EMERGENCY RENAL REPLACEMENT THERAPY WITH MANUAL DIALYSIS IN A PATIENT WITH ACUTE KIDNEY INJURY: FIRST IN HUMAN CASE REPORT

Introduction:

Severe renal disease caused by either end stage, CKD or AKI can cause death. Treatment for these renal emergencies is RRT, which is lifesaving. Access to RRT can be disrupted for a variety of reasons. Thus, there is a significant unmet need for medical devices that can perform portable inexpensive and effective RRT. We describe the first in-human use of “Kirpa Kit”, a manual dialysis device that has been proposed to offer dynamic RRT in scenarios where the standard dialysis resources are overwhelmed. 

Methods:

A 37 y-o man with no relevant medical history was brought to the ER due to a gunshot wound that resulted in significant vascular injury to the femoral vein and hemorrhagic shock requiring surgical treatment. Subsequently, the patient was admitted to the ICU, intubated and hemodynamically unstable with AKI KDIGO 3. CRRT was prescribed due to ATN secondary to hypovolemic shock. Days later, the leg became pulseless, mottled, cold and swollen, and developed septic shock from a peri femoral abscess, requiring surgical reintervention where amputation was done. The patient´s AKI continued, requiring CRRT for anuria and fluid overload; however, he was stuck in the operating room due to lack of beds in the ICU, where CRRT cannot be performed. Nephrology department evaluated the patient, and decided he was candidate for Kirpa Kit™. Informed consent was signed by a family member. The primary objective of this treatment was to perform ultrafiltration and was done as follows: We used a hemodialysis catheter that the patient already had in place, positioned ourselves on the right side of the patient, confirmed the patency of the catheter and then connected the Kirpa Kit™ device to the venous lumen of the hemodialysis catheter using aseptic technique, with previous priming of the system. We assigned the team members as follows: - Operator 1 monitored patient's venous access with the aim of clamping it in case of adverse events that put the patient at risk. - Operator 2 served as the blood pump by controlling the blood syringe (syringe #1 in Figure 1, and Image 1), pulling 60 mL batches of blood from the bypass tube and returning them through the hemofilter at a rate of approximately 1-2 batches per minute. - Operator 3 controlled the UF syringe (syringe #2 in Figure 1), withdrawing 10 to 15 mL of UF each cycle while blood was running through the hemofilter. - Operator 4 oversaw the functionality of the system, including counting the UF and replacing those who may have needed help. The operators switched roles during the treatment. 

Results:

We safely removed a total of 600 mL of UF in 60 minutes, with an overall UF rate of 600 mL/h. There were no issues related to clotting of the circuit despite a lack of systemic anticoagulation. The patient showed clinical and ultrasonographic improvement from the procedure. Before connecting the patient, the portal vein had a pulsatility of 38%. After the UF was completed, pulsatility had decreased to 31%. 

Conclusions:

The Kirpa Kit was successfully and safely deployed to treat a patient with fluid overload and has the potential to be an emergency dialysis device that can operate in austere medical conditions to bridge patients with renal emergencies to standard RRT. However, further research is warranted to understand the full capacity and limitations of this novel device. 

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.