Continuous Veno-venous Hemodiafiltration Treatment Research Articles

Continuous venovenous hemodiafiltration versus standard medical therapy for the prevention of rhabdomyolysis-induced acute kidney injury: a retrospective cohort study

AimTo determine whether continuous venovenous hemodiafiltration (CVVHDF) plus standard medical therapy (SMT) vs. SMT alone prevents rhabdomyolysis (RM)-induced acute kidney injury (AKI) and analyze the related health economics.MethodsThis retrospective cohort study involved 9 RM patients without AKI, coronary heart disease, or chronic kidney disease treated with CVVHDF plus SMT (CVVHDF + SMT group). Nine matched RM patients without AKI treated with SMT only served as controls (SMT group). Baseline characteristics, biochemical indexes, renal survival data, and health economic data were compared between groups. In the CVVHDF + SMT group, biochemical data were compared at different time points.ResultsAt 2 and 7 days after admission, serum biochemical indices (e.g., myoglobin, creatine kinase, creatinine, and blood urea nitrogen) did not differ between the groups. Total (P = 0.011) and daily hospitalization costs (P = 0.002) were higher in the CVVHDF + SMT group than in the SMT group. After 53 months of follow-up, no patient developed increased serum creatinine, except for 1 CVVHDF + SMT-group patient who died of acute myocardial infarction. In the CVVHDF + SMT group, myoglobin levels significantly differed before and after the first CVVHDF treatment (P = 0.008), and serum myoglobin, serum creatinine, and blood urea nitrogen decreased significantly at different time points after CVVHDF.ConclusionsAlthough CVVHDF facilitated myoglobin elimination, its addition to SMT did not improve biochemical indices like serum myoglobin, serum creatine kinase, creatinine, blood urea nitrogen, and lactate dehydrogenase or the long-term renal prognosis. Despite similar hospitalization durations, both total and daily hospitalization costs were higher in the CVVHDF + SMT group.

Value of extracorporeal artificial liver support in pediatric acute liver failure: A single-center experience of over 10 years.

Acute liver failure (ALF) is a life-threatening disease characterized by rapid-onset liver dysfunction, coagulopathy, and encephalopathy in patients without chronic liver disease. Today, the combined application of continuous veno-venous hemodiafiltration (CVVHDF) and plasma exchange (PEX), which are forms of supportive extracorporeal therapy (SECT), with conventional liver therapy in ALF is recommended. This study aims to retrospectively analyze the effects of combined SECT in pediatric patients with ALF. We retrospectively analyzed 42 pediatric patients, followed in the liver transplantation intensive care unit. The patients had ALF and received PEX supportive therapy with combined CVVHDF. The biochemical lab values of the results for the patients before the first combined SECT and after the last combined SECT were analyzed comparatively. Of the pediatric patients included in our study, 20 were girls and 22 were boys. Liver transplantation was performed in 22 patients, and 20 patients recovered without transplantation. After the discontinuation of combined SECT, all patients had significantly lower serum liver function test results (total bilirubin, alanine transaminase, aspartate transaminase), ammonia, and prothrombin time/international normalized ratio levels than the previous levels (p < 0.01). Hemodynamic parameters (i.e., mean arterial pressure) also improved significantly. Combined CVVHDF and PEX treatment significantly improved biochemical parameters and clinical findings, including encephalopathy, in pediatric patients with ALF. PEX therapy combined with CVVHDF is a proper supportive therapy for bridging or recovery.

Continuous venovenous hemodiafiltration in the treatment of newborns with an inborn metabolic disease: a single center experience

Background/aim Most inborn metabolic diseases are diagnosed during the neonatal period. The accumulation of toxic metabolites may cause acute metabolic crisis with long-term neurological dysfunction and death. Renal replacement therapy (RRT) modalities allow the efficient removal of toxic metabolites. In this study, we reviewed our experience with continuous venovenous hemodiafiltration (CVVHDF) as RRT for newborns with an inborn metabolic disease.Materials and methods Patients diagnosed with an inborn metabolic disease and who received CVVHDF treatment at our neonatal intensive care unit between January 2014 and December 2017 were included in this study. Their demographic and clinical data were collected, and the efficacy and safety of CVVHDF was evaluated.ResultsA total of nine continuous RRT (CRRT) sessions as CVVHDF were performed in eight newborns with a diagnosis of urea cycle defect (n = 5), maple syrup urine disease (n = 2), or methylmalonic acidemia (n = 1). The mean age at admission was 10 ± 8.6 days (range: 3–28 days). The mean plasma levels of ammonium were 1120 ± 512.6 mg/dL and 227.5 ± 141.6 mg/dL before and at the end of the treatment, respectively. Plasma levels of leucine were 2053.5 ± 1282 µmol/L and 473.5 ± 7.8 µmol/L before and at the end of the treatment, respectively. The CVVHDF duration was 32.3 ± 11.1 h (median: 37 h; range: 16–44 h), and the mean length of hospitalization was 14.6 ± 12.9 days. The mean duration of CVVHDF was 32.3 ± 11.1 h (range: 16–44 h). Circuit clotting was the most common observed complication (37.5%) and the survival rate was 50%. Among surviving patients, two developed severe and two developed mild mental and motor retardation. Conclusion CVVHDF is a CRRT modality that can be used to treat newborns with an inborn metabolic disease. Early diagnosis, commencement of specific medical therapy, diet, and extracorporeal support, if needed, are likely to result in improved short and long-term outcomes.

Effects of continuous veno-venous hemodiafiltration in patients with severe Kawasaki disease complicated with multiple organ dysfunction syndrome

Objective: To explore the effects of continuous veno-venous hemodiafiltration (CVVHDF) as a rescue therapy in children with Kawasaki disease (KD) complicated with multiple organ dysfunction syndrome (MODS). Methods: The medical records of 5 patients diagnosed as KD with MODS treated with CVVHDF, who were admitted to pediatric intensive care unit (PICU) of Shanghai Children's Hospital from November 2015 to October 2017 were retrospectively collected. The inflammatory factors and parameters of organ function before and after CVVHDF treatment were analyzed. Wilcoxon test was used to compare the changes of parameters before and after CVVHDF treatment. Results: The pediatric critical illness score (PCIS) and the pediatric risk of score mortality score Ⅲ (PRISMⅢ) were 74.0 (70.0, 81.0) and 14.5 (12.5, 17.0), respectively. The duration of CVVHDF treatment was 46.0 (24.5, 48.0) h. The levels of interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α), blood lactic acid were significantly decreased after the CVVHDF treatment (0.4 (0.1, 28.8) vs. 142.0 (123.1, 1 454.6) ng/L, Z=-2.023, P=0.043; 0.1 (0.1, 9.3) vs. 1.7(1.1, 30.0) ng/L, Z=-2.023, P=0.043; 1.2(1.1,1.4) vs. 2.5(2.4, 2.7) mmol/L, Z=-2.041, P=0.041 respectively). Moreover, the lung, liver and kidney function were significantly improved as indicated by the ratio of PaO(2) to FiO(2) (380.0 (182.5, 397.5) vs. 160.0 (52.5, 185.0)mmHg (1 mmHg=0.133 kPa), Z=2.041, P=0.041), the level of total bilirubin ((14.9±1.3) vs. (86.4±9.9) μmol/L), and the levels of creatinine (2 cases: 24.0vs. 103.0 μmol/L, 38.0 vs. 142.0 μmol/L). Conclusion: CVVHDF as an adjuvant therapy can rapidly reduce the levels of IL-6 and TNF-α,and improve the organ functions in children with KD complicated with MODS.

Efficacy of Two Combinations of Blood Purification Techniques for the Treatment of Multiple Organ Failure Induced by Wasp Stings

Background/Aims: The aim of this study was to explore the clinical efficacy of 2 combinations of blood purification techniques in patients with sting venom-induced multiple organ dysfunction syndrome (MODS). Methods: A total of 23 patients received 35 sessions of hemoperfusion (HP) + continuous veno-venous hemodiafiltration (CVVHDF) treatment and 22 sessions of plasma exchange (PE) + CVVHDF treatment, respectively. Results: Both HP + CVVHDF and PE + CVVHDF reduced the levels of inflammation, thus improving our patients' health condition. Moreover, PE + CVVHDF was found to be significantly more effective in reducing the levels of specific liver function markers and inflammatory mediators, as well as shortening prothrombin time and increasing the levels of serum albumin. Conclusion: Both combinations of blood purification techniques were capable of improving MODS. However, the PE + CVVHDF approach was more efficient for the removal of wasp venom and inflammatory mediators from the blood.

Effect of treatment choice on survival in a case with meningococcemia and multiorgan failure

We report in this paper a case had continuous veno-venous hemodiafiltration (CVVHDF) with the diagnosis of meningococcemia - multiple organ failure (MOF) and without permanent damage development although it took more than 4 weeks of loss of kidney function. Three-year-old female patient was hospitalized for unconsciousness, no spontaneous respiration, blood pressure 50/30 mmHg, and widely echimotic- purpuric rash. In her laboratory. there were 19.600 / mm3 white blood cells, 5.7 g / dL hemoglobin, 76,000 / mm3 platelets, prothrombin time was 23.9 seconds, aPTT was higher than measurable values, creatinine was 7.2 mg / dL, ALT / AST were 378/714 / L, and she was anuric. She underwent CVVHDF treatment with the diagnosis of meningococcemia and MOF. On the 48 hours of treatment, her vital signs were improved, on 55 hours MOF was revealed except for renal functions and CVVHDF treatment was discontinued. Because of the damage to the kidneys continue, she had 3 hours/ day dose of hemodialysis. At the end of hospitalization for 1 week, her hemodialysis need was declined to 3 days/ week, on 5th week to 2 days / week and on the beginning of 6 weeks, there was entirely no need for dialysis and she had been seen in services in one more week without dialysis need. On the last visit, she had normal blood pressure, creatinine clearance, urine osmolarity and protein excretion. She was followed up for 4.5 years with no abnormality. Key words: Meningococcemia, dialysis, renal failure

TNF-α depuration is a predictor of mortality in critically ill patients under continuous veno-venous hemodiafiltration treatment

IntroductionCritically ill patients with acute kidney injury (AKI) present high mortality rates. The magnitude of inflammatory response could determine the prognosis of such patients. Continuous renal replacement therapy (CRRT) may play an important role in removing inflammatory mediators in patients with AKI. AimTo investigate whether the magnitude of inflammatory mediator’s removal is associated with mortality among critically ill patients on CVVHDF, a CRRT modality. MethodsThis study consisted of 64 critically ill patients requiring CVVHDF. Plasma levels of C3a, TNF-α, IL-10, IL-6, IL-1β, sTNFRI and sTNFRII were determined by enzyme-linked immunosorbent assay (ELISA) at the beginning of CVVHDF and after 24h (outlet). Clearance of cytokines during the first 24h of CVVHDF was calculated. Clinical and laboratory data were acquired from patient’s records data. ResultsMean age of patients requiring CVVHDF was 63years, 67.2% were men and 87.3% were Caucasian. Thirty-five (35) patients (54.7%) died. Comparing non-survivors with the group of survivors we observed higher incidence of sepsis (68.6 versus 37.9%, p<0.05), higher APACHE II score (34.8±7.6 versus 29.2±7.1, p<0.05) and higher lactate levels (23.2±17.6 versus 16.4±6.6, p<0.05). According to the inter-tertile range of TNF-α clearance (ITR1 (<0.54); ITR2 (0.54–2.93); ITR3 (>2.93)) we found that those patients with higher TNF-α removal by RRT (ITR3) had a better survival. Multivariable analysis showed that lower clearance of TNF-α remained independently associated with high mortality after adjustment for sex, age, use of vasoactive drugs, APACHE II score sepsis, creatinine and lactate before CVVHDF (HR: 0.179, 95% IC: 0.049–0.661, p<0.01). ConclusionThe attenuation of inflammatory response may be related to the lower mortality observed on those patients with higher TNF-α removal by CVVHDF.

Success of continuous veno-venous hemodiafiltration treatment in children monitored in the intensive care units

Introduction: As intensive care units (ICU) have improved, presence of multiple-organ dysfunctions in majority of patients with acute renal failure (ARF) has become clearer. To facilitate multi-organ support, continuous renal replacement therapy (CRRT) techniques have been developed. This study is the one that reports the experience on children including newborns receiving CRRT monitored in ICU. Materials and Methods: The study was performed retrospectively in children who had Continuous Veno- Venous Hemodiafiltration (CVVHDF) as a CRRT modality in ICU. Clinical data, primary cause, consultation time, duration and initiation time of CVVHDF were recorded. Patients were classified as cardiac and non-cardiac in respect to primary dysfunction. Stage of renal failure was evaluated according to pRIFLE criteria. Outcome was identified as primary and secondary. Primary outcome was accepted as the composite correction of uremia and metabolic parameters, and regression of fluid overload, while secondary outcomes were assessed as improvement of hemodynamic instability and survival. Results: A total of 36 patients’ files were scanned. There were 10 cases in cardiac group and 26 cases in non-cardiac group. There were statistically better differences between primary and secondary outcome rates of cardiac cases. Although there was no difference between cardiac and non-cardiac cases in terms of primary outcome, secondary outcome was statistically significant. Timing of consultation and CVVHDF was not found to have an effect on the outcome. Conclusion: Our results indicated that CVVHDF treatment was successful even in cardiac patients with high mortality and in patients at their later stage of ARF.

Determination by LC–MS/MS of Colistins A and B in Plasma and Ultrafiltrate From Critically Ill Patients Undergoing Continuous Venovenous Hemodiafiltration

Colistin is a 50-year-old antibiotic, the use of which was ceased in the 70s and recently resumed as a "salvage therapy" against multidrug-resistant gram-negative bacteria, such as Pseudomonas aeruginosa and Acinetobacter baumannii. The narrow therapeutic range of colistin makes the choice of its correct dosage crucial, and monitoring of blood concentration is occasionally necessary for critically ill patients, including intensive care patients subjected to continuous renal replacement therapy. Two LC-MS/MS methods were developed and fully validated for the quantitative determination of colistins A and B in plasma and dialysis ultrafiltrate (UF) samples, ultimately arising from 4 patients undergoing continuous venovenous hemodiafiltration (CVVHDF). The developed methods proved to be both specific and selective. They showed good fit and linearity over the entire range of interest. Trueness and accuracy proved satisfactory. Both methods have excellent intraassay precision (percent coefficient of variations were lower than 10%) and limit of detection values in the range 20-100 ng/mL, about 1-2 orders of magnitude below the concentrations commonly detected in real samples. The mean sieving coefficient (SC) values, measured after 10 minutes of CVVHDF, were 0.42 for colistin A and 0.48 for colistin B. SC values proved to be quite stable for 24 hours, but then declined to 0.24 for colistin A and 0.32 for colistin B, respectively, after 48 hours. At the median blood flow and effluent flow rate of 120 and 28 mL/min, clearance values for colistin B were higher than 15 mL/min. During the entire duration of CVVHDF sessions, the SC and clearance values for colistin A were significantly lower than colistin B. Two simple methods for the simultaneous determination of colistins A and B have been developed and validated. Their application in the clinical setting demonstrates that CVVHDF treatment lasting 48 hours produces a relatively constant and efficient removal of the drug.

Continuous veno-venous hemodiafiltration alleviates multiple organ dysfunction syndrome in dogs

Context: Multiple organ dysfunction syndrome (MODS) is a major cause of death in critically patients. It has been hypothesized that inactivation or removal of pro-inflammatory molecules may prevent or reverse MODS.Objective: The purpose of this paper was to investigate the efficacy of continuous veno-venous hemodiafiltration (CVVHDF) as treatment for MODS in an established animal model.Materials and methods: Male Beagle dogs (n = 18) were used to establish the model and were randomly assigned to a CVVHDF, sham, or control group. The serum levels of ALT, AST, Cr, BUN, PaO2, and PaCO2 were measured as functional makers of major organs. Apoptosis, DLA-DR expression, and cytokine levels of peripheral monocytes were determined.Results: The MODS model was successfully established. After CVVHDF treatment, the WBC and neutrophil counts were lower and the monocyte count and percentage were greater, but these were unchanged in the sham and control groups. Apoptosis of CD14+ monocytes was significantly lower in the CVVHDF group than in the sham and control groups. The fraction of DLA-DR+ monocytes and IL-1β secretion was significantly greater in the sham and control groups than in the CVVHDF group. Moreover, IL-4 secretion increased significantly in the CVVHDF group but not in the control group.Discussion and Conclusion: Our study of an experimental model of MODS indicated that MODS leads to significant disruption of physiological and immune functions. CVVHDF treatment alleviated some of these symptoms due to the improvement of monocyte function, reduction of monocyte apoptosis, and increase of anti-inflammatory cytokines.

Letter to the Editor Catastrophic antiphospholipid syndrome in a patient with V Leiden variant

Letter to the Editor Catastrophic antiphospholipid syndrome in a patient with V Leiden variant

Abstract: P743 EFFECTS ON INFLAMMATORY MEDIATORS IN CRITICALLY ILL PATIENTS WITH ACUTE KIDNEY INJURY (AKI) UNDER CONTINUOUS VENO-VENOUS HEMODIAFILTRATION

Continuous veno-venous hemodiafiltration (CVVHDF) is a preferred treatment modality in hemodynamically unstable acute kidney injury (AKI) patients, because it has advantages over intermittent dialysis in terms of hemodynamic stability. However, this patient group still shows a significantly high mortality rate. To aid in the management of these high-risk patients, we evaluated the risk factors for mortality in CVVHDF-treated hypotensive AKI patients.We studied 67 patients with AKI and hypotension who were treated with CVVHDF from February 2008 to August 2010. We reviewed patient characteristics and laboratory parameters to evaluate the risk factors for 90-day mortality.Of the 67 enrolled patients (male:female=42:25; mean age=69±14 years), 18 (27%) survived until 90 days after the initiation of CVVHDF. There was no significant difference in survival rates according to the etiology of AKI [hypovolemic shock 2/10 (20%), cardiogenic shock 4/20 (20%), septic shock 12/37 (32%)]. Univariate analysis did show significant differences between survivors and non-survivors in the frequency of ventilator use (44% vs. 76%, respectively; P=0.02), APACHE II score (29±7 vs. 34±7, respectively; P=0.01), SOFA score (11±4 vs. 13±4, respectively; P=0.03), blood pH (7.3±0.1 vs. 7.2±0.1, respectively; P=0.03), and rate of urine output <500 mL for 12 hours (50% vs. 80%, respectively; P=0.03). A multivariate Cox proportional hazards model showed that a urine output<500 mL for 12 hours was the only significant risk factor for 90-day mortality following CVVHDF treatment (odds ratio=2.1, confidence interval=1.01–4.4, P=0.048).A urine output<500 mL for 12 hours before the initiation of CVVHDF is an independent risk factor for 90-day mortality in hypotensive AKI patients treated with CVVHDF.