Extracorporeal Blood Purification Techniques Research Articles

Capnocytophaga canimorsus Meningitis Complicated by Septic Shock: The Use of Extracorporeal Blood Purification Techniques

Capnocytophaga canimorsus Meningitis Complicated by Septic Shock: The Use of Extracorporeal Blood Purification Techniques

Septic Hyperinflammation-Is There a Role for Extracorporeal Blood Purification Techniques?

This manuscript investigates the role of extracorporeal blood purification techniques in managing septic hyperinflammation, a critical aspect of sepsis characterized by an uncontrolled immune response leading to multiorgan dysfunction. We provide an overview of sepsis, focusing on the dynamics of immune response, the involvement of neutrophils, and the role of the endothelium in the disease's progression. It evaluates the effectiveness of various blood purification methods, including high-cut-off membranes, high-volume hemofiltration, adsorption techniques, and albumin dialysis, in removing cytokines and endotoxin and improving hemodynamic stability. Despite some very promising results, we conclude that the current evidence does not strongly support these techniques in significantly improving survival rates in septic patients, clearly underlining the need for further research.

Impact of therapeutic plasma exchange on intact protein S, apolipoproteins, and thrombin generation

IntroductionTherapeutic plasma exchange (TPE), with solvent/detergent (S/D)-treated plasma as replacement fluid, is an extracorporeal blood purification technique with major impact on both coagulation and lipids. Our previous in vitro study showed that S/D-plasma enhances thrombin generation by lowering intact protein S (PS) levels. Aims: To evaluate the impact of altered lipid balance on coagulation phenotype during heparin-anticoagulated TPE with S/D-plasma, and to investigate whether the lowered intact PS levels with concomitant procoagulant phenotype, are recapitulated in vivo. Methods: Coagulation biomarkers, thrombin generation with Calibrated Automated Thrombogram (CAT), and lipid levels were measured before and after the consecutive 1st, 3rd and 5th episodes of TPE performed to six patients with Guillain-Barré syndrome or myasthenia gravis. The effects of in vitro dilution of S/D-plasma on thrombin generation were explored with CAT to mimic TPE. Results: Patients did not have coagulation disorders, except elevated FVIII. Intact PS, lipoproteins, especially LDL, Apolipoprotein CIII (ApoC3) and ApoB/ApoA1 ratio declined (p < 0.05). In contrast, VLDL and triglyceride levels stayed intact. CAT lag time shortened (p < 0.05). In vitro dilution of S/D plasma with co-transfused Ringer's lactate and 4% albumin partially reduced its procoagulant phenotype in CAT, which is mainly seen as peak thrombin, and modestly shortened lag time. Conclusions: After the five settings of TPE using S/D-plasma in vivo, which associated with heparinization and reduced coagulation factor activities, our observations of declining natural anticoagulant intact PS and apolipoproteins refer to rebalance of the hemostatic and lipid profiles.

Early hemofiltration as immunomodulation for septic shock in acute on chronic kidney disease: a case report

Bacterial endotoxins in sepsis induce dysregulation and excessive release of inflammatory mediators and cytokines, leading to organ dysfunction. Removing excess endotoxins and cytokines from the circulation could potentially reverse the dysregulation of the immune response. oXiris filter is capable of filtration and adsorption middle-size molecule cytokines and large molecular archives such as endotoxins.&#x0D; A man, 77 years old, weighing 70 kg, with 174 cm height and 23.17 BMI was diagnosed with septic shock with Fournier gangrene, acute on chronic kidney disease, uncontrolled blood sugar, and history of diabetes mellitus. He was put on meropenem antibiotic therapy. After necrotomies, increase in the levels of leukocytes, urea, creatinine, procalcitonin, D-dimer, NT-proBNP, and IL 6 was observed. Vasopressor dose was increased, and the patient also experienced tachycardia and fever.&#x0D; Meropenem was stopped and replaced with ceftaroline fosamil, and 24 h later hemofiltration with an oXiris filter was performed for 48 h. After hemofiltration, there was a decrease in vasopressor dose, urea, creatinine, and procalcitonin values. The patient′s hemodynamic status was stable without vasopressor, the dose of furosemide was decreased, and the urine output was increased. Then, the patient was transferred to the ward. The current patient had an upregulation of pro-inflammatory mediators as evidenced by clinical symptoms and laboratory findings. Additional treatment with extracorporeal blood purification techniques such as hemofiltration is required in these patients to facilitate the treatment of septic shock through the modulation of the immune response.&#x0D; Keywords: septic shock, dysregulation, hemofiltration, immunomodulation&#x0D; Citation: Elvia AS, Sedono R, George YWH. Early hemofiltration as immunomodulation for septic shock in acute on chronic kidney disease: a case report. Anaesth. pain intensive care 2024;28(1):182−186.DOI: 10.35975/apic.v28i1.2271&#x0D; Received: August 17, 2023; Reviewed: December 23, 2023; Accepted: December 23, 2023

Prevalence of extracorporeal blood purification techniques in critically ill patients before and during the COVID-19 pandemic in Egypt.

Extracorporeal blood-purification techniques are frequently needed in the pediatric intensive care unit (PICU), yet data on their clinical application are lacking. This study aims to review the indications, rate of application, clinical characteristics, complications, and outcomes of patients undergoing extracorporeal blood purification (i.e., by continuous renal replacement therapy [CRRT] or therapeutic plasma exchange [TPE]) in our PICU, including before the coronavirus disease 2019 (COVID-19) pandemic in 2019 and during the pandemic from 2020 to 2022. This study included children admitted for extracorporeal blood-purification therapy in the PICU. The indications for TPE were analyzed and compared to the American Society for Apheresis categories. In 82 children, 380 TPE sessions and 37 CRRT sessions were carried out children, with 65 patients (79%) receiving TPE, 17 (20.7%) receiving CRRT, and four (4.8%) receiving both therapies. The most common indications for TPE were neurological diseases (39/82, 47.5%), followed by hematological diseases (18/82, 21.9%). CRRT was mainly performed for patients suffering from acute kidney injury. Patients with neurological diseases received the greatest number of TPE sessions (295, 77.6%). Also, the year 2022 contained the greatest number of patients receiving extracorporeal blood-purification therapy (either CRRT or TPE). The use of extracorporeal blood-purification techniques increased from 2019 through 2022 due to mainly autoimmune dysregulation among affected patients. TPE can be safely used in an experienced PICU. No serious adverse events were observed in the patients that received TPE, and overall survival over the 4 years was 86.5%.

EFFECT OF MECHANICAL VIBRATION ON KINETICS OF SOLUTE ADSORPTION.

INTRODUCTION Hemoadsorption with new sorbent cartridges is an emerging extracorporeal blood purification technique. Flow distribution inside the sorbent is one of the main issues concerning the device's performance and optimal sorbent utilization. In this experiment, we aimed to investigate the efficacy of vibration during adsorption by measuring the removal of Vancomycin. METHODS In this experimental study, 1,000 mL of saline with 10 g of Vancomycin was circulated in a closed circuit (set flow of 250 mL/min) simulating a hemoadsorption blood run using HA380 minimodule cartridge containing 75 g of wet resin. This vibration model was implemented with a damping head device installed in front of the adsorption cartridge during the experiment. The kinetics of the Vancomycin were assessed by removal ratio over 120 minutes. RESULTS We found no difference between the two models. Adsorption with and without vibration did not differ significantly for partial reduction ratios, overall amount of adsorbed molecule, or adsorption kinetics. CONCLUSION The current design and structure of the minimodule cartridge demonstrated no difference in small-middle solute removal. Further improvement with the addition of mechanical vibration to the device was not observed.

Evaluation of Adsorption Therapy as an Extracorporeal Blood Purification Technique in Critically Ill Covid-19 Patients

"We aimed to evaluate the efficacy of adsorption therapy as an extracorporeal blood purification technique in critically ill patients with Coronavirus disease 2019 (COVID-19). A retrospective analysis was performed on 17 adult patients with severe COVID-19, who underwent adsorption therapy using an HA330 cartridge, at Ankara City Hospital. Each adsorption therapy was administered for three consecutive days, and each therapy session lasted three hours. Several parameters, including cytokine levels, blood count, biochemistry panel, clinical status, and mortality rate were assessed before and after each therapy session. The results obtained from this study revealed that adsorption therapy reduced IL-6 levels and improved oxygenation in the short term. However, heart rate, mean arterial pressure and SOFA score did not demonstrate significant changes. Notably, the dose of norepinephrine increased after the third session. Regrettably, only 4 out of 17 patients (23.5%) survived. Consequently, adsorption therapy appears to be effective in reducing IL-6 levels in severe COVID-19 patients. Nonetheless, further investigation is warranted to evaluate its impact on clinical outcomes."

Crush syndrome-related acute kidney injury in earthquake victims

ABSTRACT Natural disasters are unpredictable and thousands of people are affected yearly. Currently, this risk persists, given the large population living in risk areas prone to suffering another seismic event. Generally, on-site mortality is high and occurs immediately from massive trauma or asphyxia. After surviving the first event, extricated patients are at risk of developing crush syndrome caused by direct physical trauma and compression of the human body with lesions in different tissues. This could lead to several systemic complications, including acute kidney injury (AKI), sepsis, acute respiratory distress syndrome, bleeding, hypovolemic shock, arrhythmias, electrolyte disturbances and disseminated intravascular coagulation. Hence, AKI in this scenario can occur due to many causes, such as rhabdomyolysis, direct renal trauma, hypovolemia and hemodynamic alterations. The most important measure to reduce crush syndrome mortality and prevent the development of crush syndrome-related AKI in disaster situations is the immediate start of treatment. Nevertheless, despite optimal therapy delivery, these previous efforts might not suffice the development and progression of AKI, consequently, the indication of extracorporeal blood purification techniques. This narrative review provides a focused overview of crush syndrome-related AKI, including etiology, mechanisms, diagnosis, current treatment, removal of myoglobin and their limitations.

Liver replacement therapy with extracorporeal blood purification techniques current knowledge and future directions.

Clinically, it is highly challenging to promote recovery in patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF). Despite recent advances in understanding the underlying mechanisms of ALF and ACLF, standard medical therapy remains the primary therapeutic approach. Liver transplantation (LT) is considered the last option, and in several cases, it is the only intervention that can be lifesaving. Unfortunately, this intervention is limited by organ donation shortage or exclusion criteria such that not all patients in need can receive a transplant. Another option is to restore impaired liver function with artificial extracorporeal blood purification systems. The first such systems were developed at the end of the 20th century, providing solutions as bridging therapy, either for liver recovery or LT. They enhance the elimination of metabolites and substances that accumulate due to compromised liver function. In addition, they aid in clearance of molecules released during acute liver decompensation, which can initiate an excessive inflammatory response in these patients causing hepatic encephalopathy, multiple-organ failure, and other complications of liver failure. As compared to renal replacement therapies, we have been unsuccessful in using artificial extracorporeal blood purification systems to completely replace liver function despite the outstanding technological evolution of these systems. Extracting middle to high-molecular-weight and hydrophobic/protein-bound molecules remains extremely challenging. The majority of the currently available systems include a combination of methods that cleanse different ranges and types of molecules and toxins. Furthermore, conventional methods such as plasma exchange are being re-evaluated, and novel adsorption filters are increasingly being used for liver indications. These strategies are very promising for the treatment of liver failure. Nevertheless, the best method, system, or device has not been developed yet, and its probability of getting developed in the near future is also low. Furthermore, little is known about the effects of liver support systems on the overall and transplant-free survival of these patients, and further investigation using randomized controlled trials and meta-analyses is needed. This review presents the most popular extracorporeal blood purification techniques for liver replacement therapy. It focuses on general principles of their function, and on evidence regarding their effectiveness in detoxification and in supporting patients with ALF and ACLF. In addition, we have outlined the basic advantages and disadvantages of each system.

Methods of Extracorporeal Hemocorrection in Sepsis (Review)

Sepsis and septic shock remain a major problem in critical care medicine being the most common causes of death in the intensive care unit. Currently, such methods of extracorporeal blood purification as hemodiafiltration, high-volume hemofiltration, high cut-off (HCO) membrane hemofiltration are among preferable options for treatment of severe systemic disorders and pathological conditions including sepsis.The purpose of the review is to show the potentialities and prospects of the use of various extracorporeal hemocorrection methods, including those that are commonly employed in medical practice, and novel ones, either recently developed, or still under the development in experimental settings according to sepsis patho-physiology. The selected 82 papers represent comprehensible clinical and experimental data from the literature of the last five years and several earlier publications remained of current interest in a medical practice.The review presents current methods of extracorporeal hemocorrection (EHC) in patients with sepsis. The clinical pathophysiology of sepsis is described in relation to treatment options that target endotoxemia and «cytokine storm». We consider commonly used EHC methods (hemodiafiltration, high-volume hemofiltration, high cut-off membrane hemofiltration and others) and novel promising technologies that include extracorporeal kidney support device, immune support system, leukocyte inhibition module, and artificial spleen, which have been recently developed and are still under investigation in the intensive care.Conclusion. Currently, EHC methods are increasingly used not only to support renal function, but also as pathogenetic therapy option for multiple organ support and immunomodulation by reducing the level of cir-culating inflammatory mediators. Exploration of novel extracorporeal blood purification techniques for the pathogenetic treatment of patients with sepsis seems encouraging and promising.

Extracorporeal blood purification in patients with liver failure: Considerations for the low-and-middle income countries of Latin America.

Severe liver failure is common in Low-and-Medium Income Countries (LMIC) and is associated with a high morbidity, mortality and represents an important burden to the healthcare system. In its most severe state, liver failure is a medical emergency, that requires supportive care until either the liver recovers or a liver transplant is performed. Frequently the patient requires intensive support until their liver recovers or they receive a liver transplant. Extracorporeal blood purification techniques can be employed as a strategy for bridging to transplantation or recovery. The most common type of extracorporeal support provided to these patients is kidney replacement therapy (KRT), as acute kidney injury is very common in these patients and KRT devices more readily available. However, because most of the substances that the liver clears are lipophilic and albumin-bound, they are not cleared effectively by KRT. Hence, there has been much effort in developing devices that more closely resemble the clearance function of the liver. This article provides a review of various non-biologic extracorporeal liver support devices that can be used to support these patients, and our perspective keeping in mind the needs and unique challenges present in the LMIC of Latin America.

Therapeutic Plasma Exchange in Certain Immune-Mediated Neurological Disorders: Focus on a Novel Nanomembrane-Based Technology.

Therapeutic plasma exchange (TPE) is an efficient extracorporeal blood purification technique to remove circulating autoantibodies and other pathogenic substances. Its mechanism of action in immune-mediated neurological disorders includes immediate intravascular reduction of autoantibody concentration, pulsed induction of antibody redistribution, and subsequent immunomodulatory changes. Conventional TPE with 1 to 1.5 total plasma volume (TPV) exchange is a well-established treatment in Guillain-Barre Syndrome, Chronic Inflammatory Demyelinating Polyradiculoneuropathy, Neuromyelitis Optica Spectrum Disorder, Myasthenia Gravis and Multiple Sclerosis. There is insufficient evidence for the efficacy of so-called low volume plasma exchange (LVPE) (<1 TPV exchange) implemented either by the conventional or by a novel nanomembrane-based TPE in these neurological conditions, including their impact on conductivity and neuroregenerative recovery. In this narrative review, we focus on the role of nanomembrane-based technology as an alternative LVPE treatment option in these neurological conditions. Nanomembrane-based technology is a promising type of TPE, which seems to share the basic advantages of the conventional one, but probably with fewer adverse effects. It could play a valuable role in patient management by ameliorating neurological symptoms, improving disability, and reducing oxidative stress in a cost-effective way. Further research is needed to identify which patients benefit most from this novel TPE technology.

AKI in Adults with COVID-19 Infection: Mechanisms of Development and Role of Blood Filtration Devices in Treatment.

During the coronavirus disease 2019 (COVID-19) pandemic, acute kidney injury (AKI) was a common sequela of COVID-19 infection and predicted disease severity and mortality. Extracorporeal blood purification techniques involving blood filtration devices are an emerging treatment for AKI in the setting of severe COVID-19 infections. In this review, we discuss potential mechanisms for the development of AKI in COVID-19 patients as well as the various available blood filtration devices and the role they may play in managing the AKI in COVID-19 patients. A total of seven blood filters currently available were compared based on their potential in treating AKI in COVID-19 patients. Blood filtration devices show potential as an emerging treatment modality for COVID-19-induced AKI, but further clinical trials are necessary before their widespread adoption and usage.

ODP536 Rapid, Successful Control of Thyrotoxicosis Using Therapeutic Plasma Exchange as a Bridge to Thyroidectomy in an Adult Patient With Cardiogenic Shock and Hepatic Dysfunction

Abstract Background Uncontrolled Graves’ disease is associated with significant morbidity and mortality. Treatment of such patients who have developed multi-organ dysfunction is challenging, and novel interventions have to be explored. We present a case of uncontrolled thyrotoxicosis with cardiogenic shock and hepatic dysfunction successfully controlled using therapeutic plasma exchange as a bridge to definitive management with total thyroidectomy. Case Presentation Our patient is a 36-year-old Filipina with known Graves’ disease for three years but with poor compliance to medications. She was admitted due to one-month history of progressive bipedal edema, easy fatigability, palpitations, and increasing abdominal girth. On examination, she had hypotension, irregular cardiac rhythm at 120's, mild respiratory distress, jaundice, enlarged thyroid gland, decreased breath sounds, distended abdomen, and grade 2 bipedal edema. Work-up showed atrial fibrillation with rapid ventricular response, global hypokinesia, pericardial effusion, pulmonary edema, elevated liver enzymes and bilirubins, and dilated hepatic veins. The thyroid stimulating hormone was at 0. 014 uIU/mL (0.55-4.78 uIU/mL). Free T4 was at 2.54 ng/dL (0.89-1.76 ng/dL) and free T3 was at 4.1 pg/mL (2.30-4.20 pg/mL). Thyroid stimulating immunoglobulins (TSI) were positive at 7.59 IU/L (&amp;lt;0.10 IU/L). Ultrasound revealed an enlarged thyroid gland with increased vascular flow and a complicated cyst measuring 0.7×0.2×0.5 cm in the right lobe. The ongoing hepatic dysfunction precluded the use of thionamides. Radioactive iodine treatment was not considered because of its gradual effect and need for isolation which could not be done in a clinically unstable patient. Total thyroidectomy was deemed to be the best option for rapid and definitive management. Adequate pre-operative preparation was important to minimize the surgical risk. The patient was started on hydrocortisone. The medical team performed two sessions of therapeutic plasma exchange with fluid removal. The free T4 and free T3 levels decreased to 1. 0 ng/dL and 2. 04 pg/mL, respectively. The TSI level decreased to 1.45 IU/L. The liver function improved and the cardiac status stabilized. She was able to safely undergo total thyroidectomy on the ninth hospital day. Repeat 2D-echocardiogram done two days post-operatively showed improvement in ejection fraction from 33.7% to 53.1%. She was extubated three days after surgery, weaned off dobutamine within one week, and discharged nine days after surgery. Histopathology of the thyroid gland revealed papillary thyroid microcarcinoma in the right lobe. Conclusion Therapeutic plasma exchange, also known as plasmapheresis, is an extracorporeal blood purification technique that can remove circulating thyroid hormones and TSH-receptor antibodies. It's a novel treatment for complicated cases of thyroid storm but its utility is limited by cost, invasiveness, and lack of technical expertise. Our case report demonstrates that therapeutic plasma exchange is also an effective and safe treatment option for unstable patients who require rapid control of thyrotoxicosis prior to definitive treatment with thyroidectomy. Presentation: No date and time listed

Impediments that Challenged Therapeutic Plasma Exchange: Experience at a Tertiary Care Hospital in Bangladesh

Therapeutic plasma exchange (TPE) is an extracorporeal blood purification technique that removes circulating antibodies, toxin and mediators from the plasma of the patients. This study was conducted to assess the safety, type and frequency of complications with regard to the indications and technical aspects of the TPE procedure performed in patients referred with different indications. A total of 127 patients’ clinical data treated with 424 TPE cycles over a period of 6 years from June 2016 to July 2022 at the apheresis unit of the Department of Transfusion Medicine, Bangabandhu Sheikh Mujib Medical University in Bangladesh, were enrolled in this retrospective observational study. The median age was 35.26 years (range 19–63) with a male predominance. The indications were mostly American Society for Apheresis (ASFA) category I (81.895%) and the most common indications were neurological indications including Guillain–Barré Syndrome (GBS) (61.41%), Myasthenia Gravis (MG) (10.24%) followed by Acute Liver Failure (7.09%). Venous access was established with the femoral vein maintaining blood flow at 70 ml/min using acid citrate-dextrose solution A (ACD-A) anticoagulant. TPE was frontline therapy in 55.91% of the patients. Human albumin was used as a replacement fluid in 88% and fresh frozen plasma in 12% of the cycles. Incidence of procedural complication was 49% (n = 206) and majority of them were mild (n = 191; 45%) with only 3% and 0.47% being moderate and severe, respectively. Mild complications were hypocalcemia (n = 127; 29.95%), anxiety (n = 109; 25.70%), restlessness (n = 68; 16.04%) and hypotension (n = 46; 10.85%) in albumin group and anxiety (n = 31; 7.31%), hypocalcemia (n = 23; 5.42%), muscle cramp (n = 23; 5.42%) in FFP group. Interestingly, complications were almost similar in albumin and FFP groups except for allergic reactions and mild reactions which were mostly manageable and preventable with continuous, cautious monitoring. Our findings suggest that TPE is a relatively safe procedure and severe complications such as hypotension and anaphylaxis is preventable through continuous and dedicated monitoring by expert personnel.

A Review of Extracorporeal Blood Purification Techniques for the Treatment of Critically Ill Coronavirus Disease 2019 Patients.

In late 2019, a novel betacoronavirus, later termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was discovered in patients with an unknown respiratory illness in Wuhan, China. SARS-CoV-2 and the disease caused by the novel coronavirus, coronavirus disease 2019 (COVID-19), spread rapidly and resulted in the World Health Organization declaring a pandemic in March 2020. In a minority of patients infected with SARS-CoV-2, severe illness develops characterized by a dysregulated immune response, acute respiratory distress syndrome, and multisystem organ failure. Despite the development of antiviral and multiple immunomodulatory therapies, outcomes of severe illness remain poor. In response, the Food and Drug Administration in the United States authorized the emergency use of several extracorporeal blood purification (EBP) devices for critically ill patients with COVID-19. Extracorporeal blood purification devices target various aspects of the host response to infection to reduce immune dysregulation. This review highlights the underlying technology, currently available literature on use in critically ill COVID-19 patients, and future studies involving four EBP platforms: 1) oXiris filter, 2) CytoSorb filter, 3) Seraph 100 Microbind blood affinity filter, and 4) the Spectra Optia Apheresis System with the Depuro D2000 Adsorption Cartridge.

Membrane patterning through horizontally aligned microchannels developed by sulfated chopped carbon fiber for facile permeability of blood plasma components in low-density lipoprotein apheresis

Low-density lipoprotein (LDL) apheresis via membrane filtration process is an extracorporeal blood purification technique using for the treatment of patients suffering from familial hypercholesterolemia (FH) and severe coronary artery disease (CAD). As much as the importance of LDL separation, the maximum permeability of beneficial blood plasma components through the membrane is regarded as an important issue in this method. Herein, patterned membranes are produced by the effect of horizontally aligned microchannels that formed by the incorporation of sulfated chopped carbon fiber (SCCF) in the membrane structure. Characterization studies verified the binding of carrageenan as a sulfated polysaccharide on the surface of chopped carbon fiber (CCF). Transmission and reflective optical micrographs demonstrated the orientation of SCCFs in a horizontally aligned direction in the membrane structure. Surface analyses including water contact angle and zeta potential revealed the improvement of hydrophilicity and negative charge density of membranes containing SCCF, respectively. Moreover, membrane surface roughness was enhanced with the addition of SCCF that led to a better selectivity. With the enhancement of SCCF concentration, the ratio of molecular weight cut-off to molecular weight retention onset (MWCO/MWRO) that is a marker of membrane selectivity was decreased effectively. The morphology study displayed the formation of an interfacial distance between SCCF and the polymeric matrix that produced horizontally parallel microchannels in the membrane structure. Blood plasma filtration and cardiovascular disease (CVD) risk factors verified that the M−SCCF3 (containing 0.7 wt% SCCF) due to having desired morphology and characteristics had the best performance for the LDL separation, and permeability of beneficial plasma components like high-density lipoprotein (HDL), and albumin protein. Furthermore, cell cytotoxicity analysis revealed no cytotoxicity in membranes which endorsed desired interaction of developed membranes with L-929 cells as the representation of physiological ambient. Also, reduction of protein adsorption on the membrane surface, and prolongation of coagulation times endorsed the hemocompatibility of membranes. The overall results certified that the M−SCCF3 due to having the best performance and desired structural properties was the best membrane for use in LDL apheresis.

Application of combined hemadsorption with eculizumab as rescue treatment of a pediatric patient with multiple organ failure related to severe hemolytic uremic syndrome

Many different extracorporeal blood purification techniques have been proposed in critically ill adult patients with sepsis and sepsis-like syndromes. In this context, hemoperfusion devices such as CytoSorb have been recently approved for extracorporeal cytokine removal. In the neonatal and pediatric setting however, the application of this method brings with it various challenges including profound technical difficulties with data for its application in critically ill pediatric patients remaining sparse. We present a case of a 2-year-old female patient affected by severe Shiga toxin-producing Escherichia coli-hemolytic uremic syndrome (STECHUS) admitted to our Intensive Care Unit (ICU) with anuria, hemodynamic instability and severe neurological deterioration. By using a combined “rescue” therapy regimen with hemodiafiltration, hemadsorption (CytoSorb), plasmapheresis (PEX) and Eculizumab, the patient could be successfully stabilized, accompanied by a control of the hyperinflammatory response and an improvement in the neurological condition, finally leading to recovery. In pediatric patient extracorporeal blood purification techniques might potentially represent a promising adjuvant therapeutic option for the complications related to hemolytic uremic syndrome and hyperinflammation, but further studies are needed.

Plasma Exchange in Acute and Acute on Chronic Liver Failure.

Liver failure in the context of acute (ALF) and acute on chronic liver failure (ACLF) is associated with high mortality in the absence of a liver transplant. For decades, therapeutic plasma exchange (TPE) is performed for the management of immune-mediated diseases. TPE has emerged as an attractive extracorporeal blood purification technique in patients with ALF and ACLF. The basic premise of using TPE is to remove the toxic substances which would allow recovery of native liver functions by facilitating liver regeneration. In recent years, encouraging data have emerged, suggesting the benefits of TPE in patients with liver failure. TPE has emerged as an attractive liver support device for the failing liver until liver transplantation or clinical recovery. The data in patients with ALF suggest routine use of high-volume TPE, while the data for such a strategy are less robust for patients with ACLF.

Therapeutic plasma exchange in critically ill children: experience of the pediatric intensive care unit of two centers in Chile

IntroductionTherapeutic plasma exchange (TPE) is an extracorporeal blood purification technique used in a wide spectrum of diseases. We aim to review the indications, complications, and outcomes of critically ill children who received TPE and to compare a membrane versus centrifugal method in this cohort. MethodsA retrospective observational study in two pediatric intensive care units in Chile during eight years (2011–2019) Results: A total of 36 patients underwent 167 TPE sessions (20 centrifugation and 16 membrane-based). The more frequent indications for TPE were autoimmune neurological diseases in 14 cases, renal diseases (9), and rheumatological disorders (5). 58 % of children received other immunomodulatory therapy. According to ASFA, 45 % of cases were I-II category, 50 % to III, and 5% not classified. Response to treatment was complete in 64 % (23/36) and partial in 33 % (12/36). Complications occurred in 17.4 % of sessions, and the most frequent was transient hypotension during the procedure. Overall survival at discharge from the PICU was 92 %. Patients who received TPE as a single therapy (n = 26) survived 96 %. The clinical outcomes between the two apheresis methods were similar. Survivors had a significantly lower PELOD score on admission (14.5 vs. 6.5, p = 0.004). ConclusionsTPE is mainly indicated as a rescue treatment in neurological autoimmune diseases refractory to conventional immunomodulatory treatment.Complications in critically ill children are mild and low. The outcome in children requiring TPE as a single therapy is good, and no differences were observed with centrifugation or membrane method.