Implementation of a Multidisciplinary Bleeding and Transfusion Protocol Significantly Decreases Perioperative Blood Product Utilization and Improves Some Bleeding Outcomes

Perioperative transfusion of blood products is associated with increased morbidity and mortality after pediatric cardiac surgery. We report the results of a quality improvement project aimed at decreasing perioperative blood product administration and bleeding after pediatric cardiopulmonary bypass (CPB) surgery. A multidisciplinary team evaluated baseline data from 99 consecutive CPB patients, focusing on the variability in transfusion management and bleeding outcomes, to create a standardized bleeding and transfusion management protocol. A total of 62 subsequent patients were evaluated after implementation of the protocol: 17 with single pass hemoconcentrated (SPHC) blood transfusion and 45 with modified ultrafiltration (MUF). Implementation of the protocol with SPHC blood led to significant decrease in transfusion of every blood product in the cardiovascular operating room and first 6 hours in cardiovascular intensive care unit ([CVICU] p < .05). Addition of MUF to the protocol led to further decrease in transfusion of all blood products compared to preprotocol. Patients <2 months old had 49% decrease in total blood product administration: 155 mL/kg preprotocol, 117 mL/kg protocol plus SPHC, and 79 mL/kg protocol plus MUF (p < .01). There were significant decreases in postoperative bleeding in the first hour after CVICU admission: 6 mL/kg preprotocol, 3.8 mL/kg protocol plus SPHC, and 2 mL/kg protocol plusMUF (p = .02). There was also significantly decreased incidence of severe postoperative bleeding (>10 mL/kg) in the first CVICU hour for protocol plus MUF patients (p < .01). Implementation of a multidisciplinary bleeding and transfusion protocol significantly decreases perioperative blood product transfusion and improves some bleeding outcomes.

Modality and dosing of acute renal replacement therapy

Acute renal replacement therapy (ARRT) is today routinely applied in critically ill patients with acute kidney injury. Nevertheless, differently from other therapies in the acute care setting which have specific posology, duration of treatment, serum through and peak levels and clearly predetermined continuous or intermittent way of administration, ARRT may appear difficult to dose, prescribe, deliver and monitor. Additionally, current literature has provided controversial results about many aspects of ARRT administration. This review will focus on the definition of dialytic dose, extensively detailing different dimensions of ARRT delivery: as a matter of fact, the provision of a dialytic session to a critically ill patient should not be limited to the simplistic mathematical calculation of an exact dose. Adequacy of ARRT implies the concomitant consideration of more complex issues such as timing, modality and techniques of ARRT delivery, anticoagulation and substitution fluids choice, membrane selection, monitor accuracy, the role of fluid overload and other patients' comorbidities. The capacity of clinicians of considering all these aspects, adapting the different dimensions of dose to the actual patients' needs, might be the fundamental missing element in the pathway towards significant outcome improvements of critically ill AKI patients needing ARRT.

A pilot study of selective lipopolysaccharide adsorption and coupled plasma filtration and adsorption in adult patients with severe sepsis

AIM

To evaluate the safety and effectiveness of combined extracorporeal therapy in patients with severe sepsis after cardiac surgery.

MATERIALS AND METHODS

Twenty patients received combined extracorporeal therapy (LPS-adsorption with Toraymyxin columns + CPFA). The inclusion criteria were clinical signs of severe sepsis, EAA = 0.6, and PCT >2 ng/ml. 20 comparable patients in the control group received only standard therapy.

RESULTS

Each patient in the study group received 2 daily treatments of combined extracorporeal therapy. In contrast to controls, we noted an increase in the values of MAP from 73 to 82 mm Hg, (p < 0.001) and the mean oxygenation index (from 180 to 246, p < 0.001), decrease of EAA from 0.77 to 0.55, p < 0.001, and PCT (from 6.23 to 2.83 ng/ml, p < 0.001). The 28-day survival rate was 65 and 35% in the study and control groups respectively, p = 0.11.

CONCLUSION

The combined use of LPS-adsorption and CPFA in a single circuit with standard therapy is a safe and possibly effective adjunctive method for treating severe sepsis.

[Continuous Veno-venous Hemofiltration in Goat Model with Crush Syndrome]

OBJECTIVE

Crush syndrome (CS) is a common critical condition. This study aimed to establish crush syndrome goat model through muscle injection of glycerol and test the effect of continuous veno-venous hemofiltraion (CVVH).

METHODS

12 male goats at 12-15 months age were randomly assigned into control, model, and CVVH groups. After 2 weeks of normal feeding, the goats were weighed and stripped off foods for 24 h. Goats in the model and CVVH groups were then injected with 50% glycerol athind legs. Diagnosis of CS was established based on serum creatine kinase (CK) > 1 000 U/L and serum creatinine (sCr) > 2 times of standard. No intervention was given to goats in the control group. A catheter was planted to get blood access. CVVH was administered using a Prisma-flex machine, with blood flow being set at 100 mL/min and replacement fluid with predilution at 35 mL/(kg x h). After 23 h of treatment, the goats were sacrificed. Plasma and kidney samples were taken.

RESULTS

Bloody urine hyperkalemia and decrease of urine volume were found in all of the goats injected with glycerol. Serum CK and sCr increased 1 h after the injection compared with the controls. After 23 h of CVVH treatment, serum CK and sCr decreased compared with goats in the model group. The light microscope revealed manifestation of tubular necrosis and interstitial edema, but the glomeruli were almost normal. The electronic microscope found prominent signs of cell apoptosis, such as chromatin aggregation, mitochondrial swelling, and endoplasmic reticulum expansion. Caspase12 expression in the goats with CS was significantly higher than that in the controls. The CVVH treated goats had lower level of expression than those in the model group (P < 0.05). TUNEL staining identified a higher proportion of renal cell apoptosis in the goats in the model group compared with those in the CVVH group.

CONCLUSION

Muscle injection with glycerol can induce CS in goats. Early CVVH intervention improves renal function and alleviates renal tubular cell apoptosis.

ROLE OF MODIFIED ULTRFILTRATION IN ADULT CARDIAC SURGERY: A PROSPECTIVE RANDOMIZED CONTROL TRIAL

BACKGROUND

Cardiopulmonary bypass (CPB) is associated with morbidity and mortality. To reduce its adverse effect modified ultrafiltration is being increasingly employed. This study is planned to evaluate the benefits of modified ultrafiltration (MUF) in adult cardiac surgery.

METHODS

Eighty consecutive patients presenting to adult cardiac surgery as elective case were enrolled. These patients were randomly divided in to two groups. MUF group which received modified ultrafiltration after separation from CPB and control group which did not receive modified ultrafiltration. Postoperative mediastinal and chest drainage in 24 hrs, blood products requirement, reopening, ICU stay, and mortality in 30 days were recorded. These variables were compared between MUF group and control group.

RESULTS

Forty patients were randomized to control group and 40 in MUF group. Mean age was 51.15 ± 8.90 in control group as compared to 46.95 ± 13.24 MUF group (p = 0.1). Out of 40 patients in control group 7 (17.5%) were female while 11 (27.5%) out of total 40 were female in MUF group. (p = .284). Mean CBP time was 120.62 ± 20.97 in control group versus 117.37 ± 38.78 in MUF group (p = 0.64). Post-operative drain output ranged from 330 ml to 1300 ml in control group and 300 ml to 780 ml in MUF group. Mean postoperative drain output 554.25 ± 192.57 in control group versus 439.22 ± 89.59 in MUF group (p = .001). Three (7.5%) out of 40 patients required re-exploration in control group versus 1 (2.5%) in MUF group. (p = .305). Mean ICU stay was 52.80 ± 22.37 hours in control group versus 45.30 ± 21.82 hours in MUF group (p = 0.133). Three (7.5%) out of 40 patients died in control group versus 1 (2.5%) in MUF group. (p = 0.305).

CONCLUSION

Use of modified ultrafiltration is associated with low postoperative bleeding less requirements of blood and blood products.

Conventional hemofiltration during cardiopulmonary bypass increases the serum lactate level in adult cardiac surgery

OBJECTIVE

To evaluate the effect of hemofiltration during cardiopulmonary bypass on lactate level in adult patients who underwent cardiac surgery.

DESIGN

An observational study.

SETTING

Prince Sultan cardiac center, Riyadh, Saudi Arabia.

PARTICIPANTS

The study included 283 patients classified into two groups: Hemofiltration group (n=138), hemofiltration was done during CPB. Control group (n = 145), patients without hemofiltration.

INTERVENTIONS

Hemofiltration during cardiopulmonary bypass.

MEASUREMENTS AND MAIN RESULTS

Monitors included hematocrit, lactate levels, mixed venous oxygen saturation, amount of fluid removal during hemofiltration and urine output. The lactate elevated in group H than group C (P < 0.05), and the PH showed metabolic acidosis in group H (P < 0.05). The mixed venous oxygen saturation decreased in group H than group C (P < 0.05). The number of transfused packed red blood cells was lower in group H than group C (P < 0.05). The hematocrit was higher in group H than group C (P < 0.05). The urine output was lower in group H than group C (P < 0.05).

CONCLUSIONS

Hemofiltration during cardiopulmonary bypass leads to hemoconcentration, elevated lactate level and increased inotropic support. There are some recommendations for hemofiltration: First; Hemofiltration should be limited for patients with impaired renal function, positive fluid balance, reduced response to diuretics or prolonged bypass time more than 2 hours. Second; Minimal amount of fluids should be administered to maintain adequate cardiac output and reduction of priming volumes is preferable to maintain controlled hemodilution. Third; it should be done before weaning of or after cardiopulmonary bypass and not during the whole time of cardiopulmonary bypass.

High-volume hemofiltration combined with early goal-directed therapy improves alveolar-arterial oxygen exchange in patients with refractory septic shock

OBJECTIVE

This study is to evaluate the effect of high-volume hemofiltration (HVHF) and early goal-directed therapy (EGDT) on alveolar-arterial oxygen exchange in patients with refractory septic shock.

PATIENTS AND METHODS

Patients were classified into two groups by a prospective cohort study: 86 received both HVHF and EGDT (the HVHF group), and 81 treated with EGDT only (the control group). Alveolar-arterial oxygen pressure was taken at baseline and at days 1, 3, and 7, and respiratory index (RI, ratio of P(a)O2 alveolar-arterial oxygen pressure difference (P(A-a)DO2) to arterial oxygen pressure (P(a)O2) was calculated.

RESULTS

At day 7, the levels of central venous and arterial blood oxygen content were significantly higher in the HVHF vs. the control group (both with p < 0.05). The level of oxygen extraction ratio (O2ER) was significantly higher in the HVHF than the control group (p < 0.01). The levels of P(A-a)DO2 and RI were significantly lower in the HVHF than the control group (p < 0.05 and p < 0.01, respectively). RI and the ratio of P(a)O2 to the fraction of inspired oxygen were significantly higher in the HVHF than the control group (p < 0.05 and p < 0.01, respectively). The acute physiology and chronic health evaluation score and the sequential organ failure assessment score in the HVHF group were significantly lower compared to the control group (p < 0.01 and p < 0.05, respectively). At day 28, the mortality rate was lower in the HVHF vs. the control group (p < 0.01).

CONCLUSIONS

These findings demonstrated that HVHF, when used as an adjunctive therapy to the EGDP protocol, could improve alveolar-arterial oxygen exchange, clinical outcome and survival in patients with refractory septic shock.

Plasmafiltration as a possible contributor to kinetic targeting of pegylated liposomal doxorubicin (PLD) in order to prevent organ toxicity and immunosuppression

PURPOSE

To examine the removal of pegylated liposomal doxorubicin (PLD) during plasmafiltration (PF) and determine whether the drug could be withheld prior to its organ distribution responsible for mucocutaneous toxicity.

METHODS

Six patients suffering from platinum-resistant ovarian cancer were treated with a 1-h IV infusion 50 mg/m(2) of PLD/cycle-for three cycles q4w. Over 44 (46)-47(49) h postinfusion, five patients (14 cycles in total) underwent PF using a cascade PF method consisted of plasma separation by centrifugation and plasma treatment using filtration based one volume of plasma treatment, i.e., 3.18 L (±0.6 L) and plasma flow 1.0 L/h (0.91-1.48 L/h). Doxorubicin concentration in blood was monitored by a high-performance liquid chromatography method for 116 h postinfusion. Pharmacokinetic parameters determined from plasma concentration included volume of distribution, total body clearance, half-life of elimination, and area under the plasma concentration versus time. The amount of doxorubicin in the body eliminated by the patient and via extracorporeal treatment was evaluated. Toxicity was tested using CTCAE v4.0.

RESULTS

The efficacy of PF and early responses to PLD/PF combination strategy were as follows: over 44(46) h postinfusion considered necessary for target distribution of PLD to tumor, patients eliminated 46 % (35-56 %) of the dose administered. Over 44(46)-47(49) h postinfusion, a single one-volume plasma filtration removed 40 % (22-45 %) (Mi5) of the remaining doxorubicin amount in the body. Total fraction eliminated attained 81 % (75-86 %). The most common treatment-related adverse events (grade 1-2) such as nausea (4/14 cycles-28 %) and vomiting (3/14 cycles-21 %) appeared during 44 h postinfusion. Hematological toxicity-anemia (5/14 cycles-35 %) was reported after cycle II termination. Symptoms of PPE-like syndrome (grade 1-2) appeared in one patient concomitantly with thrombophlebitis and malignant effusion. In this study, only one adverse reaction (1/14-7 %) as short-term malaise and nausea was reported by the investigator as probably related to PF.

CONCLUSION

A single one-volume PF does remove a clinically important amount of doxorubicin in a kinetic targeting approach. There were no serious signs of drug toxicity and/or PF-related adverse events. Kinetically guided therapy with pegylated liposomal doxorubicin combined with PF may be a useful tool to the higher efficacy and tolerability of therapy with PLD.

Nucleosome levels and toll-like receptor expression during high cut-off haemofiltration: a pilot assessment

OBJECTIVES

To measure plasma nucleosome levels and expression of toll-like receptors (TLRs) in a pilot cohort of patients with severe acute kidney injury (AKI) within a randomised controlled trial of continuous venovenous haemofiltration with high cut-off filters (CVVH-HCO) v standard filters (CVVH-std).

METHODS

We measured plasma nucleosome levels using the Cell Death Detection ELISA PLUS (10X) assay kit. We analysed plasma levels for correlation with disease severity and compared the effects of CVVH-HCO and CVVH-std on plasma nucleosome levels over the first 72 hours. We studied cell surface TLR expression on CD14-positive monocytes in a subcohort of CVVH-HCO patients.

RESULTS

We did not detect nucleosomes in normal human plasma, but found elevated nucleosome levels in patients with severe AKI. Nucleosome levels at randomisation correlated weakly with Acute Physiology and Chronic Health Evaluation III scores (Pearson ρ=0.475, P=0.016). Treatment with CVVH-HCO or CVVH-std had no effect on nucleosome levels over 72 hours. The mean fluorescence intensity (MFI) ratios of TLR2 and TLR4 expression were elevated throughout the 72-hour period (range for TLR2, 0.97-3.98; range for TLR4, 0.91-10.18) and did not appear to decrease as a result of treatment with CVVH-HCO.

CONCLUSIONS

Nucleosome concentration was elevated in the plasma of patients with severe AKI and mildly correlated with disease severity, but was not affected by treatment with CVVH-HCO or CVVH-std. Similarly, levels of TLR2 and TLR4 expression did not decrease over time during CVVHCrit HCO treatment.

Early Fluid Resuscitation and High Volume Hemofiltration Decrease Septic Shock Progression in Swine

This study aimed to assess the effects of early fluid resuscitation (EFR) combined with high volume hemofiltration (HVHF) on the cardiopulmonary function and removal of inflammatory mediators in a septic shock swine model. Eighteen swine were randomized into three groups: control (n = 6) (extracorporeal circulating blood only), continuous renal replacement therapy (CRRT) (n = 6; ultrafiltration volume = 25 mL/Kg/h), and HVHF (n = 6; ultrafiltration volume = 85 mL/Kg/h). The septic shock model was established by intravenous infusion of lipopolysaccharides (50 µg/kg/h). Hemodynamic parameters (arterial pressure, heart rate, cardiac output, stroke volume variability, left ventricular contractility, systemic vascular resistance, and central venous pressure), vasoactive drug parameters (dose and time of norepinephrine and hourly fluid intake), pulmonary function (partial oxygen pressure and vascular permeability), and cytokines (interleukin-6 and interleukin-10) were observed. Treatment resulted in significant changes at 4-6 h. HVHF was beneficial, as shown by the dose of vasoactive drugs, fluid intake volume, left ventricular contractility index, and partial oxygen pressure. Both CRRT and HVHF groups showed improved removal of inflammatory mediators compared with controls. In conclusion, EFR combined with HVHF improved septic shock in this swine model. The combination decreased shock progression, reduced the need for vasoactive drugs, and alleviated the damage to cardiopulmonary functions.

The influence of high volume hemofiltration on extra vascular lung water and alveolar-arterial oxygen pressure difference in patients with severe sepsis

OBJECTIVE

To explore the effects of high-volume hemofiltration (HVHF) on the plasma interleukin-6 (IL-6), pro-calcitonin (PCT), extra vascular lung water index (EVLWI) and alveolar-arterial oxygen exchange in patients with septic shock.

PATIENTS AND METHODS

97 cases intensive patients with septic shock were enrolled  from Department of Intensive Care Unit (ICU) of the Provincial Hospital affiliated to Shandong University between January 2011 and December 2014. According to the puting into practice of high-volume hemofiltration (HVHF) or not, all the patients were divided in two groups (NHVHF group, group A, n = 46 cases) and (HVHF group, group B, n = 51 cases). The plasma IL-6, PCT intrathoracic blood volume index (ITBVI), extra-vascular lung water index (EVLWI) and pulmonary vascular permeability index(PVPI) was detected before treatment and after treatment 24h, 72h The Alveolar- arterial oxygen pressure difference P(A-a)DO2 was checked by arterial blood gas analysis (ABGA) at first and after treatment 24 hour, 72 hour, 7 day in two groups. The mortality at 28 day was compared between two groups.

RESULTS

After 72h treatment, the plasma IL-6, PCT in group B has a significant decrease. After 72h treatment, the level ITBVI, EVLWI and PVPI in group B had a significant improvement. The levels of P(A-a)DO2 in HVHF group were reduced more significantly than N-HVHF group after 7 day. The EVLWI and P(A-a)DO2 had a significant positive correlation (correlation ratio = 0.712, 95% confident interval [0.617, 0.773], p = 0.001). The mortality at 28 day had a significant decrease between groups (15.22% vs. 34.15% χ2 = 4.242, p = 0.038).

CONCLUSIONS

HVHF could decrease plasma inflammatory factors and EVLWI so that it could improve the levels of alveolar-arterial-oxygen exchange in patients with septic shock, so it could improve the survival rate of patients.

[INFLUENCE OF EXTRACORPOREAL DETOXIFICATION METHODS ON TISSUE PERFUSION IN SEPTIC SHOCK]

OBJECTIVE

To improve the results of abdominal sepsis treatment by comprehensive application of extracorporeal detoxification methods controlled by tissue perfusion.

SUBJECT AND METHODS

Fifteen patients with abdominal sepsis were examined, septic shock was diagnosed to all of them. Patients were divided into two groups. The first group (n = 7) consists of patients with acute renal failure, who had undergone adsorption of Lipopolysaccharide. The second group (n = 8) consists of patients with acute renalfailure, who had undergone prolonged hemofiltration regardless of the products of nitrogen metabolism level to terminate systemic inflammatory response. Dynamic monitoring of tissue perfusion was performed using Doppler ultrasound flowmeter methods.

RESULTS

According to high frequency Doppler ultrasound results all the patients with abdominal sepsis have significant peripheral circulatory disorders maintaining in volumetric and linear blood flow velocity reduction. As a result of application extracorporeal detoxification methods indexes of tissue perfusion were improved. Performance of selective endotoxine hemosorbtion and hemofiltration provides substantially stabilizing effect on Doppler microcirculation indexes: average volumetric blood flow velocity (Qam) increased 4.5 times, end-diastolic linear blood flow velocity (Vakd)--increased to 85%, peripheral resistance index (RI) reduced 2.8 times. Doppler tissue perfusion indexes monitoring allows directly monitor extracorporeal detoxification methods effectiveness, supplementing system hemodynamic monitoring data.

CONCLUSION

Timely application extracorporeal detoxification methods in abdominal sepsis can improve tissue perfusion.

[Mechanism of continuous venovenous hemofiltration combined with ulinastatin for the treatment of septic shock]

OBJECTIVE

To investigate the molecular mechanisms of continuous venovenous hemofiltration (CVVH) combined with ulinastatin (ULI) (CVVH-ULI) for the treatment of septic shock.

METHODS

Human umbilical endothelial cells (HUVECs) were incubated with serums isolated from normal healthy people (control), septic shock patients treated with conventional therapy (CT) or treated with CVVH combined with ULI (CVVH-ULI). Endothelial permeability was evaluated by the leakage of FITC-labeled albumin. The morphological changes of F-actin was evaluated by Rhodamine-phalloidin. The phosphorylated levels of p38 were determined by Western blot. Cells were then treated with p38inhibitor (SB203580), or DMSO, followed by incubation with serum from septic shock patients treated with conventional therapy. Endothelial permeability and F-actin rearrangements were also evaluated as noted above.

RESULTS

Serum from CT group increased endothelial permeability, F-actin rearrangements, and phosphorylated levels of p38, which were inhibited by CVVH-ULI treatment. Moreover, in CT group, the serum-induced endothelial hyperpermeability and F-actin rearrangements were inhibited by SB203580, the inhibitor of p38.

CONCLUSION

CVVH combined with ulinastatin decreases endothelial hyperpermeability induced by septic shock through inhibiting p38 MAPK pathways.

[Clinical study on application of intermittent hemofiltration combined with hemoperfusion in the early stage of severe burn in the prevention and treatment of sepsis]

OBJECTIVE

To investigate the effects of application of intermittent hemofiltration combined with hemoperfusion (HP) in the early stage of severe burn in the prevention and treatment of sepsis.

METHODS

Forty severely burned patients, admitted to our burn ward from June 2011 to March 2013, conforming to the study criteria, were divided into conventional treatment group (CT, n=20) and blood purification group (BP, n=20) according to the random number table. Patients in group CT received CT according to the accepted principles of treatment for a severe burn. Patients in group BP received CT and intermittent hemofiltration combined with HP once respectively on post injury day (PID) 3, 5, and 7, spanning 6 to 8 hours for each treatment. On PID 3, 5, 7, 10, and 14, body temperature, heart rate, and respiratory rate were recorded; white blood cell count (WBC), neutrophil granulocytes, blood urea nitrogen (BUN), and creatinine were determined; levels of IL-1, IL-6, TNF-α, and high-mobility group box 1 (HMGB1) in serum were determined by ELISA; level of LPS in serum was determined with the chromogenic substrate limulus amebocyte lysate method; level of procalcitonin (PCT) in serum was determined by double antibody sandwich immune chemiluminescence method. The symptoms and signs of sepsis were observed during the treatment. Data were processed with Fisher's exact test, chi-square test, analysis of variance for repeated measurement, and LSD-t test.

RESULTS

(1) Except for that on PID 5, the mean body temperature of patients in group BP was significantly lower than that of group CT at each of the rest time points (with t values from 1.87 to 2.97, P values below 0.05). The heart rate was significantly slower in patients of group BP than in group CT from PID 3 to 14 (with t values from 1.78 to 3.59, P values below 0.05). Except for that on PID 3, the respiratory rate of patients in group BP was significantly slower than that of group CT at each of the rest time points (with t values from 1.93 to 2.85, P values below 0.05). (2) The levels of WBC, neutrophil granulocytes, BUN, and creatinine of patients in group BP were significantly lower than those of group CT (with t values from 1.78 to 4.23, P values below 0.05). (3) Except for that on PID 3, the level of IL-1 of patients in group BP was significantly lower than that of group CT at each of the rest time points (with t values from 1.97 to 4.16, P values below 0.05). Except for that on PID 7, the level of IL-6 of patients in group BP was significantly lower than that of group CT at each of the rest time points (with t values from 2.11 to 6.34, P values below 0.05). The levels of TNF-α and HMGB1 of patients in group BP were significantly lower than those of group CT from PID 3 to 14 (with t values from 1.98 to 5.29, P values below 0.05). (4) On PID 3, 5, 7, 10, and 14, the levels of LPS and PCT of patients in group BP were respectively (0.23 ± 0.07), (0.27 ± 0.09), (0.22 ± 0.06), (0.20 ± 0.08), (0.15 ± 0.07) EU/mL, and (0.44 ± 0.12), (0.67 ± 0.13), (0.74 ± 0.13), (0.64 ± 0.12), (0.71 ± 0.10) ng/mL, and they were lower than those of group CT [(0.37 ± 0.08), (0.45 ± 0.09), (0.56 ± 0.09), (0.48 ± 0.08), (0.40 ± 0.08) EU/mL, and (0.74 ± 0.11), (1.16 ± 0.12), (1.40 ± 0.13), (1.55 ± 0.15), (1.49 ± 0.14) ng/mL, with t values from 1.88 to 3.43, P values below 0.05]. (5) The incidence of sepsis of patients in group BP was obviously lower than that of group CT (χ² = 6.94, P<0.01).

CONCLUSIONS

Intermittent hemofiltration combined with HP can effectively improve blood biochemical indexes and vital signs and reduce the occurrence of burn sepsis by decreasing the levels of proinflammatory cytokines, LPS, and PCT.

Haemodiafiltration, haemofiltration and haemodialysis for end-stage kidney disease

BACKGROUND

Convective dialysis modalities (haemofiltration (HF), haemodiafiltration (HDF), and acetate-free biofiltration (AFB)) removed excess body fluid across the dialysis membrane with positive pressure and accumulated middle- and larger-size accumulated solutes more efficiently than haemodialysis (HD). This increased larger solute removal combined with use of ultra-pure dialysis fluid in convective dialysis is hypothesised to reduce the frequency and severity of symptoms during dialysis as well as improve clinical outcomes. Convective dialysis therapies (HDF and HF) are associated with lower mortality compared to diffusive therapy (HD) in observational studies. This is an update of a review first published in 2006.

OBJECTIVES

To compare convective (HF, HDF, or AFB) with diffusive (HD) dialysis modalities on clinical outcomes (mortality, major cardiovascular events, hospitalisation and treatment-related adverse events) in men and women with end-stage kidney disease (ESKD).

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register (to 18 February 2015) through contact with a Trials' Search Co-ordinator using search terms relevant to this review.

SELECTION CRITERIA

We included randomised controlled trials comparing convective therapy (HF, HDF, AFB) with another convective therapy or diffusive therapy (HD) for treatment of ESKD.

DATA COLLECTION AND ANALYSIS

Two independent authors identified studies, extracted data and assessed study risk of bias. We summarised treatment effects using the random effects model. We reported results as a risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous data together with 95% confidence intervals (CI). We assessed for heterogeneity using the Chi(2) test and explored the amount of variation in treatment estimates beyond that expected by chance using the I(2) statistic.

MAIN RESULTS

Twenty studies comprising 667 participants were included in the 2006 review. In that review, there was insufficient evidence of treatment effects on major clinical outcomes to draw clinically meaningful conclusions. Searching to February 2015 identified 40 eligible studies comprising 3483 participants overall. In total, 35 studies (4039 participants) compared HF, HDF or AFB with HD, three studies (54 participants) compared AFB with HDF, and three studies (129 participants) compared HDF with HF.Risks of bias in all studies were generally high resulting in low confidence in estimated treatment effects. Convective dialysis had no significant effect on all-cause mortality (11 studies, 3396 participants: RR 0.87, 95% CI 0.72 to 1.05; I(2) = 34%), but significantly reduced cardiovascular mortality (6 studies, 2889 participants: RR 0.75, 95% CI 0.61 to 0.92; I(2) = 0%). One study reported no significant effect on rates of nonfatal cardiovascular events (714 participants: RR 1.14, 95% CI 0.86 to 1.50) and two studies showed no significant difference in hospitalisation (2 studies, 1688 participants: RR 1.23, 95% CI 0.93 to 1.63; I(2) = 0%). One study reported rates of hypotension during dialysis were significantly reduced with convective therapy (906 participants: RR 0.72, 95% CI 0.66 to 0.80). Adverse events were not systematically evaluated in most studies and data for health-related quality of life were sparse. Convective therapies significantly reduced predialysis levels of B2 microglobulin (12 studies, 1813 participants: MD -5.55 mg/dL, 95% CI -9.11 to -1.98; I(2) = 94%) and increased dialysis dose (Kt/V urea) (14 studies, 2022 participants: MD 0.07, 95% CI -0.00 to 0.14; I(2) = 90%) compared to diffusive therapy, but results across studies were very heterogeneous. Sensitivity analyses limited to studies comparing HDF with HD showed very similar results. Directly comparative data for differing types of convective dialysis were insufficient to draw conclusions.Studies had important risks of bias leading to low confidence in the summary estimates and were generally limited to patients who had adequate dialysis vascular access.

AUTHORS' CONCLUSIONS

Convective dialysis may reduce cardiovascular but not all-cause mortality and effects on nonfatal cardiovascular events and hospitalisation are inconclusive. However, any treatment benefits of convective dialysis on all patient outcomes including cardiovascular death are unreliable due to limitations in study methods and reporting. Future studies which assess treatment effects of convection dose on patient outcomes including mortality and cardiovascular events would be informative.