Continuous Venous-venous Hemofiltration Research Articles

Early high-dose continuous veno-venous hemofiltration alleviates the alterations of CD4+ T lymphocyte subsets in septic patients combined with acute kidney injury.

This study aims to determine whether early high-dose continuous venous-venous hemofiltration (CVVH) alleviates the alterations in CD4+ T lymphocyte subsets in septic patients combined with acute kidney injury. Enrolled septic patients combined with acute kidney injury were randomized into CVVH (n=50) and conventional treatment (non-CVVH, n=53) groups. Healthy volunteers (n=21) were enrolled. CVVH was initiated within 12h of intensive care unit (ICU) admission with doses of 35~60ml/kg/h and maintained for at least 72h. Th1, Th2, Th17, and Treg were measured by flow cytometry on days 1, 3, and 7 of ICU admission. Sequential organ failure assessment (SOFA) scores were calculated. Th1 percentages and Th1/Th2 ratios were lower, and Th2, Th17, and Treg percentages and Th17/Treg ratios were higher in septic patients compared to healthy volunteers. CVVH significantly increased Th1 percentages and Th1/Th2 ratios, and significantly decreased Th2, Th17, and Treg percentages and Th17/Treg ratios compared to non-CVVH. Th1 percentages and Th1/Th2 ratios were negatively correlated with SOFA scores, while Th2, Th17, and Treg percentages and Th17/Treg ratios were positively correlated with SOFA scores. Patients with CVVH had significantly lower SOFA scores on day 7 of ICU admission and a shorter ICU stay compared to those with non-CVVH. Septic patients combined with acute kidney injury exhibit different alterations of CD4+ T lymphocyte subsets. Early high-dose CVVH alleviates the alterations, which may be one of the factors associated with improved sepsis severity.

Study of coupled plasma filtration adsorption therapy for patients with severe infection and multiple organ dysfunction syndromes

Objective To investigate the effect of coupled plasma filtration adsorption (CPFA) on plasma cytokines: TNF-α, IL-1β, IL-6, cellular immunity, blood lactate acid concentration, heart rate, respiration rate, oxygenation index, hemodynamics, blood cells counts, and prognosis in patients with multiple organ dysfunction syndromes (MODS). Methods This was a prospective, randomized clinical trial in 45 patients diagnosed as MODS. Patients were randomly assigned to hemoperfution with resin adsorption (HP)+ continuous venous-venous hemofiltration (CVVH) group, CPFA group and CVVH group. The general clinical data, APACHE Ⅱ score, number of failure organ and previous mentioned biomarkers were documented. Blood samples were collected before and after blood filtration with any one of these procedures. The plasma samples were isolated and stored with frozen at -60 ℃. Data were statistically analyzed with SPSS 13.0 version software. Results In CPFA group, plasma cytokines, TNF-α、IL-1β、IL-6, decreased markedly after plasma adsorption for two hours (P<0.01); and plasma concentrations of IL-6 were further descended after subsequent CVVH for 10 hours (P<0.05). In HP+ CVVH group, plasma cytokines, TNF-α、IL-1β、IL-6, decreased markedly after HP (P<0.01), and plasma concentrations of IL-6 were further descended after subsequent CVVH for 10 hours (P<0.05). In CVVH group, plasma cytokines, TNF-α、IL-1β、IL-6, decreased after CVVH for 12 hours (P<0.05). Blood lactate acid concentration, heart rate, respiration rate, oxygenation index, T-lymphocytes subgroups (CD3+ , CD4+ , CD8+ , CD4+ /CD8+ ratio), clinical symptoms were improved and dose of vasoactive agent was reduced in the patients of three groups without differences among them. The counts of red blood cells, white blood cells and platelets after CPFA and CVVH showed no significant changes. There was no significant difference in blood cell counts between CPFA and CVVH groups. After HP+ CVVH, there was a trend of decrease in platelet count (P<0.05). Platelet counts were significantly higher in patients treated with CPFA and CVVH group than those in patients treated with HP+ CVVH group (P<0.05). There were 6 patients died in HP + CVVH group, 6 patients died in CPFA group and 5 patients died in CVVH group within 28days. Conclusions The comparison of efficacy of blood filtration among 3 modalities of HP+ CVVH, CPFA and CVVH showed CPFA had higher capacity of Inflammatory medium scavenging than CVVH, and had less damage effect on blood visible component , especially on platelet compared with HP+ CVVH. CPFA was an effective and safety modality in the treatment of the patients with multiple organ dysfunction syndrome. Key words: Hemoperfusion with resin adsorption; Coupled plasma filtration adsorption; Continuous venous-venous hemofiltration; Multiple organ dysfunction syndromes; Cytokines

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.

Impact of lung ultrasound on clinical decision making in critically ill patients

To assess the impact of lung ultrasound (LU) on clinical decision making in mechanically ventilated critically ill patients. One hundred and eighty-nine patients took part in this prospective study. The patients were enrolled in the study when LU was requested by the primary physician for (1) unexplained deterioration of arterial blood gases and (2) a suspected pathologic entity [pneumothorax, significant pleural effusion (including parapneumonic effusion, empyema, or hemothorax), unilateral atelectasis (lobar or total), pneumonia and diffuse interstitial syndrome (pulmonary edema)]. Two hundred and fifty-three LU examinations were performed; 108 studies (42.7%) were performed for unexplained deterioration of arterial blood gases, and 145 (57.3%) for a suspected pathologic entity (60 for pneumothorax, 34 for significant pleural effusion, 22 for diffuse interstitial syndrome, 15 for unilateral lobar or total lung atelectasis, and 14 for pneumonia). The net reclassification index was 85.6%, indicating that LU significantly influenced the decision-making process. The management was changed directly as a result of information provided by the LU in 119 out of 253 cases (47%). In 81 cases, the change in patient management involved invasive interventions (chest tube, bronchoscopy, diagnostic thoracentesis/fluid drainage, continuous venous-venous hemofiltration, abdominal decompression, tracheotomy), and in 38 cases, non-invasive (PEEP change/titration, recruitment maneuver, diuretics, physiotherapy, change in bed position, antibiotics initiation/change). In 53 out of 253 cases (21%), LU revealed findings which supported diagnoses not suspected by the primary physician (7 cases of pneumothorax, 9 of significant pleural effusion, 9 of pneumonia, 16 of unilateral atelectasis, and 12 of diffuse interstitial syndrome). Our study shows that LU has a significant impact on decision making and therapeutic management.

Efficacy and safety of intermittent hemodialysis in infants and young children with inborn errors of metabolism

Intermittent hemodialysis (IHD) is the most efficient form of renal replacement therapy (RRT) for removing toxic substances from patients' bodies. However, the efficacy and safety of IHD in infants and young children with inborn errors of metabolism are still not clear. This retrospective study included patients with urea cycle disorders, maple syrup urine disease, and methylmalonic acidemia who received IHD or non-IHD RRT at our hospital between 2001 and 2012 to remove ammonia, leucine, or methylmalonic acid. Both the efficacy and safety of the RRT were evaluated. Thirty-five courses of RRT, including 25 courses of IHD and ten courses of non-IHD RRT, for 15 patients were included in the analysis. Before 2006, non-IHD RRT procedures, including peritoneal dialysis (PD) and continuous venous-venous hemofiltration (CVVH), were the most often used; from 2006 onwards IHD was used. There was one procedure-unrelated death. Catheter penetration occurred in one course of IHD. The efficacy data revealed that both the median duration of dialysis and the median 50 % toxin reduction time were shorter in IHD than in non-IHD RRT. In infants and young children with inborn errors of metabolism, IHD is safe and more efficient than non-IHD RRT at removing toxins.

Role of acute kidney injury staging by KDIGO criteria in choosing the opportune time of continuous blood purification

To investigate the role of acute kidney injury staging in multiple organ dysfunction syndrome (MODS) patients with acute kidney injury (AKI) for deciding the opportune time of continuous blood purification (CBP). A retrospective study was conducted. One hundred and twenty-six MODS patients with AKI in general intensive care unit (ICU) and emergency intensive care unit (EICU) requiring continuous venous-venous hemofiltration treatment were enrolled. According to the criteria of "Kidney Disease: Improving Global Outcomes Organization (KDIGO standard)" and acute physiology and chronic health evaluation II (APACHEII) score, the patients were stratified into KDIGO 1, 2, 3 groups and APACHEII score of <15, 15-25, >25 groups. ICU survival rate and renal function outcome, CBP treatment total ultrafiltration, average ICU day and the average medical costs of survivals were compared among groups. Compared with APACHEII ≤ 25, KDIGO 1, 2 hospitalized patients had significantly higher survival rate [94.1% (32/34) vs. 76.8% (43/56), P<0.05]. Renal function improvement rate in survivors of KDIGO 1, 2 patients was significantly higher than that in APACHEII ≤ 25 [90.6% (29/32) vs. 62.8 (27/43), P<0.01], and number of patients requiring CBP treatment, mean ICU day, and medical expenses were significantly reduced (CBP treatment of total ultrafiltration: 199.0±44.7 L vs. 239.0 ± 73.3 L, the mean length of stay in ICU: 12.9±3.4 days vs. 15.1±4.8 days, medical expenses: 2.6±0.4 million vs. 3.0±1.0 million, all P<0.05). There was no significant difference in above indexes between survivors in KDIGO 3 and APACHEII>25, and the indexes in KDIGO 3 and APACHEII >25 were worse than those in KDIGD 1, 2 and APACHEII>25. In patients of MODS accompanied by AKI, compared using as APACHEIIscore≤25 as opportune time to start CBP, to commence the treatment in the period of KDIGO standard 1, 2 cannot only improve patient survival with recovery of renal function, but also can reduce the ICU stay and medical expenses.

Clinical study on blood hemoperfusion resin adsorption series connected continuous venous-venous hemofiltration treating the patients with multiple organ dysfunction syndromes

Objective To investigate the effect of blood hemoperfusion with resin adsorption connected in series to continuous veno-venous hemofiltration （ HP ＋ CVVH ） on plasma cytokines such as TNF-a, IL-1 B, IL-6 as well as cellular immunity and prognosis of patients with multiple organ dysfunction syndromes （MODS） . Methods It was a prospective, randomized clinical trial. A total of 30 patients diagnosed as MODS were randomly （random number） divided into routine treatment ＋ HP ＋ CVVH group （treatment group） and routine treatment ＋ CVVH group （control group）. In treatment group, patients received blood hemoperfusion with resin adsorption for 2 hours, and then CVVH for 10 hours every day for 3 days. In control group, patients received CVVH for 12 hours every day for 3 days. The plasma samples of patients in treatment group were obtained0 h, 2 h, 12 h, 24 h, 26 h, 36 h, 48 h, 50 h, 60h, 5 days , 7 days and 10 days after renal replacement therapy. The plasma samples of patients in control group wereobtained 0 h, 12 h, 24 h, 36 h, 48 h, 60 h, 5 days, 7 days and 10 days after renal replacement therapy. All of these patients were monitored with APACHE II score, T-lymphocytes subpopulations, blood lactate acid concentration, heart rate, respiration rate and oxygenation index. Results Plasma levels of TNF-ct, IL-113 and IL-6 decreased dramatically after HP （ P 〈 0. 01 ） and T-lymphocytes subpopulations CD3 ＋ , CIM ＋ , CD8 ＋ and CD4 ＋/CD8 increased after both HP ＋ CVVH and CVVH. The differences in plasma levels of TNF-a, IL-1Band IL-6 of patients between two groups were not noticeably obvious at the intervals of 12 h, 36 h, and 50 h after renal replacement therapy. But on the 5 th day after renal replacement therapy, plasma levels of TNF-a, IL-1Band IL-6 of patients in HP ＋ CVVH group were lower than those in control group （ P 〈 0. 05 ）. There were 5 fatal patients in HP ＋ CVVH group and 6 patients died off in CVVH group during 28 days after treatment. Conclusions Both HP ＋ CVVH and CVVH could lower the levels of plasma TNF-a, IL-1B and IL-6, and improve cellular immunity and clinical symptoms as well as signs. Compared with CVVH, plasma levels of TNF-ct, IL- 1B and IL-6 were lower on the 5th day and increase rate of 28-day survival in HP ＋ CVVH group. Key words: Hemoperfusion with resin adsorption; Continuous venous-venous hemofiltration; Multiple organ dysfunction syndromes; Cytokines

First-year experience of a Brazilian tertiary medical center in supporting severely ill patients using extracorporeal membrane oxygenation

OBJECTIVES:The aim of this manuscript is to describe the first year of our experience using extracorporeal membrane oxygenation support.METHODS:Ten patients with severe refractory hypoxemia, two with associated severe cardiovascular failure, were supported using venous-venous extracorporeal membrane oxygenation (eight patients) or veno-arterial extracorporeal membrane oxygenation (two patients).RESULTS:The median age of the patients was 31 yr (range 14–71 yr). Their median simplified acute physiological score three (SAPS3) was 94 (range 84–118), and they had a median expected mortality of 95% (range 87–99%). Community-acquired pneumonia was the most common diagnosis (50%), followed by P. jiroveci pneumonia in two patients with AIDS (20%). Six patients were transferred from other ICUs during extracorporeal membrane oxygenation support, three of whom were transferred between ICUs within the hospital (30%), two by ambulance (20%) and one by helicopter (10%). Only one patient (10%) was anticoagulated with heparin throughout extracorporeal membrane oxygenation support. Eighty percent of patients required continuous venous-venous hemofiltration. Three patients (30%) developed persistent hypoxemia, which was corrected using higher positive end-expiratory pressure, higher inspired oxygen fractions, recruitment maneuvers, and nitric oxide. The median time on extracorporeal membrane oxygenation support was five (range 3–32) days. The median length of the hospital stay was 31 (range 3-97) days. Four patients (40%) survived to 60 days, and they were free from renal replacement therapy and oxygen support.CONCLUSIONS:The use of extracorporeal membrane oxygenation support in severely ill patients is possible in the presence of a structured team. Efforts must be made to recognize the necessity of extracorporeal respiratory support at an early stage and to prompt activation of the extracorporeal membrane oxygenation team.

Effects of Continuous Venous-Venous Hemofiltration on Heat Stroke Patients: A Retrospective Study

Heat stroke (HS) is a fatal illness characterized by an elevated core body temperature above 40°C and complicated with rhabdomyolysis and acute renal failure. We retrospectively analyzed the effect of continuous veno-venous hemofiltration (CVVH) in patients with HS. A total of 16 patients with HS were retrospectively analyzed. All patients were treated by CVVH for at least 96 hours, and CVVH was initiated with replacement fluid between 25°C and 30°C for 2 hours to 2.5 hours, and 36°C thereafter. The vital signs were monitored and blood samples were collected during CVVH to measure serum urea, creatinine, myoglobin, creatine kinase, and total bilirubin. All patients survived. The core temperature of the patients decreased from 41.3 ± 0.2°C to 38.7 ± 0.1°C after 2 hours and to 36.7 ± 0.1°C after 5 hours during CVVH (p < 0.05). Compared with values before starting CVVH, there were remarkable improvements in mean arterial blood pressure, heart rate, and oxygenation index (p < 0.05). The serum creatinine, urea, myoglobin, and creatine kinase decreased significantly (p < 0.05), while the bilirubinemia had no obvious decline (p > 0.05). The scores of APACHE II and arterial lactate had also obvious decline (p < 0.05). The hemodynamic variables were stabilized during CVVH, and no obvious side effects related to CVVH were found. CVVH is safe and feasible in the treatment of patients with HS by lowering core temperature, removal of myoglobin, support of multiorgan function, and modulating systemic inflammatory response syndrome (SIRS). The impact of CVVH on patient outcome, however, still needs proof by larger randomized controlled trials.

Effect of continuous venous-venous hemofiltration on patients with severe acute pancreatitis and nursing

Objective To observe continuous venous-venous hemofiltration (CVVH) for treatments and cares of severe acute pancreatitis(SAP). Methods From August 2004 to August 2006, 15 cases with SAP were in conventional treatment (the control group), from September 2006 to August 2010, 20 cases with SAP were nursed with CVVH(the observation group). We surveyed patients' vital signs (including body temperature, heart rate, breathing and blood pressure),mental symptoms, abdominal signs and monitored liver and kidney functions. Additionally we executed APACHE Ⅱ scores. We analyzed them retrospectively. Results The afore - mentioned indexes of two groups were significant in statistics, the observation group had lower incidence of MODS、MOF than the control group after 10 days caring. Conclusions The CVVH could correct systemic inflammatory reaction of SAP and prevent complications. Standard technical operation and intensive nursing can ensure smooth process of CVVH and decrease complications caused by CVVH. Key words: Severe acute pancreatitis; Continuous venous-venous hemofiltration; Nursing

One case of successful treatment of thyroid crisis with continuous venous-venous hemofiltration

患者,女性,65岁,因怕热7年,纳差1周,意识障碍3天入院.患者于7年前诊为甲状腺功能亢进症(甲亢),予他巴唑治疗,未监测甲功.1个月前自行停用他巴唑,改中药治疗,并服用干海带.2周前停服中药.1周前无明显诱因出现纳差、呕吐胃内容物,无咖啡色物,伴腹痛及乏力,3天前无明显诱因逐渐出现神智错乱,胡言乱语,烦躁,伴胸闷、心悸加重,予安定等对症处理无效,并出现发热,体温高达38.3℃,心率160次/min,当地医院诊断甲亢危象予相应处理及冬眠合剂治疗后转入我院。

An Unusual Case of ‘Delayed‘ Febrile Non Hemolytic Transfusion Reaction in a Thalassemia Major Patient with Asymptomatic Plasmodium Falciparum Infection.

Abstract 4186We report the case of a thalassemic patient with asymptomatic malaria in which the infection became clinically manifest only after blood transfusion, mimicking a febrile non haemolytic transfusion reaction. The patient was a 19 yr old thalassemic girl from Togo regularly and uneventfully transfused every 60-90 days since the age of 5 months and splenectomised at 13 yrs. Two malaria episodes in 1995 and 1997 were treated with quinine and halofantrin respectively. In February 2008 the transfusion interval shortened (15 days) and blood transfusions were constantly followed after 30-40 hours by high fever (39-4028C) and hypotension. The patient was referred to our Hospital to clarify and overcome the transfusion problems. Malaria attacks were excluded by the referring clinic.At admission, Hb was 5.9 g/dL, Hct 18.3%, MCV 71.8 fL, MCH 23.1 pg, MCHC 32.2%, reticulocytes 0.82%. WBC 13.1 × 109/L platelet count 953 × 109/L erythroblasts 12.7% of nucleated cells. Molecular analysis of β and α genes revealed double heterozygosity for β IVS1-1 G>A and β IVS2-849 A>G, associated with deletion 3.7 (-α3.7) at the heterozygous state. G6PD 6.29 IU/g Hb (ref.values 5.97±1), Pyruvate kinase 25.1 IU/gHb (ref. v. 11.9-16.1). Red cell osmotic fragility was decreased. The cytofluorimetric analysis of red cells labelled with eosin 5 maleimide gave normal results. Direct antiglobulin test was negative and red cell alloantibodies were not detected. The patient's blood group assessed by molecular biology testing was: genotype O1A2, phenotype A2; ccDee; K-k+; Jk(a+b-); Fy(a-b+); M+N+S+s-. The patient was given 2 crossmatch negative, filtered O neg units: the post-transfusion Hb values were 9.9 g/dL. Thirty-two hours later the patient developed fever (40°C) and hypotension followed by disseminated intravascular coagulation, metabolic acidosis and anuria. Direct and indirect antiglobulin tests were negative on a post-transfusion sample. Because of the rapid worsening of clinical conditions she was admitted to the Intensive Care Unit of our Hospital. Septic shock was excluded on the basis of negative blood cultures and infectious diseases testing. Microscopic examination of thick blood smear was negative for malaria parasites on 2 consecutive days and the malaria rapid diagnostic test (RDT) (Core Malaria Pan-PV-PF®, Core Diagnostics, U.K.-Effegiemme, Nerviano, Milano, Italy) gave inconsistent results. Anti Plasmodium total antibodies (Malaria EIA New Market Laboratories U.K.- Bio-Rad Italia) were detected in the serum at high levels (odd sample/cut off 22). Vital functions were supported by mechanical ventilation, amine administration and continuous venous-venous hemofiltration (CVVH). Broad spectrum antibiotic therapy was started. Fresh frozen plasma and two units of PRC were transfused on day 1 and 2 without increment of Hb level. Three days later, the examination of the peripheral blood smear for counting schistocytes revealed the presence of parasites in a very small number of red cells. This finding was almost simultaneous to the availability of PCR testing results that were positive for P. Falciparum. The differential agglutination with anti A antibody performed on a blood sample collected at admission to ICU allowed to separate patient's and donors' red cell. Counting the number of parasitized red cells in total blood and in the donor fraction blood revealed that the parasitized cells were almost exclusively those of donors (14.4 % vs 0.029%).Treatment with quinine chlorhydrate 500 mg i.v. every 8 hr for 3 days followed by oral quinine sulphate 500 mg every 8 hr for 3 days was successfully undertaken without significant side effects leading to dramatic improvement of clinical conditions and to eradication of P. falciparum. Two RBC units were effectively transfused without any reaction, and in the following two weeks the patient maintained stable haemoglobin values. After discharge, the transfusion interval returned to the previous values (60-90 days) without any post-transfusion reaction.We therefore think that the transfusion of normal, non malaria-resistant red cells fuelled the P. falciparum infection causing fever, DIC and acidosis giving rise to a very severe, atypical febrile non haemolytic transfusion related reaction. Disclosures:No relevant conflicts of interest to declare.

Survival After Sequential Mechanical Complications of Acute Myocardial Infarction, Complicated with Heparin-Induced Thrombocytopenia and Multiple Organ Failure: Report of a Case

Ventricular wall rupture and acute mitral regurgitation due to papillary muscle rupture post-acute myocardial infarction are rare and dramatic mechanical complications. The operative mortality of both complications remains extremely high but this is the only treatment which has greatly improved the prognosis. We describe the course of a patient, who survived after left ventricular free wall rupture two days post-acute myocardial infarction. He underwent left ventricular rupture repair plus two coronary artery bypass grafting. On the fifth postoperative day he developed papillary muscle rupture and acute mitral valve regurgitation. He was reoperated as an emergency case for mitral valve replacement. The patient sustained numerous complications, such as renal failure, heparin-induced thrombocytopenia, sepsis, acute respiratory distress syndrome, and multiple organ failure. He was on continuous venous-venous hemofiltration for one week and underwent a tracheostomy on the ninth postoperative day. He remained on a ventilator for three weeks. The patient survived, was discharged home after six weeks, and remains in very good condition on follow-up so far. The operative mortality of both complications remains high but this is the only treatment which improves the prognosis. Surviving both events is rare and few cases have been reported in the literature. This case highlights the necessity of careful echocardiographic examination in any patient presented with post-myocardial infarction new onset of hemodynamic instability. Identification of a single site of rupture does not eliminate the possibility of additional ruptures in the papillary muscle and intraventricular septum, and transesophageal echocardiography should be used to search for these entities. Although repair of each of these complications carries a high mortality, failure to address them will almost certainly result in death. Using standard surgical techniques, including preoperative intraaortic balloon pump insertion and careful postoperative management, successful outcome is possible.

Early Renal Replacement Therapy in Patients with Postoperative Acute Liver Failure Associated with Acute Renal Failure: Effect on Postoperative Outcomes

Acute liver failure after major surgical procedures is associated with a high risk of multiple organ failure, including acute renal failure. The optimal time to initiate renal replacement therapy for acute renal failure is controversial because of the poor overall clinical outcomes. From July 2002 to January 2005, all patients who had no history of liver disease, but developed acute liver failure and subsequent renal failure requiring renal replacement therapy after major surgery, at a surgical intensive care unit, were retrospectively analyzed. Patients were divided into early or late dialysis groups based on an arbitrary blood urea nitrogen cut-off level of 80 mg/dL before renal replacement therapy. Eighty consecutive patients (21 women), with a mean age of 57.8+/-17.0 (SD) years, comprised the study group. The late dialysis group (n=26) had a higher ICU mortality rate (p=0.02) and a lower renal function recovery rate (p=0.02) than the early dialysis group (n=54). Fifty-three (66.3%) patients died during their ICU stay. Independent risk factors for ICU mortality were renal replacement therapy modality (intermittent hemodialysis versus continuous venous-venous hemofiltration; odds ratio [OR]=4.32, 95% CI 1.26 to 14.79; p=0.02), predialysis APACHE II score> 20 (OR=6.52, 95% CI 1.61 to 26.36; p < 0.01), and late dialysis (OR=4.01, 95% CI 1.05 to 15.27; p=0.04). The mortality rate in postoperative patients with acute liver failure-associated acute renal failure was very high. Earlier initiation of renal replacement therapy, based on the predialysis blood urea nitrogen level, with continuous venous-venous hemofiltration might provide a better ICU survival rate.

Continuous venous-venous hemofiltration for the treatment of fluid overload in continuous ambulatory peritoneal dialysis patients.

Fluid overload is not infrequent in continuous ambulatory peritoneal dialysis (CAPD) patients. In our experience, extemporaneous continuous venous-venous hemofiltration (CVVHF) was able to correct fluid imbalances refractory to high dose diuretics and hypertonic solutions. We treated 8 of 52 patients (5 females, 3 males, mean age 52 years) on CAPD from 4 to 36 months and with fluid overloads of up to 10 kg. A Biospal SCU/CAVH flat-sheet high-flux hemodialyzer employed for 10 h produced an ultrafiltration rate (QB:150 ml/min) of 11.12 +/- 4.97 ml/min. With an isotonic replacement solution, the filter provided sufficient extraction of small molecules so that CAPD could be interrupted during CVVHF. The procedure appeared well tolerated. This approach reduced the use of hypertonic dialysate, which is not devoid of side effects on ultrafiltration capacity of the peritoneal membrane.