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Song X, Liu C, Zhang M, Wei W, Yang L, Wang B, Huang Y, Song G, Wang F, Yang Y, Zhao Y, Zhang L, Fu P. The Efficacy and Safety of Continuous Veno-Venous Hemodiafiltration With High Cutoff Membrane Versus High Flux Membrane in Septic Acute Kidney Injury: A Randomized Controlled Study. Artif Organs 2025; 49:1067-1075. [PMID: 39895488 DOI: 10.1111/aor.14963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2024] [Revised: 01/13/2025] [Accepted: 01/21/2025] [Indexed: 02/04/2025]
Abstract
BACKGROUND The application of high cutoff (HCO) membranes for continuous renal replacement therapy remains unclear in septic acute kidney injury (S-AKI) patients. METHODS S-AKI patients who received continuous veno-venous hemodiafiltration (CVVHDF) were randomly assigned to the experimental group (HCO membrane) and the control group (high flux membrane, HF membrane). Interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) in serum and waste fluid were measured at 0, 2, 12, and 24 h after CVVHDF initiation and the 28-day mortality. RESULTS Eleven patients were randomized to the HCO group, and 9 patients in the HF group, with a mean age of 54.9 ± 3.2 years and 6 patients (30%) being female. After 24 h of treatment with CVVHDF, there were significant reductions in serum IL-6 and TNF-α concentrations in the HCO group (p = 0.001, 0.015) and HF group (p = 0.004, 0.031). The serum IL-6 reduction rate of the HCO group was significantly higher than that of the HF group (79.21% vs. 42.69%, p = 0.025), while serum TNF-α reduction rates were comparable between the 2 groups. There were no significant changes in serum albumin after 24 h using either HCO membrane (28.7 ± 1.7 g/L vs. 32.7 ± 1.6 g/L, p = 0.138) or HF membrane (29.6 ± 1.1 g/L vs. 32.6 ± 1.3 g/L, p = 0.055). The two groups had similar 24-h filter clotting rates and 28-day mortality. CONCLUSION While CVVHDF with the HCO membrane and HF membrane both achieved significant reductions in serum cytokine levels, the HCO membrane was associated with a greater reduction rate in IL-6 but not in TNF-α. No difference was observed in serum albumin, mortality, or filter clotting. TRIAL REGISTRATION Registry number: ChiCTR2000039725.
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Affiliation(s)
- Xiaowei Song
- Department of Nephrology, Institute of Kidney Diseases, West China Hospital of Sichuan University, Chengdu, China
- Department of Nephrology, The Third People's Hospital of Chengdu, Chengdu, China
| | - Caihong Liu
- Department of Nephrology, Institute of Kidney Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Min Zhang
- Department of Nephrology, West China Hospital of Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Wei Wei
- Department of Nephrology, Institute of Kidney Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Letian Yang
- Department of Nephrology, Institute of Kidney Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Bo Wang
- Department of Nephrology, Institute of Kidney Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Yongxiu Huang
- Department of Nephrology, Institute of Kidney Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Guojiao Song
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Fang Wang
- Department of Nephrology, West China Hospital of Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Yingying Yang
- Department of Nephrology, Institute of Kidney Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Yuliang Zhao
- Department of Nephrology, Institute of Kidney Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Ling Zhang
- Department of Nephrology, Institute of Kidney Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Ping Fu
- Department of Nephrology, Institute of Kidney Diseases, West China Hospital of Sichuan University, Chengdu, China
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An JN, Oh HJ, Oh S, Rhee H, Seong EY, Baek SH, Ahn SY, Cho JH, Lee JP, Kim DK, Ryu DR, Ahn S, Kim S. Bioimpedance-Guided Fluid Removal in Continuous KRT: The VENUS Randomized Clinical Trial. Clin J Am Soc Nephrol 2024; 19:1527-1536. [PMID: 39264719 PMCID: PMC11637699 DOI: 10.2215/cjn.0000000000000557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 09/09/2024] [Indexed: 09/14/2024]
Abstract
Key Points This study, the sole randomized trial of its kind, proposes guidelines for fluid balance management in continuous KRT (CKRT) patients using bioimpedance. Despite this, bioimpedance analysis–guided volume management did not influence the proportion of patients achieving estimated euvolemia at 7 days into CKRT. Further investigation is needed to assess whether bioimpedance analysis guidance can facilitate rapid fluid removal in the early phase of CKRT for patients with AKI. Background Ultrafiltration with continuous KRT (CKRT) can be used to manage fluid balance in critically ill patients with AKI. We aimed to assess whether bioimpedance analysis (BIA)–guided volume management was more efficacious than conventional management for achieving estimated euvolemia (e-euvolemia) in CKRT-treated patients. Methods In a multicenter randomized controlled trial from July 2017 to July 2020, the patients with AKI requiring CKRT were eligible if the weight at the start of CKRT had increased by ≥5% compared with the weight at the time of admission or total body water (TBW)/height (H)2 ≥13 L/m2. We randomly assigned 208 patients to the control (conventional fluid management; n =103) and intervention groups (BIA-guided fluid management; n =105). The primary outcome was the proportion of attaining e-euvolemia 7 days postrandomization. E-euvolemia was defined as the difference between TBW/H2 D7 and D0 was <−2.1 L/m2, or when TBW/H2 measured on D7 was <13 L/m2. The 28-, 60-, and 90-day mortality rate were secondary outcomes. Results The primary outcome occurred in 34 patients in the intervention group and 27 in the control group (47% versus 41%; P = 0.50). The mean value of TBW/H2 measured on D7 was the same at 13.9 L/m2 in both groups. The differences between TBW/H2 D7 and D0 were −1.13 L/m2 in the intervention group and −1.08 L/m2 in the control group (P = 0.84). Patients in the intervention group had a significantly higher proportion of reaching e-euvolemia on D1 than those in the control group (13% versus 4%, P = 0.02). Adverse events did not differ significantly between the groups. Conclusions BIA-guided volume management did not affect the proportion of reaching the e-euvolemia at 7 days of the start of CKRT. Clinical Trial registry name and registration number: ClinicalTrials.gov , ID: NCT03330626 (Registered on November 6, 2017; seven study participants were retrospectively registered; nonetheless, Institutional Review Board approval of each institution was completed before study participant registration).
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Affiliation(s)
- Jung Nam An
- Division of Nephrology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Hyung Jung Oh
- Department of Nephrology, Sheikh Khalifa Specialty Hospital, Ras Al Khaimah, United Arab Emirates
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sohee Oh
- Department of Biostatistics, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Harin Rhee
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Eun Young Seong
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Seon Ha Baek
- Division of Nephrology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Shin Young Ahn
- Division of Nephrology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Jang-Hee Cho
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dong-Ryeol Ryu
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Ewha Woman's University, Seoul, Republic of Korea
| | - Soyeon Ahn
- Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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Kalenka A, Arens P, Müllenbach RM, Weigand MA, Brune M, Fiedler-Kalenka MO. Effects of Oxiris ® Therapy on Cytokine Elimination after a LPS Infusion-An Experimental Animal Study. Int J Mol Sci 2024; 25:9283. [PMID: 39273234 PMCID: PMC11394842 DOI: 10.3390/ijms25179283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Revised: 08/15/2024] [Accepted: 08/26/2024] [Indexed: 09/15/2024] Open
Abstract
The clinical effectiveness of Oxiris®, particularly in reducing cytokines, remains uncertain due to the limited data provided. This study explored and analyzed the application value of Oxiris® endotoxin adsorption technology in a large animal model. Pigs received an intravenous LPS infusion. Six animals were treated 2 h after the infusion with an Oxiris® hemadsorption using a pumpless extracorporeal technique for 6 h. Five animals served as controls. Cardiocirculatory parameters, hyperspectral analysis, and a panel of cytokines were measured. The lipopolysaccharide infusion induced sepsis-like inflammation with tachycardia, elevated pulmonary pressure, elevated lactate level, as well as elevated pro-inflammatory cytokines like interferon (IFN)-γ, interleukin (IL)-1β, IL-2, IL-6, IL-8, IL-12 and tumor necrosis factor alpha (TNF-α). In addition, increases of anti-inflammatory cytokines like IL-1ra and IL-10 were found. After 3 and 6 h in both groups, pro-inflammatory cytokines were significantly reduced. No differences between the intervention and the control group could be detected after 3 and 6 h for IL-1β, IL-2, IL-6, IL-8, IL-12 and TNF-α, suggesting no effect of the Oxiris® filter on the elimination of elevated cytokines with a pumpless extracorporeal hemadsorption technique. The presented large animal model may be a promising option for studying the effects of hemadsorption techniques.
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Affiliation(s)
- Armin Kalenka
- Department of Anesthesiology, Medical Faculty, University Hospital Heidelberg, University Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
- Hospital Bergstrasse, 64646 Heppenheim, Germany
| | - Philipp Arens
- Department of Anesthesiology, Medical Faculty, University Hospital Heidelberg, University Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Ralf M Müllenbach
- Department of Anesthesiology, Critical Care Medicine, Emergency Medicine and Pain Therapy, ECMO-Center, Campus Kassel of the University of Southampton, 34125 Kassel, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Medical Faculty, University Hospital Heidelberg, University Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Maik Brune
- Department of Internal Medicine I and Clinical Chemistry, Medical Faculty, University Hospital Heidelberg, University Heidelberg, 69120 Heidelberg, Germany
| | - Mascha O Fiedler-Kalenka
- Department of Anesthesiology, Medical Faculty, University Hospital Heidelberg, University Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
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Park SJ, Park I, Kim S, Kim MK, Kim S, Jeong H, Kim D, Cho SW, Park TE, Ni A, Lim H, Joo J, Lee JH, Kang JH. Extracorporeal Blood Treatment Using Functional Magnetic Nanoclusters Mitigates Organ Dysfunction of Sepsis in Swine. SMALL METHODS 2024; 8:e2301428. [PMID: 38161256 DOI: 10.1002/smtd.202301428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/18/2023] [Indexed: 01/03/2024]
Abstract
Mitigating sepsis-induced severe organ dysfunction with magnetic nanoparticles has shown remarkable advances in extracorporeal blood treatment. Nevertheless, treating large septic animals remains challenging due to insufficient magnetic separation at rapid blood flow rates (>6 L h-1) and limited incubation time in an extracorporeal circuit. Herein, superparamagnetic nanoclusters (SPNCs) coated with red blood cell (RBC) membranes are developed, which promptly capture and magnetically separate a wide range of pathogens at high blood flow rates in a swine sepsis model. The SPNCs exhibited an ultranarrow size distribution of clustered iron oxide nanocrystals and exceptionally high saturation magnetization (≈ 90 emu g-1) close to that of bulk magnetite. It is also revealed that CD47 on the RBCs allows the RBC-SPNCs to remain at a consistent concentration in the blood by evading innate immunity. The uniform size distribution of the RBC-SPNCs greatly enhances their effectiveness in eradicating various pathogenic materials in extracorporeal blood. The use of RBC-SPNCs for extracorporeal treatment of swine infected with multidrug-resistant E. coli is validated and found that severe bacteremic sepsis-induced organ dysfunction is significantly mitigated after 12 h. The findings highlight the potential application of RBC-SPNCs for extracorporeal therapy of severe sepsis in large animal models and potentially humans.
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Affiliation(s)
- Sung Jin Park
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
| | - Inwon Park
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 44919, Republic of Korea
| | - Suhyun Kim
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
| | - Min Kyu Kim
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
| | - Seonghye Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 44919, Republic of Korea
| | - Hwain Jeong
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 44919, Republic of Korea
| | - Dongsung Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 44919, Republic of Korea
| | - Seung Woo Cho
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
| | - Tae-Eun Park
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
| | - Aleksey Ni
- School of Energy and Chemical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
| | - Hankwon Lim
- School of Energy and Chemical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
| | - Jinmyoung Joo
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
- Center for Genomic Integrity, Institute for Basic Science, Ulsan, 44919, Republic of Korea
| | - Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 44919, Republic of Korea
| | - Joo H Kang
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
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De Wolf J, Gouin C, Jouneau L, Glorion M, Premachandra A, Pascale F, Huriet M, Estephan J, Leplat JJ, Egidy G, Richard C, Gelin V, Urien C, Roux A, Le Guen M, Schwartz-Cornil I, Sage E. Prolonged dialysis during ex vivo lung perfusion promotes inflammatory responses. Front Immunol 2024; 15:1365964. [PMID: 38585271 PMCID: PMC10995259 DOI: 10.3389/fimmu.2024.1365964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/04/2024] [Indexed: 04/09/2024] Open
Abstract
Ex-vivo lung perfusion (EVLP) has extended the number of transplantable lungs by reconditioning marginal organs. However, EVLP is performed at 37°C without homeostatic regulation leading to metabolic wastes' accumulation in the perfusate and, as a corrective measure, the costly perfusate is repeatedly replaced during the standard of care procedure. As an interesting alternative, a hemodialyzer could be placed on the EVLP circuit, which was previously shown to rebalance the perfusate composition and to maintain lung function and viability without appearing to impact the global gene expression in the lung. Here, we assessed the biological effects of a hemodialyzer during EVLP by performing biochemical and refined functional genomic analyses over a 12h procedure in a pig model. We found that dialysis stabilized electrolytic and metabolic parameters of the perfusate but enhanced the gene expression and protein accumulation of several inflammatory cytokines and promoted a genomic profile predicting higher endothelial activation already at 6h and higher immune cytokine signaling at 12h. Therefore, epuration of EVLP with a dialyzer, while correcting features of the perfusate composition and maintaining the respiratory function, promotes inflammatory responses in the tissue. This finding suggests that modifying the metabolite composition of the perfusate by dialysis during EVLP can have detrimental effects on the tissue response and that this strategy should not be transferred as such to the clinic.
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Affiliation(s)
- Julien De Wolf
- Department of Thoracic Surgery and Lung Transplantation, Foch Hospital, Suresnes, France
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
| | - Carla Gouin
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
| | - Luc Jouneau
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
| | - Matthieu Glorion
- Department of Thoracic Surgery and Lung Transplantation, Foch Hospital, Suresnes, France
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
| | | | - Florentina Pascale
- Department of Thoracic Surgery and Lung Transplantation, Foch Hospital, Suresnes, France
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
| | - Maxime Huriet
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
| | - Jérôme Estephan
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
| | | | - Giorgia Egidy
- Université Paris-Saclay, INRAE, AgroParisTech, GABI, Jouy-en-Josas, France
| | - Christophe Richard
- Université Paris-Saclay, UVSQ, INRAE, BREED, MIMA2, CIMA, Jouy-en-Josas, France
| | - Valérie Gelin
- Université Paris-Saclay, UVSQ, INRAE, BREED, MIMA2, CIMA, Jouy-en-Josas, France
| | - Céline Urien
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
| | - Antoine Roux
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
- Department of Pulmonology, Foch Hospital, Suresnes, France
| | - Morgan Le Guen
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
- Department of Anesthesiology, Foch Hospital, Suresnes, France
| | | | - Edouard Sage
- Department of Thoracic Surgery and Lung Transplantation, Foch Hospital, Suresnes, France
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
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Gao Y, Huang X, Yang Y, Lei Z, Chen Q, Guo X, Tian J, Gao X. Clinical analysis of AN69ST membrane continuous venous hemofiltration in the treatment of severe sepsis. Open Med (Wars) 2023; 18:20230784. [PMID: 37724124 PMCID: PMC10505301 DOI: 10.1515/med-2023-0784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 09/20/2023] Open
Abstract
We aimed to investigate the clinical efficacy of blood purification technology based on cytokine adsorption in the treatment of sepsis. Sixty patients with sepsis were randomly divided into control (n = 30) and experimental (n = 30) groups. Both groups were given routine treatment and continuous venovenous hemofiltration, and on this basis, the experimental group received acrylonitrile/sodium methacrylate (AN69ST) blood purification. The levels of C-reactive protein, procalcitonin, white blood cell count, albumin, platelets, total bilirubin, creatinine, lactic acid, and APACE II score, as well as secretion of inflammatory factors interleukin (IL)-6 and tumor necrosis factor (TNF-α) were compared. The hospitalization time, mechanical ventilation (MV) time, drug use time, and mortality were analyzed. After treatment, the secretion levels of IL-6 and TNF-α were decreased, and other indicators were significantly improved compared with those before treatment (P < 0.05), especially in the experimental group (P < 0.05). The hospitalization time, MV time, and drug use time in the experimental group were significantly lower than those of the control group (P < 0.05), and the mortality was lower than that in the control group (P < 0.05). In conclusion, blood purification technology based on cytokine adsorption can significantly improve various indicators of sepsis patients, reduce hospitalization time, reduce mortality, and improve the prognosis.
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Affiliation(s)
- Yuqiang Gao
- Intensive Medical Unit, Hainan Medical University, 571199Haikou, China
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, 570311, Haikou, China
| | - Xiaohong Huang
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, 570311, Haikou, China
| | - Yanan Yang
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, 570311, Haikou, China
| | - Zhenlin Lei
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, 570311, Haikou, China
| | - Qingan Chen
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, 570311, Haikou, China
| | - Xu Guo
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, 570311, Haikou, China
| | - Jia Tian
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, No. 19 Xiuhua Road, 570311Haikou, China
| | - Xiaoxin Gao
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, No. 19 Xiuhua Road, 570311Haikou, China
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Li Z, Zhang H, Xie K, Zhang Y, Zhang Z, Zheng W, Yang T, Zhang L, Yu Y. EARLY INITIATION OF RENAL REPLACEMENT THERAPY IN INTENSIVE CARE UNIT PATIENTS WITH BOTH ACUTE RESPIRATORY DISTRESS SYNDROME AND SEPSIS WITH OR WITHOUT RENAL FAILURE: A RETROSPECTIVE COHORT STUDY BASED ON PROPENSITY SCORE MATCHING. Shock 2023; 59:569-575. [PMID: 36802286 DOI: 10.1097/shk.0000000000002090] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
ABSTRACT Background: It is unknown whether early renal replacement therapy (RRT) initiation strategy in intensive care unit (ICU) patients with both acute respiratory distress syndrome (ARDS) and sepsis with or without renal failure is clinically beneficial. Patients and methods: A total of 818 patients with both ARDS and sepsis admitted to the ICU of Tianjin Medical University General Hospital were included in the analysis. Early RRT was defined as initiating the RRT strategy within 24 h of admission. The relationship between early RRT and clinical outcomes, including primary (30-day mortality) and secondary (90-day mortality, serum creatinine, Pa o2 /Fi o2 , duration of invasive mechanical ventilation, cumulative fluid output, and cumulative fluid balance) outcomes, was compared using propensity score matching (PSM). Results: A total of 277 patients (33.9% of the total population) underwent an early RRT initiation strategy before PSM. After PSM, a cohort of 147 patients with early RRT and 147 patients without early RRT with matched baseline characteristics (including serum creatinine at admission) were constructed. Early RRT was not significantly associated with 30- (hazard ratio [HR], 1.25; 95% confidence interval [CI], 0.85-1.85; P = 0.258) or 90-day mortality (HR, 1.30; 95% CI, 0.91-1.87, P = 0.150). At each time point within 72 h after admission, there was no significant difference in serum creatinine, Pa o2 /Fi o2 and duration of mechanical ventilation between the early and the no early RRT groups. Early RRT significantly increased total output at all time points within 72 h of admission and reached a statistically significant negative fluid balance at 48 h. Conclusions: Early RRT initiation strategies had no statistically significant survival benefit in ICU patients with both ARDS and sepsis, with or without renal failure, nor did they significantly improve serum creatinine and oxygenation or shorten the duration of mechanical ventilation. The use and timing of RRT in such patients should be thoroughly investigated.
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Affiliation(s)
- Ziping Li
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Haoyue Zhang
- Department of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Keliang Xie
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Ying Zhang
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhen Zhang
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | | | - Tianqi Yang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Linlin Zhang
- Department of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Yonghao Yu
- Department of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, China
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Persic V, Jerman A, Malgaj Vrecko M, Berden J, Gorjup V, Stecher A, Lukic M, Jereb M, Taleska Stupica G, Gubensek J. Effect of CytoSorb Coupled with Hemodialysis on Interleukin-6 and Hemodynamic Parameters in Patients with Systemic Inflammatory Response Syndrome: A Retrospective Cohort Study. J Clin Med 2022; 11:jcm11247500. [PMID: 36556116 PMCID: PMC9788171 DOI: 10.3390/jcm11247500] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Excessive release of cytokines during systemic inflammatory response syndrome (SIRS) often leads to refractory hypotension and multiple organ failure with high mortality. Cytokine removal with hemoadsorption has emerged as a possible adjuvant therapy, but data on interleukin-6 (IL-6) reduction and outcomes in clinical practice are scarce. We aimed to evaluate the effect of CytoSorb hemoadsorption on laboratory and clinical outcomes in shocked patients with SIRS. We designed a retrospective analysis of all patients with SIRS treated with CytoSorb in intensive care units (ICU). IL-6, laboratory and hemodynamic parameters were analyzed at approximate time intervals during CytoSorb treatment in the whole cohort and in a subgroup with septic shock. Observed and predicted mortality rates were compared. We included 118 patients with various etiologies of SIRS (septic shock 69%, post-resuscitation shock 16%, SIRS with acute pancreatitis 6%, other 9%); in all but one patient, CytoSorb was coupled with renal replacement therapy. A statistically significant decrease in IL-6 and vasopressor index with an increase in pH and mean arterial pressure was observed from 6 h onward. The reduction of lactate became significant at 48 h. Results were similar in a subgroup of patients with septic shock. Observed ICU and in-hospital mortalities were lower than predicted by Sequential Organ Failure Assessment (SOFA) (61% vs. 79%, p = 0.005) and Acute Physiology and Chronic Health Evaluation (APACHE) II (64% vs. 78%, p = 0.031) scores. To conclude, hemoadsorption in shocked patients with SIRS was associated with a rapid decrease in IL-6 and hemodynamic improvement, with improved observed vs. predicted survival. These results need to be confirmed in a randomized study.
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Affiliation(s)
- Vanja Persic
- Center for Acute and Complicated Dialysis and Vascular Access, Department of Nephrology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Alexander Jerman
- Center for Acute and Complicated Dialysis and Vascular Access, Department of Nephrology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
| | - Marija Malgaj Vrecko
- Center for Acute and Complicated Dialysis and Vascular Access, Department of Nephrology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Jernej Berden
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Center of Intensive Internal Medicine, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
| | - Vojka Gorjup
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Center of Intensive Internal Medicine, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
| | - Adela Stecher
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Department of Anesthesiology and Surgical Intensive Therapy, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
| | - Milica Lukic
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Department of Infectious Diseases, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
| | - Matjaz Jereb
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Department of Infectious Diseases, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
| | - Gordana Taleska Stupica
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Department of Anesthesiology and Surgical Intensive Therapy, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
| | - Jakob Gubensek
- Center for Acute and Complicated Dialysis and Vascular Access, Department of Nephrology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Correspondence: ; Tel.: +386-1-522-31-21
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9
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Zeng Z, Zou K, Qing C, Wang J, Tang Y. Predicting mortality in acute kidney injury patients undergoing continuous renal replacement therapy using a visualization model: A retrospective study. Front Physiol 2022; 13:964312. [PMID: 36425293 PMCID: PMC9679412 DOI: 10.3389/fphys.2022.964312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 10/20/2022] [Indexed: 11/29/2023] Open
Abstract
Background: Patients with severe acute kidney injury (AKI) require continuous renal replacement therapy (CRRT) when hemodynamically unstable. We aimed to identify prognostic factors and develop a nomogram that could predict mortality in patients with AKI undergoing CRRT. Methods: Data were extracted from the Dryad Digital Repository. We enrolled 1,002 participants and grouped them randomly into training (n = 670) and verification (n = 332) datasets based on a 2:1 proportion. Based on Cox proportional modeling of the training set, we created a web-based dynamic nomogram to estimate all-cause mortality. Results: The model incorporated phosphate, Charlson comorbidity index, body mass index, mean arterial pressure, levels of creatinine and albumin, and sequential organ failure assessment scores as independent predictive indicators. Model calibration and discrimination were satisfactory. In the training dataset, the area under the curves (AUCs) for estimating the 28-, 56-, and 84-day all-cause mortality were 0.779, 0.780, and 0.787, respectively. The model exhibited excellent calibration and discrimination in the validation dataset, with AUC values of 0.791, 0.778, and 0.806 for estimating 28-, 56-, and 84-day all-cause mortality, respectively. The calibration curves exhibited the consistency of the model between the two cohorts. To visualize the results, we created a web-based calculator. Conclusion: We created a web-based calculator for assessing fatality risk in patients with AKI receiving CRRT, which may help rationalize clinical decision-making and personalized therapy.
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Affiliation(s)
- Zhenguo Zeng
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Kang Zou
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Chen Qing
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jiao Wang
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yunliang Tang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China
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10
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AN69 Filter Membranes with High Ultrafiltration Rates during Continuous Venovenous Hemofiltration Reduce Mortality in Patients with Sepsis-Induced Multiorgan Dysfunction Syndrome. MEMBRANES 2021; 11:membranes11110837. [PMID: 34832066 PMCID: PMC8618352 DOI: 10.3390/membranes11110837] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 12/29/2022]
Abstract
Polyacrylonitrile (AN69) filter membranes adsorb cytokines during continuous venovenous hemofiltration (CVVH). Although high-volume hemofiltration has shown limited benefits, the dose-effect relationship in CVVH with AN69 membranes on severe sepsis remains undetermined. This multi-centered study enrolled 266 patients with sepsis-induced multiorgan dysfunction syndrome (MODS) who underwent CVVH with AN69 membranes between 2014 and 2015. We investigated the effects of ultrafiltration rates (UFR) on mortality. We categorized patients that were treated with UFR of 20-25 mL/kg/h as the standard UFR group (n = 124) and those that were treated with a UFR >25 mL/kg/h as the high UFR group (n = 142). Among the patient characteristics, the baseline estimated glomerular filtration rates (eGFR) <60 mL/min/1.73 m2, hemoglobin levels <10 g/dL, and a sequential organ failure assessment (SOFA) score ≥15 at CVVH initiation were independently associated with in-hospital mortality. In the subgroup analysis, for patients with SOFA scores that were ≥15, the 90-day survival rate was higher in the high UFR group than in the standard UFR group (HR 0.54, CI: 0.36-0.79, p = 0.005). We concluded that in patients with sepsis-induced MODS, SOFA scores ≥15 predicted a poor rate of survival. High UFR setting >25 mL/kg/h in CVVH with AN69 membranes may reduce the mortality risk in these high-risk patients.
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11
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The Effect of Long-Term Duration Renal Replacement Therapy on Outcomes of Critically Ill Patients with Acute Kidney Injury: A Retrospective Cohort Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:6623667. [PMID: 34504539 PMCID: PMC8423547 DOI: 10.1155/2021/6623667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 06/29/2021] [Accepted: 07/28/2021] [Indexed: 11/17/2022]
Abstract
Background Renal replacement therapy (RRT), as a cornerstone of supportive treatment, has long been performed in critically ill patients with acute kidney injury (AKI). However, the majority of studies may have neglected the effect of the duration of RRT on the outcome of AKI patients. This paper is aiming to explore the effect of the long duration of RRT on the outcome of critically ill patients with AKI. Methods This retrospective study was conducted by using the Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC-II) database. The primary outcome measure of this study was the mortality at 28 days, 60 days, and 90 days in the long-duration RRT group and the non-long-duration RRT group. The secondary outcomes assessed the difference in clinical outcome in these two groups. Lastly, the effect of the duration of RRT on mortality in AKI patients was determined as the third outcome. Results We selected 1,020 patients in total who received RRT according to the MIMIC-II database. According to the inclusion and exclusion criteria, we finally selected 506 patients with AKI: 286 AKI patients in the non-long-duration RRT group and 220 in the long-duration RRT group. After 28 days, there was a significant difference in all-cause mortality between the long-duration RRT group and the non-long-duration RRT group (P=0.001). However, the difference disappeared after 60 days and 90 days (P=0.803 and P=0.925, respectively). The length of ICU stay, length of hospital stay, and duration of mechanical ventilation were significantly longer in the long-duration RRT group than those in the non-long-duration RRT group. Considering 28-day mortality, the longer duration of RRT was shown to be a protective factor (HR = 0.995, 95% CI 0.993-0.997, P < 0.0001), while 60-day and 90-day mortality were not correlated with improved protection. Conclusions The long duration of RRT can improve the short-term prognosis of AKI patients, but it does not affect the long-term prognosis of these patients. Prognosis is determined by the severity of the illness itself. This suggests that RRT can protect AKI patients through the most critical time; however, the final outcome cannot be altered.
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12
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Xiao M, Liu B, Zhou M, Wang D, Chen L. Evaluation of the timing of initiating continuous renal replacement therapy in community-acquired septic patients with acute kidney injury. CHINESE J PHYSIOL 2021; 64:135-141. [PMID: 34169919 DOI: 10.4103/cjp.cjp_16_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute kidney injury (AKI) in community-acquired septic patients is often associated with relatively high mortality rate. However, the appropriate timing for continuous renal replacement therapy (CRRT) initiation remains controversial. In the present study, we retrospectively analyzed 123 community-acquired septic patients with AKI admitted to the medical intensive care unit (ICU). The baseline patient characteristics and renal function parameters were compared between survivors and non-survivors. Then, we used the Cox proportional hazard analysis to identify the risk factors for ICU mortality. Moreover, we employed the area under the receiver operating characteristic curve analysis to determine the cutoff time for CRRT initiation. Finally, we used the cutoff time to separate the patients into early (treatment initiated earlier than the cutoff time) and late (treatment initiated later than the cutoff time) CRRT groups and performed the Kaplan-Meier survival analysis to assess the overall mortalities. At the time of ICU release, the mortality rate of the 123 patients was 48.8% (n = 60). We identified several baseline characteristics and renal function parameters that were significantly different between the survivors and the non-survivors. All of them were also identified as the risk factors for community-acquired sepsis. Importantly, the cutoff time point to distinguish the early and late CRRT initiation groups was determined to be 16 h after AKI onset. Based on such grouping, the mortality rate was significantly lower in the early CRRT initiation group at 30, 60 and 90 days. Our data suggest that initiating CRRT within 16 h may help improve the mortality rate of community-acquired septic patients.
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Affiliation(s)
- Min Xiao
- Department of Intensive Care Unit, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Bingqi Liu
- Department of Intensive Care Unit, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Mao Zhou
- Department of Intensive Care Unit, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Daqing Wang
- Department of Intensive Care Unit, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Li Chen
- Department of Intensive Care Unit, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
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13
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Lumlertgul N, Hall A, Camporota L, Crichton S, Ostermann M. Clearance of inflammatory cytokines in patients with septic acute kidney injury during renal replacement therapy using the EMiC2 filter (Clic-AKI study). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:39. [PMID: 33509215 PMCID: PMC7845048 DOI: 10.1186/s13054-021-03476-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/20/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The EMiC2 membrane is a medium cut-off haemofilter (45 kiloDalton). Little is known regarding its efficacy in eliminating medium-sized cytokines in sepsis. This study aimed to explore the effects of continuous veno-venous haemodialysis (CVVHD) using the EMiC2 filter on cytokine clearance. METHODS This was a prospective observational study conducted in critically ill patients with sepsis and acute kidney injury requiring kidney replacement therapy. We measured concentrations of 12 cytokines [Interleukin (IL) IL-1β, IL-1α, IL-2, IL-4, IL-6, IL-8, IL-10, interferon (IFN)-γ, tumour necrosis factor (TNF)-α, vascular endothelial growth factor, monocyte chemoattractant protein (MCP)-1, epidermal growth factor (EGF)] in plasma at baseline (T0) and pre- and post-dialyzer at 1, 6, 24, and 48 h after CVVHD initiation and in the effluent fluid at corresponding time points. Outcomes were the effluent and adsorptive clearance rates, mass balances, and changes in serial serum concentrations. RESULTS Twelve patients were included in the final analysis. All cytokines except EGF concentrations declined over 48 h (p < 0.001). The effluent clearance rates were variable and ranged from negligible values for IL-2, IFN-γ, IL-1α, IL-1β, and EGF, to 19.0 ml/min for TNF-α. Negative or minimal adsorption was observed. The effluent and adsorptive clearance rates remained steady over time. The percentage of cytokine removal was low for most cytokines throughout the 48-h period. CONCLUSION EMiC2-CVVHD achieved modest removal of most cytokines and demonstrated small to no adsorptive capacity despite a decline in plasma cytokine concentrations. This suggests that changes in plasma cytokine concentrations may not be solely influenced by extracorporeal removal. TRIAL REGISTRATION NCT03231748, registered on 27th July 2017.
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Affiliation(s)
- Nuttha Lumlertgul
- Department of Critical Care, Guy's and St Thomas' Hospital, King's College London, NHS Foundation Trust, 249 Westminster Bridge Road, London, SE1 7EH, UK. .,Division of Nephrology and Excellence Centre for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand. .,Critical Care Nephrology Research Unit, Chulalongkorn University, Bangkok, Thailand.
| | - Anna Hall
- Department of Critical Care, Guy's and St Thomas' Hospital, King's College London, NHS Foundation Trust, 249 Westminster Bridge Road, London, SE1 7EH, UK.,Zorgsaam Terneuzen, Rotterdam, The Netherlands
| | - Luigi Camporota
- Department of Critical Care, Guy's and St Thomas' Hospital, King's College London, NHS Foundation Trust, 249 Westminster Bridge Road, London, SE1 7EH, UK
| | - Siobhan Crichton
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Marlies Ostermann
- Department of Critical Care, Guy's and St Thomas' Hospital, King's College London, NHS Foundation Trust, 249 Westminster Bridge Road, London, SE1 7EH, UK
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14
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Kaptein MJ, Kaptein JS, Nguyen CD, Oo Z, Thwe PP, Thu MB, Kaptein EM. Changes in cardiac output with hemodialysis relate to net volume balance and to inferior vena cava ultrasound collapsibility in critically ill patients. Ren Fail 2020; 42:179-192. [PMID: 32050836 PMCID: PMC7034082 DOI: 10.1080/0886022x.2020.1726384] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Cardiac output may increase after volume administration with relative intravascular volume depletion, or after ultrafiltration (UF) with relative intravascular volume overload. Assessing relative intravascular volume using respiratory/ventilatory changes in inferior vena cava (IVC) diameters may guide volume management to optimize cardiac output in critically ill patients requiring hemodialysis (HD) and/or UF.We retrospectively studied 22 critically ill patients having relative intravascular volume assessed by IVC Collapsibility Index (IVC CI) = (IVCmax-IVCmin)/IVCmax*100%, within 24 h of cardiac output measurement, during 37 intermittent and 21 continuous HD encounters. Cardiac output increase >10% was considered significant. Net volume changes between cardiac outputs were estimated from "isonatremic volume equivalent" (0.9% saline) gains and losses.Cardiac output increased >10% in 15 of 42 encounters with IVC CI <20% after net volume removal, and in 1 of 16 encounters with IVC CI ≥20% after net volume administration (p = 0.0136). All intermittent and continuous HD encounters resulted in intradialytic hypotension. Net volume changes between cardiac output measurements were significantly less (median +1.0 mL/kg) with intractable hypotension or vasopressor initiation, and net volume removal was larger (median -22.9 mL/kg) with less severe intradialytic hypotension (p < 0.001). Cardiac output increased >10% more frequently with least severe intradialytic hypotension and decreased with most severe intradialytic hypotension (p = 0.047).In summary, cardiac output may increase with net volume removal by ultrafiltration in some critically ill patients with relative intravascular volume overload assessed by IVC collapsibility. Severe intradialytic hypotension may limit volume removal with ultrafiltration, rather than larger volume removal causing severe intradialytic hypotension.
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Affiliation(s)
- Matthew J Kaptein
- Department of Medicine, Division of Nephrology, Loma Linda University Medical Center, Loma Linda, CA, USA.,Department of Medicine, Division of Nephrology, University of Southern California, Los Angeles, CA, USA
| | - John S Kaptein
- Department of Medicine, Division of Nephrology, University of Southern California, Los Angeles, CA, USA
| | - Christopher D Nguyen
- Department of Medicine, Division of Nephrology, University of Southern California, Los Angeles, CA, USA
| | - Zayar Oo
- Department of Medicine, Division of Nephrology, University of Southern California, Los Angeles, CA, USA
| | - Phyu Phyu Thwe
- Department of Medicine, Division of Nephrology, University of Southern California, Los Angeles, CA, USA
| | - Myint Bo Thu
- Department of Medicine, Division of Nephrology, University of Southern California, Los Angeles, CA, USA
| | - Elaine M Kaptein
- Department of Medicine, Division of Nephrology, University of Southern California, Los Angeles, CA, USA
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15
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Raina R, Joshi H, Chakraborty R. Changing the terminology from kidney replacement therapy to kidney support therapy. Ther Apher Dial 2020; 25:437-457. [PMID: 32945598 DOI: 10.1111/1744-9987.13584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/16/2020] [Accepted: 09/12/2020] [Indexed: 11/28/2022]
Abstract
Kidney replacement therapy (KRT) is a common supportive treatment for renal dysfunction, especially acute kidney injury. However, critically ill or immunosuppressed patients with renal dysfunction often have dysfunction in other organs as well. To improve patient outcomes, clinicians began to initiate kidney replacement therapy in situations where nonrenal conditions may lead to acute kidney injury, such as septic shock, hematopoietic stem cell transplantation, veno-occlusive renal disease, cardiopulmonary bypass, chemotherapy, tumor lysis syndrome, hyperammonemia, and various others. In this review, we discuss the use of various modes of kidney replacement therapy in treating renal and nonrenal complications to illustrate why kidney support therapy is a more appropriate terminology than kidney replacement therapy.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Cleveland Clinic Akron General/Akron Nephrology Associates, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Hirva Joshi
- Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Ronith Chakraborty
- Department of Nephrology, Cleveland Clinic Akron General/Akron Nephrology Associates, Akron, Ohio, USA
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16
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Abstract
Acute kidney injury (AKI) is a critical burden on intensive care units in Asia. Renal replacement therapy (RRT) acts as strong supportive care for severe AKI. However, various RRT modalities are used in Asia because of the diversity in ethics, climate, geographic features, and socioeconomic status. Extracorporeal blood purification is used commonly in Asian intensive care units; however, intermittent RRT is preferred in developing countries because of cost and infrastructure issues. Conversely, continuous RRT is preferred in developed countries, indicating the predominance of hospital-acquired AKI patients with complications of hemodynamic instability. Peritoneal dialysis is delivered less frequently, although several studies have suggested promising results for peritoneal dialysis in AKI treatment. Of note, not all RRT modalities are available as a standard procedure in some Asian regions, and it is absolutely necessary to develop a sustainable infrastructure that can deliver optimal care for all AKI patients.
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Affiliation(s)
- Ryo Matsuura
- Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Kent Doi
- Department of Emergency and Critical Care and Medicine, The University of Tokyo Hospital, Tokyo, Japan.
| | - Yoshifumi Hamasaki
- Department of Hemodialysis and Apheresis, The University of Tokyo, Tokyo, Japan
| | - Masaomi Nangaku
- Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
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17
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Abstract
Burn injuries are under-appreciated injuries that are associated with substantial morbidity and mortality. Burn injuries, particularly severe burns, are accompanied by an immune and inflammatory response, metabolic changes and distributive shock that can be challenging to manage and can lead to multiple organ failure. Of great importance is that the injury affects not only the physical health, but also the mental health and quality of life of the patient. Accordingly, patients with burn injury cannot be considered recovered when the wounds have healed; instead, burn injury leads to long-term profound alterations that must be addressed to optimize quality of life. Burn care providers are, therefore, faced with a plethora of challenges including acute and critical care management, long-term care and rehabilitation. The aim of this Primer is not only to give an overview and update about burn care, but also to raise awareness of the ongoing challenges and stigmata associated with burn injuries.
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Affiliation(s)
- Marc G Jeschke
- Ross Tilley Burn Center, Department of Surgery, Sunnybrook Health Science Center, Toronto, Ontario, Canada.
- Departments of Surgery and Immunology, University of Toronto, Toronto, Ontario, Canada.
| | - Margriet E van Baar
- Association of Dutch Burn Centres, Maasstad Hospital, Rotterdam, Netherlands
- Erasmus MC, University Medical Center Rotterdam, Department of Public Health, Rotterdam, Netherlands
| | - Mashkoor A Choudhry
- Burn and Shock Trauma Research Institute, Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL, USA
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Nicole S Gibran
- Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Sarvesh Logsetty
- Departments of Surgery and Psychiatry, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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18
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Gaudry S, Quenot JP, Hertig A, Barbar SD, Hajage D, Ricard JD, Dreyfuss D. Timing of Renal Replacement Therapy for Severe Acute Kidney Injury in Critically Ill Patients. Am J Respir Crit Care Med 2020; 199:1066-1075. [PMID: 30785784 DOI: 10.1164/rccm.201810-1906cp] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Acute kidney injury (AKI) affects many ICU patients and is responsible for increased morbidity and mortality. Although lifesaving in many situations, renal replacement therapy (RRT) may be associated with complications, and the appropriate timing of its initiation is still the subject of intense debate. An early initiation strategy can prevent some metabolic complications, whereas a delayed one may allow for renal function recovery in some patients without need for this costly and potentially dangerous technique. For years, most of the knowledge on this issue stemmed from observational studies or small randomized controlled trials. Recent randomized controlled trials have indicated that a watchful waiting strategy (in the absence of life-threatening conditions such as severe hyperkalemia or pulmonary edema) during severe AKI allowed many patients to escape RRT and did not seem to adversely affect survival compared with a strategy of immediate RRT. In addition, data suggest that a delayed strategy may reduce the rate of complications (such as catheter infection) and favor renal function recovery. Ongoing studies will have to both confirm these conclusions and clarify to what extent the delay in initiating RRT can be prolonged. Pending those results, the bulk of evidence suggests that, in the absence of potential severe complications of AKI, delaying RRT is a valid and safe strategy that may also allow for considerable cost savings.
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Affiliation(s)
- Stéphane Gaudry
- 1 AP-HP, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, Bobigny, France.,2 INSERM UMR S 1155 "Common and Rare Kidney Diseases: from Molecular Events to Precision Medicine," and.,3 Health Care Simulation Center, UFR SMBH, Université Paris 13, Sorbonne Paris Cité, Bobigny, France
| | - Jean-Pierre Quenot
- 4 Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,5 Lipness Team, INSERM Research Center, LNC-UMR1231 and LabEx LipSTIC, and.,6 INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Alexandre Hertig
- 2 INSERM UMR S 1155 "Common and Rare Kidney Diseases: from Molecular Events to Precision Medicine," and.,7 Renal ICU and Transplantation, Sorbonne Universités, Hôpital Tenon, AP-HP, Paris, France
| | - Saber Davide Barbar
- 8 Unité de Réanimation Médicale, CHU de Nîmes - Hôpital Carémeau, Nîmes, France
| | - David Hajage
- 9 Département Biostatistique Santé Publique et Information Médicale, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, CIC-1421, AP-HP, Hôpital Pitié Salpêtrière, Paris, France.,10 INSERM, UMR 1123, ECEVE, Paris, France
| | - Jean-Damien Ricard
- 11 AP-HP, Hôpital Louis Mourier, Service de Réanimation Médico-Chirurgicale, Colombes, France.,12 IAME, UMRS 1137, University Paris Diderot, Sorbonne Paris Cité, Paris, France.,13 INSERM, IAME, U1137, Paris, France; and
| | - Didier Dreyfuss
- 2 INSERM UMR S 1155 "Common and Rare Kidney Diseases: from Molecular Events to Precision Medicine," and.,11 AP-HP, Hôpital Louis Mourier, Service de Réanimation Médico-Chirurgicale, Colombes, France.,14 University Paris Diderot, Sorbonne Paris Cité, Paris, France
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Gaudry S, Hajage D, Schortgen F, Martin-Lefevre L, Verney C, Pons B, Boulet E, Boyer A, Chevrel G, Lerolle N, Carpentier D, de Prost N, Lautrette A, Bretagnol A, Mayaux J, Nseir S, Megarbane B, Thirion M, Forel JM, Maizel J, Yonis H, Markowicz P, Thiery G, Tubach F, Ricard JD, Dreyfuss D. Timing of Renal Support and Outcome of Septic Shock and Acute Respiratory Distress Syndrome. A Post Hoc Analysis of the AKIKI Randomized Clinical Trial. Am J Respir Crit Care Med 2019; 198:58-66. [PMID: 29351007 DOI: 10.1164/rccm.201706-1255oc] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
RATIONALE The optimal strategy for initiation of renal replacement therapy (RRT) in patients with severe acute kidney injury in the context of septic shock and acute respiratory distress syndrome (ARDS) is unknown. OBJECTIVES To examine the effect of an early compared with a delayed RRT initiation strategy on 60-day mortality according to baseline sepsis status, ARDS status, and severity. METHODS Post hoc analysis of the AKIKI (Artificial Kidney Initiation in Kidney Injury) trial. MEASUREMENTS AND MAIN RESULTS Subgroups were defined according to baseline characteristics: sepsis status (Sepsis-3 definition), ARDS status (Berlin definition), Simplified Acute Physiology Score 3 (SAPS 3), and Sepsis-related Organ Failure Assessment (SOFA). Of 619 patients, 348 (56%) had septic shock and 207 (33%) had ARDS. We found no significant influence of the baseline sepsis status (P = 0.28), baseline ARDS status (P = 0.94), and baseline severity scores (P = 0.77 and P = 0.46 for SAPS 3 and SOFA, respectively) on the comparison of 60-day mortality according to RRT initiation strategy. A delayed RRT initiation strategy allowed 45% of patients with septic shock and 46% of patients with ARDS to escape RRT. Urine output was higher in the delayed group. Renal function recovery occurred earlier with the delayed RRT strategy in patients with septic shock or ARDS (P < 0.001 and P = 0.003, respectively). Time to successful extubation in patients with ARDS was not affected by RRT strategy (P = 0.43). CONCLUSIONS Early RRT initiation strategy was not associated with any improvement of 60-day mortality in patients with severe acute kidney injury and septic shock or ARDS. Unnecessary and potentially risky procedures might often be avoided in these fragile populations. Clinical trial registered with www.clinicaltrials.gov (NCT 01932190).
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Affiliation(s)
- Stéphane Gaudry
- 1 Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris (AP-HP), Colombes, France.,2 Unité Mixte de Recherche (UMR) S1155, Remodeling and Repair of Renal Tissue, Hôpital Tenon, French National Institute of Health and Medical Research (INSERM), Paris, France
| | - David Hajage
- 3 Epidémiologie Clinique et Évaluation Économique Appliquées aux Populations Vulnérables (ECEVE), U1123, Centre d'Investigation Clinique 1421, INSERM, Paris, France.,4 Université Paris Diderot, Sorbonne Paris Cité, ECEVE, UMRS 1123, Paris, France.,5 Département de Biostatistiques, Santé Publique, et Information Médicale, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
| | - Frédérique Schortgen
- 6 Service de Réanimation Polyvalente Adulte, Centre Hospitalier Inter-communal, Créteil, France
| | | | - Charles Verney
- 1 Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris (AP-HP), Colombes, France
| | - Bertrand Pons
- 8 Service de Réanimation, Centre Hospitalier Universitaire (CHU) de Pointe à Pitre-Abymes, Pointe à Pitre-Abymes, France.,9 CHU de la Guadeloupe, Pointe-à-Pitre, France
| | - Eric Boulet
- 10 Réanimation Polyvalente, Centre Hospitalier René Dubos, Pontoise, France
| | - Alexandre Boyer
- 11 Réanimation Médicale, CHU Bordeaux, Hôpital Pellegrin, Bordeaux, France
| | - Guillaume Chevrel
- 12 Service de Réanimation, Centre Hospitalier Sud Francilien, Corbeil Essonne, France
| | - Nicolas Lerolle
- 13 Département de Réanimation Médicale et Médecine Hyperbare, CHU Angers, Université d'Angers, Angers, France
| | | | - Nicolas de Prost
- 15 Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor, Département Hospitalo-Universitaire Ageing Thorax-Vessels-Blood, AP-HP, Créteil, France.,16 Cardiovascular and Respiratory Manifestations of Acute Lung Injury and Sepsis (CARMAS) Research Group and Université Paris-Est Créteil Val de Marne, Créteil, France
| | - Alexandre Lautrette
- 17 Réanimation Médicale, Hôpital Gabriel Montpied, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Anne Bretagnol
- 18 Réanimation Médico-Chirurgicale, Hôpital de La Source, Centre Hospitalier Régional d'Orléans, BP 6709, Orléans, France
| | - Julien Mayaux
- 19 Service de Pneumologie et Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris France
| | - Saad Nseir
- 20 Centre de Réanimation, CHU de Lille, Lille, France.,21 Faculté de Médecine, Université de Lille, Lille, France
| | - Bruno Megarbane
- 22 Réanimation Médicale et Toxicologique, Hôpital Lariboisière, Université Paris-Diderot, INSERM U1144, Paris, France
| | - Marina Thirion
- 23 Réanimation Polyvalente, CH Victor Dupouy, Argenteuil, France
| | - Jean-Marie Forel
- 24 Service de Réanimation des Détresses Respiratoires Aiguës et Infections Sévères, Hôpital Nord Marseille, Marseille, France
| | - Julien Maizel
- 25 Service de Réanimation Médicale CHU de Picardie, INSERM U1088, Amiens, France
| | - Hodane Yonis
- 26 Réanimation Médicale, Hôpital de la Croix Rousse, Lyon, France
| | | | - Guillaume Thiery
- 8 Service de Réanimation, Centre Hospitalier Universitaire (CHU) de Pointe à Pitre-Abymes, Pointe à Pitre-Abymes, France.,9 CHU de la Guadeloupe, Pointe-à-Pitre, France
| | - Florence Tubach
- 3 Epidémiologie Clinique et Évaluation Économique Appliquées aux Populations Vulnérables (ECEVE), U1123, Centre d'Investigation Clinique 1421, INSERM, Paris, France.,5 Département de Biostatistiques, Santé Publique, et Information Médicale, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France.,28 Université Pierre et Marie Curie, Sorbonne Universités, Paris, France
| | - Jean-Damien Ricard
- 1 Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris (AP-HP), Colombes, France.,29 Université Paris Diderot, Sorbonne Paris Cité, Infection, Antimicrobials, Modelling, Evolution (IAME), UMRS 1137, Paris, France; and.,30 INSERM, IAME, U1137, Paris, France
| | - Didier Dreyfuss
- 1 Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris (AP-HP), Colombes, France.,29 Université Paris Diderot, Sorbonne Paris Cité, Infection, Antimicrobials, Modelling, Evolution (IAME), UMRS 1137, Paris, France; and.,30 INSERM, IAME, U1137, Paris, France
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20
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Oh HJ, An JN, Oh S, Rhee H, Lee JP, Kim DK, Ryu DR, Kim S. VolumE maNagement Under body composition monitoring in critically ill patientS on CRRT: study protocol for a randomized controlled trial (VENUS trial). Trials 2018; 19:681. [PMID: 30541593 PMCID: PMC6292088 DOI: 10.1186/s13063-018-3056-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/15/2018] [Indexed: 01/10/2023] Open
Abstract
Background Despite recent technical advances in the management of acute kidney injury (AKI), such as continuous renal replacement therapy (CRRT), intensive care unit mortality is still high, at approximately 40 to 50%. Although several factors have been reported to predict mortality in AKI patients, fluid overload (FO) during CRRT is a well-known predictor of patient survival. However, FO has been mostly quantified as an arithmetical calculation and determined on the basis of the physicians’ perception. Even though such quantification and assessment provides an easy evaluation of a patient’s fluid status and is a simple method, it is not applicable unless a detailed record of fluid monitoring is available. Furthermore, the method cannot differentiate excess water in individual water compartments but can only reflect excess total body water. Bioimpedance analysis (BIA) has been used to measure the nutritional component of body composition and is a promising tool for the measurement of volume status. However, there has been no prospective interventional study for fluid balance among CRRT-treated AKI patients using BIA. Therefore, we will investigate the usefulness of fluid management using the InBody S10 (InBody®, Seoul, Korea), a BIA tool, compared with that of generally used quantification methods. Methods/design This will be a multicenter, prospective, randomized controlled trial. A total of 244 patients undergoing CRRT treatment will be enrolled and randomly assigned to receive either to InBody S10-guided management or to fluid management based only on clinical information for 7 days. The primary outcome is to compare the rate of euvolemic status 7 days after the initiation of CRRT, with a secondary outcome being to compare the 28-, 60-, and 90-day mortality rates between the two groups. Discussion This will be the first clinical trial to investigate the effect of using BIA-guided fluid management to achieve euvolemia in CRRT-treated AKI patients. Trial registration ClinicalTrials.gov, ID: NCT03330626. Registered on 6 November 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-3056-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hyung Jung Oh
- Ewha Institute of Convergence Medicine, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea.,Research Institute for Human Health Information, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Jung Nam An
- Department of Critical Care Medicine, Seoul National University Boramae, Medical Center, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University Boramae, Medical Center, Seoul, Republic of Korea
| | - Sohee Oh
- Department of Biostatistics, Seoul National University Boramae, Medical Center, Seoul, Republic of Korea
| | - Harin Rhee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University Boramae, Medical Center, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dong-Ryeol Ryu
- Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, Republic of Korea.,Tissue Injury Defense Research Center, Ewha Womans University, Seoul, Republic of Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.
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21
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Akiu M, Yamamoto T, Miyazaki M, Watanabe K, Fujikura E, Nakayama M, Sato H, Ito S. Using Sepsis-3 criteria to predict prognosis of patients receiving continuous renal replacement therapy for community-acquired sepsis: a retrospective observational study. RENAL REPLACEMENT THERAPY 2018. [DOI: 10.1186/s41100-018-0182-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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22
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Zhang J, Tian J, Sun H, Digvijay K, Neri M, Bhargava V, Yin Y, Ronco C. How Does Continuous Renal Replacement Therapy Affect Septic Acute Kidney Injury? Blood Purif 2018; 46:326-331. [PMID: 30173223 DOI: 10.1159/000492026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 07/10/2018] [Indexed: 12/26/2022]
Abstract
Sepsis is the leading cause of acute kidney injury (AKI) in the intensive care unit. As the most common treatment of septic AKI, it is believed that continuous renal replacement therapy (CRRT) can not only maintain the water balance and excrete the metabolic products but also regulate the inflammation and promote kidney recovery. CRRT can remove the inflammatory cytokines to regulate the metabolic adaption in kidney and restore the kidney recovery to protect the kidney in septic AKI. Second, CRRT can provide extra energy supply in septic AKI to improve the kidney energy balance in septic AKI. Third, the anticoagulant used in CRRT also regulates the inflammation in septic AKI. CRRT is not only a treatment to deal with the water balance and metabolic products, but also a method to regulate the inflammation in septic AKI.
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Affiliation(s)
- Jingxiao Zhang
- Department of Emergency and Critical Care, The Second Hospital of Jilin University, Changchun, China.,International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
| | - Jiakun Tian
- Department of Emergency and Critical Care, The Second Hospital of Jilin University, Changchun, China
| | - Hongzhi Sun
- Department of Emergency and Critical Care, The Second Hospital of Jilin University, Changchun, China
| | - Kumar Digvijay
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy.,Department of Nephrology and Research, Sir Ganga Ram Hospital, New Delhi, India
| | - Mauro Neri
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Vinant Bhargava
- Department of Nephrology and Research, Sir Ganga Ram Hospital, New Delhi, India
| | - Yongjie Yin
- Department of Emergency and Critical Care, The Second Hospital of Jilin University, Changchun, China
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
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23
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Sezer MT, Demir M, Gungor G, Senol A. Predictors of Mortality in Patients with Acute Renal Failure. ACTA MEDICA (HRADEC KRÁLOVÉ) 2018. [DOI: 10.14712/18059694.2017.129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Mortality associated with acute renal failure (ARF) remains high despite of developments in therapy strategies and definition of different prognostic factors. Therefore, this study focused on to define new prognostic factors and especially regional characteristics of the ARF patients. One hundred fifteen ARF patients, diagnosed from November 1998 to May 2003, were included to this prospective and observational study. Clinical features, laboratory parameters, Acute Physiology and Chronic Health Evaluation (APACHE) III scores and co-morbid conditions of the patients were examined. Clinical and laboratory data, and APACHE III scores were recorded at the first nephrology consult day. Thirty of the patients (26%) died. APACHE III scores, presence and the total number of co-morbid conditions and serum albumin levels at the time of first nephrology consultation were found as independent predictors of mortality. There was a negative correlation between APACHE III scores and serum albumin levels. Not only increased APACHE III score and presence of co-morbid conditions but also low serum albumin level was found as the predictors of mortality. However, only serum albumin level is seen as modifiable prognostic factor among these parameters. Therefore, further studies are necessary to determine the causes of hypoalbuminemia in patients with ARF and the effect of it’s effective treatment on patients outcome.
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24
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Düngen HD, Von Heymann C, Ronco C, Kox W, Spies C. Renal Replacement Therapy: Physical Properties of Hollow Fibers Influence Efficiency. Int J Artif Organs 2018. [DOI: 10.1177/039139880102400601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Physical properties of filters for continous renal replacement therapy have a great impact on biocompatibility. According to Poiseuille's law, a filter with more and shorter hollow fibers should offer a decreased pressure drop and, therefore, lower transmembrane pressure (TMP). The aim of this study was to study the effect of a new filter configuration in terms of TMP and clotting compared with the standard configuration. Methods In a prospective randomized cross-over study 2 polysulphone hollow fiber hemofilters, one handmade, which differed only in length and number of hollow fibers were compared. In each group 12 filters were investigated during continous venovenous hemofiltration in patients with acute renal failure due to septic shock. Pressures were measured every 3 hours and running time until filter clotting was documented. Mediators before and after the filter, at the end of treatment and in filtrate were assessed. Results The standard filter with longer hollow fibers had significantly lower TMPs (106 vs.194 mmHg, p=0.02) and longer running times (1276 vs. 851 min, p=0,04). There were no differences in hematocrit, total protein, cellular and plasmatic coagulation or blood temperature. No significant elimination of mediators was shown. Conclusion In contrast to our expectations, the filter with the longer hollow fibers had a better performance, as it ran longer and had lower TMP. This may be due to slower blood flow leading to an increase in blood viscosity in a filter with a larger cross section.
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Affiliation(s)
- H.-D. Düngen
- Department of Anesthesiology and Operative Intensive Care Medicine, Universitaetsklinikum Charité, Humboldt-University of Berlin, Berlin - Germany
| | - C. Von Heymann
- Department of Anesthesiology and Operative Intensive Care Medicine, Universitaetsklinikum Charité, Humboldt-University of Berlin, Berlin - Germany
| | - C. Ronco
- Department of Nephrology, St. Bartolo Hospital, Vicenza - Italy
| | - W.J. Kox
- Department of Anesthesiology and Operative Intensive Care Medicine, Universitaetsklinikum Charité, Humboldt-University of Berlin, Berlin - Germany
| | - C.D. Spies
- Department of Anesthesiology and Operative Intensive Care Medicine, Universitaetsklinikum Charité, Humboldt-University of Berlin, Berlin - Germany
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25
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Delanaye P, Lambermont B, Dogné JM, Dubois B, Ghuysen A, Janssen N, Desaive T, Kolh P, D'Orio V, Krzesinski JM. Confirmation of High Cytokine Clearance by Hemofiltration with a Cellulose Triacetate Membrane with Large Pores: An in vivo Study. Int J Artif Organs 2018; 29:944-8. [PMID: 17211815 DOI: 10.1177/039139880602901004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- P Delanaye
- Department of Nephrology, University of Liege, Liege - Belgium.
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26
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Cole L, Bellomo R, Davenport P, Tipping P, Ronco C. Cytokine Removal during Continuous Renal Replacement Therapy: An Ex Vivo Comparison of Convection and Diffusion. Int J Artif Organs 2018; 27:388-97. [PMID: 15202816 DOI: 10.1177/039139880402700507] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and objectives It is unknown whether cytokine adsorption to the membrane during continuous renal replacement therapy is affected by the technique. Such knowledge might affect the choice of technique in vivo. Accordingly, we conducted an ex vivo study to test whether continuous veno-venous hemofiltration (CVVH) or continuous veno-venous hemodialysis (CVVHD) affect cytokine adsorption differently. Setting Laboratory attached to the Intensive Care Unit of a tertiary hospital Design Six healthy human volunteers donated blood, which was incubated with endotoxin. Control blood was left at room temperature, and treatment blood was recirculated for eight hours through closed circuits using polyacrylonitrile membranes (AN69). The effect of CVVH and CVVHD on cytokine removal from the circuits was compared. Measurements The concentrations of interleukins (IL)-1ß, 6, 8, 10 and TNF were measured in the control samples, pre-and post-filter and in the effluent at baseline and hourly thereafter. The clearances by adsorption, and filtration were calculated. Results Control cytokine concentrations remained the same or increased slightly. Adsorption was the major mechanism of removal for all cytokines with the exception of IL-1ß, but the effect was short-lived. Peak adsorption generally occurred at baseline before the start of CVVH and CVVHD, with clearances ranging from 43.7ml/min (for IL-8) to 7.6ml/min (for IL-10). The time-weighted average total clearances during CVVH were 23.3, 4.3, 3.8, –2.0, and 15ml/min for IL-8, IL-1ß, TNF, IL-6, and IL-10 respectively. The corresponding clearances during CVVHD were 19.0, 10.7, 2.7, 2.4, and 0.3ml/min. IL-10 clearances were greater during CVVH than CVVHD (p=0.03). Non adsorptive CVVH clearance of IL-1ß was greater than CVVHD clearance, but this advantage was outweighed by an increased tendency of the membrane to release IL-1ß into the circuit during HF. Conclusions The technique of solute removal had only a minor effect on the magnitude of cytokine adsorption, and neither technique had the advantage for all the measured cytokines.
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Affiliation(s)
- L Cole
- Department of Intensive Care, Austin & Repatriation Medical Centre, Melbourne, Australia
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27
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Haase M, Bellomo R, Morger S, Baldwin I, Boyce N. High Cut-off Point Membranes in Septic Acute Renal Failure: A Systematic Review. Int J Artif Organs 2018; 30:1031-41. [DOI: 10.1177/039139880703001202] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives To review the literature on the experimental, physiological and clinical effects of blood purification with high cut-off (HCO) point membranes in septic acute renal failure (ARF). Study Design MEDLINE and PubMed database search combining relevant terms and integrating data from studies on the use of HCO membranes. Setting and Population Ex vivo studies of endotoxemia, animal studies of bacteremia and clinical studies using HCO membranes in patients with septic ARF. Selection Criteria for Studies: Original data from primary publications. Interventions: HCO membrane-based hemodialysis, hemodiafiltration or hemofiltration. Outcomes: Plasma cytokine clearance, immunological and physiological effects and safety parameters of HCO membranes. Results HCO membranes effectively remove cytokines from blood. Treatment using HCO membranes has beneficial effects on immune cell function and increases survival in animal models of sepsis. Preliminary clinical studies show that HCO membranes decrease plasma cytokine levels and the need for vasopressor therapy. HCO membrane-based blood purification has now been applied in four pilot randomized controlled studies of 70 patients with septic ARF with no reports of serious adverse effects. Limitations Because of substantial heterogeneity, no formal quantitative analysis could be performed. Conclusions The available evidence on HCO blood purification justifies larger randomized controlled trials in patients with septic ARF.
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Affiliation(s)
- M. Haase
- Intensive Care Unit, Austin Hospital, University of Melbourne - Australia
- Department of Nephrology and Intensive Care, Charité University Medicine, Berlin - Germany
| | - R. Bellomo
- Intensive Care Unit, Austin Hospital, University of Melbourne - Australia
| | - S. Morger
- Department of Nephrology and Intensive Care, Charité University Medicine, Berlin - Germany
| | - I. Baldwin
- Intensive Care Unit, Austin Hospital, University of Melbourne - Australia
| | - N. Boyce
- Australian Red Cross Blood Service, University of Melbourne - Australia
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Miao H, Wang F, Xiong X, Wang C, Zhang Y. Clinical Benefits of High-Volume Hemofiltration in Critically Ill Pediatric Patients with Severe Sepsis: A Retrospective Cohort Study. Blood Purif 2017; 45:18-27. [PMID: 29161713 DOI: 10.1159/000481249] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 09/04/2017] [Indexed: 12/22/2022]
Abstract
AIMS The study aimed to assess the clinical benefits of high-volume hemofiltration (HVHF) in pediatric patients with severe sepsis compared with standard-volume continuous veno-venous hemofiltration (CVVH). METHODS We retrospectively analyzed the medical records of 155 pediatric patients with severe sepsis admitted to the pediatric intensive care unit of Shanghai Children's Hospital from January 2010 to June 2016. A total of 93 patients were treated with HVHF and 62 patients were treated with CVVH. RESULTS HVHF treatment did not significantly reduce 28-day mortality. Moreover, there was no significant difference in reducing the plasma level of inflammatory mediators and improving hemodynamic variables between HVHF and CVVH group. However, the incidence of hyperglycemia was significantly higher in HVHF group than in CVVH group. CONCLUSIONS There is no evidence to indicate that HVHF is superior to CVVH in reducing 28-day mortality as an adjunct to the treatment of severe sepsis in pediatric patients.
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Affiliation(s)
- Huijie Miao
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Putuo District, Shanghai, China
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29
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Li P, Qu LP, Qi D, Shen B, Wang YM, Xu JR, Jiang WH, Zhang H, Ding XQ, Teng J. High-dose versus low-dose haemofiltration for the treatment of critically ill patients with acute kidney injury: an updated systematic review and meta-analysis. BMJ Open 2017; 7:e014171. [PMID: 29061597 PMCID: PMC5665234 DOI: 10.1136/bmjopen-2016-014171] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
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.
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Affiliation(s)
- Peng Li
- Department of Nephrology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, China
| | - Li-ping Qu
- Department of Obstetrics, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, China
| | - Dong Qi
- Department of Nephrology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, China
| | - Bo Shen
- Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Kidney and Dialysis Institute of Shanghai, Shanghai, China
| | - Yi-mei Wang
- Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Kidney and Dialysis Institute of Shanghai, Shanghai, China
| | - Jia-rui Xu
- Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Kidney and Dialysis Institute of Shanghai, Shanghai, China
| | - Wu-hua Jiang
- Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Kidney and Dialysis Institute of Shanghai, Shanghai, China
| | - Hao Zhang
- Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Kidney and Dialysis Institute of Shanghai, Shanghai, China
| | - Xiao-qiang Ding
- Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Kidney and Dialysis Institute of Shanghai, Shanghai, China
- Kidney and Blood Purification Laboratory of Shanghai, Shanghai, China
| | - Jie Teng
- Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Kidney and Dialysis Institute of Shanghai, Shanghai, China
- Kidney and Blood Purification Laboratory of Shanghai, Shanghai, China
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Premuzic V, Basic-Jukic N, Jelakovic B, Kes P. Continuous Veno-Venous Hemofiltration Improves Survival of Patients With Congestive Heart Failure and Cardiorenal Syndrome Compared to Slow Continuous Ultrafiltration. Ther Apher Dial 2017; 21:279-286. [PMID: 28403554 DOI: 10.1111/1744-9987.12516] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 10/27/2016] [Accepted: 11/08/2016] [Indexed: 11/27/2022]
Abstract
Continuous veno-venous hemofiltration (CVVH) could modulate the inflammatory response by removal of circulating cytokines and therefore improve cardiac function in patients with heart failure (HF). We hypothesized that patients with developed cardiorenal syndrome and treated with CVVH have lower risk for mortality than other patients treated with slow continuous ultrafiltration (SCUF). This was a prospective, longitudinal follow-up study for 24 months duration. In total, 120 patients were recruited from the intensive care units. Only patients with cardiorenal syndrome type 1 and 2 were enrolled. 54 CVVH and 23 SCUF patients survived. Mean survival time was longer in CVVH group with cardiomyopathy than in the SCUF group. When we compared patients with cardiomyopathy and hourly urine output <10 mL/h, mean survival time was significantly longer in patients treated with CVVH. This is the first study to analyze the impact of different CRRT modalities (CVVH vs. SCUF) on survival of patients with HF and who developed cardiorenal syndrome. Better survival in patients treated with CVVH, which is mostly pronounced in patients with cardiomyopathy, is a consequence of a better preserved hourly urine output. Longer survival in patients with cardiomyopathy is most probably related to cytokine removal by CVVH with smaller UF rates and longer duration of each treatment. Slow continuous ultrafiltration remains the method of choice in patients with HF and preserved renal function but in cases of developed cardiorenal syndrome is much inferior to CVVH.
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Affiliation(s)
- Vedran Premuzic
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Nikolina Basic-Jukic
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Bojan Jelakovic
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Petar Kes
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
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Villa G, Chelazzi C, Morettini E, Zamidei L, Valente S, Caldini AL, Zagli G, De Gaudio AR, Romagnoli S. Organ dysfunction during continuous veno-venous high cut-off hemodialysis in patients with septic acute kidney injury: A prospective observational study. PLoS One 2017; 12:e0172039. [PMID: 28207795 PMCID: PMC5313216 DOI: 10.1371/journal.pone.0172039] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 01/30/2017] [Indexed: 12/29/2022] Open
Abstract
Background Continuous veno-venous hemodialysis with high cut-off membranes (HCO-CVVHD) removes inflammatory mediators involved in organ dysfunction during sepsis. The aim of the present study was to assess the variations in SOFA score and identify early predictors of short-term mortality in a cohort of patients with septic shock, treated with HCO-CVVHD for acute kidney injury (AKI). Methods An observational prospective multicenter cohort study was conducted in four mixed medical-surgical ICUs. Thirty-eight patients with septic shock and AKI (KDIGO stage≥1) treated with HCO-CVVHD have been included in this study. Patients were divided into Survivors and non-Survivors according to mortality observed at 72nd hr of treatment. The variation of SOFA scores and clinical/biochemical parameters were described over time for the entire population and specifically for Survivors and non-Survivors. Similarly, circulating inflammatory mediators (as IL-6, TNF-a and IL-10) were described over time. A logistic regression analysis was used to identify the baseline clinical and biochemical parameters associated with 72 hrs-ICU mortality. Results Overall, the mean SOFA score was 12±3 at baseline, 10.9±3 at 6hrs, 9.8±3 at 12hrs, 8.9±3.3 at 24 hrs, and 8±3.5 at 48 hrs after HCO-CVVHD initiation; and 6.5±2.7 at 24 hrs and 6.6±3 at 48 hrs after HCO-CVVHD discontinuation. In the multivariate regression analysis, baseline serum lactate levels and AKI stage independently correlated with short-term mortality during HCO-CVVHD. A significant reduction was observed in circulating levels of TNFα and IL-6 among Survivors. Conclusions SOFA score significantly decreased early after initiation of HCO-CVVHD in patients with septic AKI. Baseline lactate levels and the AKI stage resulted to be associated to 72 hrs-ICU-mortality.
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Affiliation(s)
- Gianluca Villa
- Department of Health Science, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
- * E-mail:
| | - Cosimo Chelazzi
- Department of Health Science, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Elena Morettini
- Department of Health Science, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
| | - Lucia Zamidei
- Anesthesia and Intensive Care Unit, Ospedale Santo Stefano, Prato, Italy
| | - Serafina Valente
- Intensive Cardiac Coronary Unit, Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - A. Lucia Caldini
- Clinical Chemistry Laboratory, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giovanni Zagli
- Department of Health Science, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - A. Raffaele De Gaudio
- Department of Health Science, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Stefano Romagnoli
- Department of Health Science, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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High cut-off hemofiltration versus standard hemofiltration: effect on plasma cytokines. Int J Artif Organs 2016; 39:479-486. [PMID: 27834446 DOI: 10.5301/ijao.5000527] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE To study the effects of continuous veno-venous hemofiltration (CVVH) with high cut-off filters (CVVH-HCO) on plasma cytokine levels, sieving coefficient and clearance compared to CVVH using standard filters (CVVH-Std) in a nested cohort within a double-blind randomized controlled trial in severe acute kidney injury (AKI) patients. METHODS We measured plasma and post-filter levels of IL-6, TNF-alpha, IL-8, IL-1 beta, RANTES, IL-10, IFN-gamma and IFN-alpha in both study groups. We also measured cytokine levels in the ultrafiltrate and calculated sieving coefficients and clearances. RESULTS By 72 hours of treatment, IL-6 had decreased during both treatments (p = 0.009 and 0.005 respectively). In contrast, IL-10 had decreased with CVVH-Std (p = 0.03) but not CVVH-HCO (p = 0.135). None of the other cytokines showed changes over time. There were also no significant between group differences in plasma levels for each cytokine over the 72-hour treatment period. For all cytokines combined, however, the median sieving coefficient was higher for CVVH-HCO (0.31 vs. 0.16; p = 0.042) as was the mass removal rate by ultrafiltration (p = 0.027). While overall combined cytokine levels had fallen to 62.2% of baseline at 72 hours for CVVH-HCO (p<0.0001) and to 75.9% of baseline with CVVH-Std (p = 0.008) there were no between group differences. CONCLUSIONS CVVH-HCO achieved greater combined sieving coefficient and mass removal rate by ultrafiltration for a group of key cytokines than CVVH-Std. However, this effect did not differentially lower their plasma level over the first 72 hours. Our study does not support the use of CVVH-HCO to lower cytokines in critically ill patients with AKI.
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Werners AH. Treatment of endotoxaemia and septicaemia in the equine patient. J Vet Pharmacol Ther 2016; 40:1-15. [PMID: 27452161 DOI: 10.1111/jvp.12329] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 05/02/2016] [Indexed: 12/27/2022]
Abstract
Endotoxins, constituents of the cell wall of gram-positive and gram-negative bacteria, regularly result in severe illness and death in horses. In endotoxaemia, these constituents are present in the systemic circulation; in septicaemia, whole microbes invade normally sterile parts of the body. Interaction of these endotoxins with pathogen recognition receptors leads to an inflammatory response that cannot always be sufficiently contained and hence needs direct treatment. Over the last decennia, our understanding of the pathophysiology of endotoxaemia and septicaemia has significantly increased. Based on improved understanding of the interaction between receptors and endotoxins as well as the subsequent downstream signalling pathways, new therapeutic targets have been identified in laboratory animal species and humans. Important species differences in the recognition of endotoxins and pathogens by their receptors as well as the inflammatory response to receptor activation hamper extrapolation of this information to the horse (and other species). Historically, horses with endotoxaemia and septicaemia have been treated mainly symptomatically and supportively. Based on the identified therapeutic targets, this review describes the current knowledge of the treatment for endotoxaemia and septicaemia in the horse with reference to the findings in other animal species and humans.
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Affiliation(s)
- A H Werners
- Department of Anatomy, Physiology and Pharmacology, School of Veterinary Medicine, St. George's University, True Blue Campus, St. George's, Grenada, West-Indies
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Park JT, Lee H, Kee YK, Park S, Oh HJ, Han SH, Joo KW, Lim CS, Kim YS, Kang SW, Yoo TH, Kim DK. High-Dose Versus Conventional-Dose Continuous Venovenous Hemodiafiltration and Patient and Kidney Survival and Cytokine Removal in Sepsis-Associated Acute Kidney Injury: A Randomized Controlled Trial. Am J Kidney Dis 2016; 68:599-608. [PMID: 27084247 DOI: 10.1053/j.ajkd.2016.02.049] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 02/21/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Soluble inflammatory mediators are known to exacerbate sepsis-induced acute kidney injury (AKI). Continuous renal replacement therapy (CRRT) has been suggested to play a part in immunomodulation by cytokine removal. However, the effect of continuous venovenous hemodiafiltration (CVVHDF) dose on inflammatory cytokine removal and its influence on patient outcomes are not yet clear. STUDY DESIGN Prospective, randomized, controlled, open-label trial. SETTING & PARTICIPANTS Septic patients with AKI receiving CVVHDF for AKI. INTERVENTION Conventional (40mL/kg/h) and high (80mL/kg/h) doses of CVVHDF for the duration of CRRT. OUTCOMES Patient and kidney survival at 28 and 90 days, circulating cytokine levels. RESULTS 212 patients were randomly assigned into 2 groups. Mean age was 62.1 years, and 138 (65.1%) were men. Mean intervention durations were 5.4 and 6.2 days for the conventional- and high-dose groups, respectively. There were no differences in 28-day mortality (HR, 1.02; 95% CI, 0.73-1.43; P=0.9) or 28-day kidney survival (HR, 0.96; 95% CI, 0.48-1.93; P=0.9) between groups. High-dose CVVHDF, but not the conventional dose, significantly reduced interleukin 6 (IL-6), IL-8, IL-1b, and IL-10 levels. There were no differences in the development of electrolyte disturbances between the conventional- and high-dose groups. LIMITATIONS Small sample size. Only the predilution CVVHDF method was used and initiation criteria were not controlled. CONCLUSIONS High CVVHDF dose did not improve patient outcomes despite its significant influence on inflammatory cytokine removal. CRRT-induced immunomodulation may not be sufficient to influence clinical end points.
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Affiliation(s)
- Jung Tak Park
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Youn Kyung Kee
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea
| | - Seokwoo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hyung Jung Oh
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea; Kidney Research Institute, Seoul National University, Seoul, Korea
| | - Chun-Soo Lim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea; Kidney Research Institute, Seoul National University, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea; Kidney Research Institute, Seoul National University, Seoul, Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea.
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea; Kidney Research Institute, Seoul National University, Seoul, Korea.
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Chen J, Chen G, Xiao D, Peng W, Yu G, Lin Y, Zheng F. Continuous venovenous hemofiltration decreases mortality and ameliorates acute lung injury in canine model of severe salt water drowning. Scand J Trauma Resusc Emerg Med 2016; 24:40. [PMID: 27036317 PMCID: PMC4818413 DOI: 10.1186/s13049-016-0224-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 03/10/2016] [Indexed: 11/15/2022] Open
Abstract
Background Pulmonary edema is an important cause of complications and death in severe drowning. Continuous veno-venous hemofiltration (CVVH) may reduce pulmonary edema and thus may be a treatment modality for severe sea water drowning resuscitation. Methos 20 dogs were anesthetized and tracheally intubated. 10 ml/kg of sea water was infused into trachea in a minute. All animals developed signs of respiratory distress and severe hypoxia (PaO2 < 40 mmHg) within 15 minutes after infusion. They were then mechanical ventilated and randomized to receive either CVVH (n = 10) or no additional treatment (control, n = 10) and followed over 4 hours. Arterial gas, hemodynamic parameters, and the levels of circulating inflammatory cytokines including interleukin 6 (IL-6), interleukin 8 (IL-8), and tumor necrosis factor α (TNFα) were determined. Additionally, blood endothelin and the levels of oxidative stress in lung were measured at sacrifice. Results 5 animals in the control group (50 %) died within 4 hours after sea water aspiration, while 10 animals received CVVH all survived (p < 0.05). Importantly, CVVH significantly improved blood gas exchange as evidenced by higher PaO2, normal oxygen saturation, and no carbon dioxide retention after 3 hour of CVVH, while also correcting against acidosis. Levels of circulating IL-6, IL-8, and TNFα were elevated in control but not in CVVH group (p < 0.01). CVVH also reduced plasma endothelin and alleviated oxidative stress. Histology examination further revealed reductions in pulmonary alveolar injury, blood congestion, and inflammation by CVVH. Discussion and conclusions CVVH decreased mortality and pulmonary injury and largely maintained hemodynamic and acid-base balance in animals with severe sea water drowning and thus, may be added as a new measure to aid in resuscitation from severe sea water drowning. Trial registration Animal protocol number: FZG0001859 http://www.fzzyy.com.
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Affiliation(s)
- Jian Chen
- Department of Nephrology, Fuzhou General Hospital, Nanjing Military Command, Fuzhou, China
| | - Guangming Chen
- Department of Nephrology, Fuzhou General Hospital, Nanjing Military Command, Fuzhou, China
| | - Daping Xiao
- Department of Nephrology, Fuzhou General Hospital, Nanjing Military Command, Fuzhou, China
| | - Weihua Peng
- Department of Nephrology, Fuzhou General Hospital, Nanjing Military Command, Fuzhou, China
| | - Guoqing Yu
- Department of Nephrology, Fuzhou General Hospital, Nanjing Military Command, Fuzhou, China
| | - Yueyong Lin
- Department of Nephrology, Fuzhou General Hospital, Nanjing Military Command, Fuzhou, China
| | - Feng Zheng
- Department of Nephrology, The Second Hospital, and Advanced Institute for Medical Sciences, Dalian Medical University, Dalian, 116044, China.
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Hanafusa N. Application of Continuous Renal Replacement Therapy: What Should We Consider Based on Existing Evidence? Blood Purif 2015; 40:312-9. [PMID: 26657106 DOI: 10.1159/000441579] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) is performed mainly in patients with acute kidney injury, severe sepsis, or septic shock. Evidence has emerged about the indications for and therapeutic conditions of CRRT. In this review, we focus on the evidence for CRRT to date. SUMMARY CRRT employs diffusion, convection and adsorption to remove solutes from plasma. Indications can be divided into renal and non-renal indications. Concrete renal indications have not yet been determined, except for life-threatening absolute indications. Modality selection is a point of debate. Intermittent renal replacement therapy is reportedly equivalent to CRRT in terms of overall survival. However, the selection of modality must consider individual circumstances. The optimal dosage of CRRT has proven to be lower than that previously recommended, and the dosage is almost the same as the one employed in the 'real-world' setting. Patients treated by CRRT often have bleeding complications. In this situation, regional citrate anticoagulation can be used, but nafamostat is widely used in Japan. The right jugular vein is the most preferred vascular access site because it has the lowest likelihood of catheter malfunction. As for the complications of CRRT, hypophosphatemia and nutrient loss should be managed properly. When CRRT is no longer necessary, we should consider the appropriate timing of discontinuation. KEY MESSAGES Even though CRRT is an established technique, several points remain under debate. Individualization of therapy should be considered in light of the changes in patient characteristics.
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Affiliation(s)
- Norio Hanafusa
- Division of Total Renal Care Medicine, University of Tokyo Hospital, Tokyo, Japan
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Rhee H, Jang KS, Shin MJ, Lee JW, Kim IY, Song SH, Lee DW, Lee SB, Kwak IS, Seong EY. Use of Multifrequency Bioimpedance Analysis in Male Patients with Acute Kidney Injury Who Are Undergoing Continuous Veno-Venous Hemodiafiltration. PLoS One 2015; 10:e0133199. [PMID: 26186370 PMCID: PMC4505923 DOI: 10.1371/journal.pone.0133199] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 06/24/2015] [Indexed: 02/06/2023] Open
Abstract
Introduction Fluid overload is a well-known predictor of mortality in patients with acute kidney injury (AKI). Multifrequency bioimpedance analysis (MF-BIA) is a promising tool for quantifying volume status. However, few studies have analyzed the effect of MF-BIA-defined volume status on the mortality of critically ill patients with AKI. This retrospective medical research study aimed to investigate this issue. Methods We retrospectively reviewed the medical records of patients with AKI who underwent continuous veno-venous hemodiafiltration (CVVHDF) from Jan. 2013 to Feb. 2014. Female patients were excluded to control for sex-based differences. Volume status was measured using MF-BIA (Inbody S20, Seoul, Korea) at the time of CVVHDF initiation, and volume parameters were adjusted with height squared (H2). Binary logistic regression analyses were performed to test independent factors for prediction of in-hospital mortality. Results A total of 208 male patients were included in this study. The mean age was 65.19±12.90 years. During the mean ICU stay of 18.29±27.48 days, 40.4% of the patients died. The in-hospital mortality rate increased with increasing total body water (TBW)/H2 quartile. In the multivariable analyses, increased TBW/H2 (OR 1.312(1.009-1.705), p=0.043) and having lower serum albumin (OR 0.564(0.346-0.919, p=0.022) were independently associated with higher in-hospital mortality. When the intracellular water (ICW)/H2 or extracellular water (ECW)/H2 was adjusted instead of the TBW/H2, only excess ICW/H2 was independently associated with increased mortality (OR 1.561(1.012-2.408, p=0.044). Conclusions MF-BIA-defined excess TBW/H2 and ICW/H2 are independently associated with higher in-hospital mortality in male patients with AKI undergoing CVVHDF.
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Affiliation(s)
- Harin Rhee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Keum Sook Jang
- Department of Nursing, Pusan National University Hospital, Busan, Republic of Korea
| | - Min Ji Shin
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Jang Won Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Il Young Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Sang Heon Song
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Dong Won Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Soo Bong Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Ihm Soo Kwak
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Eun Young Seong
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
- * E-mail:
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Seo DJ, Yoo JS, Kim JB, Jung SH, Choo SJ, Chung CH, Lee JW. Venovenous Extracorporeal Membrane Oxygenation for Postoperative Acute Respiratory Distress Syndrome. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2015; 48:180-6. [PMID: 26078924 PMCID: PMC4463224 DOI: 10.5090/kjtcs.2015.48.3.180] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 10/22/2014] [Accepted: 10/27/2014] [Indexed: 01/11/2023]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) has recently attracted interest as a treatment for severe acute respiratory distress syndrome (ARDS). However, the outcomes of this procedure in post-surgical settings have not yet been characterized. In this study, we evaluated the outcomes of ECMO in patients with severe postoperative ARDS. Methods From January 2007 to December 2012, a total of 69 patients (aged 58.3±11.5 years, 23 females) who underwent venovenous ECMO to treat severe postoperative ARDS were reviewed. Of these patients, 22 (31.9%) had undergone cardiothoracic surgery, 32 (46.4%) had undergone liver transplantation, and 15 (21.7%) had undergone other procedures. Results Thirty-four patients (49.3%) were successfully weaned from ECMO, while the other 35 patients (50.7%) died on ECMO support. Among the 34 patients who were successfully weaned from ECMO, 21 patients (30.4%) eventually died before discharge from the hospital, resulting in 13 hospital survivors (18.8%). Multivariable analysis showed that the duration of pre-ECMO ventilation was a significant independent predictor of death (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.29 to 3.90; p=0.004), whereas the concomitant use of continuous venovenous hemodialysis (CVVHD) was associated with improved survival (OR, 0.55; 95% CI, 0.31 to 0.97; p=0.038). Conclusion Although the overall survival rate of patients treated with ECMO for postoperative ARDS was unfavorable, ECMO offered an invaluable opportunity for survival to patients who would not have been expected to survive using conventional therapy. CVVHD may be beneficial in improving the outcomes of such patients, whereas a prolonged duration of pre-ECMO ventilator support was associated with poor survival.
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Affiliation(s)
- Dong Ju Seo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jae Suk Yoo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
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Dąbrowski W, Kotlinska-Hasiec E, Jaroszynski A, Zadora P, Pilat J, Rzecki Z, Zaluska W, Schneditz D. Intra-abdominal pressure correlates with extracellular water content. PLoS One 2015; 10:e0122193. [PMID: 25849102 PMCID: PMC4388733 DOI: 10.1371/journal.pone.0122193] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 02/12/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Secondary increase in intra-abdominal pressure (IAP) may result from extra-abdominal pathology, such as massive fluid resuscitation, capillary leak or sepsis. All these conditions increase the extravascular water content. The aim of this study was to analyze the relationship between IAP and body water volume. MATERIAL AND METHODS Adult patients treated for sepsis or septic shock with acute kidney injury (AKI) and patients undergoing elective pharyngolaryngeal or orthopedic surgery were enrolled. IAP was measured in the urinary bladder. Total body water (TBW), extracellular water content (ECW) and volume excess (VE) were measured by whole body bioimpedance. Among critically ill patients, all parameters were analyzed over three consecutive days, and parameters were evaluated perioperatively in surgical patients. RESULTS One hundred twenty patients were studied. Taken together, the correlations between IAP and VE, TBW, and ECW were measured at 408 time points. In all participants, IAP strongly correlated with ECW and VE. In critically ill patients, IAP correlated with ECW and VE. In surgical patients, IAP correlated with ECW and TBW. IAP strongly correlated with ECW and VE in the mixed population. IAP also correlated with VE in critically ill patients. ROC curve analysis showed that ECW and VE might be discriminative parameters of risk for increased IAP. CONCLUSION IAP strongly correlates with ECW.
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Affiliation(s)
- Wojciech Dąbrowski
- Department of Anesthesiology and Intensive Therapy Medical University of Lublin, Lublin, Poland
| | - Edyta Kotlinska-Hasiec
- Department of Anesthesiology and Intensive Therapy Medical University of Lublin, Lublin, Poland
| | | | - Przemyslaw Zadora
- Department of Anesthesiology and Intensive Therapy Medical University of Lublin, Lublin, Poland
| | - Jacek Pilat
- Department of General Surgery, Transplantology and Clinical Nutrition Medical University of Lublin, Lublin, Poland
| | - Ziemowit Rzecki
- Department of Anesthesiology and Intensive Therapy Medical University of Lublin, Lublin, Poland
| | - Wojciech Zaluska
- Department of Nephrology Medical University of Lublin, Lublin, Poland
| | - Daniel Schneditz
- Department of Physiology, Medical University of Graz, Graz, Austria
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Schmitz M, Heering PJ, Hutagalung R, Schindler R, Quintel MI, Brunkhorst FM, John S, Jörres A. [Treatment of acute renal failure in Germany: Analysis of current practice]. Med Klin Intensivmed Notfmed 2015; 110:256-63. [PMID: 25820934 DOI: 10.1007/s00063-015-0014-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 02/16/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVES There are currently no reliable data on the differential use of renal replacement therapy (RRT) options for critically ill patients with acute renal failure in Germany. PATIENTS AND METHODS A questionnaire-based survey was delivered to 2265 German intensive care units. The questionnaire contained 19 questions regarding RRT. RESULTS A total of 423 German intensive care units participated in the survey. The offered modalities of RRT varied significantly: the smaller the facility, the fewer different RRT options were available. Intermittent dialysis procedures were available in only 35% of hospitals with up to 400 beds. In university hospitals, hemodynamically unstable patients were exclusively treated by continuous RRT, whereas in hospitals with up to 400 beds, intermittent RRT was also used. In addition, treatment practice was also dependent on the specialization of the treating physicians: Isolated acute renal failure was treated more often intermittently by nephrologists compared to anesthesiologists (79.7 vs. 43.3%). Nephrologists also used extracorporeal RRT more often in cardiorenal syndrome (54.3 vs. 35.8%), whereas anesthesiologists preferred them in sepsis (37.3 vs. 23.1%). The choice of anticoagulant varied as well: Hospitals with up to 400 beds offered regional citrate anticoagulation in only 50% compared to 90% of university hospitals. CONCLUSIONS Currently, RRT treatment in acute renal failure on German intensive care units seems to be dependent on the size, local structures, and education of the intensivists rather than patient needs. Our results demonstrate the necessity to establish cross-disciplinary standards for the treatment of acute renal failure in German intensive care units.
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Affiliation(s)
- M Schmitz
- Klinik für Nephrologie und Allgemeine Innere Medizin, Städtisches Klinikum Solingen gGmbH, Akademisches Lehrkrankenhaus Universität Köln, Gotenstraße 1, 42653, Solingen, Deutschland,
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Kim JM, Jo YY, Na SW, Kim SI, Choi YS, Kim NO, Park JE, Koh SO. The predictors for continuous renal replacement therapy in liver transplant recipients. Transplant Proc 2015; 46:184-91. [PMID: 24507049 DOI: 10.1016/j.transproceed.2013.07.075] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 07/13/2013] [Accepted: 07/30/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Acute renal failure (ARF) after liver transplantation requiring continuous renal replacement therapy (CRRT) adversely affects patient survival. We suggested that postoperative renal failure can be predicted if a clinically simple nomogram can be developed, thus selecting potential risk factors for preventive strategy. METHODS We retrospectively reviewed the medical records of 153 liver transplant recipients from January 2008 to December 2011 at Severance Hospital, Yonsei University Health System, in Seoul, Korea. There were 42 patients treated with CRRT (20 and 22 patients received transplants from living and deceased donors, respectively) and 115 were not. Univariate and stepwise logistic multivariate analyses were performed. A clinical nomogram to predict postoperative CRRT application was constructed and validated internally. RESULTS Hepatic encephalopathy (HEP; odds ratio OR, 5.47), deceased donor liver donations (OR, 3.47), Model for End-Stage Liver Disease (MELD) score (OR, 1.09), intraoperative blood loss (L; OR, 1.16), and tumor (hepatocellular carcinoma) as the indication for liver transplantation (OR, 0.11) were identified as independent predictive factors for postoperative CRRT on multivariate analysis. A clinical prediction model constructed for calculating the probability of CRRT post-transplantation was 1.7000 × HEP + [-4.5427 + 1.2440 × (deceased donor) + 0.0830 × (MELD score) + 0.000149 × the amount of intraoperative bleeding (L) - 2.1785 × tumor]. The validation set discriminated well with an area under the curve (AUC) of 0.90 (95% confidence interval, 0.85-0.95). The predicted and the actual probabilities were calibrated with the clinical nomogram. CONCLUSIONS We developed a predictive model of postoperative CRRT in liver transplantation patients. Perioperative strategies to modify these factors are needed.
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Affiliation(s)
- J M Kim
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Y Y Jo
- Department of Anesthesia and Pain Medicine, Gachon University Gil Hospital, Incheon, Korea
| | - S W Na
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - S I Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Y S Choi
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - N O Kim
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - J E Park
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - S O Koh
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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Villa G, Zaragoza JJ, Sharma A, Chelazzi C, Ronco C, De Gaudio AR. High cutoff membrane to reduce systemic inflammation due to differentiation syndrome: a case report. Blood Purif 2014; 38:234-8. [PMID: 25531172 DOI: 10.1159/000369379] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 10/27/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Differentiation syndrome is a life-threatening complication of therapy that is carried out with agents used for acute promyelocytic leukemia. Its physiopathology comprehends the production of inflammatory mediators by differentiating granulocytes, endothelial and alveolar cells due to stimulation by all-trans retinoic acid and leading to sustained systemic inflammation. METHODS Treatment with high cut-off continuous veno-venous hemodialysis (HCO-CVVHD) was performed to reduce the circulating mediators of systemic inflammation. RESULTS After 52 h of treatment, an important reduction was observed in inflammatory mediators (IL-1β: from 10 to 2 pg/ml; IL-8: from 57 to 40 pg/ml; TNF-α: from 200 to 105 pg/ml; IL-6: from 263 to 91 pg/ml), as well as in anti-inflammatory mediators (IL-10: from 349 to 216 pg/ml). CONCLUSIONS HCO-CVVHD should be explored as a part of treatment in systemic inflammation states other than sepsis (e.g., differentiation syndrome). Furthermore, its immunomodulatory effects could be particularly useful in immunocompromised patient treated with corticosteroids.
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Affiliation(s)
- Gianluca Villa
- International Renal Research Institute of Vicenza, Vicenza, Italy
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Inoue S, Kiriyama K, Hatanaka Y, Kanoh H. Adsorption properties of an activated carbon for 18 cytokines and HMGB1 from inflammatory model plasma. Colloids Surf B Biointerfaces 2014; 126:58-62. [PMID: 25543984 DOI: 10.1016/j.colsurfb.2014.12.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 12/07/2014] [Indexed: 10/24/2022]
Abstract
The ability of an activated carbon (AC) to adsorb 18 different cytokines with molecular weights ranging from 8 kDa to 70 kDa and high mobility group box-1 (HMGB1) from inflammatory model plasma at 310 K and the mechanisms of adsorption were examined. Porosity analysis using N2 gas adsorption at 77K showed that the AC had micropores with diameters of 1-2 nm and mesopores with diameters of 5-20 nm. All 18 cytokines and HMGB1 were adsorbed on the AC; however, the shapes of the adsorption isotherms changed depending on the molecular weight. The adsorption isotherms for molecules of 8-10 kDa, 10-20 kDa, 20-30 kDa, and higher molecular weights were classified as H-2, L-3, S-3, and S-1 types, respectively. These results suggested that the adsorption mechanism for the cytokines and HMGB1 in the mesopores and on the surface of the AC differed as a function of the molecular weight. On the basis of these results, it can be concluded that AC should be efficient for cytokine adsorption.
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Affiliation(s)
- Satoru Inoue
- Medical Material Laboratory, Asahi-Kasei Medical Co., Ltd., 2111-2, Oaza-sato, Oita 870-0396, Japan; Department of Chemistry, Graduate School of Science, Chiba University, 1-33 Yayoi-cho, Inage, Chiba 263-8522, Japan
| | - Kentaro Kiriyama
- Medical Material Laboratory, Asahi-Kasei Medical Co., Ltd., 2111-2, Oaza-sato, Oita 870-0396, Japan
| | - Yoshihiro Hatanaka
- Medical Material Laboratory, Asahi-Kasei Medical Co., Ltd., 2111-2, Oaza-sato, Oita 870-0396, Japan
| | - Hirofumi Kanoh
- Department of Chemistry, Graduate School of Science, Chiba University, 1-33 Yayoi-cho, Inage, Chiba 263-8522, Japan.
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Iwagami M, Yasunaga H, Noiri E, Horiguchi H, Fushimi K, Matsubara T, Yahagi N, Nangaku M, Doi K. Choice of renal replacement therapy modality in intensive care units: data from a Japanese Nationwide Administrative Claim Database. J Crit Care 2014; 30:381-5. [PMID: 25434720 DOI: 10.1016/j.jcrc.2014.11.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Revised: 11/05/2014] [Accepted: 11/06/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE This study was undertaken to assess recent trends of the choice of renal replacement therapy (RRT) modalities in Japanese intensive care units (ICUs). MATERIALS AND METHODS Data were extracted from the Japanese Diagnosis Procedure Combination database for 2011. We identified adult patients without end-stage renal disease who had been admitted to ICUs for 3 days or longer and started continuous RRT (CRRT) or intermittent RRT (IRRT). Logistic regression was used to analyze which factors affected the modality choice. We further evaluated in-hospital mortality according to the choice of RRT. RESULTS Of 7353 eligible patients, 5854 (79.6%) initially received CRRT. The choice of CRRT was independently associated with sex (female), diagnosis of sepsis, hospital type (academic) and volume, vasoactive agents, mechanical ventilation, colloid administration, blood transfusion, intra-aortic balloon pumping, and venoarterial extracorporeal membrane oxygenation. Particularly, the number of vasoactive drugs was strongly associated with the CRRT choice. Overall in-hospital mortality in the CRRT group was higher than that in the IRRT group (50.0% vs 31.1%) and was increased when IRRT was switched to CRRT (59.1%). CONCLUSIONS Continuous RRT is apparently preferred in actual ICU practice, especially for hemodynamically unstable patients, and subsequent RRT modality switch is associated with mortality.
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Affiliation(s)
- Masao Iwagami
- Department of Hemodialysis and Apheresis, The University of Tokyo Hospital, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Eisei Noiri
- Department of Hemodialysis and Apheresis, The University of Tokyo Hospital, Tokyo, Japan; Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiromasa Horiguchi
- Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization Headquarters, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Informatics and Policy, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Takehiro Matsubara
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Naoki Yahagi
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaomi Nangaku
- Department of Hemodialysis and Apheresis, The University of Tokyo Hospital, Tokyo, Japan; Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Kent Doi
- Department of Hemodialysis and Apheresis, The University of Tokyo Hospital, Tokyo, Japan; Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan.
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Dabrowski W, Kocki T, Pilat J, Parada-Turska J, Malbrain MLNG. Changes in plasma kynurenic acid concentration in septic shock patients undergoing continuous veno-venous haemofiltration. Inflammation 2014; 37:223-34. [PMID: 24043287 PMCID: PMC3929023 DOI: 10.1007/s10753-013-9733-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Kynurenic acid (KYNA) is one of the end products of tryptophan metabolism. The aim of this study was to analyse plasma KYNA concentration in septic shock patients (SSP) with acute kidney injury (AKI) undergoing continuous veno-venous haemofiltration (CVVH). Changes in KYNA content were compared to alterations in the levels of procalcitonin (PCT), C-reactive protein and lactate. Adult SSP with AKI were examined. Measurements were conducted at seven time points: before beginning CVVH and at 6, 12, 24, 48, 72 and 96 h after the beginning of CVVH. Based on clinical outcomes, the data were analysed separately for survivors and non-survivors. Twenty-seven patients were studied. CVVH was associated with reduced plasma KYNA concentration only in survivors. Plasma KYNA concentration correlated with the levels of lactate and PCT only in survivors. (1) CVVH reduced plasma KYNA concentration only in survivors; (2) lack of this reduction may predict fatal outcomes in SSP.
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Affiliation(s)
- Wojciech Dabrowski
- Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Jaczewskiego Street 8, 20-954, Lublin, Poland,
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CHEN JUN, GAO JIANLIN, YANG JIANPING, ZHANG YUKUN, WANG LINA. Effect of triptolide on the regulation of ATP-binding cassette transporter A1 expression in lipopolysaccharide-induced acute lung injury of rats. Mol Med Rep 2014; 10:3015-20. [DOI: 10.3892/mmr.2014.2636] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 07/21/2014] [Indexed: 11/05/2022] Open
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Liu LY, Zhu YJ, Li XL, Liang YF, Liang ZP, Xia YH. Blood hemoperfusion with resin adsorption combined continuous veno-venous hemofiltration for patients with multiple organ dysfunction syndrome. World J Emerg Med 2014; 3:44-8. [PMID: 25215038 DOI: 10.5847/wjem.j.issn.1920-8642.2012.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 02/06/2012] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Blood hemoperfusion with resin adsorption can clean larger molecules that exceed the molecular weight cutoff of combined continuous veno-venous hemofiltration (CVVH). Hence blood hemoperfusion with resin adsorption combined CVVH (HP+CVVH) has higher ability of mediator clearance, and can improve clinical outcomes in theory. This study aimed to investigate the effect of blood hemoperfusion with resin adsorption combined continuous veno-venous hemofiltration (HP+CVVH) on plasm cytokines like TNF-α, IL-1β, IL-6, cellular immunity and prognosis in patients with multiple organ dysfunction syndrome (MODS). METHODS This was a prospective, randomized clinical trial. A total of 30 patients who had been diagnosed with MODS were enrolled in this study. Patients were randomly allocated to routine treatment+HP+CVVH group (treatment group) and routine treatment+only CVVH group (control group). In the treatment group, patients received blood hemoperfusion with resin adsorption for 2 hours, and then received CVVH for 10 hours every day. In the control group, patients received CVVH for 12 hours only every day. The patients in the two groups received blood purification therapy for three days. The plasma of patients in the treatment group was obtained at 0, 2, 12, 24, 26, 36, 48, 50, 60 hours, 5th day, 7th day and 10th day, respectively. The plasma of patients in the control group was obtained at 0, 12, 24, 36, 48, 60 hours, 5th day, 7th day and 10th day, respectively. APACHE II score, T-lymphocytes subpopulations, blood lactate acid concentration, heart rate, breathing rate, and oxygenation index were observed. RESULTS Plasma cytokines like TNF-α, IL-1β, IL-6 decreased markedly after HP (P<0.01); T-lymphocytes subpopulations CD3+, CD4+, CD8+, CD4+/CD8+ increased after HP+CVVH or only CVVH. The plasma concentrations of TNF-α, IL-1β and IL-6 in the two groups were not markedly different at 12, 36, and 50 hours. But on the 5th day, the plasma concentrations of TNF-α, IL-1β and IL-6 in the treatment group were lower than those in the control group (P<0.05). On the 28th day, 5 patients died in the treatment group, and 6 patients in the control group. CONCLUSIONS Both HP+CVVH and CVVH can clean plasma cytokines like TNF-α, IL-1β, and IL-6, and improve cellular immunity and clinical symptoms and signs of patients. Compared with only CVVH, the plasma concentrations of TNF-α, IL-1β and IL-6 were lower on the 5th day, and patients have an increased survival rate on the 28 day in the HP+CVVH group.
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Affiliation(s)
- Lu-Yi Liu
- ICU, Yuhuangding Hospital, Yantai 264000, China
| | | | - Xiao-Li Li
- ICU, Yuhuangding Hospital, Yantai 264000, China
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Linden K, Stewart IJ, Kreyer SF, Scaravilli V, Cannon JW, Cancio LC, Batchinsky AI, Chung KK. Extracorporeal blood purification in burns: A review. Burns 2014; 40:1071-8. [DOI: 10.1016/j.burns.2014.01.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 01/06/2014] [Accepted: 01/20/2014] [Indexed: 11/15/2022]
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Septic shock secondary to β-hemolytic streptococcus-induced necrotizing fasciitis treated with a novel cytokine adsorption therapy. Int J Artif Organs 2014; 37:422-6. [PMID: 24811308 DOI: 10.5301/ijao.5000315] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2013] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Numerous animal studies and preliminary data from a clinical trial in septic patients demonstrated that a decrease in blood cytokine levels using an extracorporeal cytokine filter (CytoSorb) can effectively attenuate the inflammatory response during sepsis and possibly improve outcomes. METHODS A 60-year-old female was admitted to hospital due to a forearm fracture. After surgical wound care by osteosynthesis the patient developed surgical wound infection which progressed to necrotizing fasciitis. All diagnostic criteria for SIRS were evident with additional proven infection from β-hemolytic streptococcus. On admission to the ICU, the patient presented a full picture of multiple organ dysfunction syndrome due to septic shock including kidney failure, lung failure as well as thrombocytopenia, metabolic acidosis, and arterial hypotension. RESULTS After one day on mechanical ventilation and an IL-6 level of 70,000 pg/ml the patient was treated with CytoSorb therapy over a period of four days, resulting in a significant reduction of IL-6 to 66 pg/ml and an overall improvement of the patient's condition. Despite the necessity of enucleation, the patient was successfully stabilized until control of the surgical infectious source was achieved. Importantly, treatment was safe and well-tolerated, without any adverse events. CONCLUSIONS This is the first report of the clinical application of CytoSorb hemoadsorption in combination with a CRRT in a patient with septic shock. CytoSorb as described was able to significantly reduce IL-6 plasma levels and decrease vasopressor need while no adverse and device-related events occurred. CytoSorb seems to be an interesting and safe extracorporeal therapy to stabilize and bridge septic patients to surgery or recovery.
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Continuous venovenous hemofiltration versus continuous venovenous hemodiafiltration in critically ill patients: a retrospective cohort study from a Canadian tertiary centre. Can Respir J 2014; 21:176-80. [PMID: 24712012 DOI: 10.1155/2014/965479] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Studies comparing continuous renal replacement therapy modalities are lacking. Theoretically, continuous venovenous hemofiltration (CVVH) could be more effective than continuous venovenous hemodiafiltration (CVVHDF), and may be associated with fewer complications; however, there are no published data to support this hypothesis. OBJECTIVE To examine the effect of CVVH on mortality and other clinically important outcomes compared with CVVHDF in the intensive care unit (ICU) setting. METHODS Using a log of all continuous renal replacement therapy performed at a Canadian tertiary centre between 2007 and 2010, the records of patients meeting the inclusion criteria of being admitted to the ICU, and receiving either CVVH or CVVHDF for management of acute renal failure, were reviewed. The information retrieved included demographic data, death events, and hospital and ICU length of stay. RESULTS Data from 153 patients were included in the present study. Hospital and 30-day mortality were similar in the CVVH and CVVHDF groups (OR 0.85 [95% CI 0.38 to 1.89]; P=0.69 and OR 1.35 [95% CI 0.62 to 2.95]; P=0.45, respectively). There was no difference in hospital length of stay (mean difference -34.14 [95% CI -72.92 to 4.65]; P=0.08). CONCLUSION The present retrospective review suggests that the use of CVVH does not reduce mortality or hospital length of stay when compared with CVVHDF. Future randomized trials should control for different patient populations and continue to evaluate the removal of small molecules such as hormones.
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