Continuous Venovenous Hemodiafiltration Research Articles

Successful Extracorporeal Blood Purification Therapy using Double Haemoadsorption Device in Severe Endotoxin Septic Shock: A Case Report.

In patients admitted to the Intensive Care Unit (ICU), sepsis can lead to acute kidney injury (AKI), which may require the initiation of continuous renal replacement therapy (CRRT) in 15-20% of cases. There is no consensus about the best extracorporeal treatment to choose in septic patients with AKI. We describe the case of a 70-year-old woman admitted to the ICU with a severe endotoxin septic shock due to Neisseria meningitidis serogroup C. Despite prompt medical intervention, including fluid resuscitation, high dose vasopressor, inotrope support, and broad-spectrum antimicrobial treatment, in a few hours patient's haemodynamic worsened and she developed multi-organ failure, including severe AKI, requiring CRRT. So, continuous veno-venous haemodiafiltration was started, using an oXiris® haemodiafilter set, in series with an adsorber device (CytoSorb®). After 48 hours of this combined extracorporeal treatment, haemodynamic parameters improved, allowing a significant reduction of the vasoactive therapy, with a concomitant decrease in endotoxin and inflammatory markers serum levels. In the following days patient's conditions still improved and renal function recovered. Timely extracorporeal blood purification therapy, using a double haemoadsorption device, may be effective in the management of severe septic shock.

Kinetics of Plasma Cytokines During Two Different Modalities of Extracorporeal Blood Purification in the Critically Ill Covid 19 Patients: A Cohort Study.

In the absence of direct therapy for COVID-19, extracorporeal blood treatment (EBT) could represent an option for cytokine removal. This study aimed to describe and compare cytokine removal during intermittent haemodialysis (IHD) and continuous renal replacement therapy (CRRT) in COVID-19 patients with Acute Kidney Injury (AKI). It was a cohort study that studied patients with COVID-19-related AKI according to KDIGO criteria and admitted at Intensive Care Unit (ICU). Blood samples were collected at the start and end of both IHD using high flux (HF) membranes (10 patients) and continuous venovenous haemodiafiltration (CVVHDF:10 patients) in two sessions for measuring 13 different plasma interleukins and calculating the cytokine removal rate. There was no difference between the two groups regarding mechanical ventilation, vasoactive drug, age or prognostic scores. Patients treated by CRRT presented higher levels of IL-2 and IL-8 than patients treated by IHD at dialysis start. Cytokine removal ranged from 9% to 78%. Patients treated by CRRT presented higher cytokine removal for IL-2, IL-6 IL-8, IP-10 and TNF. The removal rates of IL-4, IL-10, IL-17A, IFN, MCP-1 and TGF-B1 were similar in two groups. After one session of CVVHDF (24 h), IL-2 and IL-1β levels did not vary significantly, whereas IL-4, IL-6, IL-8, IL-10, IL-17A, TNF, IFN, IP-10, MCP-1, IL-12p70 and TGF-B1 decreased by 33.8-76%, and this decrease was maintained over the next 24 h. In IHD groups, IL-2, IL-6, TNF, IP-10 and IL-1β levels did not decrease significantly whereas IL-4, IL-8, IL-10, IL-17A, IFN, MCP-1, IL-12p70 and TGF-B1 decreased by 21.8-72%; however, cytokine levels returned to their initial values after 24 h. Cytokine removal is lower in IHD using HF membranes than in CVVHDF, and in IHD the removal is transient and selective, which can be associated with mortality during cytokines storm-related COVID-19.

Management of Severe Hyponatremia With Modified Continuous Venovenous Hemodiafiltration (CVVHDF) Solutions

Management of Severe Hyponatremia With Modified Continuous Venovenous Hemodiafiltration (CVVHDF) Solutions

Comparison of different modalities of continuous renal replacement therapy with regional sodium citrate anticoagulation in paediatric patients.

To evaluate the efficacy and safety of continuous renal replacement therapy (CRRT) modalities with regional sodium citrate anticoagulation (RCA) in children. This retrospective study was conducted at the paediatric intensive care unit of Hunan Children's Hospital in China. Medical records of paediatric patients hospitalised for RCA-CRRT between April 2017 and March 2021 were reviewed. Patients received continuous venovenous haemodialysis, continuous venovenous haemofiltration (CVVH), or continuous venovenous haemodiafiltration (CVVHDF). Patients on continuous venovenous haemodialysis (n = 2) were excluded because of their small sample size. The remaining participants were divided into CVVH and CVVHDF groups; 80 patients received CRRT, with 40 and 62 sessions in the CVVH and CVVHDF groups, respectively. The filtre lifespan was longer in the CVVHDF group than in the CVVH group (median value [interquartile range]; 47 [15] hours vs. 35 [17.5] hours; p = 0.029). Compared with the CVVHDF group, the hazard ratio for filtre lifespan in the CVVH group was 3.023 (95% confidence interval 1.820-5.023, p < 0.001). There were no significant differences in ionised calcium levels of the circuits between the two groups at different time points (p < 0.05). Metabolic alkalosis, hyperlactataemia, hypocalcaemia, and hypercalcaemia occurred in both groups, with metabolic alkalosis being the most common complication. No patients in either group experienced sodium citrate accumulation or hypernatraemia. Inter-group differences in the incidence of these complications were not statistically significant (p > 0.05). Our results suggest that CVVHDF is a better option for RCA-CRRT than CVVH.

Severe Rhabdomyolysis After COVID-19 Vaccine

A 65-year-old man presented with muscle pain and muscle weakness lasting 1 week that started after his second BNT162b2 COVID-19 vaccine. He had been taking rosuvastatin and gemfibrozil for several years. He was diagnosed with acute kidney failure caused by rhabdomyolysis resulting from a statin-fibrate interaction from a COVID-19 vaccination and was admitted for continuous venovenous hemodiafiltration. Rhabdomyolysis following messenger RNA COVID-19 vaccination is a rare but important adverse event in patients using high-dose statins combined with fibrates. Such patients should be warned to seek medical attention in case of ongoing muscle symptoms after vaccination.

Fine-tuned continuous renal replacement therapy with calcium-free dialysate to manage severe hypercalcemia refractory to medical and intermittent hemodialysis.

Malignancy-related hypercalcemia is a leading cause of hypercalcemia among hospitalized patients that carries poor prognosis. Parathyroid carcinoma is a rare form of primary hyperparathyroidism that may be associated with PTH dependent hypercalcemia. Severe hypercalcemia is life-threatening and may require management in an intensive care unit by means of medical therapy consisting of volume expansion, loop diuretics, cinacalcet, calcitonin and bisphosphonates. Renal replacement therapy such as intermittent hemodialysis has been successfully used among patients with severe hypercalcemia who become refractory to medical treatment. However, little data are available for cases of severe refractory hypercalcemia that fail to respond to both optimal medical therapy and hemodialysis. Our present case illustrates the successful use of continuous veno-venous hemodiafiltration (CVVHDF) with calcium-free dialysate calcium and markedly increased dialysate flow rate, to restore normal calcemia in a patient with metastatic parathyroid carcinoma with severe refractory hypercalcemia.

Validation of a Protocol for Continuous Hemodiafiltration with Regional Citrate Anticoagulation with Omni®

Introduction: Omni® (B Braun, Melsungen, Germany) is able to run continuous renal replacement therapy (CRRT) in continuous veno-venous hemofiltration (CVVH), hemodialysis (CVVHD), and hemodiafiltration (CVVHDF) modes. However, to date, there is no validated protocol to guide the use of Omni® in CVVHDF mode with regional citrate anticoagulation (RCA). Methods: We designed a protocol for CVVHDF-RCA tailored for Omni®. This protocol was tested in patients included in an observational study conducted in our center between January and March 2021. For all study patients, we collected baseline characteristics, laboratory results, CRRT circuit lifespan as well as plasma and effluent samples at 12, 24, 48, and 72 h of CRRT circuit initiation. At each study time point, we computed urea, creatinine, and β2-microglobulin clearance as well as effluent/blood ratios. Data from circuits in CVVHDF-RCA mode are compared with those in standard therapy (CVVHD-RCA) with the same device. Results: We analyzed ten circuits (5 patients) in CVVHDF-RCA mode and 32 (13 patients) in CVVHD-RCA mode. No adverse events related to the therapy were observed. In CVVHDF-RCA mode, median circuit running time was 68 (IQR 8.1) hours versus 46 (IQR 9.0) in CVVHD mode, p = 0.053. Therapy adaptations (dialysate rate and/or blood flow) were required in one (10%) circuit (15.6% in CVVHD mode, p = 0.56). Compared to CVVHD, CVVHDF was able to achieve similar clearance and effluent/blood ratio for urea, creatinine, and β2-microglobulin across the entire duration of circuit lifetime. Conclusion: The proposed protocol for CVVHDF-RCA for Omni® was associated with similar circuit lifetime, number of required adaptations and clearances to standard CVVHD-RCA. It appears to be safe and feasible.

Pharmacokinetics and Time above the MIC Exposure of Cefepime in Critically Ill Patients Receiving Extracorporeal Membrane Oxygenation (ECMO)

This study determined the pharmacokinetics of cefepime in patients requiring extracorporeal membrane oxygenation (ECMO) support to guide dosage selection. Cefepime population pharmacokinetics where characterized in Pmetrics for R for six critically ill patients receiving ECMO. Simulation was employed to determine the fT>MIC and total trough concentration of varying regimens in each patient to evaluate ability to achieve optimal pharmacodynamic exposure and thresholds for cefepime-associated neurotoxicity. Of the six participants, two required continuous veno-venous hemodiafiltration (CVVHDF) while four had a CrCL between 92-199 ml/min. All patients received 2 g q8h as a 3h infusion. A two-compartment model fitted the data best with median (range) parameter estimates as follows: clearance, 5.99 (4.10-10.29) L/h; volume of central compartment, 10.08 (2.45-15.14) L; and intercompartment transfer constants (k12), 3.58 (2.01-4.99) h-1 and k21, 1.70 (1.00-2.88) h-1. The 2g q8h (3h infusion) regimen resulted in >70% fT>MIC in all patients up to an MIC of 16 µg/mL, whereas 2g q12h (0.5h) resulted in 5/6 patients achieving 70% ƒT>MIC at 8 µg/mL but only 1/6 at 16 µg/mL. Aggressive dosing regimens resulted in trough concentrations exceeding conservative neurotoxicity thresholds. No patient demonstrated signs or symptoms of neurotoxicity during treatment. For ECMO patients with normal to augmented renal clearance similar to those presented here, or those receiving CVVHDF, these data support dosing regimens of 2g q8h (3h infusions) to empirically target MICs up to 16 µg/mL. Larger studies are needed to determine how ECMO affects cefepime pharmacokinetics.

MO633: Survival Comparison Between CVVHDF and CVVH for Septic Acute Kidney Injury

Abstract BACKGROUND AND AIMS The mortality rate of septic acute kidney injury (AKI) remains high despite improvements in renal replacement technology. Adding dialysis to continuous veno-venous hemofiltration (CVVH) can increase survival in these patients, although hemofiltration leads to better clearance of inflammatory mediators in sepsis than hemodialysis. We tested whether continuous veno-venous hemodiafiltration (CVVHDF) is more effective than CVVH with the same net effluent according to body weight in intensive care unit (ICU) patients with septic AKI. METHOD The mortality rate of septic acute kidney injury (AKI) remains high despite improvements in renal replacement technology. Adding dialysis to continuous veno-venous hemofiltration (CVVH) can increase survival in these patients, although hemofiltration leads to better clearance of inflammatory mediators in sepsis than hemodialysis. We tested whether continuous veno-venous hemodiafiltration (CVVHDF) is more effective than CVVH with the same net effluent according to body weight in intensive care unit (ICU) patients with septic AKI. RESULTS In this prospective randomized pilot study, 100 patients were assigned to CVVH (n = 47, M: F = 25:22, age 64 ± 15 years) or CVVHDF (n = 49, M: F = 30:19, age 65 ± 11 years). Baseline characteristics including age, sex, body weight, serum creatinine, blood urea nitrogen (BUN), beta-2 microglobulin, Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores did not vary between the two groups. There were no significant differences in the reduction ratios of serum creatinine, BUN, beta-2 microglobulin, APACHE II and SOFA scores between the two groups. Seven-, 28- and 60-day survival also did not vary. CONCLUSION In conclusion, CVVH and CVVHDF led to similar clearance of waste products and survival at the same net effluent in this study. Future large-scale randomized prospective studies will be needed to confirm these results in critically ill patients with septic AKI.

Population pharmacokinetics of ciprofloxacin in critically ill patients receiving extracorporeal membrane oxygenation (an ASAP ECMO study)

IntroductionThis study aimed to describe the pharmacokinetics (PK) of ciprofloxacin in critically ill patients receiving ECMO and recommend a dosing regimen that provides adequate drug exposure. MethodsSerial blood samples were taken from ECMO patients receiving ciprofloxacin. Total ciprofloxacin concentrations were measured by chromatographic assay and analysed using a population PK approach with Pmetrics®. Dosing simulations were performed to ascertain the probability of target attainment (PTA) represented by the area under the curve to minimum inhibitory concentration ratio (AUC0−24/MIC) ≥ 125. ResultsEight patients were enrolled, of which three received concurrent continuous venovenous haemodiafiltration (CVVHDF). Ciprofloxacin was best described in a two-compartment model with total body weight and creatinine clearance (CrCL) included as significant predictors of PK. Patients not requiring renal replacement therapy generated a mean clearance of 11.08 L/h while patients receiving CVVHDF had a mean clearance of 1.51 L/h. Central and peripheral volume of distribution was 77.31 L and 90.71 L, respectively. ECMO variables were not found to be significant predictors of ciprofloxacin PK. Dosing simulations reported that a 400 mg 8 -hly regimen achieved > 72% PTA in all simulated patients with CrCL of 30 mL/min, 50 mL/min and 100 mL/min and total body weights of 60 kg and 100 kg at a MIC of 0.5 mg/L. ConclusionOur study reports that established dosing recommendations for critically ill patients not on ECMO provides sufficient drug exposure for maximal ciprofloxacin activity for ECMO patients. In line with non-ECMO critically ill adult PK studies, higher doses and therapeutic drug monitoring may be required for critically ill adult patients on ECMO.

The effect of citrate in cardiovascular system and clot circuit in critically ill patients requiring continuous renal replacement therapy

We aimed to evaluate the impact of citrate on hemodynamic responses and secondary outcomes, including the filter life span, metabolic complications, and levels of inflammatory cytokines, in critically ill patients who required CRRT compared with those who underwent the heparin-free method. This prospective, multicenter, open-label randomized trial compared regional citrate anticoagulation (RCA) with a heparin-free protocol in severe acute kidney injury (AKI) patients who received continuous venovenous hemodiafiltration (CVVHDF) in the postdilution mode. We measured hemodynamic changes using the FloTrac Sensor/EV1000™ Clinical Platform at certain time points after starting CRRT (0, 6, 12, 24, 48, and 72 h.). The levels of inflammatory cytokines (IL-1β, IL-6, IL-8, IL-10 and TNF-ɑ) were measured on days 1 and 3. Forty-one patients were recruited and randomized into the heparin (n = 20) and citrate groups (n = 21). The cardiac performances were not significantly different between the 2 groups at any time point. The inflammatory cytokines declined similarly in both treatment arms. The maximum filter survival time was insignificantly longer in the RCA group than in the heparin-free group (44.64 ± 26.56 h. vs p = 0.693 in citrate and heparin free group). No serious side effects were observed for either treatment arm, even in the group of liver dysfunction patients. RCA did not affect hemodynamic changes during CRRT. Inflammatory cytokines decreased similarly in both treatment arms.The filter life span was longer in the citrate group. RCA is a valid alternative to traditional anticoagulation and results in stable hemodynamic parameters.

Optimizing Antimicrobial Dosing for Critically Ill Patients with MRSA Infections: A New Paradigm for Improving Efficacy during Continuous Renal Replacement Therapy.

The dosage regimen of vancomycin, teicoplanin and daptomycin remains controversial for critically ill patients undergoing continuous renal replacement therapy (CRRT). Monte Carlo simulation was applied to identify the optimal regimens of antimicrobial agents in patients with methicillin-resistant Staphylococcus aureus (MRSA) infections based on the mechanisms of different CRRT modalities on drug clearance. The optimal vancomycin dosage for patients received a CRRT doses ≤ 30 mL/kg/h was 20 mg/kg loading dose followed by 500 mg every 8 h, while 1 g every 12 h was appropriate when 35 mL/kg/h was prescribed. The optimal teicoplanin dosage under a CRRT dose ≤ 25 mL/kg/h was four loading doses of 10 mg/kg every 12 h followed by 10 mg/kg every 48 h, 8 mg/kg every 24 h and 6 mg/kg every 24 h for continuous veno-venous hemofiltration, continuous veno-venous hemodialysis and continuous veno-venous hemodiafiltration, respectively. When the CRRT dose increased to 30–35 mL/kg/h, the teicoplanin dosage should be increased by 30%. The recommended regimen for daptomycin was 6–8 mg/kg every 24 h under a CRRT dose ≤ 25 mL/kg/h, while 8–10 mg/kg every 24 h was optimal under 30–35 mg/kg/h. The CRRT dose has an impact on probability of target attainment and CRRT modality only influences teicoplanin.

A Loading Micafungin Dose in Critically Ill Patients Undergoing Continuous Venovenous Hemofiltration or Continuous Venovenous Hemodiafiltration: A Population Pharmacokinetic Analysis: Erratum.

A Loading Micafungin Dose in Critically Ill Patients Undergoing Continuous Venovenous Hemofiltration or Continuous Venovenous Hemodiafiltration: A Population Pharmacokinetic Analysis: Erratum.

Effect of different connection schemes of continuous renal replacement therapy and extracorporeal membrane oxygenation on arterial and venous pressure: an in vitro and in vivo study

To investigate the effects of different connection schemes of continuous renal replacement therapy (CRRT) and extracorporeal membrane oxygenation (ECMO) on arterial pressure (PA), venous pressure (PV), and transmembrane pressure (TMP), and to provide a theoretical basis for choosing a suitable connection scheme. (1) In vitro study: the different connection schemes of CRRT and ECMO were simulated and divided into 6 schemes according to the connection between CRRT and ECMO circuits at different positions. Scheme A: connected to the front and back points of the oxygenator; scheme B: connected to the points behind and in front of the oxygenator; scheme C: connected to the points in front of the oxygenator and in front of the centrifugal pump; scheme D: connected to the points behind the oxygenator and in front of the centrifugal pump; scheme E: connected to the points in front of the oxygenator and the return catheter; scheme F: connected to the points after the oxygenator and the return catheter. Each set of ECMO circuits was measured 5 times under each connection scheme and different flow rates (2, 3, 4, 5, 5.5 L/min). Six ECMO circuits for a total of 30 measurements, and the PA, PV, and TMP of the 6 schemes were compared. (2) In vivo study: the patients who were treated with ECMO combined with CRRT in the department of critical care medicine of the First Affiliated Hospital of Wannan Medical College from August 2017 to August 2021 changed the connection scheme due to high PA or PV (from scheme A or B to scheme E or F) were retrospectively analyzed. The changes of PA and PV before and after changing the scheme were compared. (1) In vitro study results: there was no significant difference in PA between schemes A and B, C and D, E and F under different ECMO blood flow (2-5.5 L/min). The PA of schemes C and D was the lowest, followed by schemes E and F. PV of scheme B was higher than that of scheme A under different ECMO blood flow (2-5.5 L/min). There was no significant difference in PV between schemes C and D, E and F under high ECMO blood flow (3-5.5 L/min), and the absolute value of PV was lowest in schemes E and F. Compared with schemes A and B [partial PA > 300 mmHg (1 mmHg ≈ 0.133 kPa) at high flow rate], C and D (partial PV > 350 mmHg at high flow rate), schemes E and F were more reasonable connection schemes. TMP was negative in schemes C and D at ECMO blood flow of 5 L/min and 5.5 L/min (mmHg; 5 L/min: scheme C was -29.14±11.42, scheme D was -42.45±15.70; 5.5 L/min: scheme C was -35.75±13.21, scheme D was -41.58±15.42), which indicated the presence of dialysate reverse filtration. Most of the differences in TMP among schemes A, B, E, and F under different ECMO blood flow (2-5.5 L/min) were statistically significant, and the absolute value of mean fluctuation was 9.89-49.55 mmHg, all within the normal range. (2) In vivo study results: a total of 10 patients who changed the connection scheme (from scheme A or B to E or F) due to high PA or PV were enrolled, including 8 males and 2 females; 7 cases of venous-arterial ECMO (VA-ECMO) and 3 cases of venous-venous ECMO (VV-ECMO), all used continuous veno-venous hemodiafiltration (CVVHDF) mode. After changing the scheme, both PA and PV decreased significantly as compared with those before changing [PA (mmHg): 244.00±22.58 vs. 257.20±21.92, PV (mmHg): 257.20±18.43 vs. 326.40±15.41, both P < 0.01], and PV decreased more significantly than PA [difference (mmHg): 69.20±6.55 vs. 13.20±5.45, P < 0.01]. For patients treated with ECMO in combination with CRRT, the scheme of connecting the access line of CRRT to the pre-oxygenator or post-oxygenator and connecting the return line to the point of the return catheter can significantly reduce PA and PV and maintains normal CRRT operation even running high-flow ECMO.

520 Efficacy of high volume hemofiltration (HVHF) with step-down approach in critically ill burn patients

IntroductionContinuous renal replacement therapy (CRRT) is the standard of care for critically ill burn patients with acute kidney injury. Historical mortality rates for burn patients requiring CRRT is over 50%. High volume hemofiltration (HVHF) is a purification method that may have superior outcomes in the critically ill but has not been well studied in burn patients. We report results of utilizing HVHF with a step-down approach in our burn center.MethodsRetrospective review of all adult burn patients at a verified adult and pediatric burn center requiring continuous veno-venous hemodiafiltration (CVVHDF) from 2018 to 2021 when HVHF (50ml/kg/hr) for 18-24 hours with a step-down approach (25-30ml/kg/hr) was started. A normocarbia bicarbonate based dialysate was used with blood flow rates of 200ml/hr along with citrate anticoagulation. Demographics, indications and duration of CVVHDF, duration of vasopressor requirements, days on mechanical ventilation, length of stay, correction of acidosis and mortality were recorded.ResultsThirteen patients were identified, of which four were excluded as they had an exfoliative skin disease (two patients) or were treated with conventional CVVHDF (two patients). Of the remaining nine patients (six male and three female) the average age was 58.7 years (range: 42-75) and average total body surface area burn (%TBSA) was 46% (range: 20-92). All patients were diagnosed with AKI (Acute Kidney Injury Network [AKIN] Class III) with the indication for CRRT being diuretic resistant fluid overload in three patients and sepsis in the remaining six patients. Of the three patients with fluid overload, two developed sepsis while on CRRT. Acute respiratory distress syndrome (ARDS) as defined by the Berlin criteria was noted in six patients (66%). Three patients died (33% mortality) with the remaining six being eventually converted to intermittent hemodialysis and progressing to renal recovery. Amongst survivors, the duration of CRRT ranged between 7-33 days (average 13.8 days) and duration of vasopressor support from 1-30 (average 17 days). Metabolic acidosis resolved in all survivors within 48 hours. No hemorrhagic events were noted and all patients tolerated regional citrate anticoagulation well. Reduction in serum creatinine was noted to be significant.ConclusionsHigh volume hemofiltration resulted in improved mortality rates compared to what is reported in the literature. Further research and comparative studies are required to determine if HVHF with a step-down approach is superior.

Clinical Assessment of Continuous Hemodialysis with the Medium Cutoff EMiC®2 Membrane in Patients with Septic Shock

Introduction: At the time of renal replacement therapy, approximately 20% of critically ill patients have septic shock. In this study, medium cutoff (MCO) continuous venovenous hemodialysis (CVVHD) was compared to high-flux membrane continuous venovenous hemodiafiltration (CVVHDF) in terms of hemodynamic improvement, efficiency, middle molecule removal, and inflammatory system activation. Methods: This is a monocenter crossover randomized study. Between December 31, 2017, and December 31, 2019, 20 patients with septic shock and stage 3 acute kidney injury (AKI) admitted to 2 Italian ICUs were enrolled. All patients underwent CVVHD with Ultraflux® EMiC®2 and CVVHDF with AV1000S® without washout. Each treatment lasted 24 h. Results: Compared to AV1000S®-CVVHDF, EMIC®2-CVVHD normalized cardiac index (β = −0.64; p = 0.02) and heart rate (β = 5.72; p = 0.01). Interleukin-8 and myeloperoxidase removal were greater with AV1000S®-CVVHDF than with EMiC®2-CVVHD (β = 0.35; p < 0.001; β = 0.43; p = 0.03, respectively). Leukocytosis improved over 24 h in EMiC®2-CVVHD-treated patients (β = 4.13; p = 0.03), whereas procalcitonin levels decreased regardless of the modality (β = 0.89; p = 0.01) over a 48-h treatment period. Reduction rates, instantaneous plasmatic clearance of urea, creatinine, and β2-microglobulin were similar across modalities. β2-Microglobulin removal efficacy was greater in the EMiC®2 group (β = 0–2.88; p = 0.002), while albumin levels did not differ. Albumin was undetectable in the effluent in both treatments. Discussion: In patients with septic shock and severe AKI, the efficacy of uremic toxin removal was comparable between MCO-CVVHD and CVVHDF. Further, MCO-CVVHD was associated with improved hemodynamics. Fraction of filtration and transmembrane pressure reduction and the maintenance of equal efficacy might be the key features of CVVHD with MCO membranes in critically ill patients.

Continuous veno-venous hemodiafiltration in neonates with maple syrup urine disease.

Herein, we aimed to discuss our experience in 16 newborn patients with Maple syrup urine disease (MSUD) who were treated with urgent renal replacement therapy (RRT). The patients underwent continuous veno-venous hemodiafiltration (CVVHDF) or peritoneal dialysis (PD) as renal replacement therapy. Eleven (68.75%) patients underwent CVVHDF and five (31.25%) underwent peritoneal dialysis. The median leucine reduction rate per hour was 2.56% (1.75-7.6) in the CVVHDF group, 0.78% (0.54-1.83) in the PD group, and was significantly higher in the CVVHDF group (p=0.001). Posttreatment plasma leucine levels were found to be 198 (20-721) μmol/L in the CVVHDF group and 600 (250-967) μmol/L in the PD group, and CVVHDF was found to be significantly lower (p=0.08). Complications such as hypotension, electrolyte imbalance, and filter obstruction occurred in the CVVHDF group. This study showed that CVVHDF is more effective than PD for rapidly eliminating elevated leucine levels caused by MSUD in the newborn and it is not associated with increased complication rates.

Model selection and curative effect judgment criteria for artificial liver in the treatment of liver failure

Artificial liver is one of the effective methods to treat liver failure. Patients with liver failure are critically ill and have great individualized differences. Therefore, the specific program for the treatment of liver failure with artificial liver should be individualized. The commonly used non-biological artificial liver models include simple plasmapheresis, double filtration plasmapheresis, plasma filtration with dialysis, double plasma molecular adsorption system, molecular absorbent recirculating system, hemodiafiltration, continuous venovenous hemodiafiltration, hybrid, etc. The curative effect should be properly judged from patient's symptoms, laboratory test indicators, survival rate and other aspects after artificial liver therapy.

Ammonia Clearance with Different Continuous Renal Replacement Therapy Techniques in Patients with Liver Failure

Introduction: Continuous renal replacement therapy (CRRT) can be used to treat hyperammonaemia. However, no study has assessed the effect of different CRRT techniques on ammonia clearance. Methods: We compared 3 different CRRT techniques in adult patients with hyperammonaemia, liver failure, and acute kidney injury. We protocolized CRRT to progressively deliver continuous veno-venous haemofiltration (CVVH), haemodialysis (CVVHD) or haemodiafiltration (CVVHDF). Ammonia was simultaneously sampled from the patient’s arterial blood and effluent fluid for each technique. We applied accepted equations to calculate clearance. Results: We studied 12 patients with a median age of 47 years (interquartile range [IQR] 25–79). Acute liver failure was present in 4 (25%) and acute-on-chronic liver failure in 8 (75%). There was no significant difference in median ammonia clearance between CRRT technique; CVVH: 27 (IQR 23–32) mL/min versus CVVHD: 21 (IQR 17–28) mL/min versus CVVHDF: 20 (IQR 14–28) mL/min, p = 0.32. Moreover, for all techniques, ammonia clearance was significantly less than urea and creatinine clearance; urea 50 (47–54) mL/min versus creatinine 42 (IQR 38–46) mL/min versus ammonia 25 (IQR 18–29) mL/min, p = 0.0001. Conclusion: We found no significant difference in ammonia clearance according to CRRT technique and demonstrated that ammonia clearance is significantly less than urea or creatinine clearance.

Optimal indicator for changing the filter during the continuous renal replacement therapy in intensive care unit patients with acute kidney injury: A crossover randomized trial.

The study aims to investigate an optimal indicator for changing the filter during the continuous renal replacement therapy (CRRT) in intensive care unit (ICU) patients with acute kidney injury (AKI). Patients with AKI requiring CRRT in an ICU were randomly divided into two groups for crossover trial, i.e., groups A and B. Patients in the group A were firstly treated with continuous veno-venous hemofiltration (CVVH), followed by continuous veno-venous hemodiafiltration (CVVHDF). Patients in the group B were firstly treated with CVVHDF followed by CVVH. Delivered doses of solutes with different molecular weights at the indicated time points between groups were compared. A correlation analysis between the delivered dose and pre-filter pressure (PPRE) and transmembrane pressure (PTM) was performed. Receiver operating characteristic (ROC) curves were constructed to evaluate the accuracy of PTM as an indicator for filter replacement. A total of 50 cases were analyzed, 27 in the group A and 23 in the group B. Delivered doses of different molecular-weight solutes significantly decreased before changing the filter in both modalities, compared with those at the initiation of treatment (all P<0.05). In the late stage of CRRT, the possible rebound of serum medium-molecular-weight solute concentration was observed. PTM was negatively correlated with the delivered dose of medium-molecular-weight solute in both modalities. The threshold for predicting the rebound of serum concentration of medium-molecular-weight solute by PTM was 146.5 mmHg (1 mmHg=0.133 kPa). The filter can be used as long as possible within the manufacturer's safe use time limits to remove small-molecular-weight solutes. PTM of 146.5 mmHg may be an optimal indicator for changing the filter in CRRT therapies to remove medium-molecular-weight solutes.