Continuous Hemodiafiltration Research Articles

外傷性膝窩動脈損傷の治療経験

外傷性膝窩動脈損傷の治療経験

Efficacy of high flow-volume continuous hemodiafiltration (CHDF) in cases of circulatory failure following cardiac surgery under cardiopulmonary bypass complicated with cardiac surgery-associated acute kidney injury

Efficacy of high flow-volume continuous hemodiafiltration (CHDF) in cases of circulatory failure following cardiac surgery under cardiopulmonary bypass complicated with cardiac surgery-associated acute kidney injury

Investigation of 104 Cases with Continuous Hemodiafiltration for Severe Acute Pancreatitis

Investigation of 104 Cases with Continuous Hemodiafiltration for Severe Acute Pancreatitis

A comparison of circuit lifespan between original and generic agent of nafamostat mesilate in hemodialysis patients who had been undergone continuous hemodiafiltration just after open cardiovascular surgery

A comparison of circuit lifespan between original and generic agent of nafamostat mesilate in hemodialysis patients who had been undergone continuous hemodiafiltration just after open cardiovascular surgery

Severe Hyperphosphatemia Resulting in Acute Renal Failure and Ischemic Encephalopathy in a Patient with Infantile Leukemia

Tumor lysis syndrome (TLS), hyperleukocytosis, and disseminated intravascular coagulation (DIC) are representative oncological emergencies that overlap mutually at the beginning of therapy for aggressive leukemia. Lately recombinant urate oxidase (rUO) enables to control uric acid level and its crystallization, the most frequent risk factor for clinical TLS; therefore, hyperphosphatemia appears to be the main risk in the rUO era. We here report an infantile leukemia patient who developed severe hyperphosphatemia, resulting in acute renal failure and ischemic encephalopathy. A 9-month-old female baby was adynamic with a bulging anterior fontanel, and was diagnosed as infantile acute lymphoblastic leukemia with a mixed lineage leukemia gene rearrangement. A laboratory examination revealed leukocytosis, bicytopenia, hyperuricemia, a prolonged prothrombin time, activated partial thromboplastin time, and elevated lactate dehydrogenase level. Soon after a reduced dose of prednisolone was administered, she developed hypoxia caused by systemic inflammatory response syndrome and heart failure. Her white blood cell count decreased sharply, leading to acute renal failure due to hyperphosphatemia, which required continuous hemodiafiltration for 48 hours. Although renal function subsequently recovered, severe ischemic encephalopathy remained. She achieved morphological remission once, however, relapsed and passed away soon after. We have to pay attention to the progression of hyperphosphatemia, hyperkakemia and DIC, although hyperuricemia was controlled using rUO. Changes in electrolyte levels must be continuously monitored, and TLS, DIC and/or hyperleukocytosis should be promptly managed especially in patients who are sensitive to therapy.

Renal thrombotic microangiopathy in a patient with septic disseminated intravascular coagulation

BackgroundThe mechanism for the development of thrombotic microangiopathy (TMA) during sepsis has only been partially elucidated. TMA is recognized as a disease caused by various factors, and may be involved in the emergence of organ damage in severe sepsis. Here we report a case of TMA that followed disseminated intravascular coagulation (DIC) due to severe infection in a patient with a reduced ADAMTS-13 activity level.Case presentationAn 86-year-old Japanese woman was admitted to our hospital because of low back pain and fever. A careful evaluation led to a diagnosis of acute obstructive pyelonephritis due to a ureteral stone. Proteus mirabilis was isolated from both blood and urine cultures. The patient developed systemic inflammatory response syndrome and DIC, and was treated with antibiotics and daily continuous hemodiafiltration. Although infection and the coagulation abnormalities due to DIC were successfully controlled, renal failure persisted and her consciousness level deteriorated progressively in association with severe thrombocytopenia and microangiopathic hemolytic anemia. We therefore suspected the presence of TMA and started plasma exchange, which resulted in an impressive improvement in consciousness as well as the laboratory abnormalities. The ADAMTS-13 activity was 44% and the patient tested negative for the ADAMTS-13 inhibitor prior to the initiation of plasma exchange. A renal biopsy was performed to determine the etiology of acute renal injury, which revealed findings that were interpreted to be compatible with the sequelae of TMA. The follow-up studies performed after the successful treatment of TMA showed that her plasma ADAMTS-13 activity level remained persistently low. It is surmised that septic DIC occurring in the presence of preexisting reduced ADAMTS-13 activity have led to the development of secondary TMA in the present case.ConclusionThe present case suggests that TMA can be superimposed on sepsis-induced DIC, and plasma exchange is expected to be beneficial in such situations. Clinicians should consider the possibility of secondary TMA that follows sepsis-induced DIC in certain indicative clinical settings.

Brown Tubular-Shaped Object Rectally Expelled in a Patient With Persistent Diarrhea

GAST Question: A 72-year-old man presented to the emergency room of our hospital. The patient was diagnosed with cerebral infarction by computed tomography. Laboratory investigation revealed dehydration, renal failure (serum blood urea nitrogen, 38 mg/dL; serum creatinine, 7.8 mg/dL), inflammatory reaction (white blood cell count, 18,700/mL; serum Creactive protein, 39 mg/dL), and disseminated intravascular coagulation (DIC). We began continuous infusion therapy with heparin for the cerebral infarction, continuous hemodiafiltration for renal failure, gabexate mesylate for DIC, and antibiotics. Bloody, watery, and mushy diarrhea, as well as persistent fever, were also present. The duration of the diarrhea was approximately 3 weeks, although the patient’s stool was negative for Clostridium difficile toxin. At day 23, the patient spontaneously passed a 66-cm, tubular-shaped, brown object from the rectum (Figure A, B). On physical examination and palpation, he frowned but did not show tenderness, rebound tenderness, or muscular defense. Laboratory investigation revealed that the white blood cell count and serum C-reactive protein had decreased. Contrast computed tomography revealed that the entire colon was thin-walled except for the ascending colon and inferior end of the rectum, with no vascular thrombosis. Additionally, the wall of the ascending colon and inferior end of the rectum were edematous and there was no free air, ascites, pneumatosis, or portal venous gas (Figure C, D). What is the brown tubular-shaped object? What is the appropriate management? Look on page 1500 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Efficacy of Series Double Continuous Hemodiafiltration Using Two Polymethyl Methacrylate Membrane Hemofilters for Patients With Hypercytokinemia

Continuous hemodiafiltration using a hemofilter made from a membrane with cytokine adsorption properties is thought to be effective to remove cytokines in septic patients. In order to enhance cytokine removal capacity by increasing adsorption area, we devised a double polymethyl methacrylate continuous hemodiafiltration method, which involves serial connection of two polymethyl methacrylate membrane hemofilters, and we report clinical efficacy with this method. Of 74 patients who underwent continuous hemodiafiltration and had interleukin-6 blood levels measured during their ICU stay between March 2010 and June 2012, 13 patients with hypercytokinemia (interleukin-6 blood level >900 pg/mL) underwent series double continuous hemodiafiltration to be treated for hypercytokinemia. Cytokine reduction rate and clinical efficacy were compared between those 13 patients and those with a similar pathological condition who underwent continuous hemodiafiltration using the single polymethyl methacrylate membrane hemofilter. Interleukin-6 blood levels 6 h after continuous hemodiafiltration initiation increased in the single continuous hemodiafiltration group from 17040 ± 33660 pg/mL to 26290 ± 66250 pg/mL; however, interleukin-6 blood level significantly decreased in the series double continuous hemodiafiltration group from 20220 ± 29120 pg/mL to 6790 ± 10820 pg/mL. Interleukin-6 reduction rate during the period between initiation and 6 h after initiation of continuous hemodiafiltration was significantly higher in the series double continuous hemodiafiltration group(63.5 ± 38.9%) compared to that of the single continuous hemodiafiltration group (-342 ± 1306%)(P = 0.039). Series double continuous hemodiafiltration using two polymethyl methacrylate hemofilters with cytokine adsorbing capacity is effective to remove cytokine in hypercytokinemic septic patients.

The First Case of Septicemia Caused by Imipenem-Susceptible, Meropenem-Resistant Klebsiella pneumoniae

The First Case of Septicemia Caused by Imipenem-Susceptible, Meropenem-Resistant <i>Klebsiella pneumoniae</i>

Application of propofol sedation in patients undergoing continuous venous-venous haemodiafiltration

To study the use of propofol sedation in patients undergoing continuous venous-venous haemodiafiltration (CVVHDF) and assess the curative effects. A retrospective study was conducted. Data from 74 patients with continuous sedation of propofol in emergency intensive care unit (ICU) from April 2009 to June 2011 were analyzed. There were 26 cases suffering from acute renal failure in CVVHDF group and 48 critical cases in non-CVVHDF group. Propofol administration duration, dose, the clearance rate and the average recovery time in both groups were analyzed, and plasma concentrations of propofol at inflow side and outflow side of CVVHDF circuit in 26 patients with CVVHDF were determined. Compared with non-CVVHDF group, it took a longer administration time (298.37±28.73 hours vs. 173.44±17.27 hours, P<0.05) and higher dose (35.89±0.76 g vs. 21.82±0.62 g, P<0.05) in CVVHDF group. There were no statistical significances on clearance rate at 2, 6, 24 hours after administration (2 hours: 13.85±1.15 ml/min vs. 14.41±1.21 ml/min, 6 hours: 5.92±0.52 ml/min vs. 6.32±0.59 ml/min, 24 hours: 4.75±0.41 ml/min vs. 5.33±0.45 ml/min) and recovery time (8.89±1.46 minutes vs. 8.47±1.37 minutes) between CVVHDF and non-CVVHDF groups (all P>0.05). Plasma concentrations of propofol at inflow side and outflow side of CVVHDF circuit were not different after propofol administration in 26 CVVHDF patients. Compared with patients in non-CVVHDF group, the patients who received propofol in CVVHDF required higher total dosage and longer delivery time to maintain a good sedation. In both two groups clearance rate of propofol and maintenance of a stable blood concentration were the same. The use of a proper dose of propofol in CVVHDF did not affect wake up time of the patients, there were no complications.

Acute liver disease in Japan: a nationwide analysis of the Japanese Diagnosis Procedure Combination database

Accurate data on the incidence of acute liver disease (ALD) is lacking in most countries. We investigated the incidence of ALD-related admission in Japan using a large sample in a nationwide Japanese database. Data from the Diagnosis Procedure Combination database were analyzed for 1 July to 31 December 2007-2010. Patient characteristics, in-hospital mortality, and clinical practices, including drugs and procedures during hospitalization, were analyzed. We identified 10509 patients with ALD from a total of 11.61 million inpatients in the database. The median age was 53 years and 54.7 % were male. The annual incidence of ALD-related hospital admission was estimated to be 131.1 cases/1 million people. The overall mortality rate was 5.9 % (622 cases). The infant (0-3 years), child (4-18 years), and adult in-hospital mortality rates were 2.7 % (7/261), 1.0 % (5/494), and 6.3 % (610/9754), respectively. The infant and child mortality rates were significantly lower than the adult mortality rate (Chi square test: P = 0.03 and P < 0.001, respectively). Hepatitis A virus- and hepatitis C virus-induced ALD had favorable outcomes, with in-hospital mortality rates of approximately 2 %. Plasma exchange and continuous hemodiafiltration were performed in 5.3 % (556 cases) and 3.4 % (360 cases) of all ALD cases, respectively. In-hospital mortality of ALD in Japan was acceptably low, and was affected by the etiology and patient background characteristics. The present study adds important information on the incidence and prognosis of ALD in Japan. Improvement of public health surveillance systems is necessary for population-based patient monitoring.

Use of Continuous Hemodiafiltration for the Treatment of a Neonate with Hyperammonemia Secondary to Argininosuccinate Lyase (ASAL) Deficiency

Use of Continuous Hemodiafiltration for the Treatment of a Neonate with Hyperammonemia Secondary to Argininosuccinate Lyase (ASAL) Deficiency

Occurrence of Reversible Posterior Leukoencephalopathy Syndrome in a Continuous Ambulatory Peritoneal Dialysis Patient

A 25 year-old man presented with reversible posterior leukoencephalopathy syndrome manifesting as seizure, loss of consciousness and severe hypertension. He had contracted end stage kidney disease due to Alport syndrome and was treated with continuous ambulatory peritoneal dialysis for one year. Because his residual renal function was declining, he had refractory hypertension for several months before admission. On the admission, brain T-2 intensified magnetic resonance imaging revealed hyperintensive changes that were restricted to the cortex and the subcortical white matter of the parietal lobe, temporal lobe and posterior lobe. His clinical symptoms were improved by appropriate control of blood pressure using antihypertensive drugs and fluid depletion by continuous hemodiafiltration. Previous hyperintensive lesions disappeared in brain magnetic resonance imaging. He was transferred to maintenance hemodialysis three times weekly and discharged. One month later, he had a seizure attack again because of refractory hypertension which may be derived from low compliance with sodium and water restriction. We report here a reversible posterior leukoencephalopathy syndrome patient on peritoneal dialysis with severe hypertension and volume overload.

炭酸リチウムおよびバルプロ酸ナトリウム徐放剤を大量服用し，持続的血液濾過透析により救命した1例

炭酸リチウムおよびバルプロ酸ナトリウム徐放剤を大量服用し，持続的血液濾過透析により救命した1例

Polyarteritis nodosa diagnosed by surgically resected jejunal necrosis following acute abdomen

The differential diagnosis of acute abdomen is typically extremely broad in range, with vasculitis posing a rare but potentially life-threatening cause of acute abdomen. Here, we report a case of acute abdomen with bowel wall thickening limited to jejunum, accompanied by unexplained renal dysfunction. Later, the patient was diagnosed as having polyarteritis nodosa based on surgically resected jejunal necrosis. Despite aggressive treatment, including the use of steroid pulse therapy and continuous hemodiafiltration, the patient died. Although polyarteritis nodosa is extremely rare in patients with acute abdomen, acute abdomen is relatively common manifestation of that. And it is reported that involvement of small intestine suggests poorer prognosis. Our case highlights the importance of vasculitis as a differential diagnosis of patients with atypical acute abdomen. In this report, we not only review possible clues that might have led to an earlier diagnosis in this case, but also attempt to draw some lessons for treating similar cases in the future.

Sepsis and cardiorenal syndrome: Etiopathogenesis, diagnosis and treatment

Introduction: Sepsis is the most common cause of acute renal failure in intensive care units. Aim: Tis study aimed to analyse the etiopathogenesis of sepsis and the clinical significance of early detection and timely treatment of sepsis in intensive care units. Method: We analysed literature and clinical studies addressing the pathogenesis, diagnosis and treatment of sepsis syndrome. Results: There was a 1.5% increase in the number of patients with sepsis over one year. Severe sepsis is defined as sepsis with hypotension, hypoperfusion and organ dysfunction. Sepsis is characterised by activation of the patient's immune system and enhancement of the creation of mediators that play an important role in the development of multiple organ system failure in patients with sepsis. The strategy for preventing acute renal failure in patients with sepsis includes early targeted therapy (in the first 6 hours), which consists of an early increase in blood volume circulating fluids (at least 20 ml/kg crystalloid in the first hour). Initial therapy should be achieved by central venous pressure of 8-12 mmHg, mean arterial blood pressure greater than 65 mmHg, urine output greater than 0.5 ml/kg/h and mixed venous blood saturation of oxygen greater than 70%. The ventilation strategy to protect the lungs and kidneys in patients on mechanical ventilation includes a tidal volume of 6 ml/kg and an end-inspiratory pressure plateau less than 30 cmH2O. To remove a mediator from the serum of patients, high-volume haemofiltration and continuous haemodiafiltration with PMMA are used. Conclusion: Early follow-up and early implementation of targeted therapies play a key role in preventing the development of acute heart and kidney damage.

Specific Variability of Teicoplanin Protein Binding in Patients Receiving Continuous Hemodiafiltration&lt;br/&gt;—Comparison with Hypoalbuminemia Patients—

Variation in protein binding ratio (PBR) of teicoplanin (TEIC) was investigated in continuous hemodiafiltration (CHDF) patients. TEIC is classified as a high PBR drug (≧90%), and it was reported that the PBR of TEIC decreased with an decrease in the serum albumin level in hypoalbuminemia patients. However, few reports can be found about the variation of PBR of TEIC for CHDF patient. An antibiotic activity is directly determined by the level of unbound antibiotics species (Cfree) in the target site, namely, an increase in the Cfree enhances the risks of TEIC as well as the therapeutic effect against Methicillin-resistant Staphylococcus aureus (MRSA). In this study, both the total concentration (Ctotal) and Cfree of TEIC were determined and the PBRs were compared between a patient with normal albumin level, hypoalbuminemia patients and CHDF patients. Similarly to the previous report, the lowering of PBR of TEIC was demonstrated in the hypoalbuminemia patients. On the other hand, the CHDF patients showed lower value of PBR suggesting some change in the protein binding ability, although showed higher values of serum albumin level in comparison with the hypoalbuminemia patients. It was not necessary to measure the Cfree value for the hypoalbuminemia patient routinely, but the monitoring of Cfree as well as Ctotal for the CHDF patients can be important for the proper TEIC use because of the potential specialty of PBR.

The clinical evaluation of continuous hemodiafiltration (CHDF) with small surface area dialyzer

The clinical evaluation of continuous hemodiafiltration (CHDF) with small surface area dialyzer

Hypercalcemic crisis resulting from near drowning in an indoor public bath

Patient:Male, 66Final Diagnosis:Hypercalcemic crisisSymptoms:Near drowning stateMedication:—Clinical Procedure:—Specialty:Critical care medicineObjective:Challenging differential diagnosisBackground:Hypercalcemic crisis, generally caused by malignancy or primary hyperparathyroidism, is a life-threatening emergency that can result in multi-organ failure. Lowering the patient’s calcium level immediately and determining the correct etiology are essential.Case Report:We report a case of hypercalcemic crisis with a novel etiology. A 66-year-old male presented to the emergency room in cardiac arrest with a ventricular arrhythmia after being discovered submerged in an indoor public bath. He underwent cardioversion and was emergently intubated. Computed tomography showed bilateral pulmonary edema, suspected from water aspiration. Laboratory data revealed severe hypercalcemia and mild hypernatremia. Following three days of continuous hemodiafiltration, serum Ca decreased to and remained within normal limits. We concluded the etiology of hypercalcemia was absorption of Ca resulting from aspirated water.Conclusions:Near drowning can be a cause of hypercalcemic crisis. For cases of near drowning, it is important to investigate the source of the aspirated water and consider electrolyte abnormalities in the diagnosis.

オルニチントランスカルバミラーゼ欠損症による高アンモニア血症に対し高流量持続血液濾過透析が有効であった1例

オルニチントランスカルバミラーゼ欠損症による高アンモニア血症に対し高流量持続血液濾過透析が有効であった1例