorado Health, Aurora, CO.

³ University of Colorado School of Public Health, Aurora, CO.

⁴ Division of Renal Diseases and Hypertension/Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Renal Section, Rocky Mountain Regional VA Medical Center, Aurora, CO.

⁵ Division of Renal Diseases and Hypertension/Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.

⁶ Department of Biostatistics, Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA.

⁷ Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.

⁸ Division of Nephrology/Department of Medicine, University of Iowa, Iowa City, IA.

Free PMC article

Free PMC article

Affiliations

¹ Division of Renal Diseases and Hypertension/Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO. Electronic address: benjamin.griffin@cuanschutz.edu.

² University of Colorado Health, Aurora, CO.

³ University of Colorado School of Public Health, Aurora, CO.

⁴ Division of Renal Diseases and Hypertension/Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Renal Section, Rocky Mountain Regional VA Medical Center, Aurora, CO.

⁵ Division of Renal Diseases and Hypertension/Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.

⁶ Department of Biostatistics, Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA.

⁷ Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.

⁸ Division of Nephrology/Department of Medicine, University of Iowa, Iowa City, IA.

Abstract

Rationale & objective: Clinical practice guidelines recommend delivering a continuous renal replacement therapy (CRRT) dose of 20 to 25mL/kg/h. However, practice patterns nationwide are highly variable; this inconsistent prescribing may lead to errors in medication dosing and increase rates of electrolyte and acid-base abnormalities. We describe an initiative to standardize CRRT practice patterns and reduce dosing variability.

Study design: Quality improvement study.

Setting & participants: Adult patients treated with CRRT at the University of Colorado Hospital between January 2016 and October 2017.

Quality improvement activities: An assessment of the magnitude of the variability in CRRT dosing and the following specific interventions were implemented during the course of 1 year: (1) modification of the electronic medical record (EMR) to include calculated average 24-hour dose in real time, (2) modification of the CRRT procedure note to include comments on dosing, (3) modification of the CRRT order set to display calculations, and (4) yearly educational sessions for renal fellows outlining CRRT-specific dosing targets.

Outcomes: The primary outcome was weekly percentage of CRRT treatments with an average delivered daily dose of 20 to 25mL/kg/h. Process and balancing outcomes included CRRT flowsheet accuracy, documentation of rates of delivered dose, and nursing satisfaction.

Analytical approach: Rates of weekly CRRT dosing in compliance with national guidelines were determined and used to create run charts showing compliance rates before and after the quality improvement interventions.

Results: Among 837 treatments before the intervention, 279 (33%) daily CRRT sessions achieved an average dose of 20 to 25mL/kg/h. Following implementation of interventions, 631 of 952 (66%) treatments achieved this goal. Week-to-week variation in dosing was significantly reduced.

Limitations: A single-center study generating data that may not be generalizable to institutions with different CRRT nursing models or different EMR systems.

Conclusions: Changes to the EMR and documentation templates and education of CRRT providers about dosing were associated with doubling of the rate of appropriate CRRT dosing and reduction in dosing variability.

Keywords: Quality improvement; acute kidney injury (AKI); best practices; continuous renal replacement therapy (CRRT); critical care; dialysis dose; electronic health record (EHR); evidence-based medicine; guideline implementation; inpatient care; intensive care unit (ICU); nursing practice; quality of care.

Conflict of interest statement

Financial Disclosures

The authors declare that they have no financial conflicts of interest.

Cited by

Research on the Application Effect of Strengthening Risk Management in Continuous Renal Replacement Therapy Nursing of Critically Ill Patients.

Yang H, Chen Y, Fu M. Yang H, et al. Evid Based Complement Alternat Med. 2022 Jul 8;2022:2363877. doi: 10.1155/2022/2363877. eCollection 2022. Evid Based Complement Alternat Med. 2022. PMID: 35845585 Free PMC article. Retracted.

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continuous renal replacement therapy / methods*

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continuous renal replacement therapy / mortality

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dialysis solutions / administration & dosage*

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national center for biotechnology information

# data[].attributes.attachment_link.title
Continuous Renal Replacement Therapy Dosing in Critically Ill Patients: A Quality Improvement Initiative - PubMed

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Changes to the EMR and documentation templates and education of CRRT providers about dosing were associated with doubling of the rate of appropriate CRRT dosing and reduction in dosing variability.

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                       Another Explanation of CRRT 

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                       Another Explanation of CRRT 

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There are a lot great videos out there that explain this intervention. Check out this one from a YouTube Channel called ICU Advantage.

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Kim et al., (2023) found that:

Sustained VT occurrence after starting CRRT is associated with increased patient mortality. The monitoring of electrolytes and acid-base status during CRRT is essential because of its relationship with the risk of VT.

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Seong Geun Kim, 1 Donghwan Yun, 1 Jayoun Kim, 2 Jinwoo Lee, 1 Min Woo Kang, 1 Yong Chul Kim, 1 Dong Ki Kim, 1 Kook-Hwan Oh, 1 Kwon Wook Joo, 1 Hoseok Koo, 3 Yon Su Kim, 1 and Seung Seok Han 1

Abstract

Background

Despite efforts to treat critically ill patients who require continuous renal replacement therapy (CRRT) due to acute kidney injury (AKI), their mortality risk remains high. This condition may be attributable to complications of CRRT, such as arrhythmias. Here, we addressed the occurrence of ventricular tachycardia (VT) during CRRT and its relationship with patient outcomes.

Methods

This study retrospectively enrolled 2,397 patients who started CRRT due to AKI from 2010 to 2020 at Seoul National University Hospital in Korea. The occurrence of VT was evaluated from the initiation of CRRT until weaning from CRRT. The odds ratios (ORs) of mortality outcomes were measured using logistic regression models after adjustment for multiple variables.

Results

VT occurred in 150 patients (6.3%) after starting CRRT. Among them, 95 cases were defined as sustained VT (i.e., lasting ≥30 seconds), and the other 55 cases were defined as non-sustained VT (i.e., lasting <30 seconds). The occurrence of sustained VT was associated with a higher mortality rate than a nonoccurrence (OR, 2.04 and 95% confidence interval [CI], 1.23-3.39 for the 30-day mortality; OR, 4.06 and 95% CI, 2.04-8.08 for the 90-day mortality). The mortality risk did not differ between patients with non-sustained VT and nonoccurrence. A history of myocardial infarction, vasopressor use, and certain trends of blood laboratory findings (such as acidosis and hyperkalemia) were associated with the subsequent risk of sustained VT.

Conclusion

Sustained VT occurrence after starting CRRT is associated with increased patient mortality. The monitoring of electrolytes and acid-base status during CRRT is essential because of its relationship with the risk of VT.

Keywords: Acute kidney injury, Continuous renal replacement therapy, Electrolytes, Mortality, Ventricular tachycardia

Introduction

Acute kidney injury (AKI) is a common complication in critically ill patients, and interest in this condition has increased due to its relationship with high mortality [ 1, 2]. Continuous renal replacement therapy (CRRT) is frequently the first option used to treat patients with severe AKI who require renal replacement therapy, particularly when they are hemodynamically unstable [ 3- 5]. Despite the success of the therapeutic approach with this modality, the mortality rates have not decreased to <50% over the past two decades [ 2, 6, 7]. Several adverse events that may arise in patients on CRRT may hinder its clinical usefulness, even with appropriate initiation [ 8- 10]; these adverse events include hypotension, an imbalance in major and minor electrolytes, hypothermia, hematologic abnormalities, and catheter-related complications [ 9]. Certain arrhythmias may occur during CRRT [ 6, 9, 11]; new-onset atrial fibrillation has been reported in >10% of patients on CRRT, and its occurrence is associated with worse patient outcomes [ 11]. Other arrhythmias may also occur, but their characteristics, risk factors for occurrence, and subsequent outcomes have not been thoroughly evaluated.

Ventricular tachycardia (VT) is a rare subset of arrhythmias in healthy individuals, but it may frequently occur if abnormalities in the heart structure, metabolites, and electrolytes exist [ 12]. Patients undergoing hemodialysis may be at extremely high risk of VT because they have myocardial fibrosis, a microvascular disorder, left ventricular hypertrophy, and electrical instability due to the repeated fluid shifts that occur during hemodialysis [ 13]. Similarly, patients with CRRT typically experience regional impairment in cardiac contractility [ 14]; thus, VT may occur in patients on CRRT, but no studies have examined this issue. The present study evaluated the prevalence of VT in patients after starting CRRT due to AKI, predictors related to its occurrence, and its relationship with overall mortality outcomes.

Methods

Patients and data collection

This was a retrospective observational study of 2,832 patients who underwent CRRT at Seoul National University Hospital from June 2010 to December 2020. Among these, patients who were under 18 years old (n = 58) and those who had been on chronic hemodialysis because of end-stage kidney disease (n = 377) were excluded. Finally, 2,397 patients were analyzed in the present study. The study design was approved by the Institutional Review Board of Seoul National University Hospital (No. H-2110-085-1262) and complied with the Declaration of Helsinki. The requirement for informed consent was waived by the review board.

Baseline information at the time that CRRT began was collected, such as age, sex, weight, cause of AKI (e.g., septic and nonseptic), initial CRRT settings (e.g., target dose, blood flow rate, and target ultrafiltration), mechanical ventilation, use of vasopressors, the division of intensive care unit, and severity indices (e.g., the sequential organ failure assessment [SOFA], the Acute Physiology and Chronic Health Evaluation [APACHE] II, and the Charlson comorbidity index [CCI]). The SOFA, APACHE II, and CCI scores were calculated using the original formulas [ 15- 17]. Laboratory values, such as pH, potassium, bicarbonate, and phosphate levels, were measured at least twice a day after starting CRRT until the day of VT occurrence or of CRRT discontinuation for patients who did not develop VT. Systolic and diastolic blood pressures were also collected both before and after the VT events.

All patients were monitored with bedside monitors, which produced waveforms of electrocardiograms. VT events were documented in their electronic medical records, and the first VT event was retrospectively collected for the present study. VT was classified as non-sustained VT (NSVT) or sustained VT (SVT) as follows: NSVT, ≥3 consecutive ventricular beats with an R-R interval of 600 ms and lasting <30 seconds; and SVT, a ventricular rhythm of >100 beats per minute lasting ≥30 seconds or requiring termination due to hemodynamic instability.

Outcomes

The primary outcome was all-cause mortality after CRRT, and it was stratified by timeframe (e.g., 7 days, 30 days, and 90 days). Any change in blood pressure during the VT events was additionally evaluated.

Statistical analysis

Categorical and continuous variables are presented as proportions and means ± standard deviations when they were normally distributed and as medians with interquartile ranges when they were not normally distributed, respectively. The normality of the distribution was analyzed using the Kolmogorov-Smirnov test. The chi-square test or Fisher exact test was employed to compare categorical variables. The Student t test or the Mann-Whitney U test was used to analyze continuous variables with or without a normal distribution. The Wilcoxon signed-rank test was carried out to confirm significant changes in continuous variables.

We assessed the effect of VT on mortality outcomes by constructing Kaplan-Meier curves and performing a log-rank test. The hazard ratios and confidence intervals for mortality outcomes were calculated using the Cox proportional hazard regression model. Due to a violation of the Cox proportion assumption, we used a logistic regression model and calculated the odds ratios (ORs) of mortality outcomes with adjustment for multiple variables. The adjusted variables were selected based on the significance of their association with mortality. A competing risk Cox proportional hazard regression model was used at multiple time points of CRRT with time-dependent variables (e.g., pH, potassium, bicarbonate, and phosphate) to investigate the predictors of VT. Time-dependent variables were obtained until VT occurrence or discontinuation of CRRT. All statistical analyses were performed using the IBM SPSS version 27 (IBM Corp.) and R software version 3.5.1) (R Foundation for Statistical Computing). A p-value of <0.05 was considered statistically significant.

Results

Patient demographics

The baseline characteristics are presented in Table 1 . The mean patient age was 64 ± 15 years, and 38.6% of the patients were female. The proportion of patients with sepsis was 54.9%. VT occurred in 150 patients (6.3%); most cases took place within 1 week after CRRT initiation ( Fig. 1 ). Patients who developed VT were more likely to require mechanical ventilation or ≥3 vasopressors and had higher SOFA scores than patients without VT.

Table 1.

Characteristic

Overall

Non-VT group

VT group

p-value

The relationship between ventricular tachycardia and mortality

During a median follow-up period of 12 days (interquartile range, 3-29 days), 1,591 patients (66.4%) died. The mortality incidence was 24.3 deaths per 1,000 person-days. When a univariable Cox regression model was applied, several variables, including age, sex, septic AKI, initial CRRT settings (such as blood flow rate and target ultrafiltration), mechanical ventilation, use of ≥3 vasopressors, and SOFA, APACHE II, and CCI scores, were identified as significant factors related to mortality ( Table 2 ), and these variables were included in subsequent multivariable regression models for adjustment.

Table 2.

Variable

Hazard ratio (95% CI)

p-value

Fig. 2A shows the Kaplan-Meier survival curves for patients with and without VT, and their survival rates differed (p < 0.001). When VT was classified according to duration, an apparent violation of the proportionality of hazards assumption was observed because the NSVT and non-VT curves crossed (p = 0.97) ( Fig. 2B ). Similarly, the multivariable regression model confirmed that only SVT was independently associated with a high mortality risk, irrespective of the timeframes ( Table 3 ). Blood pressures were compared before and after the VT events to explore the hemodynamic effects. Although NSVT was not associated with hemodynamic fluctuation, SVT decreased blood pressure, which might be the cause of the high mortality in patients with SVT ( Fig. 3 ).

Table 3.

Outcome

Variable

Odds ratio (95% CI)a

p-value

7-day mortality

Non-sustained VT

0.71 (0.35-1.46)

0.36

30-day mortality

Non-sustained VT

1.16 (0.65-2.10)

0.62

90-day mortality

Non-sustained VT

1.72 (0.89-3.31)

0.11

Risk factors for ventricular tachycardia in patients on continuous renal replacement therapy

Table 4 shows a competing risk Cox regression analysis that was carried out to identify risk factors for either SVT or NSVT. A history of myocardial infarction, vasopressor use, and certain trends, such as acidosis and hyperkalemia, were independently associated with the occurrence of SVT. A history of congestive heart failure and a hypophosphatemia trend were associated with the occurrence of NSVT.

Table 4.

Variable

Non-sustained VT

Sustained VT

Hazard ratio (95% CI)

p-value

Hazard ratio (95% CI)

p-value

Discussion

Several arrhythmias may occur after starting CRRT and may exacerbate patients' existing conditions. The present study focused on VT in patients receiving CRRT, and the occurrence of SVT was associated with worse outcomes, such as a high mortality rate and low blood pressure. Certain factors were correlated with a high risk of VT, such as vasopressor use, acidosis, hyperkalemia, and hypophosphatemia.

A previous study of 595 patients revealed that 2.3% of patients on CRRT had VT [ 9]. In another multinational cohort of patients treated with CRRT for AKI, VT occurred in 0.2% of patients [ 6]. The present cohort had a prevalence of 6.3%, and the differences might have depended on the different characteristics of patients in these respective studies. Among all episodes of VT, the incidence of SVT was 4.0%, while that of NSVT was 2.3%. Depending on the definitions for SVT and NSVT, a difference in prevalence might exist between studies [ 18].

Patients on CRRT frequently require the support of vasopressors because of hemodynamic instability. Vasopressors are generally administered based on the assumption that short-term clinical recovery will be facilitated by an enhanced cardiac output or vascular tone. However, these agents may lead to fatal adverse events, such as sinus tachycardia, asymptomatic ventricular ectopic activity, and other ventricular arrhythmias [ 19, 20]. Our data suggested that the use of many vasoactive agents was associated with an increased risk of SVT, regardless of the severity of illness, which supports the findings reported previously.

According to the time-dependent analysis, hyperkalemia and acidosis were associated with the risk of SVT. Systemic acidosis provokes arrhythmias via both the direct action of Na⁺-H⁺ and Na⁺-Ca2⁺ exchangers and the indirect action of inflammatory or hyperoxidative injury [ 21]. Some clinical studies have documented the association between systemic acidosis and VT [ 22- 24]. The presence of systemic acidosis was the strongest determinant of ventricular arrhythmia in patients with ST-elevated myocardial infarction after reperfusion therapy [ 24]. In addition to the role of hypokalemia as a risk factor for fatal ventricular arrhythmias [ 25- 27], hyperkalemia also exerts effects on cardiac excitability, which predisposes hearts to reentrant tachyarrhythmias, such as VT [ 28, 29]. When combined with hypoxia and acidosis, hyperkalemia promotes phase 2 reentry by further increasing the repolarization reserve in epicardial ventricular tissue [ 30]. As refractory acidosis and hyperkalemia are frequent complications observed following severe AKI, our data indicate that insufficient dialysis at the early stage of CRRT might be one of the causative factors for VT. Hypophosphatemia, which occurs in 10% to 60% of patients receiving CRRT [ 31- 33], is associated with adverse events, such as prolonged mechanical ventilation or vasoactive agent support in critically ill patients [ 34, 35]. Although an association between NSVT and mortality was not documented in this study, we recommend that phosphate levels be monitored during CRRT because the results of previous studies have demonstrated the potential risk of NSVT [ 36- 38].

Although the current study is informative, certain limitations remain to be addressed. Because of its retrospective design, unmeasured biases and confounders might have interfered with the analyses. Alterations in practice may be related to mortality but were not considered in the present study. The cause of death was not available in the present dataset. Heart function was not thoroughly evaluated, which might be a main cause of VT occurrence. The occurrence of VT and its risk factors may also differ depending on the cause of AKI, but the present study did not categorize nonseptic patients into further specific causes.

The present study indicated that the occurrence of VT in patients on CRRT was associated with an unfavorable prognosis, particularly in those with SVT. Several factors, such as vasopressor use, acidosis, hyperkalemia, and hypophosphatemia, were associated with the risk of VT, and some of them were considered modifiable during CRRT implementation. Accordingly, monitoring VT and making early attempts to reduce the risk factors for VT will therefore be needed after patients begin CRRT.

Footnotes

Conflicts of interest

All authors have no conflicts of interest to declare.

Data sharing statement

The data are available from the authors upon reasonable request.

Authors' contributions

Conceptualization: SGK, SSH

Data curation: DY, JL, YSK

Formal analysis: DY, JK, JL, YCK, DKK, KHO, KWJ, HK, YSK

Investigation: DY, JL, MWK, YCK, DKK, KHO, KWJ

Methodology: JK, YCK, HK

Writing-original draft: SGK, SSH

Writing-review & editing: SSH

All authors read and approved the final manuscript.

References

18. Zipes DP, Libby P, Bonow RO, Braunwald E. Braunwald's Heart disease: a textbook of cardiovascular medicine. 7th ed. Saunders; 2004. [ Google Scholar]

26. Schupp T, Behnes M, Zworowsky MV, et al. Hypokalemia but not hyperkalemia is associated with recurrences of ventricular tachyarrhythmias in ICD recipients. Clin Lab. 2020 Mar 1; doi: 10.7754/clin.lab.2019.190645. [Epub]. DOI: [[ PubMed] [ CrossRef] Google Scholar]

Articles from Kidney Research and Clinical Practice are provided here courtesy of Korean Society of Nephrology

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Risk of ventricular tachycardia and its outcomes in patients undergoing continuous renal replacement therapy due to acute kidney injury

# data[].attributes.attachment_link.description
Despite efforts to treat critically ill patients who require continuous renal replacement therapy (CRRT) due to acute kidney injury (AKI), their mortality risk remains high. This condition may be attributable to complications of CRRT, such as arrhythmias. ...

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There is a very high risk of early mortality with an ICU admission and an AKI requiring CRRT. Although it is only provided to those critically ill, these statistics can help advise us just how ill a patient is and help to create additional strategies to improve their outcomes.