Early Continuous Venovenous Hemofiltration Research Articles

Effects of early hemofiltration on organ function and intra-abdominal pressure insevere acute pancreatitis patients with abdominal compartment syndrome .

To study the effects of early continuous veno-venous hemofiltration (CVVH) on organ function and intra-abdominal pressure (IAP) in severe acute pancreatitis (SAP) patients with abdominal compartment syndrome (ACS). 48 SAP patients with ACS were included in this study. Among them, 37 patients, receiving both conventional treatment and hemofiltration therapy in the ICU, were regarded as the treatment group, and the rest, receiving only conventional treatment, were regarded as the control group. Symptoms, signs, and adverse reactions of both groups were observed and recorded during treatments. Serum and urine amylase, liver and kidney function, C-reactive protein, and intra-abdominal pressure of the patients were detected before and on days 1, 2, 3, 4, 5, and 6 after treatment. 1. Symptoms and signs in the treatment group disappeared quickly, and their hospitalization time was significantly shorter than those of control group (p < 0.05). 2. After treatment, on days 1, 2, 3, 4, 5, and 6, patients' serum and urine amylase levels, C-reactive protein, and intra-abdominal pressure were significantly lower, and liver and kidney function was significantly better than those of the control group (p < 0.05). Early hemofiltration in SAP with ACS can effectively reduce intra-abdominal pressure, improve symptoms, accelerate liver and renal function recovery, avoid multiple organ failure and decrease mortality rate.

Early continuous veno-venous hemofiltration may prevent development of intra-abdominal hypertension in patients with severe acute pancreatitis

Early continuous veno-venous hemofiltration may prevent development of intra-abdominal hypertension in patients with severe acute pancreatitis

Early Continuous Veno-Venous Hemofiltration Is Effective in Decreasing Intra-Abdominal Pressure and Serum Interleukin-8 Level in Severe Acute Pancreatitis Patients with Abdominal Compartment Syndrome

Objective: The aim of this study was to evaluate the efficacy of early continuous veno-venous hemofiltration (CVVH) in decreasing the intra-abdominal pressure (IAP) and serum interleukin-8 (IL-8) level in severe acute pancreatitis (SAP) patients with abdominal compartment syndrome (ACS). Methods: Twenty-five ACS patients of SAP were enrolled in a prospective study conducted according to the standard management protocol. They were treated in the intensive care unit (ICU) of Affiliated Yidu Central Hospital of Weifang Medical College and underwent CVVH. Eleven patients were set up as the control group that received no hemofiltration and surgical treatment due to economic or other reasons but solely conventional treatment. Serum amylase, liver and kidney function, and C reactive protein were investigated before and after treatment. IAP and blood level of IL-8 were measured daily to investigate their time course of changes and the correlation between the 2 parameters. Results: Serum amylase levels, C-reactive protein and IAP were significantly lower and liver and kidney function was significantly better than those of the control group (p < 0.05). IAP on admission to the ICU was high, at 22.9 ± 2.1 mm Hg. The IAP was significantly lower to 17.2 ± 2.2 mm Hg (p < 0.01) 24 h after the initiation of CVVH, and thereafter decreased rapidly. The average blood level of IL-8 was high at 88.2 ± 25.1 ng/L on admission. However, it significantly decreased to 63.2 ± 18.7 ng/L (p < 0.01) 24 h after the initiation of CVVH, and subsequently decreased. There was a significant positive correlation between the blood level of IL-8 and IAP(r = 0.62, p < 0.01). Conclusions: CVVH is effective to decrease the IAP and the blood level of IL-8 in ACS patients of SAP. The blood level of IL-8 was significantly correlated with IAP, suggesting that IL-8 might play an important role in the pathogenesis of ACS. Early CVVH appeared to be effective in the treatment of ACS in patients with SAP through the removal of causative cytokines such as IL-8, and it thereby decreased interstitial edema to lower IAP and should be applied in the early stage of ACS. Video Journal Club ‘Cappuccino with Claudio Ronco' at http://www.karger.com/?doi=480223.

Effects of Early Continuous Venovenous Hemofiltration on E-Selectin, Hemodynamic Stability, and Ventilatory Function in Patients with Septic-Shock-Induced Acute Respiratory Distress Syndrome.

Objective. To investigate the effects of 72-hour early-initiated continuous venovenous hemofiltration (ECVVH) treatment in patients with septic-shock-induced acute respiratory distress syndrome (ARDS) (not acute kidney injury, AKI) with regard to serum E-selectin and measurements of lung function and hemodynamic stability. Methods. This prospective nonblinded single institutional randomized study involved 51 patients who were randomly assigned to receive or not receive ECVVH, an ECVVH group (n = 24) and a non-ECVVH group (n = 27). Besides standard therapies, patients in ECVVH group underwent CVVH for 72 h. Results. At 0 and 24 h after initiation of treatment, arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio, extravascular lung water index (EVLWI), and E-selectin level were not significantly different between groups (all P > 0.05). Compared to non-ECVVH group, PaO2/FiO2 is significantly higher and EVLWI and E-selectin level are significantly lower in ECVVH group (all P < 0.05) at 48 h and 72 h after initiation of treatment. The lengths of mechanical ventilation and stay in intensive care unit (ICU) were shorter in ECVVH group (all P < 0.05), but there was no difference in 28-day mortality between two groups. Conclusions. In patients with septic-shock-induced ARDS (not AKI), treatment with ECVVH in addition to standard therapies improves endothelial function, lung function, and hemodynamic stability and reduces the lengths of mechanical ventilation and stay in ICU.

Coagulation, Fibrinolysis and Inhibitors in Failing Filters during Continuous Venovenous Hemofiltration in Critically Ill Patients with Acute Kidney Injury: Effect of Anticoagulation Modalities

Introduction: The mechanisms of early filter failure and clotting with different anticoagulation modalities during continuous venovenous hemofiltration (CVVH) are largely unknown. Methods: Citrate, heparin and no anticoagulation were compared. Blood was drawn pre- and post filter up to 720 min. Concentrations of the thrombin-antithrombin (TAT), activated protein C-protein C inhibitor (APC-PCI), and type I plasminogen activator inhibitor (PAI-1) were determined. Results: In case of early filter failure (<24 h), inlet concentrations of TAT and APC-PCI were higher over time, irrespective of anticoagulation. There was more production of APC-PCI and platelet-derived PAI-1 in the filter after 10 min in the heparin group than in other groups. In clotting filters, production of APC-PCI and PAI was also higher with heparin than citrate. Conclusion: Coagulation activation in plasma and inhibition of anticoagulation in plasma and filter may partly determine early CVVH filter failure due to clotting, particularly when heparin is used. Regional anticoagulation by citrate circumvents the inhibition of anticoagulation and fibrinolysis by platelet activation following heparin.

Management of abdominal compartment syndrome in severe acute pancreatitis patients with early continuous veno-venous hemofiltration.

The present study investigates whether early continuous veno-venous hemofiltration (CVVH) is effective for decreasing intra-abdominal pressure (IAP) and serum TNF-α in abdominal compartment syndrome (ACS) patients of severe acute pancreatitis (SAP), and to study the correlation between IAP and serum TNF-α level. Twenty-five ACS patients of SAP were treated in the ICU and underwent CVVH. IAP and blood level of TNF-α were measured daily to investigate their time-course of changes and the correlation between the two parameters. IAP on admission to the ICU was high (22.9±2.1 mmHg). The IAP was significantly lower (17.2±2.2 mmHg; p <0.01) 24 h after initiation of CVVH, and thereafter decreased rapidly. Mean the blood level of TNF-α was high (59.9±18.2 ng/L) on admission. However, it significantly decreased (41.1±12.8 ng/L; p <0.01) 24 h after initiation of CVVH, and subsequently decreased. There was a significant positive correlation between blood level of TNF-α and IAP (r = 0.53, p <0.01). CVVH significantly decreased IAP and TNF-α in ACS patients of SAP. TNF-α was significantly correlated with IAP, suggesting that TNF-α may play an important role in the pathogenesis of ACS. Early CVVH can improve vascular permeability through elimination of cytokines such as TNF-α, and thereby decrease interstitial edema to lower IAP and should be applied in the early stages of ACS.

Early Classic Hemofiltration Exhibits No Benefits in Severe Acute Pancreatitis With Early Organ Failure: A Retrospective Case-Matched Study

Continuous venovenous hemofiltration (CVVH) is an important organ supportive technique. This study aimed to evaluate the impact of early classic CVVH on the outcomes of severe acute pancreatitis (SAP) patients with early organ failure (EOF). Between 2008 and 2012, a total of 44 SAP patients with EOF were admitted to our department. The 44 patients were classified into two groups according to whether they received early classic CVVH (2 L/h, initiated within 24 h after admission): 25 patients received early CVVH (ECVVH group), and 19 patients did not receive early CVVH (control group). The two groups were matched for age and Acute Physiology and Chronic Health Evaluation II scores. The severity of organ dysfunctions was evaluated by Sequential Organ Failure Assessment (SOFA) scores. Each group included 19 patients. The baseline characters between the two groups were balanced. The SOFA scores in the ECVVH group increased compared with those in the control group. The time to weaning from mechanical ventilation was significantly longer in the ECVVH group (log-rank test: χ(2) = 4.007, P = 0.045). Renal support was also significantly prolonged in the ECVVH group (the number of patients receiving CVVH 72 h after admission: 10 vs. 3, respectively, P = 0.038). Nine patients died in the ECVVH group versus six patients in the control group (P = 0.508). In conclusion, our study failed to prove that early classic CVVH had any benefits on the outcomes of SAP patients with EOF. Unexpectedly, early classic CVVH worsened organ functional capacity. However, it is possible that CVVH using advanced techniques may be beneficial in SAP patients with EOF.

Invited Commentary

A generally accepted essential element for successful separation from extracorporeal membrane oxygenation is the removal of excess body water. What remain controversial are when and how to remove the fluid: early or late, with diuretics or with hemofiltration techniques. In this series, the authors [1] demonstrate increased acute kidney injury and death when early continuous venovenous hemofiltration (CVVH) is used during pediatric cardiac support and conclude that “early” CVVH is not justified.

Early Renal Replacement Therapy During Pediatric Cardiac Extracorporeal Support Increases Mortality

Acute kidney injury is a common comorbidity for children placed on extracorporeal membrane oxygenation (ECMO) because of primary cardiac disease. Continuous venovenous hemofiltration (CVVH) can optimize fluid status and lessen inflammatory response during ECMO. However, published data are derived primarily from children without primary cardiac disease. A retrospective analysis of our institutional ECMO database from 2002 to 2011 was performed. To limit the bias that CVVH initiation was after evidence of end-organ injury, we considered "early CVVH" to be instituted within 48 hours of ECMO initiation. Multivariate logistic regression was undertaken to adjust for covariates. Of 153 cardiac ECMO patients, 59 (39%) received early CVVH. Time from ECMO initiation to CVVH initiation was 1.7±0.7 days (median 1 day). Pre-ECMO and post-ECMO serum creatinine levels were similar in both groups. However, peak serum creatinine was 1.1±0.4 mg/dL (median 1.0 mg/dL) in the ECMO and CVVH group and 0.9±0.4 mg/dL (median 0.8 mg/dL) in the ECMO alone group (p=0.003). Patients who received CVVH had a higher mortality (p<0.0001), were less likely to have had ECPR (p=0.004), and had a longer duration on ECMO (p<0.0001). In multivariate analysis subjects receiving CVVH support within 48 hours of ECMO cannulation were 3 times more likely to die during their hospitalization (odds ratio 3.02; 95% confidence interval 1.32 to 6.9, p=0.009) after adjusting for other significant risk factors. Early CVVH in pediatric cardiac patients requiring ECMO is associated with increased mortality. Early CVVH in the cardiac ECMO population does not appear justified.

Renal Protective Effects of Early Continuous Venovenous Hemofiltration in Rhabdomyolysis: Improved Renal Mitochondrial Dysfunction and Inhibited Apoptosis

Rhabdomyolysis (RM) and subsequent myoglobin (Mb) deposition can lead to acute kidney injury. Continuous venovenous hemofiltration (CVVH) can remove Mb, but direct renal protection is unclear. We hypothesized that CVVH can improve renal mitochondrial dysfunction in its early stage. Twenty-four mongrel dogs were randomly divided into four groups: (A) control; (B) model; (C) model + CVVH (50 mL/kg/h); and (D) model + CVVH (30 mL/kg/h). RM was induced by glycerol via intramuscular injection. The dogs were closely monitored for urine flow and renal function. Mb, plasma tumor necrosis factor-α (TNF-α), and interleukin (IL)-6 were measured by enzyme-linked immunosorbent assay. After 8 h of CVVH, the morphological changes of renal mitochondria were observed and mitochondrial function indicators (reactive oxygen species, malondialdehyde, and respiratory control index) were detected. Western blot analysis was used to detect the expression of Mb, TNF-α, and IL-6 in renal tubules. The terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling assay method and Western blot analysis were used to detect apoptosis and apoptosis-related proteins. In group B, the dog urine output gradually decreased with increased blood creatinine. In groups C and D, the urine output was normal and stable. CVVH effectively eliminated Mb. High-dose CVVH was significantly better for removal efficiency than low-dose CVVH. CVVH significantly reduced the deposition of circulating Mb in the kidney in a dose-dependent manner. The impact of CVVH on TNF-α and IL-6 were not observed. The morphological changes of mitochondria and function indicators were significantly improved in group C compared with groups D and B. Compared with group B, renal apoptosis and apoptosis-related protein expression were inhibited in groups C and D. Group C was significantly better for mitochondrial improvement and apoptosis inhibition than group D. At the cellular and molecular level, CVVH can improve renal mitochondrial function and inhibit cell apoptosis. Early CVVH can protect from RM-caused renal injuries in a dose-dependent manner.

Continuous veno-venous hemofiltration for treatment of enterovirus 71-induced fulminant cardiopulmonary failure: a case report

IntroductionFulminant cardiopulmonary failure is a severe complication of hand, foot and mouth diseases due to enterovirus 71 infection, with a high mortality rate. The treatment is mainly supportive with aggressive cardiopulmonary resuscitation. We report the use of continuous veno-venous hemofiltration in a patient with pulmonary edema and shock due to enterovirus 71 infection. To the best of our knowledge, this is the first report of the use of continuous veno-venous hemofiltration to successfully treat a patient with fulminant cardiopulmonary failure due to enterovirus 71 infection.Case presentationA 36-month-old Asian girl presented to our hospital with pulmonary edema, refractory hypotension and severe cardiac dysfunction due to enterovirus 71 infection. In addition to the standard management and care, we performed continuous veno-venous hemofiltration to overcome refractory shock and our patient eventually made a full recovery. At a three-month follow-up, a full assessment revealed no neurological sequelae.ConclusionsIn the management of patients with enterovirus 71-related fulminant cardiopulmonary failure, early continuous veno-venous hemofiltration may be considered as an alternative treatment to improve patient survival and to prevent severe neurological disabilities.

Effect of continuous veno-venous hemofiltration in treatment of severe acute pancreatitis

Objective To explore the effect of continuous veno-venous hemofiltration(CVVH) on patients with severe acute panereatitis(SAP). Methods Twenty patients with severe acute pancreatitis were treated with CVVH. Their clinical data including cell gene mensuration、part of biochemistry index、APACHEⅡscore etc were analysed. Results All patients'temperature and abdominal distention、bellyache were evidently easely after the CVVH treat ment,TNF-α、IL-8 in blood were declined, K+ 、 Cr were also improved to some extent. Exactly after treated 24 hours. The steadiness of haemodynamics was maintainable. Conclusion The early CVVH treatment in patients with SAP could alleviate clinical sign obviously in acute reactive period. Key words: Continuous veno-venous hemofileration; Ssevere acute pancreatitis

Continuous venovenous hemofiltration in severely burned patients with acute kidney injury: a cohort study

IntroductionAcute kidney injury (AKI) is a common and devastating complication in critically ill burn patients with mortality reported to be between 80 and 100%. We aimed to determine the effect on mortality of early application of continuous venovenous hemofiltration (CVVH) in severely burned patients with AKI admitted to our burn intensive care unit (BICU).MethodsWe performed a retrospective cohort study comparing a population of patients managed with early and aggressive CVVH compared with historical controls managed conservatively before the availability of CVVH. Patients with total body surface area (TBSA) burns of more than 40% and AKI were treated with early CVVH and their outcomes compared with a group of historical controls.ResultsOverall, the 28-day mortality was significantly lower in the CVVH arm (n = 29) compared with controls (n = 28) (38% vs. 71%, P = 0.011) as was the in-hospital mortality (62% vs. 86%, P = 0.04). In a subgroup of patients in shock, a dramatic reduction in the pressor requirement was seen after 24 and 48 hours of treatment. Compared with controls (n = 19), significantly fewer patients in the CVVH group (n = 21) required vasopressors at 24 hours (100% vs 43%, P < 0.0001) and at 48 hours (94% vs 24%, P < 0.0001). In those with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), there was a significant increase from baseline in the partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ratio at 24 hours in the CVVH group (n = 16, 174 ± 78 to 327 ± 122, P = 0.003) but not the control group (n = 20, 186 ± 64 to 207 ± 131, P = 0.98).ConclusionsThe application of CVVH in adult patients with severe burns and AKI was associated with a decrease in 28-day and hospital mortality when compared with a historical control group, which largely did not receive any form of renal replacement. Clinical improvements were realized in the subgroups of patients with shock and ALI/ARDS. A randomized controlled trial comparing early CVVH to standard care in this high-risk population is planned.

Influence of continuous veno-venous hemofiltration on the course of acute pancreatitis

To investigate whether continuous veno-venous hemofiltration (CVVH) in different filtration rate to eliminate cytokines would result in different efficiency in acute pancreatitis, whether the saturation time of filter membrane was related to different filtration rate, and whether the onset time of CVVH could influence the survival of acute pancreatitis. Thirty-seven patients were classified into four groups randomly. Group 1 underwent low-volume CVVH within 48 h of the onset of abdominal pain (early CVVH, n = 9). Group 2 received low-volume CVVH after 96 h of the onset of abdominal pain (late CVVH, n = 10). Group 3 underwent high-volume CVVH within 48 h of the onset of abdominal pain (early CVVH, n = 9). Group 4 received high-volume CVVH after 96 h of the onset of abdominal pain (late CVVH, n = 9). CVVH was sustained for at least 72 h. Blood was taken before hemofiltration, and ultrafiltrate was collected at the start of CVVH and every 12 h during CVVH period for the purpose of measuring the concentrations of TNF-alpha, IL-1beta and IL-6. The concentrations of TNF-alpha, IL-1beta and IL-6 were measured by swine-specific ELISA. The Solartron 1 255 B frequency response analyzer (British) was used to observe the resistance of filter membrane. The survival rate had a significant difference (94.44% vs 68.42%, P<0.01) high-volume and low-volume CVVH patients. The survival rate had also a significant difference (88.89% vs 73.68%, P<0.05) between early and late CVVH patients. The hemodynamic deterioration (MAP, HR, CVP) was less severe in groups 4 and 1 than that in group 2, and in group 3 than in group 4. The adsorptive saturation time of filters membranes was 120-180 min if the filtration rate was 1 000-4 000 mL/h. After the first, second and third new hemofilters were changed, serum TNF-alpha concentrations had a negative correlation with resistance (r: -0.91, -0.89, and -0.86, respectively in group 1; -0.89, -0.85, and -0.76, respectively in group 2; -0.88, -0.92, and -0.82, respectively in group 3; -0.84, -0.87, and -0.79, respectively in group 4). The decreasing extent of TNF-alpha, IL-1beta and IL-6 was significantly different between group 3 and group 1 (TNF-alpha P<0.05, IL-1beta P<0.05, IL-6 P<0.01), between group 4 and group 2 (TNF-alpha P<0.05, IL-1beta P<0.05, IL-6 P<0.01), between group 1 and group 2 (TNF-alpha P<0.05, IL-1beta P<0.05, IL-6 P<0.05), and between group 3 and group 4 (TNF-alpha P<0.01, IL-1beta P<0.01, IL-6 P<0.05), respectively during CVVH period. The decreasing extent of TNF-alpha and IL-1beta was also significantly different between survival patients and dead patients (TNF-alpha P<0.05, IL-1beta P<0.05). In survival patients, serum concentration of TNF-alpha and IL-1beta decreased more significantly than that in dead patients. High-volume and early CVVH improve hemodynamic deterioration and survival in acute pancreatitis patients. High-volume CVVH can eliminate cytokines more efficiently than low-volume CVVH. The survival rate is related to the decrease extent of TNF-alpha and IL-1beta. The adsorptive saturation time of filter membranes are different under different filtration rate condition. The filter should be changed timely once filter membrane adsorption is saturated.