Blood Purification Therapy Research Articles

ACUTE DIALYSIS QUALITY INITIATIVE (ADQI) XIV SEPSIS PHENOTYPES AND TARGETS FOR BLOOD PURIFICATION IN SEPSIS: THE BOGOTÁ CONSENSUS.

Despite widespread use, there is currently no consensus on how extracorporeal blood purification therapies should be applied or studied in patients with sepsis. One major obstacle has been the lack of clear descriptions of specific sepsis phenotypes tied to mechanisms that would permit the identification of molecular targets. Current evidence suggests that sepsis-related morbidity and mortality involve widely different clinical phenotypes that variably include mitochondrial dysfunction, abnormalities of vascular biology including endothelial dysfunction and coagulopathy, epithelial dysfunction, and immune suppression and dysregulation. While most cases of sepsis involve some element of all of these pathobiologic processes, the magnitude of each varies greatly from patient to patient in part as a result of the pathogen and in part related to host-specific factors. Thus, the purpose of the fourteenth international consensus conference of acute dialysis quality initiative was to develop consensus for a conceptual model of sepsis-induced organ failure that can be treated by extracorporeal blood purification and possibly also with drugs or other therapies. We assembled a group of experts from around the world and used a modified Delphi method to reach consensus. Specific findings and recommendations for future research are provided in the four accompanying papers.

IMMUNE CELL PHENOTYPE AND FUNCTION IN SEPSIS.

Cells of the innate and adaptive immune systems play a critical role in the host response to sepsis. Moreover, their accessibility for sampling and their capacity to respond dynamically to an acute threat increases the possibility that leukocytes might serve as a measure of a systemic state of altered responsiveness in sepsis.The working group of the 14th Acute Dialysis Quality Initiative (ADQI) conference sought to obtain consensus on the characteristic functional and phenotypic changes in cells of the innate and adaptive immune system in the setting of sepsis. Techniques for the study of circulating leukocytes were also reviewed and the impact on cellular phenotypes and leukocyte function of nonextracorporeal treatments and extracorporeal blood purification therapies proposed for sepsis was analyzed.A large number of alterations in the expression of distinct neutrophil and monocyte surface markers have been reported in septic patients. The most consistent alteration seen in septic neutrophils is their activation of a survival program that resists apoptotic death. Reduced expression of HLA-DR is a characteristic finding on septic monocytes, but monocyte antimicrobial function does not appear to be significantly altered in sepsis. Regarding adaptive immunity, sepsis-induced apoptosis leads to lymphopenia in patients with septic shock and it involves all types of T cells (CD4, CD8, and Natural Killer) except T regulatory cells, thus favoring immunosuppression. Finally, numerous promising therapies targeting the host immune response to sepsis are under investigation. These potential treatments can have an effect on the number of immune cells, the proportion of cell subtypes, and the cell function.

難治性膠原病における血液浄化療法

新規の免疫抑制剤や生物学的製剤の登場により, それまで治療が困難な症例も寛解導入が可能となってきた. 一方で, 未だ有効な治療法がない難治性病態も確かに存在する. 例えば, びまん型全身性強皮症における進行性の皮膚硬化は, 関節可動域の狭小化, さらに進行すると関節の拘縮に至り患者のADLを著しく低下させる. また, 筋炎症状の乏しい皮膚筋炎に合併する間質性肺炎は急速に肺機能を低下させ, 有効な治療法のないこともあり未だに致死率が高い病態である. これら難治性病態に対して血液浄化療法が行われ, 全身性強皮症では血漿交換療法が有効であった症例が報告され, 劇症型の間質性肺炎についてはシクロスポリンとシクロホスファマイドなどの免疫抑制剤にエンドトキシン吸着療法の併用療法が有効であったことが報告され, その治療効果が期待されている. これら疾患以外にも, 血管炎により発症する急速進行性糸球体腎炎では腎機能の廃絶により血液透析に至る率は依然として高い. 今後も難治性膠原病疾患に対して血液浄化療法は有効な治療法の一つと考える.

Two patients who underwent blood purification therapy for the acute exacerbation of Maple syrup urine disease

Two patients who underwent blood purification therapy for the acute exacerbation of Maple syrup urine disease

A long-term blood purification therapy in an adult patient with congenital heart disease complicated by cyanotic nephropathy: case study

A long-term blood purification therapy in an adult patient with congenital heart disease complicated by cyanotic nephropathy: case study

The reevaluation of scoring systems for critical care during acute blood purification therapy

The reevaluation of scoring systems for critical care during acute blood purification therapy

The role of Japanese nurse practitioner in acute blood purification therapy

The role of Japanese nurse practitioner in acute blood purification therapy

Kinetic modeling for blood purification in critical care: this article is based on a study first reported in kidney and dialysis (in Japanese)

In blood purification therapies for critical care, there are no guidelines for selecting modalities of the treatment or for determining the treatment schedule, treatment time, and operating conditions, such as dialysate flow rate (Q D) and filtration flow rate (Q F). In this paper, the solute removal characteristics of blood purification for critical care and the optimal operating conditions for individual patients are discussed from the viewpoint of kinetic modeling. An in vitro study using an aqueous solution involving several marker solutes was performed. From a result of the continuous hemodialysis (CHD) experiments, the Q D should be required at least twice the patient’s blood flow rate (Q B) for sufficient removal of small molecular substances. CHD is of limited use for the removal of middle-sized molecules. During the continuous hemofiltration (CHF) experiments in the post-dilution mode, the maximum Q F value can be determined as about 1/4 of the Q B because of the existence of the formed elements. In summary of the continuous hemodiafiltration (CHDF) experiments, the Q F is about 1/4 of Q B value and the Q D should be set up at least twice the Q B value. The determination of adequate operating conditions for individual patients can be summarized from a kinetic modeling viewpoint: Measurement of the removed amount of solute by collecting the spent dialysate and/or filtrate is recommended to maintain an adequate plasma level of the targeted solute of patients, who often have unstable states. The adequate operating conditions for each patient can be determined from a kinetic modeling viewpoint.

Adsorption of Selected Antibiotics to Resins in Extracorporeal Blood Purification

Background/Aims: Extracorporeal blood purification systems (EBS) use specific adsorbents for the elimination of toxins and cytokines. The aim of this study was to test different adsorbents for their ability to reduce antibiotics in parallel to extracorporeal blood purification therapy. Methods: The in vitro adsorption experiments were carried out in human plasma with a newly established hydrophobic resin (Amberchrom CG161c) and adsorbents commercially available and approved in the clinics. The concentration of antibiotic was chosen equivalent to the recommended therapeutic dosage applied intravenously and was measured in plasma using ELISA test kits and high-performance liquid chromatography methods. Results: The adsorbent that reduced all tested antibiotics in plasma close to the detection limit was the dia MARS AC250, which is an activated charcoal involved in the Molecular Adsorbents Recirculation System. Conclusion: For better antibiotic monitoring in sepsis treatment, further investigations have to be performed to determine the clearance rate of antibiotics by different EBS devices.

Blood purification therapy prolongs the duration of intensive care unit stay to 14 days or more

In the intensive care unit (ICU), severely ill or injured patients who undergo specific treatments, including artificial ventilation and blood purification (BT), may require a longer duration of ICU stay than patients not receiving specific treatments.

Retrospective study of primary IgA nephropathy with crescent formation and/or rapidly progressive glomerulonephritis in children

IgA nephropathy is the most common type of glomerulonephritis in the world. Its clinical and pathological manifestations vary. A few of the patients with IgA nephropathy present with rapidly progressive glomerulonephritis (RPGN) and/or crescent formation. Their conditions are serious and acute, but there are few reports on their characteristics, treatment and outcome. This study aimed to analyze the clinicalopathological features, treatment and prognosis of primary IgA nephropathy in children, to provide a reference for clinical diagnosis and treatment. A retrospective study was conducted in children with primary IgA nephropathy with crescent formation and/or rapidly progressive glomerulonephritis admitted to our department from 2000 to 2014. The patients meeting the inclusion and exclusion criteria were included. Patients were divided into RPGN group and non-RPGN group according to the clinical manifestations, crescent formation group and non-crescent group, crescentic IgA nephropathy group and non-crescentic IgA nephropathy group according to renal biopsy. Their clinical manifestations and pathological features, treatment and prognosis were compared. A total of 265 patients were recruited, 10 patients (3.8%) had RPGN, 151 patients (57.0%) had crescent formation, 19 cases (7.2%) showed crescentic IgA nephropathy.Compared with non-RPGN group, RPGN group showed more gross hematuria, higher serum creatinine, lower creatinine clearance correction at biopsy and follow-up, and more crescentic IgA nephropathy (P<0.05). The percent of patients who received methylprednisolone pulse and blood purification therapy in RPGN group is higher than that of non-RPGN group (P<0.05). Compared with non-crescent group, crescent formation group showed more gross hematuria at biopsy and follow-up, higher serum creatinine at biopsy, lower creatinine clearance correction, more 24-hour urinary protein at biopsy and higher serum creatinine at follow-up (P<0.05). The percentage of patients received more methylprednisolone pulse, oral steroids, cyclophosphamide pulse in crescent formation group was higher than that of non-crescent group (P<0.05). Compared with non-crescentic IgA nephropathy group, crescentic IgA nephropathy group showed more RPGN percent, higher serum creatinine, more 24-hour urinary protein at biopsy (P<0.05). The percentage of patients who received more methylprednisolone pulse and blood purification therapy in crescentic IgA nephropathy group was more than non-crescentic IgA nephropathy group (P<0.05). At follow-up, 20.0% of the patients with RPGN and crescent nephritis returned to normal renal function and the percent of crescent glomerulonephritis but not RPGN was 71.4%, RPGN but not crescent glomerulonephritis was 80.0%, crescent formation but not crescent nephritis was 87.5%. In primary IgA nephropathy with crescent formation and/or rapidly progressive glomerulonephritis, the patients with both RPGN and crescentic IgA nephropathy showed the worst clinical manifestations, its prognosis was worst while the patients with crescent formation showed the mildest clinical manifestations and best prognosis.

Plasma Adiponectin Levels in Acute Liver Failure Patients Treated with Plasma Filtration with Dialysis and Plasma Exchange.

Plasma filtration with dialysis (PDF) is a blood purification therapy in which simple plasma exchange (PE) is performed using a selective membrane plasma separator while the dialysate flows outside of the hollow fibers. Improvement of hypoadiponectinemia is considered to be a useful therapeutic approach for ameliorating fatal conditions including cardio-metabolic and infectious disease. We investigated the effects of PDF in comparison to PE in terms of plasma adiponectin (APN) changes in patients with acute liver failure. Seventeen patients with liver failure were studied; PDF was performed 55 times and PE 14 times. Plasma APN levels increased significantly after PDF, while decreasing significantly after PE. PDF appears to be among the most useful blood purification therapies in acute liver failure cases in terms of increasing APN levels.

Application and exploration of critical illness children interhospital transportation system

Objective To investigate the value of the interhospital transportation and the advantage of the cooperative network to the critically ill children. Methods The clinical data of 232 critically ill children transported from other hospitals in long distances to PICU of Fudan University Affiliated Children Hospital cooperated with Shanghai 120 interprovincial transport Department, between Oct 2010 and Oct 2013, were analyzed retrospectively. Results A total of 232 critically ill children were transported from 31 hospitals of Eastern China region including five provinces and the city of Shanghai.Among these critically ill children 141 cases were male and 91 cases were female, with age from 29 days to 13 years(median age was 12 months) and weight from 2.5 to 66 kg(median weight was 10 kg). The average pediatric clinical illness score was 80.4±7.7, 155 cases(66.8%) were single organ dysfunction, 55 cases(23.7%) were multiple organs dysfunction, 105 cases(45.3%) were mechanical ventilation required for transportation.Referral radius was 50-1 000 km(median). Among these patients, 87 cases(37.3%) were transported over 200 km radius and 73 cases(36%) were transported 101-200 km, 62 cases(26.7%) were transported 100 km or less.During the transportation, 0 case died, 3 cases(1.3%) received cardiopulmonary resuscitation treatment, 2 cases(0.9%) received electrical conversion treatment, 2 cases(0.9%) were replaced endotracheal intubation, the success rate of transportation was 100%.The top 4 diseases were respiratory diseases(90 cases, 38.8%), neural diseases(43 cases, 18.5%), cardiovascular diseases(36 cases, 15.5%) and acute pediatric trauma(28 cases, 12.1%). All 232 critically ill children were admitted to our PICU for further treatment through the Green Channel.In the end, 178 cases(76.7%) discharged, 24 cases(10.3%) gave up and 32 cases(13.8%) died.Among these 232 critically ill children, 30 cases(12.9%) received special organ replacement treatment, 4 cases(1.7%) of whom were treated with extracorporeal membrane oxygenation, 26 cases(11.1%) received blood purification therapy. Conclusion Establishing the system of transportation between PICU of hospitals will be propitious to treat the critically ill children energetically and effectively.It is worth promoting to master the transportation indication of children with critical illness, which is safe and reliable. Key words: Critical ill; Inter-hospital transportation; Children

Clinical characteristics and influencing factors of nosocomial candidemia

To retrospectively explore the clinical features and risk factors of nosocomially acquired candidemia. Retrospective analyses were conducted for general information, underlying diseases, risk factors, clinical features and laboratory tests of blood culture Candida-positive cases at Beijing Hospital from January 1, 2006 to December 31, 2011. Comparisons were made with regards to the clinical features, prognostic factors, risk factors of candidemia pathogen distribution between dead and survival groups and Candida albicans vs non-Candida albicans groups. Statistical analysis was performed with SPSS 19.0. A total of 30 Candida albicans and 35 non-candida albicans cases were recruited. Their mean age was (76±14) years and total in-hospital fatality rate 58.5% (38/65). The acute physiology and chronic health evaluation II (APACHE II) score, ratio of APACHE II score>24 points, ratio of shock, primary diagnosis time (from onset to reporting time of positive outcome of blood culture) and ratio of serum albumin≤30 g/L of death group were (28.7±8.6) score, 55.3% (21/38), 71.1% (27/38), (138.7±50.4) h, 47.4% (18/38) respectively. And the values were significantly higher than those of survival group, i.e. (20.1±8.0) score, 29.6% (8/27), 44.4% (12/27), (127.2±50.2) h and 22.2% (6/27) respectively. Multivariate Logistic regression analysis showed that shock (OR=4.821, P=0.030), primary diagnosis time (OR=1.594, P=0.027) and APACHE II score (OR=1.096, P=0.032) were independent risk factors for death. However continuous blood purification therapy was an independent protective factor (OR=0.014, P=0.004). And diabetes was an independent risk factors for non-Candida albicans infection (OR=4.426, P=0.016). Advanced age, more underlying diseases, severe clinical conditions and high fatality rate are the major clinical characteristics of candidemia. Shock, APACHE II score and primary diagnosis time are independent risk factors for death. Continuous blood purification therapy is a protective factor. And diabetes is an independent risk factor for non-Candida albicans candidemia.

Efficacy analysis of sequential blood purification treatment of bee poisoning complicated by multiple organ disfunction syndrome

Objective To study the efficacy of sequential blood purification treatment of bee poisoning complicated by multiple organ disfunction syndrome (MODS). Methods The 11 cases of children with bee poisoning and MODS from Wuhan Children's Hospital were treated with sequential blood purification therapy, and they were treated with plasma exchange(PE), hemoperfusion (HP)and sequential continuous renal replacement therapy(CRRT) simultaneously in the early stage, and then were treated with intermittent hemodialysis (IHD)in the remission stage.Different modes of purification treatment were applied in different stages.The trends of liver function, renal function and myocardial enzymes were observed in 11cases before and after therapy, later a retrospective analysis was performed, and the efficacy of sequential blood purification was studied. Results Ten in 11 cases of children were treated with HP, CRRT and IHD therapy, and among them 6 cases were treated with PE on the first day of admission.One case, the youngest of children admitted to hospital less than 24 hours, died of sudden cardiac arrhythmia due to toxic myocarditis.In ten cases of the children after treatment, their myocardial enzymes returned to normal at first, and then jaundice and hepatic function improved, and renal function gradually improved after 10 days.Two weeks after discharge, through reviewing of the liver and kidney function, myocardial enzymes returned to normal indicators.In review of urine, 5 cases were accompanied with microscopic hematuria, 3 cases were accompanied with hematuria and proteinuria, and 2 cases were completely normal.The improved cure rate was 91%(10/11 cases). Conclusions Sequential blood purification treatment is the main and effective means for severe bee poisoning complicated with MODS in children in the early stage. Key words: Sequential blood purification; Bee poisoning; Multiple organ disfunction syndrome; Child

Experience in therapeutic plasma exchange by membrane filtration at an academic center in Colombia: Registry of the first 500 sessions.

Therapeutic plasma exchange (TPE) is an extracorporeal blood purification therapy that is part of the treatment of various diseases. Plasma and blood cells can be separated by centrifugation or using membrane separators. A descriptive analysis, in which the first 500 TPE sessions using membrane filtration without anticoagulation of the extracorporeal circuit are described. Five hundred (500) TPE sessions were performed on 68 patients over a period of 5 years. Therapeutic indications were 17 different diseases. 5% albumin was the most frequent replacement solution used in 62% of sessions. The mean number of plasma volume replacements was 1.33. Complications occurred in 7.6% of the sessions. Arterial hypotension was the most common event and clotting of the extracorporeal circuit was documented in just one TPE session. Electrolyte tests performed in patients during the procedure showed: 11% hypocalcemia, with a similar distribution of hypokalemia. Twenty-two percent (22%) and 37% of phosphorus and magnesium records, respectively, were higher than normal. No symptoms associated with electrolyte abnormalities were documented. TPE by membrane filtration is one of the techniques by which it is possible to perform such therapy. In this registry, a low rate of complications was documented. While the need for anticoagulation may be related not only to clotting of the circuit but also to the efficiency of the therapy, clinical response in this series of patients was as expected for each disease. Continuous monitoring and an individualized analysis of electrolytes should be performed in TPE patients.

The clearing effects and safety research of various blood purification modes on β2-microglulin in acute kidney injury children

Objective To investigate the clearing effects and safety of various blood purification modes on β2-microglulin (β2-MG)in acute kidney injury(acute kidney injury, AKI)children. Methods We collected 38 acute kidney injury children including 98 cases by blood purification treatment in department of nephrology and immunology and PICU in Children's Hospital of Guiyang from March 2011 to March 2013, of which males 20 and females 18, aged from 5 months to 14.Sixty-six cases underwent continuous renal replacement therapy(CRRT)including continuous veno-venous hemofiltration(CVVH) and continuous veno-venous hemodiafiltration(CVVHDF), while 32 cases underwent intermittent hemodialysis(IHD). The primary disease of children: 7 cases of circulatory disturbance, 10 cases of nephrotoxic drugs and toxic poisoning, 9 cases of sepsis with multiple organ failure and 12 cases of renal parenchymal disease, such as nephrotic syndrome, poststreptococcal glomerulonephritis, lupus nephritis, rapidly progressive glomerulonephritis.The CRRT group were treated for 8 h to 16 h and the IHD group for 2.5 h to 3 h. Then we investigated blood urea nitrogen(BUN), serum creatinine(SCr), and disturbance of acid-base balance and β2-MG, etc. Results There were 98 cases treated by AKI of blood purification therapy(IHD, CVVH, CVVHDF). Sixty-six of them were CRRT group(CVVH or CVVHDF), others were IHD group.Two cases progressed to ESRD(accounted for 5%). They needed a long term dialysis in treatment.The mortality rates were 0.(1)Before and afert treastment of CRRT group, the difference of serum BUN[(22.34±2.08)mmol/L, (12.24±0.98)mmol/L] and Scr[(310.23±85.34)μmol/L, (178.15±34.12)μmol/L]had statistical significane(t=12.39, t=5.906, P all<0.05). Before and after trentment of IHD group, the difference of serum BUN[(23.80±2.14)mmol/L, (7.39±0.88)mmol/L] and Scr[(350.11±78.42)μmol/L, (108.20±28.20)μmol/L]had statistical significance(t=29.04, t=13.83, P all<0.05); (2)The clearing effects of β2-MG in CRRT group(40.50±7.20)% were better than IHD group(1.50±0.05)%.The difference had statistical significance(P<0.05). (3)The adverse reactions of CRRT group were mild.Its safety was higher than IHD group.In patients hemodynamics and vital signs were maintained stable after CRRT. Conclusion CRRT is good for the clearing effects of β2-MG and hemodynamics in acute kidney injury children.It is a quickly effective and safe method for treating acute kidney injury children. Key words: Acute kidney injury; Children; Continuous renal replacement therapy; Intermittent hemodialysis; β2-microglulin

Sequential blood purification therapy for critical patients with hyperlipidemic severe acute pancreatitis.

To evaluate the efficacy of sequential blood purification therapy in the treatment of critical patients with hyperlipidemic severe acute pancreatitis. Thirty-one intensive care unit (ICU) patients with hyperlipidemic severe acute pancreatitis treated at the Second Affiliated Hospital of Harbin Medical University were divided into either a study group (n = 15; July 1, 2012 to June 30, 2014) or a control group (n = 16; July 1, 2010 to June 30, 2012) based on the implementation of sequential blood purification therapy. The control group received continuous venous-venous hemofiltration (CVVH) on the basis of conventional treatments, and the therapeutic dose of CVVH was 30 mL/kg per hour. The study group received sequential plasma exchange and CVVH on the basis of conventional treatments. The anticoagulation regimen of CVVH is the regional citrate anticoagulation. Mortality rate on day 28, rates of systemic and local complications, duration of ICU, and time to target serum lipid level, as well as physiologic and laboratory indices were compared between the two groups. The mortality rate on day 28 was significantly lower in the study group than in the control group (13.33% vs 37.50%; P < 0.05). The duration of ICU stay was significantly shorter in the study group than in the control group (7.4 ± 1.35 d vs 9.19 ± 2.99 d, P < 0.05). The time to target serum lipid level was significantly shorter in the study group than in the control group (3.47 ± 0.52 d vs 7.90 ± 1.14 d, P < 0.01). There were no significant differences in the rates of systemic complications and local complications between the two groups (60% vs 50% and 80% vs 81%, respectively). In the comparisons of physiologic and laboratory indices, serum albumin and C-reactive protein were significantly better in the study group than in the control group after treatment (37.8 ± 4.6 g/L vs 38.9 ± 5.7 g/L, and 20.5 ± 6.4 mg/L vs 28.5 ± 7.1 mg/L, respectively, both P < 0.05). With the exception of plateletcrit, no other indices showed significant differences between the two groups. Sequential blood purification therapy is effective in the treatment of ICU patients with hyperlipidemic severe acute pancreatitis and can improve patient prognosis.

Prolonged renal tubular injury following acute kidney injury in an infant treated with blood purification therapy

Prolonged renal tubular injury following acute kidney injury in an infant treated with blood purification therapy

Risk management in acute blood purification therapy

Risk management in acute blood purification therapy