Development of a new miniaturized system for ultrafiltration

Acute decompensated heart failure and fluid overload are the most common causes of hospitalization in heart failure patients, and often, they contribute to disease progression. Initial treatment encompasses intravenous diuretics although there might be a percentual of patients refractory to this pharmacological approach. New technologies have been developed to perform extracorporeal ultrafiltration in fluid overloaded patients. Current equipment allows to perform ultrafiltration in most hospital and acute care settings. Extracorporeal ultrafiltration is then prescribed and conducted by specialized teams, and fluid removal is planned to restore a status of hydration close to normal. Recent clinical trials and European and North American practice guidelines suggest that ultrafiltration is indicated for patients with refractory congestion not responding to medical therapy. Close interaction between nephrologists and cardiologists may be the key to a collaborative therapeutic effort in heart failure patients. Further studies are today suggesting that wearable technologies might become available soon to treat patients in ambulatory and de-hospitalized settings. These new technologies may help to cope with the increasing demand for the care of chronic heart failure patients. Herein, we provide a state-of-the-art review on extracorporeal ultrafiltration and describe the steps in the development of a new miniaturized system for ultrafiltration, called AD1 (Artificial Diuresis).

Effects of haemodiafiltration or haemofiltration compared with haemodialysis on prognosis in patients with end-stage renal disease: protocol an updated systematic review and meta-analysis of randomised trials with trial sequential analysis

INTRODUCTION

Haemodialysis is the most common treatment option for patients with life-sustaining end-stage kidney disease (ESKD). In recent years, haemodiafiltration or haemofiltration has been widely used in patients with ESKD, and there are still conflicting findings as to whether both are superior to traditional haemodialysis. This systematic review and meta-analysis were designed to determine whether haemodiafiltration or haemofiltration is more effective than haemodialysis in reducing all-cause mortality risk in patients with ESKD.

METHODS AND ANALYSIS

We will perform a systematic PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library and Scopus search, including studies published before September 2023. Randomised controlled trials will be included exploring the effects of haemodiafiltration or haemofiltration compared with haemodialysis on prognosis in patients with ESKD. Outcomes of interest include all-cause mortality, cardiovascular events, dialysis adequacy and adverse effects. The Cochrane Collaboration tools (ROB-2) will assess the bias risk. Available data will be used to calculate effect sizes. Heterogeneity between studies will be evaluated with I2. The trial sequential analysis will be used to eliminate false-positive results. The certainty of the evidence will be assessed using Grading of Recommendations, Assessment, Development and Evaluation criteria.

ETHICS AND DISSEMINATION

This systematic review and meta-analysis was deemed exempt from ethics review. Results will be disseminated through publication in peer-reviewed journals and research conferences.

PROSPERO REGISTRATION NUMBER

CRD42023464509.

A single-center experience of non-bioartificial DFAPP support systems among Chinese patients with hyperlipidemic moderate/severe acute pancreatitis

To assess the clinical efficacy of Double Filtration Plasmapheresis (DFAPP), a novel blood purification method, in treating hyperlipidemic moderate/severe pancreatitis (HL-M/SAP). A total of 68 HL-M/SAP patients were enrolled in this study. The observation group, comprising 34 patients, received DFAPP treatment, while the control group underwent CVVH + PA treatment. We compared the efficacy changes between the two groups post-treatment. Patients treated with DFAPP showed significant improvements in clinical outcomes. After 72 h of DFAPP treatment, HL-M/SAP patients exhibited notably lower multiple organ failure scores and a reduced mortality rate compared to those in the CVVH + PA group. Triglyceride levels in HL-M/SAP patients treated with DFAPP for 48 h averaged 3.75 ± 1.95, significantly lower than the 9.57 ± 3.84 levels in the CVVH + PA group (P < 0.05). Moreover, CRP levels decreased markedly, IL-17 levels diminished, IL-10 levels increased, and the decline in IL-35 levels was significantly less pronounced compared to the CVVH + PA group. The recurrence rate of pancreatitis was also significantly lower after 6 months. The early implementation of DFAPP in HL-M/SAP patients effectively reduces triglyceride levels, suppresses pro-inflammatory factors, enhances anti-inflammatory factors, and mitigates cytokine storm-induced sepsis damage. Consequently, this leads to a decrease in the incidence of multiple organ failure, improved patient survival rates, and a reduce the recurrence rate of lipogenic pancreatitis.Trial registration: Chinese Clinical Trial Registry, ChiCTR2300076066.

A simplified protocol of regional citrate anticoagulation with phosphate-containing solutions in infants and children treated with continuous kidney replacement therapy

BACKGROUND

Regional citrate anticoagulation (RCA) is the preferred modality of anticoagulation used in continuous kidney replacement therapy (CKRT) in adults and less extensively in children. Potential metabolic complications limit widespread use in infants, neonates, and in children with liver failure.

METHODS

We report our experience with a simplified protocol in 50 critically ill children, infants, and neonates, some of them with liver failure, with commercially available solutions containing phosphorous and higher concentration of potassium and magnesium.

RESULTS

RCA allowed attainment of a mean filter lifetime of 54.5 ± 18.2 h, 42.5% of circuits lasted more than 70 h, and scheduled change was the most frequent cause of CKRT interruption. Patient Ca++ and circuit Ca++ were maintained in the target range with mean values of 1.15 ± 0.13 mmol/l and 0.38 ± 0.07 mmol/l, respectively. No session had to be stopped because of metabolic complications. The most frequent complications were hyponatremia, hypomagnesemia, and metabolic acidosis mostly related to primary disease and critical illness. No session had to be stopped because of citrate accumulation (CA). Transitory CA occurred in 6 patients and was managed without requiring RCA interruption. No patients with liver failure presented CA episodes.

CONCLUSIONS

In our experience, RCA with commercially available solutions was easily applied and managed in critically ill children, even in patients with low weight or with liver failure. Solutions containing phosphate and higher concentrations of magnesium and potassium allowed reduction of metabolic derangement during CKRT. Prolonged filter life was ensured with no detrimental effects on patients and reduced staff workload. A higher resolution version of the Graphical abstract is available as Supplementary information.

Neurocognitive Function with Conventional Hemodialysis versus Post-Dilution Hemofiltration as Initial Treatment in ESKD Patients: A Randomized Controlled Trial - The DA-VINCI Study

INTRODUCTION

The ideal modality choice and dialysis prescription during the first renal replacement therapy (RRT) session remain unclear. We conducted a pilot study to determine the safety risk for hemodialysis (HD) versus hemofiltration (HF) and its relationship with neurocognitive assessment on incident RRT patients.

METHODS

Twenty-four incident RRT patients were included. Patients were randomized to the conventional HD group or post-dilution HF group. Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MOCA) tests were applied in all patients before and after session, and brain magnetic resonance image (MRI) was performed in 7 patients from the conventional HD group and 8 patients from the post-dilution HF group before and after the intervention.

RESULTS

Baseline characteristics were similar between groups. Compared to conventional HD, post-dilution HF had longer treatment time. There were no significant changes in blood pressure after RRT in both groups. The MMSE test showed no significant differences between groups or within groups. The MOCA test showed an increase in the total score for the post-dilution HF group with no significant changes between groups. The MRI evaluation showed no differences between or within groups.

CONCLUSION

Post-dilution HF is a safe alternative for the first HD session in incident RRT; it allows longer treatment time if ultrafiltration is required and has a similar neurological risk than conventional HD. This is a pilot study and that larger studies are needed to confirm the findings.

Membrane-based therapeutic plasma exchange: Proposed techniques for preventing filter failure

BACKGROUND AND OBJECTIVES

Therapeutic plasma exchange (TPE) is commonly performed using membrane-based TPE (mTPE) and is prone to filter failure.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We report on 46 patients, with a total of 321 mTPE treatments using the NxStage machine. This was a retrospective study with an aim to evaluate the effect of heparin, pre-filter saline dilution and the impact of total plasma volume exchanged (< 3 L vs. ≥3 L) on the rate of filter failure. Primary outcome was the overall rate of filter failure. Secondary outcomes included factors that may have indirectly influenced the rate of filter failure, including hematocrit, platelet count, replacement fluid (Fresh Frozen Plasma vs. albumin), and access type.

RESULTS

We found that treatments that received both pre-filter heparin and saline had a statistically significant decrease in filter failure rate as compared to those that received neither (28.6% vs. 5.3%, P = .001), and compared to the treatments that received pre-filter heparin alone (14.2% vs. 5.3%, P = .015). In treatments that received both pre-filter heparin and saline predilution, we noted a significantly higher filter failure rate when the plasma volume exchanged was ≥3 L as compared to those that had <3 L exchanged (12.2% vs. 0.9%, P = .001).

CONCLUSIONS

Rate of filter failure in mTPE can be reduced by implementing several therapeutic interventions including pre-filter heparin and pre-filter saline solution. These interventions were not associated with any clinically significant adverse events. Despite the above-mentioned interventions, large plasma volume exchanges of ≥3 L can negatively impact filter life.

Simplified regional citrate anticoagulation protocol for CVVH, CVVHDF and SLED focused on the prevention of KRT-related hypophosphatemia while optimizing acid-base balance

BACKGROUND

Hypophosphatemia is a common electrolyte disorder in critically ill patients undergoing prolonged kidney replacement therapy (KRT). We evaluated the efficacy and safety of a simplified regional citrate anticoagulation (RCA) protocol for continuous venovenous hemofiltration (CVVH), continuous venovenous hemodiafiltration (CVVHDF) and sustained low-efficiency dialysis filtration (SLED-f). We aimed at preventing KRT-related hypophosphatemia while optimizing acid-base equilibrium.

METHODS

KRT was performed by the Prismax system (Baxter) and polyacrylonitrile AN69 filters (ST 150, 1.5 m2, Baxter), combining a 18 mmol/L pre-dilution citrate solution (Regiocit 18/0, Baxter) with a phosphate-containing solution (HPO42- 1.0 mmol/L, HCO3- 22.0 mmol/L; Biphozyl, Baxter). When needed, phosphate loss was replaced with sodium glycerophosphate pentahydrate (Glycophos™ 20 mmol/20 mL, Fresenius Kabi Norge AS, Halden, Norway). Serum citrate measurements were scheduled during each treatment. We analyzed data from three consecutive daily 8-h SLED-f sessions, as well as single 72-h CVVH or 72-h CVVHDF sessions. We used analysis of variance (ANOVA) for repeated measures to evaluate differences in variables means (i.e. serum phosphate, citrate). Because some patients received phosphate supplementation, we performed analysis of covariance (ANCOVA) for repeated measures modelling phosphate supplementation as a covariate.

RESULTS

Forty-seven patients with acute kidney injury (AKI) or end stage kidney disease (ESKD) requiring KRT were included [11 CVVH, 11 CVVHDF and 25 SLED-f sessions; mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score 25 ± 7.0]. Interruptions for irreversible filter clotting were negligible. The overall incidence of hypophosphatemia (s-P levels <2.5 mg/dL) was 6.6%, and s-P levels were kept in the normality range irrespective of baseline values and the KRT modality. The acid-base balance was preserved, with no episode of citrate accumulation.

CONCLUSIONS

Our data obtained with a new simplified RCA protocol suggest that it is effective and safe for CVVH, CVVHDF and SLED, allowing to prevent KRT-related hypophosphatemia and maintain the acid-base balance without citrate accumulation.

TRIAL REGISTRATION

NCT03976440 (registered 6 June 2019).

Standardization of Nomenclature for the Mechanisms and Materials Utilized for Extracorporeal Blood Purification

In order to develop a standardized nomenclature for the mechanisms and materials utilized during extracorporeal blood purification, a consensus expert conference was convened in November 2022. Standardized nomenclature serves as a common language for reporting research findings, new device development, and education. It is also critically important to support patient safety, allow comparisons between techniques, materials, and devices, and be essential for defining and naming innovative technologies and classifying devices for regulatory approval. The multidisciplinary conference developed detailed descriptions of the performance characteristics of devices (membranes, filters, and sorbents), solute and fluid transport mechanisms, flow parameters, and methods of treatment evaluation. In addition, nomenclature for adsorptive blood purification techniques was proposed. This report summarizes these activities and highlights the need for standardization of nomenclature in the future to harmonize research, education, and innovation in extracorporeal blood purification therapies.

Extracorporeal Techniques in Kidney Failure

During the last decades, various strategies have been optimized to enhance clearance of a variable spectrum of retained molecules to ensure hemodynamic tolerance to fluid removal and improve long-term survival in patients affected by kidney failure. Treatment effects are the result of the interaction of individual patient characteristics with device characteristics and treatment prescription. Historically, the nephrology community aimed to provide adequate treatment, along with the best possible quality of life and outcomes. In this article, we analyzed blood purification techniques that have been developed with their different characteristics.

Adsorption and Clearance of the Novel Fluorescent Tracer Agent MB-102 During Continuous Renal Replacement Therapy: In Vitro Results

MB-102 is a novel fluorescent tracer agent that is exclusively removed from the body by glomerular filtration. This agent can be detected transdermally to provide a real-time measurement of glomerular filtration rate at the point-of-care and is currently in clinical studies for such. MB-102 clearance during continuous renal replacement therapy (CRRT) is unknown. Its plasma protein binding (~0%), molecular weight (~372 Da) and volume of distribution (15-20 L) suggest that it may be removed by renal replacement therapies. To determine the disposition of MB-102 during CRRT, an in vitro study assessing the transmembrane clearance (CL TM ) and adsorptive clearance of MB-102 was conducted. A validated in vitro bovine blood continuous hemofiltration (HF) and continuous hemodialysis (HD) models were performed using two types of hemodiafilters to evaluate CL TM of MB-102. For HF, three different ultrafiltration rates were evaluated. For HD, four different dialysate flow rates were evaluated. Urea was used as a control. No MB-102 adsorption to the CRRT apparatus or either of hemodiafilters was observed. MB-102 is readily removed by HF and HD. Dialysate and ultrafiltrate flow rates directly influence MB-102 CLTM. Hence MB-102 CLTM should be measurable for critically ill patients receiving CRRT.

Hemoadsorption: Research Agenda and Potential Future Applications

After initial tentative steps with bioincompatible sorbents, hemoadsorption is making a comeback. This has been fueled by improved coating technology and improved sorbent technology. Both have markedly increased the safety, biocompatibility, and efficiency of hemoadsorption. Despite such development and an emerging body of evidence, the research agenda for hemoadsorption is substantial and, in most ways, unfulfilled. In this chapter, we highlight the need for more extensive and sophisticated work to understand the biological effect of hemoadsorption in key areas (especially sepsis). We also explain why more technical research needs to be conducted ex vivo and in large animals to understand the performance characteristics of hemoadsorption sorbent cartridge, including optimal blood flow, optimal anticoagulation, and optimal duration of application. Finally, we focus on the need to develop registries of the use of this technique so that more extensive information can be obtained about current use and real-world performance.

CVVHD results in longer filter life than pre-filter CVVH: Results of a quasi-randomized clinical trial

BACKGROUND

Filter clotting is a major issue in continuous kidney replacement therapy (CKRT) that interrupts treatment, reduces delivered effluent dose, and increases cost of care. While a number of variables are involved in filter life, treatment modality is an understudied factor. We hypothesized that filters in pre-filter continuous venovenous hemofiltration (CVVH) would have shorter lifespans than in continuous venovenous hemodialysis (CVVHD).

METHODS

This was a single center, pragmatic, unblinded, quasi-randomized cluster trial conducted in critically ill adult patients with severe acute kidney injury (AKI) at the University of Iowa Hospitals and Clinics (UIHC) between March 2020 and December 2020. Patients were quasi-randomized by time block to receive pre-filter CVVH (convection) or CVVHD (diffusion). The primary outcome was filter life, and secondary outcomes were number of filters used, number of filters reaching 72 hours, and in-hospital mortality.

RESULTS

In the intention-to-treat analysis, filter life in pre-filter CVVH was 79% of that observed in CVVHD (mean ratio 0.79, 95% CI 0.65-0.97, p = 0.02). Median filter life (with interquartile range) in pre-filter CVVH was 21.8 (11.4-45.3) and was 26.6 (13.0-63.5) for CVVHD. In addition, 11.8% of filters in pre-filter CVVH were active for >72 hours, versus 21.2% in the CVVHD group. Finally, filter clotting accounted for the loss of 26.7% of filters in the CVVH group compared to 17.5% in the CVVHD group. There were no differences in overall numbers of filters used or mortality between groups.

CONCLUSIONS

Among critically patients with severe AKI requiring CKRT, use of pre-filter CVVH resulted in significantly shorter filter life compared to CVVHD.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04762524. Registered 02/21/21-Retroactively registered, https://clinicaltrials.gov/ct2/show/NCT04762524?cond=The+Impact+of+CRRT+Modality+on+Filter+Life&draw=2&rank=1.

Manual Single-Lumen Alternating Micro-Batch Device as Renal Replacement Therapy in Austere Environments

<b><i>Introduction:</i></b> Electrolyte derangements, acidosis, and volume overload remain life-threatening emergencies in people with acute kidney injury in austere environments. A single-lumen alternating micro-batch (SLAMB) dialysis technique was designed to perform renal replacement therapy using a single-lumen access, low-cost disposable bags and tubing, widely available premade fluids, and a dialysis filter. A manual variation (mSLAMB) works without electricity, battery, or a pump. We modeled mSLAMB dialysis and predicted it could achieve adequate small solute clearance, blood flow rates, and ultrafiltration accuracy. <b><i>Methods:</i></b> A 25- to 30-kg pediatric patient’s blood volume was simulated by a 2-L bag of expired blood and spiked with 5 g of urea initially, then with 1–2 g between experiments. Experiments had 8 cycles totaling prescription volumes of 800–2,400 mL and were conducted with different ratios of hemofiltration fluid to blood volume. Concentrations of urea and potassium, final effluent volumes, and cycle duration were measured at the end of each cycle to determine clearance, ultrafiltration accuracy, and blood flow rates. <b><i>Results:</i></b> Each cycle lasted 70–145 s. Experiments achieved a mean urea reduction ratio of 27.4 ± 7.1% and a mean potassium reduction of 23.4 ± 9.3%. The largest urea and potassium reduction percentage occurred with the first cycle. Increased hemofiltration fluid to blood volume ratio did not increase clearance. Mean (+/− standard deviation) blood flow ranged from 79.7 +/− 4.4 mL/min to 90.8 +/− 6.5 mL/min and increased with larger batch volume and height difference between reservoirs. Ultrafiltration accuracy ranged from 0 to 2.4% per cycle. <b><i>Discussion:</i></b> mSLAMB dialysis is a simple, manual, cost-effective mode of dialysis capable of providing clearance and accurate ultrafiltration. With further refinement of technique, we believe this can be a potentially lifesaving treatment in austere conditions and low-resource settings.

Ionic homeostasis, acid-base balance and the risk of citrate accumulation in patients after cardiovascular surgery treated with continuous veno-venous haemofiltration with post-dilution regional citrate anticoagulation - An observational case-control study

BACKGROUND

Patients after cardiovascular surgery, requiring renal replacement therapy, can benefit from adequate non-heparin circuit anticoagulation. Simplified regional citrate anticoagulation (RCA) protocol proposes the use of citric acid dextrose formula A (ACD-A) during post-dilutional continuous veno-venous hemofiltration (CVVH) with standard bicarbonate buffered calcium containing replacement solution. Citrate accumulation diagnosed upon total to ionized calcium ratio (tCa/iCa) and low ionized calcium (iCa) are considered as the biggest risks related to regional citrate accumulation.

METHODS

This prospective observational case-control study evaluated electrolyte and acid-base homeostasis in cardiovascular surgery patients treated with post-dilution CVVH with a simplified RCA protocol with ACD-A. In total, 50 consecutive cardiovascular surgery patients were evaluated. Base excess, pH, bicarbonate, lactate, Na+, Cl-, Mg++, and inorganic phosphate concentrations, the total to ionized calcium ratio (tCa/iCa), and high anion gap metabolic acidosis were assessed during haemofiltration treatment in survivors and non-survivors.

RESULTS

Thirty-three (66%) patients died. The therapies were very well balanced in sodium and chloride homeostasis. The lactate concentration and anion gap decreased during CVVH sessions lasting longer than 72 hours, but no inter-group difference was observed. The tCa/iCa ratio exceeded 4.5% and was significantly higher in non-survivors (p=0.037). Initial lactate concentration did not correlate with tCa/iCa ratio during haemofiltration. Magnesium and phosphate concentrations decreased and additional supplementation with magnesium was necessary. The magnesium concentration was lower in the non-survivors.

CONCLUSIONS

The incidence of citrate accumulation exceeded 4% and was significantly higher in non-survivors. Supplementation with magnesium and phosphate ions is needed in CVVH with RCA.

Haemofiltration in the Management of Severe Paediatric Burns - Experience in a UK Burns Centre and Systematic Review

Paediatric burns are life-threatening injuries due to the acute injury and secondary complications. In acute phase burns, hypovolaemia and vasoconstriction cause renal impairment. Sepsis and multi-organ failure compound the problem resulting in morbidity and mortality. This paper outlines 5 years' experience using haemofiltration in major paediatric burns, and a review of the current literature.Retrospective patient data collection was undertaken identifying relevant paediatric burns undergoing Continuous Veno-Venous Haemofiltration. Data were analysed to identify demographics, indication, duration of therapy, and outcomes. A systematic review was also performed using PRISMA principles. PubMed, Science Direct and OVID databases were explored and relevant papers were included.From January 2015-December 2019, haemofiltration was utilised in 5 cases. Age range 3-15 years (mean: 12), 4 males / 1 female, mean weight 56kg (12-125kg). TBSA 21-61% (mean: 37.6%), mechanism of injury was scald-60%, flame-40%. Overall survival was 100%. 3 patients were filtered for a brief period during the first 24 hours to correct metabolic acidosis and control temperature. 2 patients required prolonged therapy. All patients recovered without further long term renal support. A total of 3814 papers were identified for systematic review. 3 were considered relevant for inclusion.This paper reflects the benefits of haemofiltration in the management of severe paediatric burns. Renal replacement therapy is useful in managing metabolic acidosis, temperature control and renal failure. The current literature supports judicious use on a patient-by-patient basis. Given the lack of evidence in the literature, further studies are required to establish guidelines for the use of haemofiltration in paediatric burns.

Outcomes With Ultrafiltration Among Hospitalized Patients With Acute Heart Failure (from the National Inpatient Sample)

Acute heart failure (HF) management is a complex and often involves a delicate balance of both cardiac and renal systems. Although pharmacologic diuresis is a mainstay of the pharmacologic management of decompensated HF, ultrafiltration (UF) represents a nonpharmacologic approach in the setting of diuretic resistance. We conducted a cross-sectional analysis of the 2009 through 2014 hospitalization data from the National Inpatient Sample. The study population consisted of hospitalizations with a discharge Diagnosis Related Groups of HF who were older than 18 years of age, did not have end-stage kidney disease, acute kidney injury and had not undergone hemodialysis or hemofiltration. There were 6,174 hospitalizations which included UF among the 7,799,915 hospitalizations for HF. Hospitalizations which included UF were among patients significantly younger in age (68.1 ± 1.0 vs 73.8 ± 0.1 years), male (61.9% vs 47.7%), and with higher prevalence of co-morbid conditions including chronic kidney disease (58% vs 31%), diabetes mellitus (53% vs 42%), and higher rates of co-morbidity (Charlson comorbidity score ≥2, 92% vs 80%). All-cause mortality was significantly higher among hospitalizations which included an UF (4.68% vs 2.24%). Hospitalizations with UF had a longer mean length of stay (6.2 vs 4.3 days, p <0.01) average total charges ($42,035 vs 24,867 USD, p <0.01) as compared with those without UF. Hospitalizations with UF were associated with a greater adjusted odds of all-cause mortality (odds ratio: 3.36, [95% confidence interval 1.76,6.40]), greater than DRG-level target length of stay (odds ratio, 2.46; [95 confidence interval 1.65,3.67]), and a 72% increase in the average hospital charges. In conclusion, hospitalizations which included UF identified a subgroup of HF patients with more co-morbid conditions who are at higher risk of mortality and increased resource burden in terms of length of stay and costs. These findings also highlight that the need for UF may identify patients who are most likely to benefit from a multidisciplinary cardiorenal approach to alter the trajectory of their disease.

Efficacy and safety of blood purification in the treatment of deep burns: A systematic review and meta-analysis

INTRODUCTION

This meta-analysis aimed to systematically review and evaluate randomized controlled trials (RCTs) and cohort studies examining the efficacy and safety of blood purification in the treatment of patients with deep burns.

METHODS

The PubMed, Cochrane Library, and Embase databases and relevant references were systematically searched for RCTs and cohort studies published until the end of September 2020 to investigate the potential of blood purification in improving the prognosis of severely burned patients. The primary outcome of this systematic review was overall patient mortality; secondary outcomes included the incidence of sepsis and infection prevention (vital signs and routine blood tests).

RESULTS

A total of 6 RCTs and 1 cohort study were included, with a total of 538 burn patients (274 patients who received blood purification and 264 control patients). Compared with patients who received conventional treatment, those treated with blood purification displayed significant 2-day reduction in mortality and sepsis with relative risks of 0.62 and 0.41, respectively (95% confidence intervals [CIs], 0.74-0.82 and 0.25-0.67, respectively; P < .05). In terms of vital signs and blood biochemistry, the respiratory rates and blood urea nitrogen levels of patients in the blood purification group 3 days post-treatment were significantly higher than those in the control group (randomized standard deviations (SMDs), 0.78 and 0.77, respectively; 95% CIs, 0.33-1.23 and 1.22-0.31, respectively; P < .05). However, there were no significant differences between groups on day 3 with regard to temperature (P = .32), heart rate (P = .26), white blood cell count (P = .54), or neutrophil count (P = .74), potentially owing to the small sample size or the relatively short intervention time. Heterogeneous differences existed between the groups with respect to blood urea nitrogen (SMD = -1.22; 95% CI, -2.16 to -0.40; P < .00001) and Cr (SMD = -3.13; 95% CI, -4.92 to -1.33; P < .00001) on day 7. No systematic adverse events occurred.

CONCLUSIONS

Blood purification treatment for deep burn patients can significantly reduce the mortality rate and the incidence of complications.

Contemporary Management of Severe Acute Kidney Injury and Refractory Cardiorenal Syndrome: JACC Council Perspectives

Acute kidney injury (AKI) and cardiorenal syndrome (CRS) are increasingly prevalent in hospitalized patients with cardiovascular disease and remain associated with poor short- and long-term outcomes. There are no specific therapies to reduce mortality related to either AKI or CRS, apart from supportive care and volume status management. Acute renal replacement therapies (RRTs), including ultrafiltration, intermittent hemodialysis, and continuous RRT are used to manage complications of medically refractory AKI and CRS and may restore normal electrolyte, acid-base, and fluid balance before renal recovery. Patients who require acute RRT have a significant risk of mortality and long-term dialysis dependence, emphasizing the importance of appropriate patient selection. Despite the growing use of RRT in the cardiac intensive care unit, there are few resources for the cardiovascular specialist that integrate the epidemiology, diagnostic workup, and medical management of AKI and CRS with an overview of indications, multidisciplinary team management, and transition off of RRT.

Th17/Treg imbalance in patients with severe acute pancreatitis: Attenuated by high-volume hemofiltration treatment

BACKGROUND

To investigate the effect of high-volume hemofiltration (HVHF) on Th17/Treg imbalance in patients with severe acute pancreatitis (SAP).

METHODS

Forty-two patients with SAP were randomly received 24 hours of continuous HVHF (n = 21) or without HVHF (n = 21). At day 28, all 42 patients were divided into survival group (n = 32) and non-survival group (n = 10). Venous blood samples collected at 0, 6, 12, and 24 hours during HVHF treatment (or equivalent time in non-HVHF group) were assessed by flow cytometry to detect Th17 and Treg cells. Concentrations of IL-6, IL-17, IL-10, and TGF-β1 were detected by enzyme-linked immunosorbent assay.

RESULTS

Th17%, Treg%, Th17/Treg, and levels of related cytokines were significantly higher in SAP patients than healthy controls (P < .05), and these changes were more pronounced in SAP patients with multiple organ failure than those with single organ failure (P < .05). After HVHF treatment, Th17%, Treg%, Th17/Treg, IL-6, IL-17, and IL-10 significantly reduced (P < .05), while there were no significant changes in non-HVHF group (P > .05). In addition, acute physiology and chronic health evaluation II and sequential organ failure assessment scores decreased markedly after HVHF treatment. Baselines of Th17%, Treg%, Th17/Treg, and related cytokines were significantly higher in non-survival group than survival group. Both acute physiology and chronic health evaluation I score and IL-6 level were positively correlated with Th17% before and after HVHF treatment (P < .01).

CONCLUSIONS

Th17/Treg imbalance is present in SAP and may be correlated with its severity and prognosis. HVHF effectively attenuates the Th17/Treg imbalance in SAP patients. The beneficial effect of HVHF on Th17/Treg imbalance is possibly associated with removing excess inflammatory mediators.

Cytokine Blood Filtration Responses in COVID-19

The real issue with the COVID-19 pandemic is that a rapidly increasing number of patients with life-threatening complications are admitted in hospitals and are not well-administered. Although a limited number of patients use the intensive care unit (ICU), they consume medical resources, safety equipment, and enormous equipment with little possibility of rapid recovery and ICU discharge. This work reviews effective methods of using filtration devices in treatment to reduce the level of various inflammatory mediators and discharge patients from the ICU faster. Extracorporeal technologies have been reviewed as a medical approach to absorb cytokines. Although these devices do not kill or remove the virus, they are a promising solution for treating patients and their faster removal from the ICU, thus relieving the bottleneck.

Effect of sub-hypothermia blood purification technique in cardiac shock after valvular disease surgery

To observe the effect of sub-hypothermia (HT) blood purification technique in the treatment of cardiac shock after heart valve disease.The patients were randomly divided into normothermic (NT) continuous blood purification (CBP) group (NT group) and HT CBP group (HT group). Observe the cardiac index (CI), the oxygen delivery (DO2) and oxygen consumption (VO2) ratio, Acute Physiology and Chronic Health Evaluation III(APACHE III) score, multiple organ dysfunction syndrome (MODS) score, dynamic monitoring of electrocardiograph, blood loss with or without muscle tremors, intensive care unit stay, mechanical ventilation time, CBP time, and the cases of infection and mortality at 0 day, 1 day, 2 day, 3 day; all above indicators were compared between 2 groups.Ninety-five patients were randomly assigned into HT group (48 cases) and NT group (47 cases); there were no significant differences between the 2 groups for age, gender, pre-operative cardiac function, cardiothoracic ratio, and type of valve replacement (P > .05). There were no significant differences among the 1 day, 2 day, 3 day after recruited for CI, DO2/VO2 ratio, APACHE III score, MODS score (P > .05). But in HT group, DO2/VO2 ratio had been significantly improved after treatment for 1 day (2.5 ± 0.7 vs 1.8 ± 0.4, P = .024), and CI (3.0 ± 0.5 vs 1.9 ± 0.7, P = .004), APACHE III score (50.6 ± 6.2 vs 77.5 ± 5.5 P = .022), MODS score (6.0 ± 1.5 vs 9.3 ± 3.4, P = .013) also had been significantly improved after treatment for 3 days. In clinical outcomes, there were no significant differences between 2 groups for blood loss (617.0 ± 60.7 ml vs 550.9 ± 85.2 ml, P = .203), infection ratio (54.17% vs 53.19%, P = .341), the incidence of ventricular arrhythmia (31.25% vs 36.17%, P = .237), and muscle tremors (14.58% vs 8.51%, P = .346), while there were significant differences between 2 groups for intensive care unit stay (6.9 ± 3.4 days vs 12.5 ± 3.5 days, P = .017,), mechanical ventilation time (4.2 ± 1.3 days vs 7.5 ± 2.7 days, P = .034,), CBP time (4.6 ± 1.4 days vs 10.5 ± 4.0 days, P = .019), mortality (12.50% vs 23.40%, P = .024). But the incidence of bradycardia in HT group was much higher than the NT group (29.16% vs 14.89%, P = .029).HT blood purification is a safer and more effective treatment than NT blood purification for patients who suffered from cardiac shock after valve surgery.

The premature closure of ROMPA clinical trial: mortality reduction in septic shock by plasma adsorption

OBJECTIVES

Coupled Plasma Filtration and Adsorption (CPFA) use in septic shock remains controversial. The objective is to clarify whether the application of high doses of CPFA in addition to the current clinical practice could reduce hospital mortality in septic shock patients in Intensive Care Units at 28 days and at 90 days follow-up.

DESIGN

We designed a prospective randomised clinical trial, Reducción de la Mortalidad Plasma-Adsorción (ROMPA), to demonstrate an absolute mortality reduction of 20% (α=0.05; 1-β=0.8; n=190 (95×2)).

SETTING

Being aware of the pitfalls associated with previous medical device trials, we developed a training programme to improve CPFA use (especially clotting problems). The protocol was approved by the ethics committees of all participating centres. Circumstances beyond our control produced a change in recruitment conditions unacceptable to ROMPA researchers and the trial was discontinued.

PARTICIPANTS

By closure, five centres from an initial 10 fulfilled the necessary trial criteria, with 49 patients included, 30 in the control group (CG) and 19 in the intervention group (IG).

INTERVENTION

CPFA.

MAIN OUTCOME MEASURES

Hospital mortality at 28 days and 90 days follow-up.

RESULTS

After 28 days, 14 patients died (46.7%) from the CG and 11 (57.9%) from the IG, not reaching statistical significance (p=0.444). At 90 days, 19 patients had died (63.3%) from the CG and 11 patients (57.9%) from the IG, (p=0.878). The adjustment by propensity score or the use of the Kaplan-Meier technique failed to achieve statistical difference, neither by Intention to Treat nor by the Actual Intervention Received.

CONCLUSION

We herewith present the results gained from the prematurely closed trial. The results are inconclusive due to low statistical power but we consider that this data is of interest for the scientific community and potentially necessary for any ensuing debate.

REGISTER

NCT02357433 in clinicaltrials.gov.

Efficacy of blood purification for severe pancreatitis and acute respiratory distress syndrome

BACKGROUND

This study will assess the efficacy and safety of blood purification (BP) for severe pancreatitis (SP) and acute respiratory distress syndrome (ARDS).

METHODS

We will search the following electronic databases of Ovid MEDLINE, EMBASE, Web of Science, Cochrane Library, Scopus, Cumulative Index to Nursing and Allied Health Literature, the Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, and WANGFANG from inception to the present without language restriction. A systematic review and data synthesis will be carried out of randomized controlled trials of BP for the treatment of patients with SP and ARDS. RevMan 5.3 software will be used for statistical analysis.

RESULTS

This systematic review will evaluate the efficacy and safety of BP for the treatment of patients with SP and ARDS. The primary outcome includes respiratory indexes, blood biochemical and inflammatory factors. The secondary outcomes consist of complications, sepsis, abdominal hemorrhage, renal failure, length of hospital stay, and mortality.

CONCLUSION

This study will provide up-to-date evidence of BP for the treatment of patients with SP and ARDS.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42019139467.

Sepsis Management with a Blood Purification Membrane: European Experience

BACKGROUND

Septic shock is a leading cause of acute kidney injury (AKI). Endotoxins and cytokine levels are associated with the occurrence and severity of AKI, and different blood purification devices are available to remove them from circulation. One such device, oXiris, is a hollow-fibre purification filter that clears both endotoxins and cytokines. Due to limited evidence, clinical use of this device is not currently advocated in guidelines. However, clinics do regularly use this device, and there is a critical need for guidance on the application of it in sepsis with and without AKI.

METHOD

A modified Delphi-based method was used to collate -European experts' views on the indication(s), initiation and discontinuation criteria and success measures for oXiris.

RESULTS

A panel of 14 participants was selected based on known clinical expertise in the areas of critical care and sepsis management, as well as their experience of using the oXiris blood purification device. The participants used different criteria to initiate treatment with oXiris in sepsis patients with and without AKI. Septic shock with AKI was the priority patient population, with oXiris used to rapidly improve haemodynamic parameters. Achieving haemodynamic stability within 72 h was a key factor for determining treatment success.

CONCLUSION

In the absence of established guidelines, users of hollow-fibre purification devices such as oXiris may benefit from standardised approaches to selecting patients and initiating and terminating treatment, as well as measuring success. Further evidence in the form of randomised clinical trials is urgently required.

Continuous blood purification for severe acute pancreatitis: A systematic review and meta-analysis

BACKGROUND

The incidence of acute pancreatitis (AP) is rising around the world, thus further increasing the burden on healthcare services. Approximately 20% of AP will develop severe acute pancreatitis (SAP) with persistent organ failure (>48 h), which is the leading cause of high mortality. To date, there is no specific drug in treating SAP, and the main treatment is still based on supportive care. However, some clinical control studies regarding the superiority of continuous blood purification (CBP) has been published recently. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy of CBP in SAP treatment.

METHODS

Four databases (Medline, SinoMed, EMBASE, and Cochrane Library) were searched for eligible studies from 1980 to 2018 containing a total of 4 randomized controlled trials and 8 prospective studies.

RESULTS

After the analysis of data amenable to polling, significant advantages were found in favor of the CBP approach in terms of Acute Physiology and Chronic Health Evaluation II (APACHE II) score (WMD = -3.00,95%CI = -4.65 to -1.35), serum amylase (WMD = -237.14, 95% CI = -292.77 to 181.31), serum creatinine (WMD = -80.54,95%CI = 160.17 to -0.92), length of stay in the ICU (WMD = -7.15,95%CI = -9.88 to -4.43), and mortality (OR = 0.60, 95%CI = 0.38-0.94). No marked differences were found in terms of C-reactive protein (CRP), alamine aminotransferase (ALT) and length of hospital stay (LOS).

CONCLUSION

Compared with conventional treatment, CBP remedy evidently improved clinical outcomes, including reduced incidence organ failure, decreased serum amylase, APACHE II score, length of stay in the ICU and lower mortality rate, leading us to conclude that it is a safer treatment option for SAP. Furthermore, relevant multicenter RCTs are required to prove these findings.

Commercial Low-citrate Anticoagulation Haemofiltration in High Risk Patients with Frequent Filter Clotting

This study assessed the safety and efficacy of a commercial low-citrate concentration-based pre-filter replacement fluid during continuous veno-venous haemofiltration (CVVH) in patients with frequent filter clotting and high risk of bleeding. We used a commercial low-citrate fluid as pre-dilution replacement fluid during CVVH (citrate: 11 mmol/l (33 meq/l), sodium: 140 mmol/l, chloride: 108 mmol/l and potassium: 1 mmol/l). A calcium and magnesium infusion was delivered separately by central line for the maintenance of serum ionized calcium (Cai) and total magnesium (Mg). In this prospective observational study, 30 patients, 124 filters and 1,515 treatment-hours were observed. Median filter life of citrate CVVH was 9.5 hours. Filter life in the 48 hours prior to citrate CVVH was also observed. In the patients on prior non-anticoagulant CVVH (n=14) filter life increased significantly with citrate (9.5 hours vs 5 hours; P<0.0001). In patients on prior heparin CVVH (n=15), filter life was similar with citrate (10 hours vs 8 hours; P=0.68). However, in patients with prior early/frequent filter clotting despite heparin (n=11) filter life increased significantly (10 hours vs 7 hours; P=0.038). Of 411 serum Cai measurements, none showed a Cai<0.85 mmol/l and, of 84 observations, none showed a serum Mg<0.6mmol/l. One patient with sepsis and shock needed to cease citrate CVVH because of progressive ionized hypocalcaemia and increasing anion gap. No other adverse effects were observed. In selected patients, CVVH with a commercial low-citrate concentration solution as pre-filter replacement fluid and a simultaneous calcium and magnesium infusion protocol appears generally safe. Filter life was acceptable and superior to that achieved with previous treatment.

Effect of high-volume hemofiltration on mortality in critically ill patients: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

High-volume hemofiltration (HVHF) is widely used for blood purification in critically ill patients with systemic inflammatory syndromes. The purpose of this study was to evaluate the effect of HVHF on mortality at different follow-up periods in critically ill patients.

METHODS

We systematically searched PubMed, Embase, and the Cochrane Library through April 2017 to identify trials that evaluated the effect of HVHF on mortality in critically ill patients. Summary relative risks (RRs) and 95% confidence intervals (CIs) were employed to calculate the treatment effect using a random effects model. Eleven trials involving 1048 critically ill patients were included in this study.

RESULTS

The summary results indicated no significant differences between HVHF and usual care for the incidence of 28-day mortality (RR: 0.93; 95%CI: 0.80-1.08; P = .321), 7-day mortality (RR: 0.72; 95%CI: 0.50-1.03; P = .072), 60-day mortality (RR: 1.00; 95%CI: 0.86-1.16; P = .997), and 90-day mortality (RR: 1.01; 95%CI: 0.88-1.16; P = .927). Subgroup analysis suggested HVHF significantly reduced the risk of 28-day mortality (RR: 0.64; 95%CI: 0.42-0.97; P = .035) if pooled the study sample size < 100.

CONCLUSION

Our findings suggest HVHF significantly reduced the incidence of 28-day mortality when pooled the study sample size < 100. Further, HVHF had a marginal effect on the incidence of 7-day mortality.

Evaluation of safety and efficacy of different continuous blood Purification methods in treating infantile sepsis

The aim of this study was to compare the safety and the efficacy of two methods of continuous blood purification (CBP), continuous veno-venous hemofiltration (CVVH) and high volume hemofiltration (HVHF), for treatment of infantile sepsis. Eighty-six children with sepsis were enrolled in this study and randomly divided into two groups with 47 cases in the CVVH group and 39 cases in the HVHF group. Survival rate, duration of blood filtration, mean arterial pressure (MAP), mean heart rate and SaO2, APACHE II score, procalcitonin, hs-CRP and TXB2 were compared between the two groups. Results showed that survival rate, MAP, mean heart rate and SaO2 in the two groups did not have any significant differences. Duration of blood filtration and APACHE II score in the HVHF group was significantly shorter than that in the CVVH group. After therapy, levels of procalcitonin, hs-CRP and TXB2 declined dramatically in both groups, however this reduction was more significant in the HVHF group. We conclude that HVHF is a safer and more effective method as it produced stable hemodynamics, shorter filtration time, better APACHE II scores and better results in alleviating inflammatory reactions.

[Methods of Molecular Transfusion in the Intensive Therapy of Critical States]

Development of extracorporeal blood purification acquires greater significance in the intensive care of multiple organ failures (MOF) with all the pathophysiological aspects of its constituent parts. MOF are the main cause of mortality among critically ill patients and treatment of these patients require significant investment. The purpose of the implementation of extracorporeal blood correction techniques today is multiple organ support therapy (MOST). Early extracorporeal therapy is used only in the treatment of renal failure. Today extracorporeal techniques are increasingly being used to replace the functions of various organs and systems. MOST includes diffusion, convection, filtration, sorption, apheresis methodic. They affect the molecular and electrolyte composition of blood, allow to correct, repair, replace, and maintain homeostasis in severe multiorgan dysfunction. Extracorporeal new molecular technologies have been successfully applied in the intensive care of severe heart and respiratory failure, acute kidney injury and acute hepatic dysfunction, in the treatment of severe sepsis, metabolic disorders, the correction of immune imbalance.

The Big Bang of Hemofiltration: The Beginning of a New Era in the Third Millennium for Extra-Corporeal Blood Purification!

Since the last decade, hemofiltration and especially high volume hemofiltration has rapidly evolved from a somewhat experimental treatment towards a potentially effective “adjunctive” therapy in severe septic shock and especially refractory or catecholamine resistant hypodynamic septic shock. Nevertheless, this approach lacks prospective randomized studies (PRT'S) evaluating the critical role of early hemofiltration in sepsis. An important step forward which could be called the “big bang” in term of hemofiltration was the publication of a PRT in patients with acute renal failure (ARF) (1). Before this study (2), nobody believed that hemofiltration could change the survival rate in intensive care. Since that big bang, many physicians consider that hemofiltration at a certain dose can change the survival rate in intensive care. So the world of hemofiltration in ICU is not a definitive world, it is still in expansion. Indeed, we now have to try to define what will be the exact dose we need in septic acute renal failure. This dose might well be “higher” than 35 ml/kg/hour in the septic acute renal failure “group” as suggested by many studies (2–5). At present, it is the issue of continuous dose of high volume hemofiltration that has to be tested in future randomized studies. Since the Vicenza study (2) has shown that 35 ml/kg/h is the best dose in terms of survival, dealing with non septic acute renal failure in ICU, several studies from different groups have shown that, in septic acute renal failure, a higher dose might correlate with better survival. This has also been shown in some way by the study of the “Vicenza group” but not with a statistically significant value (2). New PRT'S have just started in Europe like the IVOIRE study (hIgh VOlume in Intensive caRE) (6) and the RENAL study. Another large study is looking more basically at dose in non septic acute renal failure in Australasia and is led by the group of Rinaldo Bellomo in Melbourne (7) as well as the ATN study (8) led by Palevsky and colleagues in the USA, also testing the importance of dose in the treatment for ARF. Nevertheless, “early goal-directed hemofiltration therapy” like early goal directed therapy (9) has to be studied in our critical ill patients. Regarding this issue, fewer studies, mainly retrospective exist, but again the IVOIRE study (6) will address this issue by studying septic patients with acute renal injury according to the Rifle classification (10). So, this review focuses on the early application and on the adequate dose of continuous high volume hemofiltration in septic shock in order to improve not only hemodynamics, but survival in this very severely ill cohort of patients. This could well be called the “big bang of hemofiltration” as one could never have anticipated that an adequate dose of hemofiltration could markedly influence the survival rate of ICU-septic acute renal failure patients. On top of the use of early and adequate dose of hemofiltration in sepsis, a higher dose could also provide better renal recovery rate and reduce the risk of associate chronic dialysis in these patients. Furthermore, this paper also reviews “brand” new theories regarding the rationale for hemofiltration in sepsis. Finally, this paper also addresses the so-called negative studies as well anticipated side effects.

Confirmation of High Cytokine Clearance by Hemofiltration with a Cellulose Triacetate Membrane with Large Pores: An in vivo Study

Objective

To confirm in vivo the hypothesis that hemofiltration with a large pore membrane can achieve significant cytokine clearance.

Method

We used a well-known animal model of endotoxinic shock (0.5 mg/kg of lipopolysaccharide from Escherichia Coli over a period of 30 mins). Six pigs were hemofiltrated for 3 hours with a large pore membrane (78 Å pore, 80 kDa cut off) (Sureflux FH 70, Nipro, Osaka, Japan). The ultrafiltration rate was 45 ml/kg/min. Samples were taken from arterial, venous line and in the ultrafiltrate at T120 and T240. We measured concentrations of interleukin 6, interleukin 10 and albumin.

Results

At T120 and T240, the IL-6 clearances were 22 ± 7 and 15 ± 3 ml/min, respectively. The IL-6 sieving coefficients were 0.97 and 0.7 at T120 and T240, respectively. At T120 and T240, the IL-10 clearances were 14 ± 4 and 10 ± 7 ml/min, respectively. The sieving coefficients were 0.63 and 0.45 at T120 and T240, respectively. The concentrations of IL-6 and IL-10 were the same at T0 and T240. At T60 and T240, the plasmatic albumin concentrations were 24 ± 4 g/L and 23 ± 4 g/L, respectively (p = 0.13).

Conclusions

In this animal model of endotoxinic shock, we confirm the high cytokine clearance observed when hemofiltration is applied to a large pore membrane. The loss of albumin seems negligible. The impact of such clearances on hemodynamic stability and survival remains to be proved.

Safety of Citrate Based Hemofiltration in Critically Ill Patients at High Risk for Bleeding: A Comparison with Nadroparin

Purpose

To study the incidence and severity of bleeding in high risk critically ill patients during high volume, citrate based continuous veno-venous hemofiltration (CVVH).

Design

A prospective 1-year observational cohort study comparing citrate based CVVH with nadroparin based CVVH.

Procedures

Critically ill patients with multiple organ dysfunction and in need of CVVH were observed for bleeding complications during their CVVH sessions. Pre-defined criteria determined that patients were treated with citrate based CVVH in case of active bleeding or increased risk for bleeding. Otherwise nadroparin was used as anticoagulant.

Statistical and Outcome Methods

The incidence of bleeding complications, the number of transfused blood cell concentrates and the filter-run-time were recorded. Analyses were made by non-parametric tests.

Main Findings

Fifty-five patients received 272 CVVH sessions. In the citrate group 14.8% experienced a bleeding complication compared to 25% in the nadroparin group (p=0.04). The number of transfused red blood cell concentrates was not different between groups. The nadroparin group had a longer filter run time (median 31.5 hours versus 22.5 hours, p=0.0001).

Conclusions

In high risk critically ill patients citrate based anticoagulation for CVVH is safe in terms of bleeding complications and transfusion requirements.

Hypertriglyceridemia: Apheretic Treatment

Patients with extremely high triglyceride levels and associated lipemia are at high risk for acute pancreatitis. Two factors can increase triglyceride-rich lipoproteins; one is overproduction and other is a defect in clearance. Either mechanism can cause hypertriglyceridemia and both may exist simultaneously. Causes can be either primary or secondary.

Plasmapheresis is efficacious for severe hypertryceridemia in patients who have not responded to previous therapies.

We have treated 15 cases of hypertrygliceridemia complicating the course of patients receiving Cyclosporin A after bone marrow transplantation. Five patients were treated with plasmapheresis, the other ten with cascade filtration. The removal rate for triglycerides was 58.0% for patients treated by cascade filtration and 63.5% for patients treated by plasmapheresis. The removal rates for triglycerides were low possibly as a consequence of early saturation of the filter.

Hyperviscosity Syndrome in Hematological Diseases and Therapeutic Apheresis

The hyperviscosity syndrome classified into pleiocytosic, sclerotic and sieric syndromes according to the blood components involved are characterized by a different degree of clinical signs and symptoms related to rheological modification of blood. Therapeutic management of these syndromes is complex and the choice of apheresis treatment is generally restricted to emergency episodes in order to overcome the acute phase and to reverse the symptoms until definitive therapy is effective.

Low-dose Citrate Continuous Veno-venous Hemofiltration (CVVH) and Acid-base Balance

Objective

To evaluate the acid-base effect of low-dose regional citrate anticoagulation (RCA) during continuous veno-venous hemofiltration (CVVH).

Design

Prospective observational study.

Setting

ICUs of tertiary public and private hospitals.

Subjects

Thirty critically ill patients with acute renal failure at risk of bleeding or with a major contraindication to heparin-CVVH and/or short filter life.

Methods

We used a commercial citrate-based fluid (11 mmol/L, sodium: 140 mmol/L, chloride: 108 mmol/L and 1 mol/L of potassium) as pre-dilution replacement fluid during CVVH. Further potassium was added according to serum potassium levels. We measured all relevant variables for acid-base analysis according to the Stewart-Figge methodology.

Results

Before treatment, study patients had a slight metabolic acidosis, which worsened over 6 hours of RCA-CVVH (pH from 7.39 to 7.38, p<0.005; bicarbonate from 23.2 to 21.6 mmol/L, p<0.0001 and base excess from −2.0 to −3.0 mEq/L, p<0.0001) due to a significant increase in SIG (from 5.8 to 6.6 mEq/L, p<0.05) and a decrease in SIDa (from 37.5 to 36.6 mEq/L, p<0.05). These acidifying effects were attenuated by hypoalbuminemia and a decrease in lactate (from 1.48 to 1.34 mmol/L, p<0.005) and did not lead to progressive acidosis. On cessation of treatment, this acidifying effect rapidly self-corrected within six hours.

Conclusions

Low dose RCA-CVVH induces a mild acidosis secondary to an increased strong ion gap and decreased SIDa which fully self-corrects at cessation of therapy. Clinicians need to be aware of these effects to correctly interpret changes in acid-base status in such patients.

Hemofiltration during Cardiopulmonary Bypass for High Risk Adult Cardiac Surgery

Aims

The role of hemofiltration (HF) during cardiopulmonary bypass (CPB) in adult cardiac surgery is controversial. It may be beneficial during prolonged CPB in high-risk surgery. Accordingly, we sought to compare two groups of patients undergoing high-risk cardiac surgery with or without HF.

Methods

One hundred and eighteen patients who underwent complex cardiac surgical procedures during a 12-month period were divided into two groups. Group I (n=61) comprised patients who were treated with hemofiltration during CPB. Group II (n=57) were not filtered. Estimated risk of death, standard demographic, clinical and surgical features were obtained and predetermined outcomes were studied. Statistical comparisons were made.

Results

Age, procedure times and mortality rates were similar in both groups. The mean volume of fluid removed in group I was 3.4 L. The preoperative mean Parsonnet score was 24.8 in group I and 22.5 in group II (ns). Postoperative serum hemoglobin, hematocrit, platelet, and albumin levels were all significantly higher in group I patients (p = 0.0015) indicating hemoconcentration. Post-operative chest drainage showed a trend toward decreased post-operative bleeding in group I (p=0.065). Postoperative pleural effusions requiring chest tube drainage were significantly less in group I (9.8% vs. 29.8% 6; p = 0.0062). The incidence of lung infection was also decreased from 26.3% to 13.1% (p=0.05). Operative mortality was similar in both groups (11.4% in group I, 10.5% in group II, ns).

Conclusion

Hemofiltration during CPB attenuates postoperative anemia, thrombocytopenia and hypoalbuminemia, may reduce post-operative bleeding and appears to decrease post-operative pulmonary complications.

Extracorporeal Blood Treatment (EBT) Methods in SIRS/Sepsis

Background

Extracorporeal blood purification treatment (EBT) methods have been used in the treatment of experimental and human SIRS/Sepsis in a variety of settings and with variable reports of efficacy and safety. Their role in the management of SIRS/Sepsis remains controversial.

Objectives

To develop consensus statements regarding important aspects of research, practice and technical management concerning EBT.

Methods

Systematic review of published study. Evidence-based grading of information available. Consensus development regarding fundamental questions about EBT.

Results

Consensus was achieved on all questions posed during the conference. It was agreed that there is currently a clear biological rational for EBT in SIRS and Sepsis. It was agreed that conventional CVVH has sufficiently been shown not to be effective in SIRS/Sepsis in the absence of concomitant ARF and that other therapies such as plasmapheresis or high-volume hemofiltration or coupled plasma filtration adsorption appear more promising and should be tested in multicentre randomized controlled trials. Patients with ARF and SIRS/Sepsis should be treated differently from those with ARF alone even though current practice in this field is not well known. Patients with refractory septic shock should be considered for EBT. Appropriate end points for clinical trials can be defined and chosen according to the goals of the trial. Different technologies exist for EBT and better understanding of the merits and safety of each is needed as well as better standardization of methodology and dose.

Conclusions

Broad consensus can be achieved on several aspects of EBT and can be used to inform clinical practice and to help guide the establishment of a future research agenda.

Continuous Hemofiltration dose Calculation in a Newborn Patient with Congenital Heart Disease and Preoperative Renal Failure

Objective

To report a case of a newborn patient with renal failure due to polycystic kidneys requiring renal replacement therapy, and total anomalous pulmonary venous return requiring major cardiosurgical intervention.

Setting

Pediatric cardiosurgery operatory room and pediatric cardiologic intensive care. Patient: A 6-day-old newborn child weighing 3.1 kg.

Results

Renal function (creatinine value and urine output) was monitored during the course of the operation and intraoperative renal replacement therapy was not initiated. Serum creatinine concentration decreased from 4.4 to 3 mg/dL at cardiopulmonary bypass (CPB) start and to 1.5 at the end of surgery: the creatinine decrease was provided by the dilutional effect of CPB priming and the infusion of fresh blood from transfusions together with an adequate filtration rate (800 m/L in about 120 minutes). After the operation, extracorporeal membrane oxygenation (ECMO) for ventricular dysfunction and continuous hemofiltration for anuria refractory to medical therapy were prescribed. The hemofiltration machine was set in parallel with the ECMO machine at a blood flow rate of 60 ml/min and a predilution replacement solution infusion of 600 ml/h (4.5 ml/min of creatinine clearance once adjusted on extracorporeal circuits; 3000 mL/m2 hemofiltration): after a single hemofiltration session lasting 96 hours, serum creatinine reached optimal steady state levels around 0.5 mg/dL on postoperative day 2 and 3.

Conclusion

Administration of intraoperative continuous hemofiltration is not mandatory in the case of a 3-kg newborn patient with established renal failure needing major cardiosurgery: hemodilution secondary to CPB, transfusion of hemoderivates, and optimal UF rate appear to be effective methods for achieving solute removal. If postoperative continuous hemofiltration is started, however, a “dialytic dose” of 4.5 ml/min allows an adequate creatinine clearance, quick achievement of a steady state of serum creatinine concentration and an eventual acceptable rate of inflammatory mediator removal.

[Bilirubin removal with Coupled Plasma Filtration and Adsorption in patients affected by hilar cholangiocarcinoma]

BACKGROUND

Patients affected by hilar cholangiocarcinoma are eligible for surgery only in the 20-30% of the cases and postoperative mortality is 40-50%. Many specialists are involved in the treatment of this disease, like surgeons, gastroenterologists, oncologists and radiotherapists. Recent studies have shown that preoperative bilirubinaemia is a predictor of morbidity and mortality after surgery. Coupled Plasma Filtration and Adsorption (CPFA) is a blood purification extracorporeal therapy recommended for sepsis and able to reduce bilirubinaemia.

METHODS

We treated 10 patients referred to our centre affected by hilar cholangiocarcinoma complicated by obstructive jaundice with 34 CPFA sessions to test its ability to reduce preoperative bilirubin levels and we checked for mortality at 90 days.

RESULTS

CPFA reduced preoperative bilirubin of 30% for session; it also improved others inflammation and coagulation tests. Mortality at 90 days was 40%.

CONCLUSIONS

CPFA is an effective therapy for hyperbilirubinaemia. Lowering preoperative bilirubinaemia and improvement of coagulation tests subsidized the management of the patients but in our study did not affect postoperative mortality. Further studies to evaluate the indications for treatments that remove bilirubin in this setting are needed.

Acute Kidney Injury in the Critically Ill

Acute kidney injury (AKI) occurs frequently in the surgical intensive care unit and results in significant morbidity and mortality. AKI needs to be identified early and underlying causes treated or eliminated. Sepsis, major surgery such as coronary artery bypass, and hypovolemia are the most common causes and patients with underlying comorbidities have increased susceptibility. Treatment should begin by ensuring that patients are adequately resuscitated and all contributing causes are replaced or eliminated. After stabilization of hemodynamic status and elimination of contributing causes, treatment becomes largely supportive and may require the use of a renal replacement therapy.

High-volume hemofiltration in adult burn patients with septic shock and acute kidney injury: a multicenter randomized controlled trial

BACKGROUND

Sepsis and septic shock occur commonly in severe burns. Acute kidney injury (AKI) is also common and often results as a consequence of sepsis. Mortality is unacceptably high in burn patients who develop AKI requiring renal replacement therapy and is presumed to be even higher when combined with septic shock. We hypothesized that high-volume hemofiltration (HVHF) as a blood purification technique would be beneficial in this population.

METHODS

We conducted a multicenter, prospective, randomized, controlled clinical trial to evaluate the impact of HVHF on the hemodynamic profile of burn patients with septic shock and AKI involving seven burn centers in the United States. Subjects randomized to the HVHF were prescribed a dose of 70 ml/kg/hour for 48 hours while control subjects were managed in standard fashion in accordance with local practices.

RESULTS

During a 4-year period, a total of nine subjects were enrolled for the intervention during the ramp-in phase and 28 subjects were randomized, 14 each into the control and HVHF arms respectively. The study was terminated due to slow enrollment. Ramp-in subjects were included along with those randomized in the final analysis. Our primary endpoint, the vasopressor dependency index, decreased significantly at 48 hours compared to baseline in the HVHF group (p = 0.007) while it remained no different in the control arm. At 14 days, the multiple organ dysfunction syndrome score decreased significantly in the HVHF group when compared to the day of treatment initiation (p = 0.02). No changes in inflammatory markers were detected during the 48-hour intervention period. No significant difference in survival was detected. No differences in adverse events were noted between the groups.

CONCLUSIONS

HVHF was effective in reversing shock and improving organ function in burn patients with septic shock and AKI, and appears safe. Whether reversal of shock in these patients can improve survival is yet to be determined.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01213914 . Registered 30 September 2010.

High-dose versus low-dose haemofiltration for the treatment of critically ill patients with acute kidney injury: an updated systematic review and meta-analysis

OBJECTIVE

The purpose of this study was to perform a systematic review and meta-analysis to evaluate the effect of high-dose versus low-dose haemofiltration on the survival of critically ill patients with acute kidney injury (AKI). We hypothesised that high-dose treatments are not associated with a higher risk of mortality.

DESIGN

Meta-analysis.

SETTING

Randomised controlled trials and two-arm prospective and retrospective studies were included.

PARTICIPANTS

Critically ill patients with AKI.

INTERVENTIONS

Continuous renal replacement therapy.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes: 90-day mortality, intensive care unit (ICU) mortality, hospital mortality; secondary outcomes: length of ICU and hospital stay.

RESULT

Eight studies including 2970 patients were included in the analysis. Pooled results showed no significant difference in the 90-mortality rate between patients treated with high-dose or low-dose haemofiltration (pooled OR=0.90, 95% CI 0.73 to 1.11, p=0.32). Findings were similar for ICU (pooled OR=1.12, 95% CI 0.94 to 1.34, p=0.21) and hospital mortality (pooled OR=1.03, 95% CI 0.81 to 1.30, p=0.84). Length of ICU and hospital stay were similar between high-dose and low-dose groups. Pooled results are not overly influenced by any one study, different cut-off points of prescribed dose or different cut-off points of delivered dose. Meta-regression analysis indicated that the results were not affected by the percentage of patients with sepsis or septic shock.

CONCLUSION

High-dose and low-dose haemofiltration produce similar outcomes with respect to mortality and length of ICU and hospital stay in critically ill patients with AKI.This study was not registered at the time the data were collected and analysed. It has since been registered on 17 February 2017 at http://www.researchregistry.com/, registration number: reviewregistry211.

Intestinal probiotics in relieving clinical symptoms of severe hand, foot, and mouth disease and potential mechanism analysis

OBJECTIVE

In this prospective cohort study, the efficacy and action mechanism of an intestinal probiotic formulation, Golden Bifid, in severe hand, foot, and mouth disease (HFMD) were determined in 63 consecutively admitted patients successfully treated in the Pediatrics Emergency Department of our hospital.

PATIENTS AND METHODS

All patients had a persistent fever; 43 patients had rashes on hands, feet, crissum, and hips; and 45 patients had neurological signs and symptoms. Patients were treated with standard supportive therapy along with ventilator-assisted respiration combined with bedside hemofiltration for removal of circulatory toxins and to achieve acid-base equilibrium and electrolyte stability. Golden Bifid was orally administered for 2 weeks, and vaccination was performed after patients were in stable condition. Additional supportive nursing care was also provided. Patients were categorized into the effective treatment (n = 40) and ineffective treatment (n = 23) groups.

RESULTS

Serum levels of proinflammatory factors [interleukin (IL)-1β, IL-6, tumor necrosis factor-α, and interferon-γ] were significantly decreased and those of anti-inflammatory factors (IL-13, IL-4, and IL-10) were significantly increased after treatment in the effective treatment group. In contrast, in the ineffective treatment group, serum proinflammatory factor levels were significantly increased and serum anti-inflammatory factor levels were significantly decreased. Between-group difference was significant. After treatment, serum D-lactic acid, diamine oxidase, and endotoxin levels were significantly decreased in the effective group and significantly increased in the ineffective group by intra- and inter-group comparisons.

CONCLUSIONS

Intestinal probiotics were effective in relieving clinical symptoms of severe HFMD, maintaining intestinal immunity and anti-inflammatory responses, and enhancing intestinal barrier function, with better safety and efficacy, which should be further evaluated for more extensive clinical applications.

Antifungal Extraction by the Extracorporeal Membrane Oxygenation Circuit

Invasive candidiasis is common and often fatal in patients supported with extracorporeal membrane oxygenation (ECMO), and treatment relies on optimal antifungal dosing. The ECMO circuit can extract drug and decrease drug exposure, placing the patient at risk of therapeutic failure. This ex vivo study determined the extraction of antifungal drugs by the ECMO circuit. Fluconazole and micafungin were studied separately in three closed-loop circuit configurations to isolate the impact of the oxygenator, hemofilter, and tubing on circuit extraction. Each circuit was primed with human blood, and flow was set to 1 L/min. Drug was dosed to achieve therapeutic concentrations. Each antifungal was added to a separate tube of blood to serve as a control. Serial blood samples were collected over 24 hours and concentrations were quantified with a validated assay. Drug recovery was calculated at each time point: (C t /C i )*100, with C t and C i the concentrations at time = t and 1 minute, respectively. After 24 hours of recirculation, mean recovery of fluconazole in the ECMO circuit (95-98%) and controls (101%) was high. In contrast, mean recovery of micafungin was dependent on the time and circuit configuration. Recovery at 4 hours was only 46% when a hemofilter was in-line but was much higher when the hemofilter was removed (91%). By 24 hours, however, micafungin recovery was low in all circuit configurations (26-43%), regardless of the presence of a hemofilter, as well as in the controls (57%). In conclusion, these results suggest that micafungin is extracted by the ECMO circuit, which may result in decreased drug exposure in vivo.

Outpatient Emergencies: Acute Heart Failure

Heart failure is an epidemic in the United States and a major health problem worldwide. The syndrome of acute heart failure is marked by a recent onset of symptoms usually in terms of days to a few weeks of worsening fatigue, shortness of breath, orthopnea, swelling, and sudden onset of weight gain. Physicians caring for patients with heart failure must know the risk factors for this disease, pathophysiology, symptomatology, important examination findings, key diagnostic tests, and management approach so as to improve symptoms and reduce mortality.

Regional citrate anticoagulation for continuous renal replacement therapy in children

BACKGROUND

Anticoagulation of the continuous renal replacement therapy (CRRT) circuit is an important technical aspect of this medical procedure. Most studies evaluating the efficacy and safety of citrate use have been carried out in adults, and little evidence is available for the pediatric patient population. The aim of this study was to compare regional citrate anticoagulation versus systemic heparin anticoagulation in terms of the lifetime of hemofilters in a pediatric population receiving CRRT at a pediatric center in Bogota, Colombia.

METHODS

This was an analytical, observational, retrospective cohort study in which we assessed the survival of 150 hemofilters (citrate group 80 hemofilters, heparin group 70 hemofilters) used in a total of 3442 hours of CCRT (citrate group 2248 h, heparin group 1194 h). Hemofilter survival was estimated beginning at placement and continuing until filter replacement due to clotting or high trans-membrane pressures.

RESULTS

Hemofilter survival was higher in the citrate group than in the heparin group (72 vs. 18 h; p <0.0001). Bivariate analysis showed that the hemofilter coagulation risk was significantly increased when heparin was used, regardless of hemofilter size and pump flow (hazard ratio 3.70, standard error 0.82, 95% confidence interval 2.39-5.72; p <0.00001).

CONCLUSIONS

Regional citrate anticoagulation could be more effective than heparin systemic anticoagulation in terms of prolonging the hemofilter lifetime in patients with acute renal injury who require CRRT.