Improving Continuous Renal Replacement Therapy Downtime Through Tandem Therapeutic Plasma Exchange – Results from New Study Show Benefits

A research team from UPMC Children’s Hospital of Pittsburgh Divisions of Critical Care Medicine and Pediatric Nephrology published results in Blood Purification on a study examining the effect that tandem therapeutic plasma exchange (TPE) has on downtime in patients needing continuous renal replacement therapy (CRRT).

The study’s senior author was Dana Y. Fuhrman, DO, MS, associate professor of pediatrics in the Division of Pediatric Nephrology at UPMC Children’s Hospital of Pittsburgh. Dr. Fuhrman also is an associate professor in the Department of Critical Care Medicine. She is a co-director of the Continuous Renal Replacement Therapy program at UPMC and director of the Pediatric Intensive Care Medicine Fellowship.

CRRT use for treating acute kidney injury in pediatric patients has increased significantly. However, CRRT is often paused in critically ill patients in order to maintain the circuit, facilitate other treatments the patient may need, or for other reasons.

For many critically ill patients needing CRRT, TPE is also required, for example, in cases of sepsis or other complex renal conditions. Stopping and starting CRRT for TPE therapy can significantly affect the total downtime of CRRT patients in need of the therapy, and this downtime can potentially influence care and outcomes negatively.

However, CRRT conducted in tandem with TPE obviates the need to pause CRRT, thus allowing patients to remain on CRRT with fewer interruptions.

Study Overview and Clinical Findings

The UPMC Children’s research team examined the effect of tandem CPE on CRRT downtimes by examining cases prior to the institution of a tandem CRRT/TPE protocol implemented at UPMC Children’s in 2018.

After accounting for exclusionary factors, the team found the total of all CCRT + TPE sessions during the evaluation period to be 49. Thirty of these cases occurred before tandem the tandem TPE protocol was implemented, and 19 cases after the protocol went into effect in 2018.

The median time CRRT was interrupted in patients requiring TPE prior to the protocol was 14.6%. This percentage dropped significantly to a median of 3.4% in the cases after protocol initiation.

Before the tandem protocol, the two most common reasons for interrupting a CCRT session were filter clotting followed by TPE, 32, and 31 sessions, respectively. After the protocol, filter clotting and difficulties with access were the two most frequent contributors to CRRT downtime (15 and 16 sessions, respectively). TPE as a reason for CRRT interruption dropped in frequency to only six sessions.

Patient-specific factors including age, race, ethnicity, and sex did not affect CRRT downtime either before the tandem TPE was implemented or after.

"Limiting the CRRT downtime for these very critically ill patients is of great importance. Our analysis showed the TPE plays a large role in this downtime, but we also show that with a tandem protocol in place, this downtime can be cut significantly," says Dr. Fuhrman. "There are many benefits for patients if we can limit their CRRT downtime to the bare minimum. Tandem TPE is one approach, and we'll be continuing our studies to learn more about how this affects patient outcomes and morbidities."

Read more about the study design and clinical findings using the reference link below.

Reference

Foglia MJ, Pelletier JH, Bayir H, Fleck A, Konyk L, McSteen C, Fisher D, Fuhrman DY. Tandem Therapeutic Plasma Exchange Reduces Continuous Renal Replacement Therapy Downtime. Blood Purif. 2022; 51(6): 523-530