Volume 104 · Issue 44 · 2024

Continuous renal replacement therapy (CRRT) has become a crucial treatment for critical acute kidney injury (AKI) patients. With the widespread application of CRRT, the need for standardized evaluation and control of CRRT medical quality has emerged as a significant issue in nephrology and related fields. This article reviews the development of CRRT, from its origins to technological advancements and current widespread use, explores the framework for evaluating CRRT medical quality, emphasizes the importance of balancing efficacy and safety, and provides recommendations for improving medical quality including the formation of multidisciplinary teams and goal-directed renal replacement therapy to ensure the efficacy and safety.

Anticoagulant therapy is an important component of continuous renal replacement therapy (CRRT). This article is based on evidence-based medicine and systematically summarizes the status and issues of anticoagulant regimens such as unfractionated heparin, regional heparinization, low molecular weight heparin, regional citrate anticoagulation, agatroban, nafamostat mesylate, and prostacyclin during CRRT in patients with or without high-risk bleeding, heparin induced thrombocytopenia or liver dysfunction, and provides recommendations, aiming to guide clinicians in the rational selection of anticoagulant regimens for CRRT.

Continuous renal replacement therapy (CRRT) is an important support treatment technique for critically ill patients. Anticoagulation is a crucial part for CRRT. High bleeding risk, hypercoagulability, liver failure, and tissue hypoperfusion are very common in critically ill patients. Patients with these conditions, neonate/infant patients, and old patients need special considerations on clearance of anticoagulant and the efficacy and safety of anticoagulation for CRRT. Therefore, bleeding risk, coagulation status, metabolism characteristics of anticoagulation drug, and treatment needs should be considered when tailored anticoagulation strategies are chosen for CRRT in these patients. Additionally, closely monitoring of the relevant indicators and side effects are needed, and dosage and mode of different anticoagulants should be adjusted in a timely manner.

Continuous renal replacement therapy (CRRT) plays a crucial role in the volume management for critically ill patients. Net ultrafiltration (NUF) rate, as an important therapeutic parameter of CRRT, has received widespread attention for its individualized prescription and functionin volume management of critically ill patients. The aim of this article is to identify the relationship between NUF rate settings and the prognosis of critically ill patients in the clinical practice of CRRT, determine the optimal therapeutic range of NUF rate, and thus improve the effect of CRRT volume management, and provide insights into to future NUF rate studies.

Cardiomyopathies encompass a spectrum of disorders characterized by alterations in cardiac structure, function, histology, and the conduction system due to myocardial cell injury, with significant variability in clinical presentation and prognosis. Despite overlapping morphological features among different types of cardiomyopathies, phenotypic similarities limit the precision of diagnosis and consequently affect the development of therapeutic strategies and prognosis assessment. Diagnosis begins with the screening of myocardial morphology and function abnormalities, primarily relying on multimodal non-invasive imaging techniques such as echocardiography, CT scans, and cardiac magnetic resonance imaging. These techniques comprehensively summarize the structural, functional, and tissue characteristics of various cardiomyopathies, highlighting differences among them. In view of the unique needs and current situation in this field in China, an expert group has jointly developed the"Clinical guideline for non-invasive imaging techniques in diagnosing adult cardiomyopathies (2024 edition)."These guidelines integrate the latest evidence, and systematically introduce the diagnosis and monitoring of cardiomyopathy, the application of non-invasive imaging techniques, and the analysis of features of cardiomyopathies, thereby to enhance the precise diagnosis of cardiomyopathy and aid in offering information for therapeutic decision-making, aiming to provide reasonable recommendations for clinicians in China.

To evaluate the association between early net ultrafiltration (NUF) rate and risk of death in patients with cardiac surgery-associated acute kidney injury (CSA-AKI) requiring continuous renal replacement therapy (CRRT).

Adult patients who received CRRT for more than 24 hours due to CSA-AKI in the First Affiliated Hospital of Nanjing Medical University from January 2016 to December 2021 were prospectively included. The NUF rate during the first 48 hours of CRRT was taken as a classified variable (low rate:<1.70 ml·kg^-1·h^-1; moderate rate: 1.70-2.47 ml·kg^-1·h^-1; high rate:>2.47 ml·kg^-1·h^-1). The association between 90-day mortality and NUF rates was analyzed by Cox regression and mediation analyses.

A total of 262 patients were enrolled (171 males and 91 females), with the median (Q₁, Q₃) age of 64 (54, 71) years and median (Q₁, Q₃) NUF rate of 2.03 (1.58, 2.62) ml·kg^-1·h^-1. The 90-day mortality was 60.3% (158/262). Compared with the moderate NUF rate, patients with the low NUF rate (adjusted HR=1.52, 95%CI: 1.01-2.27, P=0.043) and high NUF rate (adjusted HR=1.54, 95%CI: 1.02-2.33, P=0.039) had a significantly higher risk of 90-day death. In mediation analysis, compared with the moderate NUF rate, the putative effect of the high NUF rate on 90-day mortality was direct [adjusted average direct effects (ADE)=1.12, 95%CI: 1.04-1.21,P=0.004] and not mediated by effects of the NUF rate on fluid balance [adjusted average causal mediation effects (ACME)=1.00, 95%CI:0.98-1.01, P=0.502]. The putative effect of the low NUF rate on mortality was not direct (adjusted ADE=0.93, 95%CI:0.81-1.05, P=0.274), but was mediated by its effect on fluid balance (adjusted ACME=0.93, 95%CI:0.87-0.98, P=0.018).

Compared with NUF rates between 1.70-2.47 ml·kg^-1·h^-1 within the first 48 hour of CRRT, NUF rates>2.47 and<1.70 ml·kg^-1·h^-1 were associated with higher mortality in CSA-AKI patients receiving CRRT.

To evaluate the efficacy of early goal-directed renal replacement therapy (GDRRT) in patients with severe pneumonia associated acute kidney injury (AKI).

Patients with severe pneumonia and diagnosed with AKI, and underwent GDRRT at Zhongshan Hospital between January 1, 2017 and December 31, 2022 were retrospectively enrolled. All patients were divided into early RRT group and regular RRT group according to fluid status, inflammation progression, and hemodynamics at RRT initiation.The primary endpoint was in-hospital all-cause mortality, and the secondary endpoints included recovery of renal function at discharge, and 90-day and 1-year all-cause mortality. The multivariate Cox regressionwas employed to analyze therelationship between timing of RRT initiation and patient′s prognosis.

A total of 170 patients aged (71±13) years were enrolled, including 122 males (71.8%). There were 86 and 84 cases in the early and regular RRT groups, respectively. No statistically significant differences of demographic characteristics were detected between the two groups (all P>0.05). At RRT initiation, the patients in the early RRT group displayed a lower percentage of fluid load [2% (1%, 3%) vs 3% (2%, 4%), P<0.001], lower rate of using high-dose of vasoactive agents [11.6% (10/86) vs 40.5% (34/84), P<0.001] and higher rate of radiographic progression within 72 h in the intensive care unit (ICU) [58.1% (50/86) vs 33.3% (28/84), P<0.001] than those in the regular RRT group. The all-cause in-hospital mortality was significantly lower in the early RRT group than that in regular RRT group [37.2% (32/86) vs 67.9% (57/84), P<0.001]. Patients in the early RRT group displayed a significantly higher proportion of complete renal recovery at discharge [44.2% (38/86) vs 7.1% (6/84), P<0.001]. The 90-day [46.5% (40/86) vs 82.1% (69/84), P<0.001] and 1-year [65.1% (56/86) vs 92.9% (78/84), P<0.001] mortality were significantly lower in the early RRT group. Multivariate Cox proportional hazards regression model revealed that the early initiation of GDRRT significantly decreased the risk of in-hospital mortality (HR=0.57, 95%CI: 0.37-0.88, P=0.011).

This study indicates that early GDRRT for the treatment of severe pneumonia-associated AKI based on fluid status, hemodynamics and inflammation progression is associated with reduced hospital mortality and better recovery of renal function.

To evaluate the association between fluid balance within 48 hours after initiating continuous renal replacement therapy (CRRT) and 90-day mortality of patients with cardiac surgery-associated acute kidney injury (CSA-AKI).

Adult patients who received CRRT for CSA-AKI for more than 24 hours between January 2016 and December 2021 in the First Affiliated Hospital of Nanjing Medical University were prospectively included. Exposures were fluid input, fluid output, fluid balance and percentage of fluid overload change (defined as weight-standardized fluid input/output difference) within 48 hours after CRRT initiation. The primary outcome was 90-day mortality. The relationship between the exposures and 90-day mortality was determined by restricted cubic spline and segmented Cox regression.

The study enrolled 262 patients, and 90-day mortality was 60.3% (158/262). There were 171 males and 91 females, with a median age of 64 (54, 71) years. The dead patients (n=158) had more fluid input [6.43 (5.62, 7.34) L vs 6.07 (5.09, 6.90) L, P=0.013], greater fluid balance [-0.01 (-1.36, 1.34) L vs -0.65 (-1.71, 0.42) L, P=0.005] and higher percentage of fluid overload change [-0.01% (-2.17%, 2.01%) vs -0.85% (-2.49%, 0.52%), P=0.013] within 48 hours after CRRT initiation than the survived patients (n=104). The cumulative fluid balance and fluid overload changes have a "J" curve relationship with 90-day mortality. Higher positive fluid balance (adjusted HR per 1 L increase above 0.5 L=1.33, 95%CI: 1.17-1.50) and greater proportion of fluid overload changes (adjusted HR per 1% increase above 0.7%=1.20, 90%CI: 1.11-1.30) were associated with an increased risk of death. Cumulative fluid input was linearly related to the 90-day mortality. Higher input (adjusted HR per 1 L increase=1.13, 95%CI: 1.03-1.24) was associated with an increased risk of death. The cumulative fluid output showed a U-shaped relationship with risk of death. Both lower output (adjusted HR per 1 L increase below 6.7 L=0.73, 95%CI: 0.58-0.90) and higher output (adjusted HR per 1 L increase above 6.7 L=1.24, 95%CI: 1.01-1.53) were associated with increased risk of death.

In patients with CSA-AKI, excessive fluid input, insufficient or excessive output and a positive fluid balance or percentage of fluid overload change within the first 48 hours after CRRT initiation are associated with increased risk of 90-day mortality.

To investigate the influence of different post-filter ionic calcium (Ca²⁺) gradients (0.25-0.35 mmol/L vs>0.35-0.50 mmol/L) on the extracorporeal lifetime of local citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT).

Patients who underwent CRRT with RCA at West China Hospital of Sichuan University from March 2021 to June 2022 were retrospectively selected. The basic information and the values of post-filter Ca²⁺at 0, 2, and 6 hours after the start of treatment and every 6 hours thereafter were collected. The patients were divided into low concentration group (0.25-0.35 mmol/L mmol/L) and high concentration group (>0.35-0.50 mmol/L) according to the mean value of Ca²⁺concentration per treatment, and propensity score matching was performed in a 1∶1 ratio to evaluate the effect of post-filter [iCa²⁺] on the duration of extracorporeal circulation in different groups.

A total of 232 patients (147 males and 85 females) aged (58.2±16.9) years were enrolled. There were 431 cases treated with CRRT for 12 592 h, including 317 cases (73.5%) in the low concentration group and 114 cases (26.5%) in the high concentration group. The baseline data of the two groups were matched and analyzed. Coagulation events occurred in 54.9% (62/113) and 54.0% (61/113) in the low and high concentration groups, respectively (P=0.894). The median survival on extracorporeal circulation was 65.0 (29.0, 72.0) h and 68.0 (31.5, 72.0) h in the two groups, respectively (P=0.805). Multivariate Cox regression analyses showed that post-filter [iCa²⁺] had no effect on extracorporeal life expectancy (HR=0.99, 95%CI:0.55-1.79).

During CRRT treatment with RCA, the desired anticoagulant effect can still be achieved when the post-filter [iCa²⁺] target was set to 0.25-0.50 mmol/L.

To explore the feasibility of transthoracic cardiac shear wave elastography (SWE) for non-invasive quantitative measurement of myocardial stiffness in healthy volunteers (HV) and hypertrophic cardiomyopathy (HCM) patients, and analyze the relationship between myocardial shear wave velocity (SWV) and left ventricular diastolic function.

A total of 16 HV who underwent health check-ups and 5 HCM patients who visited the Cardiology Outpatient Clinic at Fujian Medical University Affiliated Union Hospital from September 2022 to October 2023 were prospectively recruited. The SWE technique was used to measure SWV of the basal segment of the interventricular septum, including left ventricular long-axis myocardial shear wave velocity (LA-SWV) and short-axis myocardial shear wave velocity (SA-SWV). The intraclass correlation coefficient (ICC) was employed to evaluate the intra-observer and inter-observer consistency of SWV measurements. Spearman′s correlation analysis was performed to evaluate the correlation between baseline characteristics, echocardiography parameters and SWV. Quantitative data were expressed as median (interquartile range) [M (Q₁, Q₃)].

The HV group had the age of 34.5 (24.0, 51.0) years, including 8 males (50%); the HCM group had the age of 34.0 (27.0, 46.0) years, including 3 males (60%). The intra-observer and inter-observer ICC (95%CI) for LA-SWV measurements were 0.806 (0.592-0.907) and 0.785 (0.471-0.949), respectively, indicating high consistency; the intra-observer and inter-observer ICC (95%CI) for SA-SWV measurements were 0.746 (0.359-0.862) and 0.602 (0.245-0.834), indicating moderate consistency. LA-SWV [1.74 (1.65, 1.77) vs 1.25 (1.22, 1.33) m/s, P<0.001] and SA-SWV [1.98 (1.96, 2.15) vs 1.52(1.46, 1.55) m/s, P<0.001] were significantly higher in HCM group than those in HV group. There was no significant correlation between SWV and gender, age or body mass index (all P>0.05). In the left ventricular long-axis view, interventricular septal end-diastolic thickness (IVSDT) (r=0.749, P<0.001), early diastolic mitral valve flow velocity/early diastolic mitral annular peak motion velocity (E/e′) (r=0.669, P<0.001), and left ventricular mass index (LVMI) (r=0.679, P<0.001) were positively correlated with LA-SWV, while e′ (r=-0.545, P<0.001) and late diastolic mitral annular peak motion velocity (r=-0.489, P=0.021) were negatively correlated with LA-SWV. In the left ventricular short-axis view, IVSDT (r=0.784, P<0.001), E/e′ (r=0.657, P<0.001), and LVMI (r=0.660, P<0.001) were positively correlated with SA-SWV, while e′ was negatively correlated with SA-SWV (r=-0.658, P<0.001).

The use of SWE technique to measure myocardial SWV can be applied to assess the stiffness differences between normal myocardium and HCM myocardium. Additionally, SWV is correlated with left ventricular diastolic function indices and can effectively evaluate the diastolic dysfunction of the left ventricle caused by HCM.

This paper reports a patient with differentiation syndrome caused by giretinib after hematopoietic stem cell transplantation in acute myeloid leukemia. The patient was admitted to the hospital for more than half a month due to repeated fever. After admission, he still had repeated fever, with a fever peak of 40 ℃, accompanied by chest tightness, and later developed weight gain (>5 kg compared with basal weight). The patient did not respond to various antibacterial, antiviral, antifungal and anti-tuberculosis mycobacterial treatments. Traditional etiology and metagenomic second-generation sequencing were negative. CT and B-ultrasound repeatedly found thoracic, abdominal and pericardial effusion. Pericardial effusion examination ruled out the possibility of infection and extramedullary infiltration of leukemia. The treatment was discontinued with giretinib and dexamethasone 10 mg, twice a day for anti-inflammatory treatment. At the same time, oxygen inhalation, albumin plasma supplementation and diuresis were given. The patient's body temperature was controlled, the chest tightness symptoms were relieved, the weight returned to the basic weight, the blood pressure was normal, the inflammatory indexes (C-reactive protein, erythrocyte sedimentation rate, interleukin-6) dropped to normal, the re-examination of B-ultrasound showed no obvious effusion in the pericardium, abdominal cavity and bilateral pleural cavity, and the chest CT showed basic absorption of the two lower lung infection lesions.

This paper reports a case of idiopathic inflammatory myopathy with right ventricular dilatation, right heart failure and right ventricular thrombosis as main manifestations. A 32-year-old woman was clinically presented with systemic sclerosing overlapping myositis, while serologically presented a rare positive anti-Ku antibody. After immunosuppressive therapy, the patient's symptoms improved and the cardiac function partially recovered.

The main treatment modes of endometrial cancer (EC) are surgery and selective adjuvant therapy. Among them, adjuvant radiotherapy is an important part of postoperative treatment of EC patients. The choice of adjuvant therapy is mainly based on clinicopathological factors. This article mainly reviews the current stratification of risk factors and adjuvant radiotherapy regimen after EC surgery, focuses on the role of molecular typing in adjuvant radiotherapy regimen decision-making under the new stage 2023 of the International Federation of Obstetrics and Gynecology (FIGO), and introduces the formulation of radiotherapy plan and the application of adjuvant radiotherapy in advanced EC. In 2023, FIGO staging fully integrated molecular typing, and postoperative adjuvant therapy for EC focused more on individualization. Up to now, the National Comprehensive Cancer Network (NCCN) guidelines for postoperative adjuvant therapy have not been guided by molecular typing, while the European Society of Gynecological Oncology/European Society of Radiotherapy and Oncology/European Society of Pathology (ESGO/ESTRO/ESP) guidelines stratify risks according to clinicopathological parameters and molecular typing, so that a more individualized postoperative adjuvant radiotherapy regimen can be selected accordingly, which is worthy of promotion.

Fibrosis is a highly dynamic pathophysiological process that has long plagued human life and health. It can involve almost any organ and is associated with 45% of disease-related deaths in industrialized countries. More and more studies have reported that homologous domain interacting protein kinase 2 (HIPK2), as a key regulator of various pro-fibrotic pathways (such as Wnt/β-catenin, transforming growth factor-β, etc.), is deeply involved in the fibrosis of lung, heart, kidney and other organs. These studies reveal that targeting HIPK2 to develop effective strategies for the treatment of fibrosis is promising. This paper systematically summarizes the role of HIPK2 in the development of multiple organ fibrosis and the research progress of HIPK2 anti-fibrosis inhibitors.

Acute myeloid leukemia (AML) is a highly heterogeneous hematological malignancy characterized by abnormal proliferation of myeloid cells in the bone marrow. With the application of chemotherapy, targeted therapy and hematopoietic stem cell transplantation, the prognosis of AML has improved to some extent, but some patients are still refractory and relapsed. In recent years, cellular immunotherapy represented by chimeric antigen receptor T cells (CAR-T) has achieved remarkable results in the treatment of hematological tumors. Among them, human C-lectin-like molecule 1 (CLL-1) is highly expressed on AML leukemia stem cells (LSCs) and blasts, but not on normal hematopoietic stem cells, which is considered to be a potential ideal target for the treatment of AML. This article reviews the latest research progress of CLL-1 CAR-T in AML.