Extracorporeal Blood Purification Research Articles

Continuous renal replacement therapy and therapeutic plasma exchange in pediatric liver failure.

Patients with acute liver failure (ALF) and acute on chronic liver failure (ACLF) have significant morbidity and mortality. They require extracorporeal blood purification modalities like continuous renal replacement therapy (CRRT) and therapeutic plasma exchange (TPE) as a bridge to recovery or liver transplantation. Limited data are available on the outcomes of patients treated with these therapies. This is a retrospective single-center study of 23 patients from 2015 to 2022 with ALF/ACLF who underwent CRRT and TPE. We aimed to describe the clinical characteristics and outcomes of these patients.Median (IQR) age was 0.93 years (0.57, 9.88), range 16 days to 20 years. Ten (43%) had ALF and 13 (57%) ACLF. Most (n = 19, 82%) started CRRT for hyperammonemia and/or hepatic encephalopathy and all received TPE for refractory coagulopathy. CRRT was started at a median of 2 days from ICU admission, and TPE started on the same day in most. The liver transplant was done in 17 (74%), and 2 recovered native liver function. Four patients, all with ACLF, died prior to ICU discharge without a liver transplant. The median peak ammonia pre-CRRT was 131 µmol/L for the whole cohort. The mean (SD) drop in ammonia after 48h of CRRT was 95.45 (43.72) µmol/L in those who survived and 69.50 (21.70) µmol/L in those who did not (p 0.26). Those who survived had 0 median co-morbidities compared to 2.5 in non-survivors (aOR (95% CI) for mortality risk of 2.5 (1.1-5.7), p 0.028). Conclusion: In this cohort of 23 pediatric patients with ALF or ACLF who received CRRT and TPE, 83% survived with a liver transplant or recovered with their native liver. Survival was worse in those who had ACLF and those with co-morbid conditions. What is Known: • Pediatric acute liver failure is associated with high mortality. • Patients may require extracorporeal liver assist therapies (like CRRT, TPE, MARS, SPAD) to bridge them over to a transplant or recovery of native liver function. What is New: • Standard volume plasma exhange has not been evaluated against high volume plasma exchange for ALF. • The role, dose, and duration of therapeutic plasma exchange in patients with acute on chronic liver failure is not well described.

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

Porous Microspheres as Pathogen Traps for Sepsis Therapy: Capturing Active Pathogens and Alleviating Inflammatory Reactions.

Sepsis is a systemic inflammatory response syndrome caused by pathogen infection, while the current antibiotics mainly utilized in clinical practice to combat infection result in the release of pathogen-associated molecular patterns (PAMPs) in the body. Herein, we provide an innovative strategy for controlling sepsis, namely, capturing active pathogens by means of extracorporeal blood purification. Carbon nanotubes (CNTs) were modified with dimethyldiallylammonium chloride (DDA) through γ-ray irradiation-induced graft polymerization to confer a positive charge. Then, CNT-DDAs are blended with polyurethane (PU) to prepare porous microspheres using the electro-spraying method. The obtained microspheres with a pore diameter of 2 μm served as pathogen traps and are termed as PU-CNT-DDA microspheres. Even at a high flow rate of 50 mL·min-1, the capture efficiencies of the PU-CNT-DDAs for Escherichia coli and Staphylococcus aureus remained 94.7% and 98.8%, respectively. This approach circumvents pathogen lysis and mortality, significantly curtails the release of PAMPs, and hampers the production of pro-inflammatory cytokines. Therefore, hemoperfusion using porous PU-CNT-DDAs as pathogen traps to capture active pathogens and alleviate inflammation opens a new route for sepsis therapy.

Extracorporeal Organ Support for Burn-Injured Patients

As mortality relating to severe acute burn injury improves, patients are surviving longer into the critical care phase, which is commonly complicated by multisystem organ failure. Extracorporeal organ support (ECOS) represents a set of potential therapeutic technologies for managing patients with organ-specific complications. This article provides a comprehensive review of the existing literature, focusing on the use of continuous kidney replacement therapy, extracorporeal membrane oxygenation, extracorporeal carbon dioxide removal, and extracorporeal blood purification. Though promising, many of these technologies are in the early phases of implementation and are restricted to well-resourced medical systems, limiting their use in large scale casualty and austere scenarios.

Efferent methods of therapy for critical illness

Extracorporeal blood purification is intended to eliminate dysregulation of the immune system. The concept of extracorporeal therapy is based on the nonspecific clearance of inflammatory mediators and triggers, which attenuates the systemic expression of inflammatory mediators. The main types of extracorporeal therapy are hemoadsorption and plasma exchange. Hemoadsorption is used primarily as an adjuvant treatment for septic shock and other severe inflammatory conditions, including severe forms of COVID-19 with cytokine storm.
 Reliable data demonstrating the benefit of hemoadsorption in critically ill patientsis is limited. Recommendations for the use of hemoadsorption devices are often based on incomplete data or questionable interpretations of available data. Given the lack of evidence for the benefit of hemoadsorption in the treatment of severe inflammation, sepsis, liver failure and rhabdomyolysis, its routine use in clinical practice is not justified until the mechanisms underlying these findings are fully elucidated.
 Plasma replacement is a potentially life-saving invasive extracorporeal blood purification procedure that replaces plasma with a substitute fluid (saline, albumin solution, fresh frozen plasma, or a combination of these) with the risk of side effects and complications. There is still uncertainty regarding the timing, type of plasma exchange, volume and frequency of plasma filtration. Although plasma replacement is considered to be relatively safe, there is still insufficient evidence to support its inclusion in sepsis treatment protocols.
 Reports of the use of extracorporeal methods in the treatment of patients with severe refractory systemic inflammation provide evidence of decreased levels of inflammatory biomarkers, improved hemodynamic parameters, and decreased organ failure. However, according to the results of randomized clinical trials, extracorporeal therapy does not affect clinical outcomes, and in some even increases mortality. To clarify the effectiveness of extracorporeal therapy, it is necessary to study the mechanisms of interaction of the devices used with target and non-target blood components and large-scale randomized controlled trials assessing the ability of this therapy to improve clinical outcomes.

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.

The use of extracorporeal blood purification therapies and sequential extracorporeal support in patients with septic shock (EROICASS): a study protocol for a national, non-interventional, observational multicenter, prospective study

BackgroundSeptic shock, a critical condition characterized by organ failure, presents a substantial mortality risk in intensive care units (ICUs), with the 28-day mortality rate possibly reaching 40%. Conventional management of septic shock typically involves the administration of antibiotics, supportive care for organ dysfunction, and, if necessary, surgical intervention to address the source of infection. In recent decades, extracorporeal blood purification therapies (EBPT) have emerged as potential interventions aimed at modulating the inflammatory response and restoring homeostasis in patients with sepsis. Likewise, sequential extracorporeal therapy in sepsis (SETS) interventions offer comprehensive organ support in the setting of multiple organ dysfunction syndrome (MODS). The EROICASS study will assess and describe the utilization of EBPT in patients with septic shock. Additionally, we will evaluate the potential association between EBPT treatment utilization and 90-day mortality in septic shock cases in Italy.MethodsThe EROICASS study is a national, non-interventional, multicenter observational prospective cohort study. All consecutive patients with septic shock at participating centers will be prospectively enrolled, with data collection extending from intensive care unit (ICU) admission to hospital discharge. Variables including patient demographics, clinical parameters, EBPT/SETS utilization, and outcomes will be recorded using a web-based data capture system. Statistical analyses will encompass descriptive statistics, hypothesis testing, multivariable regression models, and survival analysis to elucidate the associations between EBPT/SETS utilization and patient outcomes.ConclusionsThe EROICASS study provides valuable insights into the utilization and outcomes of EBPT and SETS in septic shock management. Through analysis of usage patterns and clinical data, this study aims to guide treatment decisions and enhance patient care. The implications of these findings may impact clinical guidelines, potentially improving survival rates and patient outcomes in septic shock cases.

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%.

The clinical efficacy and suitable implementation of two extracorporeal blood purification therapies: AN69-oXiris versus PMX-HP.

In septic shock patients, pathogens and excessive endotoxins continuously overstimulate the host's immune system with a cytokine storm that can lead to multi-organ failure and even mortality. Various types of extracorporeal blood purification treatments have recently been introduced to remove excessive endotoxins and cytokines. Herein, we compared the clinical efficacy of two blood purification methods, PMX-HP and AN69-oXiris, and discussed their detailed indications according to disease severity. From December 2016 to April 2023, patients who underwent emergent surgery due to septic shock secondary to peritonitis and subsequently received blood purification treatment with AN69-oXiris or PMX-HP were enrolled. Propensity score (PS)-matching was conducted to adjust for baseline characteristics between the two groups, and the changes in clinical parameters and outcomes were compared. Clinical outcomes were assessed in subgroups of patients who underwent PMX-HP treatment divided according to SOFA scores into low (0-7), intermediate (8-13), and high (> 13) disease severity groups. Forty patients received blood purification therapy with either PMX-HP or AN69-oXiris during the study period. After 1:2 PS matching, six patients in the AN69-oXiris group and 12 patients in the PMX-HP group were finally analyzed. Vasoactive-inotropic scores (VISs) decreased in both groups after 48 h of treatment compared to the baseline values, but the change in VISs was more pronounced in the PMX-HP group {-57.6 [interquartile range (IQR) = -166.4 - (-10)] vs. -22.9 [IQR = -64-0], respectively, p = 0.041}. Decreases in cardiovascular SOFA scores were significantly pronounced in the PMX-HP group [-1.5 (IQR = -4 - 0) vs. 0 (IQR = -1 - 1), respectively, p = 0.035]. The 7-day mortality rate was significantly lower than the predicted mortality rate in a subgroup analysis of patients treated with PMX-HP in both the low disease severity group and the intermediate disease severity group. PMX-HP and AN69-oXiris could be therapeutic options for refractory septic shock patients with intra-abdominal origins, especially after the surgical elimination of the infectious sources. A tailored modality choice that takes into account patient characteristics, such as disease severity and cost burden, could optimize the efficacy of this strategy.

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.

New directions of scientific research and clinical practice in the field of extracorporeal hemocorrection in patients with multiple organ dysfunction: a review

INTRODUCTION: Due to the COVID-19 (infectious disease caused by the SARS-CoV-2 virus) pandemic, we had to take a completely different approach to the nature of critical conditions. The pandemic also made us reconsider many views about it. Moreover, that contributed to the development of new practical approaches for treatment and prevention, including the ones in the field of extracorporeal hemocorrection. OBJECTIVE: Methods for purification of blood and plasma began to be considered as an independent link for the treatment of organ disorders or as a part of extracorporeal support for the life support of the body. MATERIALS AND METHODS: The article consists of three sections: a description of the role of extracorporeal hemocorrection methods in intensive care, their classification and main characteristics; the concept of sequential targeted extracorporeal therapy for a treatable symptom in sepsis; extracorporeal hemocorrection as part of the concept of extracorporeal life support. This article uses literary sources published from January 1, 2022 to July 1, 2023. Materials related to COVID-19 and other specific pathologies (poisoning, acute liver failure, itching, systemic diseases, etc.), requiring separate discussion, are intentionally excluded. RESULTS: Technologies in extracorporeal hemocorrection provide support and/or replacement of organ functions; restoration of body resistance and balance between inflammatory and anti-inflammatory response; restoration of body tolerance (metabolism and regeneration). Nevertheless, despite the convincing pathophysiological rationale for the use of these methods in critical conditions, evidence of its effectiveness is limited. Current trends indicate that future research should be primarily aimed at finding biomarkers that can simultaneously designate specific biological processes; characterize different subgroups of patients; allow targeted choice for the method of therapy. The modulation of biomarkers under the influence of this therapy can show its effectiveness for this particular subgroup of patients at this stage of the disease. CONCLUSIONS: Methods of extracorporeal blood purification should be aimed at prevailing biological processes, at this stage of pathogenesis, and, accordingly, evaluated by the effectiveness of the impact on these processes.

Current clinical practice in using adjunctive extracorporeal blood purification in sepsis and septic shock: results from the ESICM “EXPLORATION” survey

BackgroundDespite a lack of clear evidence extracorporeal blood purification (EBP) is increasingly used as an adjunctive treatment in septic shock based on its biological plausibility. However, current state of praxis and believes in both efficacy and level of evidence are very heterogeneous.MethodsThe “EXPLORATION” (Current Clinical Practice in using adjunctive extracorporeal blood purification in septic shock), a web-based survey endorsed by the European Society of Intensive Care Medicine (ESICM), questioned both the current local clinical practices as well as future perspectives of EBP in sepsis and septic shock.ResultsOne hundred and two people participated in the survey. The majority of three quarters of participants (74.5%) use adjunctive EBP in their clinical routine with a varying frequency of description. Unselective cytokine adsorption (CA) (37.5%) and therapeutic plasma exchange (TPE) (34.1%) were by far the most commonly used modalities. While the overall theoretical rational was found to be moderate to high by the majority of the participants (74%), the effectively existing clinical evidence was acknowledged to be rather low (66%). Although CA was used most frequently in clinical practice, both the best existing clinical evidence endorsing its current use (45%) as well the highest potential to be explored in future clinical trials (51.5%) was attributed to TPE.ConclusionsAlthough the majority of participants use EBP techniques in their clinical practice and acknowledge a subjective good theoretical rationale behind it, the clinical evidence is assessed to be limited. While both CA and TPE are by far the most common used technique, both clinical evidence as well as future potential for further exploration in clinical trials was assessed to be the highest for TPE.

Clinical effects of occupational clonidine poisoning and efficacy of extracorporeal blood purification therapies

Clinical effects of occupational clonidine poisoning and efficacy of extracorporeal blood purification therapies

In vitro Removal of Protein-Bound Retention Solutes by Extracorporeal Blood Purification Procedures

Introduction: When the kidneys or liver fail, toxic metabolites accumulate in the patient's blood, causing cardiovascular and neurotoxic complications and increased mortality. Conventional membrane-based extracorporeal blood purification procedures cannot remove these toxins efficiently. The aim of this in vitro study was to determine whether commercial hemoperfusion adsorbers are suitable for removing protein-bound retention solutes from human plasma and whole blood as well as to compare the removal to conventional hemodialysis. Methods: For in vitro testing of the removal of protein-bound substances, whole blood and plasma were spiked with uremic retention solutes (homocysteine, hippuric acid, indoxyl sulfate, 3-carboxy-4-methyl-5-propyl-2-furanpropionic acid) and the toxins of liver failure (bilirubin, cholic acid, tryptophan, phenol). Subsequently, the protein binding of each retention solute was determined. The adsorption characteristics of the hemoperfusion adsorbers, Jafron HA and Biosky MG, both approved for the adsorption of protein-bound uremic retention solutes and Cytosorb, an adsorber recommended for adsorption of cytokines, were tested by incubating them in spiked whole blood or plasma for 1 h. Subsequently, the adsorption characteristics of the adsorbers were tested in a dynamic system. For this purpose, a 6-h in vitro hemoperfusion treatment was compared with an equally long in vitro hemodialysis treatment. Results: Hippuric acid, homocysteine, indoxyl sulfate, and tryptophan were most effectively removed by hemodialysis. Bilirubin and cholic acid were removed best by hemoperfusion with Cytosorb. A treatment with Jafron HA and Biosky MG showed similar results for the adsorption of the tested retention solutes and were best for removing phenol. 3-Carboxy-4-methyl-5-propyl-2-furanpropionic acid could not be removed with any treatment method. Discussion/Conclusion: A combination of hemodialysis with hemoperfusion seems promising to improve the removal of some toxic metabolites in extracorporeal therapies. However, some very strongly protein-bound metabolites cannot be removed adequately with the adsorbers tested.

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."

Sorbent functionalization with vancomycin enhances bacteria killing in extracorporeal hemoadsorption.

The level of bacteremia in patients with sepsis and septic shock is a predictor of complications and mortality, regardless of the type of bacteria. Devices for bacteria, endotoxin and cytokines removal by adsorption have been recently developed. Thus, extracorporeal blood purification therapies have been proposed as adjunctive therapy in sepsis in combination with drugs. Some potentially useful drugs, however, are precluded due to their organ or metabolic toxicity. The present study represents a preliminary report on the invitro effect of a sorbent device (minimodule with HA380 beads, Jafron medical, Zhuhai, China) in which the particles have been functionalized with vancomycin on the surface. The impact of the surface-modified beads on circulating bacteria (Staphylococcus aureus) has been tested in a simulated invitro circulation. In vitro experiments were carried out with 800 mL of blood enriched with S. aureus species. Blood was circulated in the vancomycin-functionalized and non-functionalized mini-module cartridges in hemoadsorption setup (300 mL each) and the bactericidal effect was assessed. Also, 200 mL of blood was used as a control. A significant increase in the time to positivity of blood cultures was observed after 60 min and also after 120 min of therapy with the mini-module functionalized with vancomycin as opposed to the non-functionalized cartridge. These results suggest a possible way of treating sepsis by using drug- or antibiotic-functionalized cartridges without worrying about pharmacological toxicity. The prolongation of the time to bacterial culture positivity to S. aureus after a passage through a column packed with beads functionalized with vancomycin represents a proof of concept.

The use of CytoSorb in acute oral mercuric chloride poisoning at a potentially lethal dose.

The study aims to present a case of acute mercuric chloride poisoning treated successfully with continuous renal replacement therapy using the CytoSorb filter. A 21-year-old female patient after a suicide attempt by intentional ingestion of mercuric chloride, was admitted to the hospital with features of multiple organ damage for specific treatment. The performed laboratory tests confirmed high levels of mercury in the blood (1051 μg/L) and urine (22,960 μg/L). Due to acute renal failure, continuous renal replacement therapy (CRRT) CVVHD Ci-Ca was initiated; the procedure was then converted to CVVHDF Ci-Ca with ultrafiltration to optimise therapy, and CytoSorb was added to the artificial kidney system on day 3. Specific antidote therapy (DMPS) was administered concurrently. The ongoing treatment resulted in a reduction in subjective complaints, a decrease in blood mercury levels to 580 μg/L, and an improvement in parenchymal organ function. In the event of poisoning with inorganic mercury compounds (mercuric chloride), continuous renal replacement therapy using the CytoSorb filter as an extracorporeal blood purification method may be considered.

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.