Oxiris Membrane in Sepsis and Multiple Organ Failure

Background Acute kidney injury (AKI) is the most common cause of organ failure in multiple organ dysfunction syndrome (MODS) and is associated with increased mortality. This study aimed at determining the efficacy of sequential organ failure assessment (SOFA), and acute physiology and chronic health evaluation II (APACHE-II) scoring systems in assessing the prognosis of critically ill patients with AKI undergoing continuous renal replacement therapy (CRRT). At present, APACHE-II score and SOFA score were also used to evaluate and predict the prognosis of critically ill patients with AKI. Methods The predictive value of SOFA and APACHE-II scores for 28- and 90-d mortality in patients with AKI undergoing CRRT were determined by multivariate analysis, sensitivity analysis, and curve-fitting analysis. Results A total of 836 cases were included in this study. Multivariate Cox logistic regression analysis showed that SOFA scores were associated with 28- and 90-d mortality in patients with AKI undergoing CRRT. The adjusted HR of SOFA for 28-d mortality were 1.18 (1.14, 1.21), 1.24 (1.18, 1.31), and 1.19 (1.13, 1.24) in the three models, respectively, and the adjusted HR of SOFA for 90-d mortality was 1.12 (1.09, 1.16), 1.15 (1.10, 1.19), and 1.15 (1.10, 1.19), respectively. The subgroup analysis showed that the SOFA score was associated with 28-d and 90-d mortality in patients with AKI undergoing CRRT. APACHE-II score was not associated with 28- and 90-d mortality patients with AKI undergoing CRRT. Curve fitting analysis showed that SOFA scores increased had a higher prediction accuracy for 28- and 90-d than APACHE-II. Conclusions The SOFA score showed a higher accuracy of mortality prediction in critically ill patients with AKI undergoing CRRT than the APACHE-II score.

Introduction: Severe acute respiratory viral infections are frequency accompanied by multiple organ dysfunction, including acute kidney injury (AKI). In December 2019, the coronavirus disease 2019 (COVID-19) outbreak began in Wuhan, Hubei Province, China, and rapidly spread worldwide. While diffuse alveolar damage and acute respiratory failure are the main features of COVID-19, other organs may be involved, and the incidence of AKI is not well described. We assessed the incidence and clinical characteristics of AKI in patients with laboratory-confirmed COVID-19 and its effects on clinical outcomes. Methods: We conducted a multicenter, retrospective, observational study of patients with COVID-19 admitted to two general hospitals in Wuhan from 5 January 2020 to 21 March 2020. Demographic data and information on organ dysfunction were collected daily. AKI was defined according to the KDIGO clinical practice guidelines. Early and late AKI were defined as AKI occurring within 72 h after admission or after 72 h, respectively. Results: Of the 116 patients, AKI developed in 21 (18.1%) patients. Among them, early and late AKI were found in 13 (11.2%) and 8 (6.9%) patients, respectively. Compared with patients without AKI, patients with AKI had more severe organ dysfunction, as indicated by a higher level of disease severity status, higher sequential organ failure assessment (SOFA) score on admission, an increased prevalence of shock, and a higher level of respiratory support. Patients with AKI had a higher SOFA score on admission (4.5 ± 2.1 vs. 2.8 ± 1.4, OR 1.498, 95% CI 1.047–2.143 ) and greater hospital mortality (57.1% vs. 12.6%, OR 3.998, 95% CI 1.088–14.613) than patients without AKI in both the univariate and multivariate analyses. Patients with late AKI, but not those with early AKI, had a significantly prolonged length of stay (19.6 vs. 9.6 days, p = 0.015). Conclusion: Our findings show that admission SOFA score was an independent risk factor for AKI in COVID-19 patients, and patients with AKI had higher in-hospital mortality. Moreover, AKI development after 72 h of admission was related to prolonged hospitalization time.

The novel coronavirus disease, COVID-19, is caused by a SARS-COV-2 infection and manifested in some clinical forms from mild to critical disease. The Sequential Organ Failure Assessment (SOFA) score has been used to predict the clinical outcomes of patients admitted to intensive care units with multiple organ failures. This study aimed to analyse the cut-off of the SOFA score with the best accuracy in predicting mortality in severe and critical COVID-19 population, and compared the survival rate difference of the high and low SOFA score according to the cut-off with the best accuracy from our study. This retrospective observational study analysed all of the severe and critical COVID-19 patients admitted to DR.Soetomo Hospital, Surabaya, Indonesia, from June to September 2020. We excluded patients who had died less than 48 hours upon ICU admission and patients who were discharged against medical advice (DAMA). A total of 123 patients were eligible. SOFA score significantly predicted ICU mortality of COVID-19 patients with the Area-under-curve of 0.9 (p<0.001). The survival rate of patients with the SOFA score of ?7 was 90%, compared to patients with the SOFA score of >7 with a survival rate of 10%. Patients with SOFA score ? 7 had a significantly longer survival time during ICU care (HR=15.85, p<0.001). Our study proved that patients with higher SOFA scores had a significantly different survival outcome during the ICU stay, with the score cut-off of 7. This score cut-off could significantly discriminate ICU survival with high predictive values.

To describe risk factors for the development of acute renal failure (ARF) in a population of intensive care unit (ICU) patients, and the association of ARF with multiple organ failure (MOF) and outcome using the sequential organ failure assessment (SOFA) score. Prospective, multicenter, observational cohort analysis. Forty ICUs in 16 countries. All patients admitted to one of the participating ICUs in May 1995, except those who stayed in the ICU for less than 48 h after uncomplicated surgery, were included. After the exclusion of 38 patients with a history of chronic renal failure requiring renal replacement therapy, a total of 1411 patients were studied. Of the patients, 348 (24.7%) developed ARF, as diagnosed by a serum creatinine of 300 micromol/l (3.5 mg/dl) or more and/or a urine output of less than 500 ml/day. The most important risk factors for the development of ARF present on admission were acute circulatory or respiratory failure; age more than 65 years, presence of infection, past history of chronic heart failure (CHF), lymphoma or leukemia, or cirrhosis. ARF patients developed MOF earlier than non-ARF patients (median 24 vs 48 h after ICU admission, p < 0.05). ARF patients older than 65 years with a past history of CHF or with any organ failure on admission were most likely to develop MOF. ICU mortality was 3 times higher in ARF than in other patients (42.8% vs 14.0%, p < 0.01). Oliguric ARF was an independent risk factor for overall mortality as determined by a multivariate regression analysis (OR = 1.59 [CI 95%: 1.23-2.06], p < 0.01). Infection increased the risk of death associated with all factors. Factors that increased the ICU mortality of ARF patients were a past history of hematologic malignancy, age more than 65 years, the number of failing organs on admission and the presence of acute cardiovascular failure. In ICU patients, the most important risk factors for ARF or mortality from ARF are often present on admission. During the ICU stay, other organ failures (especially cardiovascular) are important risk factors. Oliguric ARF was an independent risk factor for ICU mortality, and infection increased the contribution to mortality by other factors. The severity of circulatory shock was the most important factor influencing outcome in ARF patients.

Pelvic and retroperitoneal trauma is a major cause of morbidity and mortality in multiply injured patients. The Injury Severity Score (ISS) has been criticized for underrepresenting and inaccurately defining mechanical injury. The influence of pelvic injury volume on organ dysfunction and multiple organ failure (MOF) has not been described. Through the use of CT, this investigation sought to precisely define volumes of mechanical tissue damage by anatomic region and examine its impact on organ failure. (1) Do patients with MOF have a greater volume of pelvic and retroperitoneal tissue damage when compared with those without MOF? (2) In patients who sustained pelvic trauma, does the magnitude of pelvic injury differ in patients with MOF? (3) Does the magnitude of organ dysfunction correlate with pelvic tissue damage volume? Seventy-four multiply injured patients aged 18 to 65 years with an ISS ≥ 18 admitted to the intensive care unit for a minimum of 6 days with complete admission CT scans were analyzed. Each identifiable injury in the head/neck, chest, abdomen, and pelvis underwent volumetric determination using CT to generate regional tissue damage volume scores. Primary outcomes were the development of MOF as measured by the Denver MOF score and the degree of organ dysfunction by utilization of the Sequential Organ Failure Assessment (SOFA) score. Mean pelvic and retroperitoneal tissue damage volumes were compared in patients who developed MOF and those who did not develop MOF using Student's t-test. Among patients who sustained pelvic injuries, we compared mean volume of tissue damaged in patients who developed MOF and those who did not. We assessed whether there was a correlation between organ dysfunction, as measured by the SOFA score as a continuous variable, and the volume of pelvic and retroperitoneal tissue damage using the Pearson product-moment correlation coefficient. The average volume of tissue damage was greater in patients with MOF when compared with those without (MOF: 685.667 ± 1081.344; non-MOF: 195.511 ± 381.436; mean difference 490.156 cc [95% confidence interval {CI}, 50.076-930.237 cc], p = 0.030). Among patients who sustained pelvic injuries, those with MOF had higher average tissue damage volumes than those without MOF (MOF: 1322.000 ± 1197.050; non-MOF: 382.750 ± 465.005; mean difference 939.250 [95% CI, 229.267-1649.233], p = 0.013). Organ dysfunction (SOFA score) correlated with higher volumes of pelvic tissue damage (r = 0.570, p < 0.001). This investigation demonstrated that greater degrees of pelvic and retroperitoneal tissue damage calculated from injury CT scans in multiply injured patients is associated with more severe organ dysfunction and an increased risk of developing MOF. Early identification of polytrauma patients at risk of MOF allows clinicians to implement appropriate resuscitative strategies early in the disease course. Improved stratification of injury severity and a patient's anticipated clinical course may aid in the planning and execution of staged orthopaedic interventions. Future avenues of study should incorporate the ischemic/hypoperfusion component of pelvic injury in conjunction with the mechanical component presented here for improved stratification of multiply injured patients at higher risk of MOF. Level III, prognostic study.

To the Editor: Severe coronavirus disease infection continues to carry a high mortality with no definitive therapy to improve outcomes. Profound inflammation and coagulopathy are often present and predict a poor outcome. Therapeutic plasma exchange has been proposed as a potential therapy in this critically ill subset of coronavirus disease patients through its actions along these pathways. In our series of eight patients receiving adjunct therapeutic plasma exchange for severe coronavirus disease pneumonia complicated by sepsis with multiple organ dysfunction, C-reactive protein and ferritin levels significantly decreased with therapeutic plasma exchange, whereas D-dimer decreased to a lesser degree. Sequential Organ Failure Assessment scores also improved although the clinical impact cannot be assessed due to lack of controls. Our findings offer potentially useful information for the development of prospective trials of therapeutic plasma exchange for severe coronavirus disease infection. During the severe acute respiratory syndrome (SARS) epidemic of 2012, researchers noted that late-term disease progression was unrelated to the initial viremia, rather to the host's immunopathologic response (1). This pathologic cascade of cytokine storm, endothelial activation, and microcirculatory thrombosis has been well described in sepsis and appears to be common to coronavirus disease 2019 (COVID-19) (1,2). Early autopsy reports have demonstrated von Willebrand factor and fibrin clots along with severe endothelial injury and widespread microthrombosis in the lungs of coronavirus disease (COVID) nonsurvivors (3). Therapeutic plasma exchange (TPE) offers potentially unique therapy by removing excessive, harmful cytokines, stabilizing injured endothelial membranes, and restoring the normal hemostatic milieu. Busundet al (4) showed a trend toward improved mortality is sepsis of any cause with adjunct TPE, whereas Patel et al (5) demonstrated clinical improvement in a case series of pediatric patients with acute respiratory distress syndrome (ARDS) and shock receiving adjunct TPE during the H1N1 influenza pandemic of 2009. These data raise the hypothesis that TPE may be efficacious in critically ill patients with severe COVID infection. We report outcomes of eight critically ill patients with severe COVID complicated by ARDS, sepsis, and multiple organ dysfunction syndrome (MODS) treated with adjunct TPE. METHODS We performed a retrospective review of medical records of eight adult patients admitted to Lexington Medical Center (LMC) with laboratory-confirmed SARS coronavirus-2 infection, complicated by ARDS, sepsis, and MODS who received adjunct TPE as part of their management. Patients were considered for TPE under the 2019 American Society for Apheresis guidelines for sepsis with multiple organ failure (6) if they fulfilled the following criteria: 1) sepsis due to COVID-19 infection, 2) ARDS (as defined by the Berlin criteria), and 3) evidence of greater than or equal to two organ dysfunctions. Patients with poor long-term prognosis not due to COVID-19 were not considered for TPE. Baseline characteristics of the patients are outlined in Table 1. All patients received standard care for sepsis and ARDS according to the Surviving Sepsis Campaign and ARDS network guidelines. Patients also received specific therapies for COVID-19, as outlined in Table 1. TABLE 1. - Clinical Characteristics, Treatment, and Outcomes of Eight Patients Treated for Coronavirus Disease 2019 With Therapeutic Plasma Exchange Patient Characteristic Patient Demographics 1 2 3 4 5 6 7 8 Sex Male Male Male Male Male Male Female Female Age, yr 73 68 67 61 78 41 68 65 Comorbid conditions Hyperlipidemia, gastroesophageal reflux disease Hypertension Cerebral palsy, diabetes mellitus Systemic lupus erythematosus, hypertension, benign prostatic hypertrophy Prostate cancer status post transurethral resection of the prostate Obesity Dementia, pseudotumor cerebri, end-stage renal disease, hypertension, stroke Hypertension, obstructive sleep apnea, chronic kidney disease, obesity, atrial fibrillation, diastolic heart failure Living situation, prior to admission Home Home Extended care Home Home Home Home Home COVID 2019 disease presentation Admit to ICU transfer, d 1 2 5 0 3 0 3 2 ICU Admission SOFA 2 4 7 10 3 15 8 5 Admit to first TPE, d 9 9 11 6 3 0 7 4 Number of TPE treatments 2 3 4 7 4 2 1 1 Maximum respiratory support Mechanical ventilation Mechanical ventilation Mechanical ventilation Mechanical ventilation Mechanical ventilation Mechanical ventilation Mechanical ventilation Bilevel positive airway pressure Proned, yes/no No Yes No Yes Yes Yes No No Inhaled nitric oxide, yes/no No No No Yes Yes Yes No No Paralytic infusion, yes/no No Yes No Yes Yes Yes No No Vasopressor therapy, hr 50 7 42 219 42 13 2 30 Other therapeutic interventions Steroids Methylprednisolone Methylprednisolone Methylprednisolone Methylprednisolone Methylprednisolone Methylprednisolone Methylprednisolone None COVID-specific medications Hydroxychloroquine, azithromycin, zinc Hydroxychloroquine, azithromycin, zinc Hydroxychloroquine, azithromycin, zinc, tocilizumabe Hydroxychloroquine, azithromycin, zinc, tocilizumabe Hydroxychloroquine, azithromycin, zinc Azithromycin Azithromycin, Ivermectin None Convalescent plasma, yes/no No No No Yes Yes Yes Yes No Anticoagulation Enoxaparin prophylaxis Heparin prophylaxis Argatroban, apixaban Enoxaparin full-dose, argatroban Argatroban, heparin infusion Argatroban, apixaban Argatroban, apixaban Apixaban Clinical outcomes Number of ventilator days 2 7 6 21 13 9 2 0 ICU stay, d 10 11 18 29 23 11 17 7 Hospital stay, d 19 17 33 29 26 35 22 14 Hospital discharge SOFA 2 0 1 N/a N/a 4 4 0 Discharge disposition Acute rehabilitation Home Extended care Deceased Deceased Home Home Home COVID = coronavirus disease, SOFA = Sequential Organ Failure Assessment, TPE = therapeutic plasma exchange. The primary outcomes were change in Sequential Organ Failure Assessment (SOFA) score, C-reactive protein (CRP), ferritin, and D-dimer levels in relation to TPE. One way repeated measure analysis of variance was used to compare before and after effect of the earliest TPE session on available values. Secondary outcomes included effect on oxygen support, hospital mortality, ICU and hospital lengths of stay, and discharge disposition. The study was performed in accordance with the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the Institutional Review Board at LMC. Consent for treatment was obtained from each patient or his/her surrogate decision-maker at the time of treatment as part of routine care. TPE TREATMENT Vascular access was obtained by venous insertion of a 14-French double-lumen temporary hemodialysis catheter. TPE was performed with the Spectra Optia (TerumoBCT, Denver, CO) apheresis system. Unless specified, treatment consisted of three consecutive daily treatments using approximately 100% of the calculated total plasma volume, using fresh frozen plasma as replacement fluid. Patients may not have received all three TPE treatments if their clinical status improved prior to the third treatment. In patients receiving convalescent plasma, no further treatments were planned after convalescent transfusion. Patients with a prolonged course may have received additional treatments based on hemodynamic and/or laboratory values suggesting ongoing organ failure, including inflammation and coagulopathy. RESULTS Eight patients were treated with TPE (age range, 41–78 yr; 6 males, 2 females). Six patients were alive at the time of submission, whereas two patients died in the ICU. All six survivors have been discharged from the hospital. Four were discharged home, one discharged to acute rehabilitation, and one returned to extended care (from which he was admitted). ICU lengths of stay were 7–18 days with total hospital stays 14–35 days (Table 1). SOFA scores were calculated at ICU admission and hospital discharge, as well as prior to, and following, each TPE procedure (Tables 1 and 2). Mean ICU admission SOFA score was 6.8, and mean discharge SOFA was 2.2. A total of 24 TPE procedures were performed: 16 (66.7%) had improved SOFA scores post TPE, six (25%) had no change, whereas two (8.3%) had a worsening SOFA score. SOFA scores significantly decreased with the first TPE treatment (mean ± sd) pre = 9.3 ± 4.5 to post = 6.4 ± 3.5; ratio of variance (F) = 18.6; p = 0.004) (Table 2). TABLE 2. - Change in Sequential Organ Failure Assessment and Inflammatory Biomarkers Before and After Therapeutic Plasma Exchange Among Eight Patients with Severe Coronavirus Disease 2019 Infection Patient TPE Treatment Sequential Organ Failure Assessment C-Reactive Protein Ferritin D-Dimer Pre Post Pre Post Pre Post Pre Post 1 1 3 3 147 76 1,009 445 2,346 1,880 2 3 3 83 35 679 445 2,215 1,009 2 1 13 7 — — — — 4,172 6,111 2 7 5 115 94 1,324 714 6,111 4,720 3 4 3 125 24 1,397 1,980 2,854 3,323 3 1 12 8 73 23 516 427 25,000 9,148 2 8 7 14 10 393 556 7,777 3,315 3 7 7 10 36 556 904 3,315 9,553 4 7 7 36 37 904 388 9,553 1,772 4 1 10 7 588 514 1,845 1,610 8,729 5,318 2 7 4 514 114 1,610 847 5,318 1,542 3 4 3 74 37 841 595 2,450 3,535 4 6 6 48 28 745 407 6,242 4,275 5 5 8 105 109 601 495 2,853 3,278 6 13 9 93 19 1,044 365 2,811 950 7 18 14 164 74 1,600 600 1,030 672 5 1 3 2 281 113 1,586 990 432 405 2 2 2 113 26 990 702 405 339 3 2 5 26 11 702 523 339 541 4 6 5 52 121 926 1,063 3,045 2,286 6 1 15 12 311 200 925 494 800 353 2 12 11 370 80 1,721 1,025 2,811 2,911 7 1 11 9 348 168 2,629 2,211 1,832 1,907 8 1 7 3 — — — — — — Means (first TPE Treatment) 9.3 6.4 266.1 176.5 1,404.9 984.4 6,187.3 3,588.8 Pre-post comparison F, p 18.6, p < 0.01 18.3, p < 0.01 32.0, p < 0.01 1.3, p = 0.3 F = ratio of variance, TPE = therapeutic plasma exchange.Dashes indicate values are unavailable as they were not measured. CRP, ferritin, and D-dimer levels in relation to TPE are reported in Table 2. All three typically decreased with each treatment (18/22 CRP; 18/22 ferritin; 15/23 D-dimer). CRP (mean ±SD) pre = 266.1 ± 169.7 to post = 176.5 ± 162.6; F = 18.3; (p = 0.005) and ferritin (mean ± SD) pre = 1404.9 ± 696.3 to post = 984.4 ± 684.5; F = 32.0; (p = 0.001) significantly decreased with the first TPE treatment, whereas D-dimer did not (mean ± SD) pre = 6187.3 ± 8,758.9 to post = 3,588.8 ± 3,332.0; F = 1.3; (p = 0.3). Daily arterial blood gases were not routinely checked, so Pao2/Fio2 ratios could not be trended to objectively assess changes in respiratory status. Instead, Figure 1 demonstrates changes in the mode of supplemental oxygen support required by each patient. All seven mechanically ventilated patients were initially liberated from the ventilator, although two patients required reintubation and ultimately died from their acute illness. Four survivors were weaned to room air prior to discharge, and two survivors were discharged on low-flow oxygen.Figure 1.: Respiratory support timeline for patients with coronavirus disease 2019 who received therapeutic plasma exchange (TPE) (n = 8).DISCUSSION We observed a clinical and laboratory response that may not have been predicted based on early outcome data in severe COVID infection (7), but the relationship of these findings to TPE is uncertain. The temporal relationship of our outcome measures to TPE is undeniable, but the clinical relationship and impact cannot be determined. Without matched controls, it is impossible to determine if these patients would have improved without TPE as part of the natural disease course, or whether other treatments, alone or in combination, are responsible for the outcomes we observed. Identifying patients with poor prognosis and potential to benefit from adjunct therapy is key in sepsis. Hypercytokinemia is associated with increased mortality in sepsis and may manifest clinically as hypotension and multiple organ failure. CRP, ferritin, and D-dimer may serve as nonspecific markers, and elevated levels have been associated with increased mortality in COVID-19 (8,9). These levels all generally improved with TPE in our patients. Defining pathologic levels, evaluating their response to TPE, and correlating these values with clinical outlines may prove valuable in future studies of TPE for severe COVID infection. Although others have reported the feasibility and safety of TPE for sepsis (10), it is important to note that TPE alters the immune system in a nonselective way, and the net effect is not certain. The effect on humoral immunity is a concern, with the potential removal of host-generated antibodies that theoretically may adversely affect the clinical condition. Prospective studies should be performed, not only to evaluate the efficacy of TPE but any potential adverse effects. As the number of critically ill patients with COVID-19 continues to grow, it is important that we continue to investigate treatment options. TPE offers treatment that targets the pathologic host response on multiple levels and has been effective in patients with a similar presentation of sepsis due to other pathogens. A well-designed prospective trial is desired to investigate this promising therapy for critically ill COVID patients. CONCLUSIONS TPE offers a potential therapy in critically ill patients with COVID-19 through its action on the inflammatory and coagulation pathways. Our case series shows favorable decreases in nonspecific markers of these pathways following TPE, but the clinical effect of these changes is uncertain. Prospective trials are needed to investigate the efficacy and safety of TPE in this patient population.

ObjectiveWe retrospectively analyzed risk factors on in-hospital mortality in CRRT-therapy patients with open cardiac surgery (CS)-induced acute kidney injury (AKI), to provide the clinical basis for predicting and lowering the in-hospital mortality after CS.Methods84 CS-AKI patients with CRRT were divided into survival and death groups according to discharge status, and the perioperative data were analyzed with R version 4.0.2.ResultsThere were significant differences between the two groups, including: urea nitrogen, Sequential Organ Failure Assessment (SOFA) score and vasoactive-inotropic score (VIS) on the first day after operation; VIS just before CRRT; SOFA score and negative balance of blood volume 24 h after CRRT; the incidence rate of bleeding, severe infection and MODS after operation; and the interval between AKI and CRRT. Univariate logistic regression analysis showed that SOFA score and VIS on the first day after operation; VIS just before CRRT; VIS and negative balance of blood volume 24 h after CRRT; the incidence rate of bleeding, infection and multiple organ dysfunction syndrome (MODS) after operation; bootstrap resampling analysis showed that SOFA score and VIS 24 h after CRRT, as well as the incidence of bleeding after operation were the independent risk factors.ConclusionMaintaining stable hemodynamics and active prevention of bleeding are expected to decrease the in-hospital mortality.

Objective To investigate the curative effect of continuous renal replacement therapy(CRRT) in patients with multiple organ dysfunction syndrome(MODS). Methods 194 patients with multiple organ dysfunction syndrome were divided into two groups. 89 patients without using CRRT treatment for various reasons, as a routine treatment group, were treated by the conventional treatment, including etiological treatment, anti-inflammatory, organ function support and other symptomatic supportive treatment.The other 105 patients were treated with continuous renal replacement therapy on the basis of conventional therapy as the CRRT group. analysis of two groups of Patients before and after treatment for 24 hours The acute Physiology and chronic health evaluation Ⅱ score, Marshall score, Sequential Organ Failure Assessment (SOFA) score, the changes of calcitonin original, mean arterial Pressure, creatinine, oxygenation index and 7 days survival rate of two groups of patients before and after treatment for 24 hours were compared, and the efficacy of treatment was analyzed. Results Before and after treatment in the CRRT group, APSCHE Ⅱ scores were (24.1±7.9) and (19.8±7.6), Marshall scores were (7.3±2.7) and (6.8±2.9), and SOFA scores were (11.9±2.7) and (10.8±3.2) with significant differences (P<0.05). Before and after treatment in the conventional group, the APACHE Ⅱ score were (23.2 ± 8.4) and (23.1 ± 8.6), Marshall score were (7.1 ± 3.1) and (7.3 ± 3.1), SOFA score were (11.1±3.3) and (11.2±3.5) with no significant differences. Before and after treatment in the CRRT group, procalcitonin were 10.6 (7.1, 16.1) & 4.7 (2.5, 6.9), mean arterial pressure were (76.3±19.7) and (83.2±15.6), creatinine were 199 (147.5, 328.5) & 149, and oxygenation index were (228.9±105.1) and (269.1±111.5) with significant differences (P<0.05). Before and after treatment in the conventional treatment group, procalcitonin were 13.7 (10.1, 19.6) & 13.4. 10.1, 21.6), mean arterial pressure were (83.0±17.9) and (80.0±15.9), creatinine were 180 (119.5, 281.0) & 195 (113.5, 313.5), and oxygenation index were (286.3±139.3) and(283.2±126.6)with no significant differences. The 7-day survival rate of the CRRT group was significantly improved (P<0.05). Conclusions in Patients with multiple organ dysfunction syndrome were treated early with continuous renal replacement therapy. APACHE Ⅱ grade, Marshall, SOFA score were significantly reduced. Inflammation, cardiovascular system function, renal function, and respiratory function were improved significantly. Sothe short-term survival rate can be significantly improved. Key words: continuous renal replacement therapy; multiple organ dysfunction syndrome; Short-term survival rate

BackgroundNeutrophil gelatinase-associated lipocalin (NGAL) is a diagnostic marker for acute kidney injury (AKI). NGAL expression is highly induced not only in kidney injury but also in bacterial infection, inflammation, and cancer. The factors regulating NGAL expression are proinflammatory cytokines, and plasma NGAL levels have been increased in septic shock. However, there are no reports of urine neutrophil gelatinase-associated lipocalin (uNGAL) levels after open esophagectomy.MethodsWe prospectively enrolled critically ill patients, including patients with sepsis (n = 45) and patients who underwent open esophagectomy (n = 40). We compared vital signs, PaO2/FIO2, serum C-reactive protein (CRP) levels, acute physiology and chronic health evaluation (APACHE) II score, sequential organ failure assessment (SOFA) score, and uNGAL levels between the sepsis group and the esophagectomy group. Then, we investigated whether uNGAL is associated with the severity of illness and organ failure, and whether uNGAL is a reliable screening test for AKI.ResultsThe median uNGAL levels, APACHE II score, SOFA score, and serum CRP levels were significantly (p < 0.001) higher in the sepsis group than in the esophagectomy group on ICU day 1. In the sepsis group, uNGAL levels were significantly (p < 0.05) correlated with APACHE II score and SOFA score on intensive care unit (ICU) day 1, 2, and 3. In the esophagectomy group, uNGAL levels were significantly (p < 0.05) correlated with SOFA score on ICU day 3 and 4. In the sepsis group, 1 patient developed AKI stage 2 and 6 patients developed AKI stage 3. No patients developed AKI in the esophagectomy group. In a total of 85 patients of this study, 80 patients had an abnormal value of uNGAL and only 7 patients (8.7%) of those 80 patients developed AKI.ConclusionsuNGAL levels were correlated with the severity of illness and organ failure in critically ill patients. The value of uNGAL increases under the surgical and inflammatory responses, thereby losing a significance of a screening test of AKI in critically ill patients.

Sepsis causes immune dysregulation and endotheliitis, with an increase in mid-regional pro-adrenomedullin (MR-proADM). The aim of the study is to determine an MR-proADM value that, in addition to clinical diagnosis, can identify patients with localized infection or those with sepsis/septic shock, with specific organ damage or with the need for intensive care unit (ICU) transfer and prognosis. The secondary aim is to correlate the MR-proADM value with the length of stay (LOS). In total, 301 subjects with sepsis (124/301 with septic shock) and 126 with localized infection were retrospectively included. In sepsis, MR-proADM ≥ 3.39 ng/mL identified acute kidney injury (AKI); ≥2.99 ng/mL acute respiratory distress syndrome (ARDS); ≥2.28 ng/mL acute heart failure (AHF); ≥2.55 ng/mL Glascow Coma Scale (GCS) < 15; ≥3.38 multi-organ involvement; ≥3.33 need for ICU transfer; ≥2.0 Sequential Organ Failure Assessment (SOFA) score ≥ 2; and ≥3.15 ng/mL non-survivors. The multivariate analysis showed that MR-proADM ≥ 2 ng/mL correlates with AKI, anemia and SOFA score ≥ 2, and MR-proADM ≥ 3 ng/mL correlates with AKI, GCS < 15 and SOFA score ≥ 2. A correlation between mortality and AKI, GCS < 15, ICU transfer and cathecolamine administration was found. In localized infection, MR-proADM at admission ≥ 1.44 ng/mL identified patients with AKI; ≥1.0 ng/mL with AHF; and ≥1.44 ng/mL with anemia and SOFA score ≥ 2. In the multivariate analysis, MR-proADM ≥ 1.44 ng/mL correlated with AKI, anemia, SOFA score ≥ 2 and AHF. MR-proADM is a marker of oxidative stress due to an infection, reflecting severity proportionally to organ damage.

The multiple organ dysfunction (MOD) score and sequential organ failure assessment (SOFA) score are measures of organ dysfunction and have been validated based on the association of these scores with mortality. We sought to compare the performance of the SOFA and MOD scores in a large cohort of consecutive multisystem intensive care unit (ICU) patients.Prospective automated daily measurements of MOD and SOFA scores were performed in 1,436 patients admitted to a multisystem ICU in the Calgary Health Region over a one-year period. Logistic regression modeling techniques were used to describe the association of SOFA and MODS with mortality. Receiver operator characteristic (ROC) curves were used to assess the model's discriminatory ability.For ICU and hospital mortality, there was very little practical difference between the SOFA and MOD scores in their ability to discriminate outcome as determined by the area under the ROC. However, compared to previous literature, the discriminatory ability of both scores in this population was weak. As well, the calibration of the models was poor for both scores. The SOFA cardiovascular component score performed better than the MOD cardiovascular component score in the discrimination of both ICU and hospital mortality.SOFA and MOD scores had only a modest ability to discriminate between survivors and non-survivors. These results question the appropriateness of using organ dysfunction scores as a 'surrogate' for mortality in clinical trials and suggest further work is necessary to better understand the temporal relationship and course of organ failure with mortality.

Background: The Sequential Organ Failure Assessment (SOFA) score is an excellent tool for assessing the extent of organ dysfunction in critically ill patients. This study was planned to compare outcome and organ failure status of community (CAARF) and hospital acquired acute renal failure (HAARF) patients requiring dialysis using SOFA score.Methods: The present prospective observational study was conducted on fifty consecutive acute renal failure patients age more than 18 years of either sex requiring dialysis. Patients who developed ARF after 24 hours of admission were referred as HAARF and patients who had acute renal failure on admission were considered as CAARF. The Sequential Organ Failure Assessment (SOFA) score was used to track a patient's status during the stay in an intensive care unit in both HAARF and CAARF patients.Results: Out of 50 patients, 31(62%) patients had community acquired renal failure and 19 (38%) patients had hospital acquired renal failure. Mean SOFA in HAARF patients was high (8.84±3.13) compare to CAARF patients (6.16± 2.80). The p value calculated was 0.003 which was significant. High SOFA Score (&gt;11) were seen predominantly in HAARF (83.3%) patients compare to CAARF (16.7%), followed by 57.1% of patients in HAARF and 42.9% of patients in CAARF had SOFA score between 9 to11.Conclusions: High SOFA Score were seen predominantly in HAARF patients compare to CAARF and so poor outcome compare to CAARF. So, SOFA score may be used in explaining prognosis and outcome of ARF patients.

IntroductionThe Sequential Organ Failure Assessment (SOFA) score is a widely utilized clinical tool for evaluating the severity of organ failure in critically ill patients and assessing their condition and prognosis in the intensive care unit (ICU). Research has demonstrated that higher SOFA scores are associated with poorer outcomes in these patients. However, the predictive value of the SOFA score for acute kidney injury (AKI), a common complication of diabetic ketoacidosis (DKA), remains uncertain. Therefore, this study aims to investigate the relationship between SOFA scores and the incidence of AKI in patients with DKA.MethodsThe study population was divided into two groups based on the median SOFA score (Q1: SOFA ≤3; Q2: SOFA &amp;gt;3). The primary endpoint was the incidence of AKI in patients with DKA. Secondary endpoints included renal replacement therapy (RRT) utilization and in-hospital mortality. Kaplan–Meier survival analysis, Cox proportional hazards models, and logistic regression models were employed to assess the association between SOFA and therisk of AKI in patients with DKA.ResultsOverall, 626 patients with DKA were included in this study, of which 335 (53%) were male. Kaplan–Meier survival analysis included that patients with higher SOFA scores experienced significantly increased cumulative incidences of AKI, higher rates of RRT utilization, and elevated in-hospital mortality. Furthermore, after adjusting for confounding factors, logistic regression and Cox proportional hazards analyses confirmed that SOFA scores remained significantly associated with the incidence of AKI in patients with DKA.ConclusionsOur study indicates that a high SOFA score is an independent risk predictor for the occurrence of AKI, the utilization of RRT, and in-hospital mortality in patients with DKA. The sofa score can be utilized as a biomarker to assess the risk of AKI in this patient population.

BackgroundThe Sequential Organ Failure Assessment (SOFA) score has been developed to score the severity of organ dysfunction in critically ill sepsis patients and has been proven to have a high predictive value for intensive care unit (ICU) mortality in severely ill patients. Our goal was to evaluate the prognostic value of the SOFA score as well as trends in SOFA score for ICU mortality in COVID-19 patients.MethodsAll consecutive patients with confirmed COVID-19 pneumonia admitted to the ICU between March 13th, 2020, and October 17th, 2020 were included in this retrospective cohort study. The worst SOFA score was evaluated daily. Multiple logistic regression models were used to evaluate the predictive value of SOFA in ICU mortality.Results103 patients were included in this study. 30 patients (29%) died during their ICU stay and 73 (71%) patients were discharged alive. The ICU admission SOFA score was 5.2 ± 3.3 in ICU non-survivors vs. 4.3 ± 2.9 in ICU survivors (P = 0.15). The maximum SOFA score in ICU non-survivors was 11.7 ± 4.7 vs. 7.4 ± 4.3 in ICU survivors. SOFA scores increased the first week in both survivors and non-survivors, but the increase was less pronounced in survivors. In the multiple logistic regression models, neither admission SOFA score nor combination with delta SOFA in the first 48 hours was statistically significantly related to ICU mortality. Only the maximum SOFA score remained significant (OR = 1.23, 95% CI: 1.11–1.37, P < 0.001) in the multiple logistic models with an AUC of 0.91.ConclusionsEvaluation of SOFA scores in the first 48 hours after ICU admission is not a good prognostic indicator in COVID-19 patients. Only the maximum SOFA score was predictive for ICU mortality.

Decision letter: An open label trial of anakinra to prevent respiratory failure in COVID-19