Extracorporeal Detoxification Research Articles

Severe course of leptospirosis: A case report

This study describes a clinical case of severe leptospirosis. Patient K., was admitted to the neurosurgical department on November 26, 2023, with a diagnosis of “Closed craniocerebral injury dated 22.11.2023. Severe brain injury. Linear fracture of the occipital bone. Eyelid hematoma. An abrasion of the upper eyelid on the right.” On November 29, 2023, an objective examination drew attention to an increase in body temperature to 39.5°C, subictericity of the sclera and skin, and conjunctival injections. Hemorrhagic rash appeared on the skin of the trunk and limbs. The hemodynamics was unstable, with episodes of arterial hypotension. Laboratory examination revealed mild anemia, signs of hepatic–renal insufficiency, hyperbilirubinemia, and increased concentrations of creatine phosphokinase, C-reactive protein, and procalcitonin. Fluctuations in hepatic–renal insufficiency and levels of creatine phosphokinase and procalcitonin increased. In addition, the differential diagnostic search aimed at identifying the following infectious diseases: hemorrhagic fever with renal syndrome, leptospirosis, malaria, and viral hepatitis. IgM to Leptospira interrogans were detected (December 11, 2023). The patient received antibacterial therapy, extracorporeal detoxification, artificial ventilation, infusion therapy, and correction of the hemostasis system. With the complex treatment, the patient’s condition stabilized, and the patient was discharged from the hospital on the 61st day with restoration of health.

Extra-corporeal detoxification in insects

Upon uptake of toxins, insects launch a detoxification program. This program is deployed in multiple organs and cells to raise their tolerance against the toxin. The molecular mechanisms of this program inside the insect body have been studied and understood in detail. Here, we report on a yet unexplored extra-corporeal detoxification of insecticides in Drosophila melanogaster. Wild-type D. melanogaster incubated with DDT, a contact insecticide, in a closed environment died as expected. However, incubation of a second cohort in the same environment after removal of the dead flies was not lethal. The effect was significantly lower if the flies of the two cohorts were unrelated. Incubation assays with Chlorpyrifos, another contact insecticide, yielded identical results, while incubation assays with Chlorantraniliprole, again a contact insecticide, was toxic for the second cohort of flies. A cohort of flies incubated in a DDT environment after an initial incubation of a honeybee survived treatment. Together, our data suggest that insects including Apis mellifera and D. melanogaster have the capacity to modify their proximate environment. Consequently, in their ecological niche, following individuals might be saved from intoxication thereby facilitating colonisation of an attractive site.

Clinical and pathogenetic justification for the use of therapeutic plasma exchange in the complex of preoperative preparation of patients with non-small cell lung cancer complicated by the inflammatory process

Purpose of the study. Determination of pathogenetic substantiation and indication criteria for the inclusion of extracorporeal detoxification methods in preoperative preparation of patients with non-small cell lung cancer (NSCLC) complicated by inflammation.Patients and methods. This study included the data on 222 patients with newly diagnosed stage I–IV NSCLC referred for elective surgical treatment to the Department of Thoracic Oncology, National Medical Centre for Oncology, in 2017–2019. Endogenous intoxication was evaluated in all patients depending on the leukogram results: leukocytic intoxication index (LII), body resistance index (BRI), reactive neutrophil response (RNR), and neutrophil-lymphocyte ratio (NLR). Indicators of the inflammatory response, i. e. interleukin 6 and procalcitonin, were also studied.Results. 36.5 % of NSCLC patients developed inflammation. That over 70 % of the NSCLC patients showed pronounced clinical and laboratory signs of endogenous intoxication and inhibited protective systems of homeostasis. Initial sub- or decompensated endotoxicosis together with reduced overall reactivity of the body poses a high risk of systemic inflammatory response to antitumor surgical treatment. This justifies the inclusion of extracorporeal detoxification into preoperative preparation of this category of patients as an active preoperative therapy.Conclusions. Simultaneous elevation of LII, RNR and NLR characterizing the presence of endotoxicosis in sub- and decompensation of endogenous intoxication by own physiological detoxification systems requires an active preoperative preparation with extracorporeal detoxification.

Effective treatment of septic shock using oXiris-therapy in a patient with diffuse fecal peritonitis and severe comorbid background

To assess the efficiency of using the methods of extracorporeal detoxification in the complex treatment of sepsis and septic shock so as to eliminate endotoxin, cytokines as well as to replace the function of organs. The article presents a successful experience of using two sessions of hemofiltration with an oXiris set for extrarenal indications in a patient with diffuse fecal peritonitis and severe comorbid background after surgery. The complex of therapeutic measures, dynamics of clinical and laboratory data before and after both sessions of oXiris therapy is presented. Positive effect of hemofiltration on the patient's condition using the oXiris set was noted 48–72 hours after the start of the procedure and 72 hours after its completion. The use of two sessions of oXiris therapy in the treatment of septic shock in a patient with diffuse fecal peritonitis and severe comorbid background allowed stabilizing hemodynamics 48–72 hours after the start of treatment; a significant improvement of a patient’s condition occurred 72 hours after the end of the second procedure.

Diagnosis and treatment tactics acute pancreatitis

Aim. Improving the immediate results of the treatment of patients with acute pancreatitis.Material and methods. We studied the results of diagnosis and treatment of 126 patients diagnosed with acute pancreatitis. In our observation, the main causes of acute pancreatitis in 92 (73.0%) patients were cholelithiasis (biliary genesis), in 25 (19.8%) patients, acute pancreatitis (AP) had an alcoholic genesis, in 4 (3.2%) cases, pancreatitis occurred as a result of duodenal ulcer penetration into the head of the gland, and in 5 (4.0%) cases, АР had a traumatic genesis.Results. In 38 observed patients, extracorporeal detoxification methods were used in complex treatment, in addition, hemofiltration was used in 17.0% of cases, plasmapheresis was performed in 71.0% of patients, and peritoneal dialysis was performed in combination with plasmapheresis in 12.0% of cases. Minimally invasive methods of treatment were performed in 27 (21.4%) patients with acute pancreatitis.In 17 patients, we performed percutaneous drainage interventions with ultrasound navigation. Surgical interventions were performed in 36 (28.6%) patients with acute pancreatitis. Of these, 9 (7.1%) patients were operated on within 5 days, 21 (16.7%) patients were operated on within 14 days, the remaining 6 (4.8%) patients were operated on within 24 to 14days. 30 days.Against the background of the use of a complex differentiated individual approach in the patients we observed with destructive forms of AP, the incidence of fatal cases was 9.5% (n=12), which were due to the development of progressive multiple organ failure.Conclusion. The main tasks in the treatment of patients with acute pancreatitis should be the urgent elimination of etiopathogenetic factors in the development of this pathology, the timely appointment of intensive therapy with the implementation of minimally invasive surgical interventions.

Current View on the Use of Extracorporeal Detoxification Methods for the Treatment of Rhabdomyolysis (Review)

Rhabdomyolysis is a syndrome caused by destruction and necrosis of muscle tissue, which is accompanied by the release of intracellular contents into the systemic circulation. The etiology of rhabdomyolysis is multifaceted, however, regardless of the etiological factor, the central element of its pathophysiology is systemic endotoxemia with multiple organ failure syndrome. Acute renal failure is one of the most common manifestations of organ dysfunction. Considering the pathogenetic model of the development of systemic endotoxemia, the timely use of extracorporeal therapy, which reduces mortality in organ failure, seems promising. All the current types of extracorporeal therapy can be divided into convection (hemofiltration), diffusion (hemodialysis), convection/diffusion (hemodiafiltration), sorption (hemoperfusion) and plasma exchange (plasmapheresis, plasma exchange, plasma sorption, etc.) methods based on physical principle.The aim of the reviewwas to summarize the available clinical data on extracorporeal treatments for rhabdomyolysis and to assess the feasibility and best indications for these methods based on the current pathogenetic model of rhabdomyolysis.Material and methods.The search for information was carried out in the Web of Science, Scopus, Medline, PubMed, RSCI, E-library and other databases. Eighty-one sources were identified containing current therapeutic approaches and relevant data of clinical and scientific research on the subject of this review.Results.In this review, the main etiological, epidemiological and pathogenetic models of acute renal injury in rhabdomyolysis have been discussed. The main methods of extracorporeal therapy have been reviewed and evaluated based on current understanding, and latest clinical data on their effectiveness have been summarized.Conclusion.The choice of the optimal extracorporeal treatment method, the time of initiation and duration of the procedure still remain controversial. The solution to this issue can potentially help to better correct the electrolyte disturbances and could protect against organ dysfunction, which would improve the outcome in patients with rhabdomyolysis.

Renal dysfunction in general overheating (literature review)

Over the past 30 years, climate change has taken one of the leading places among the ten main causes of death due to natural disasters. Rising temperatures have been shown to increase emergency department admissions for a wide range of kidney diseases, including acute kidney injury (AKI), chronic kidney disease, kidney stones, and urinary tract infections. The occupational effect of heat stress is also associated with AKI, which can quickly progress to acute kidney failure with high mortality. The basis of the pathogenetic mechanisms of heat-induced AKI is a decrease in the circulating blood volume and electrolyte disturbances due to increased perspiration. Water evaporation from the surface of the skin contributes to dehydration with an increase in serum osmolarity. In response to this, vasopressin is activated, the specific gravity of urine increases, and the amount of urine decreases. The glomerular filtration rate progressively decreases. Hypokalemia develops, which changes to hyperkalemia within 12 hours. Tubular endothelium is damaged, which leads to microthrombosis of afferent and efferent renal arteries, the development of an inflammatory response, and exhaustion of the renal interstitium. Possible rhabdomyolysis and myoglobinemia with subsequent tubular obstruction worsen existing kidney damage. According to the leading mechanism of damage, there are two types of acute heat damage to the kidneys: classical rhabdomyolysis and acute interstitial nephritis. Although modern medical advances have contributed to the development of effective treatment and management strategies (rapid cooling, extracorporeal detoxification methods, etc.), mortality in kidney damage due to general overheating has decreased slightly over the past decades. For health care and industry researchers, it is necessary to identify the harmful occupational conditions that lead to heat stress nephropathy and to develop certain occupational safety strategies.

Alternative anticoagulation during extracorporeal detoxification

The role of heparin anticoagulation in the development of hemorrhagic syndrome after extracorporeal detoxification (ECD) procedures in patients with initial hemostasis disorders, as well as the place of alternative citrate anticoagulation in extracorporeal treatment have not yet received a final assessment and require further study. The aim of this work was to compare the results of treatment of patients with severe intoxication using heparin and citrate as anticoagulants during ECD procedures. The conducted study confirms that the use of heparin anticoagulation in ECD leads to a spasmodic progression of the manifestations of DIC that were present before the procedure. Citrate anticoagulation demonstrates the benefits consisting in the absence of a spasmodic increase in coagulopathy, hypofibrinemia, and thrombocytopenia during an ECD session, which is characteristic of the heparin use. However, when ECD is initiated against the background of more severe initial coagulopathy and, interrelatedly, more severe multiple organ failure (MOF), this does not improve treatment outcomes. Moreover, among patients with severe MOF taken for ECD, there was a greater mortality rate and a large proportion of deaths during and immediately after the session when using citrate anticoagulation. Thus, ECD procedures with citrate anticoagulation may have a negative impact on the condition of patients who already have severe MOF and severe coagulopathy. This risk may be associated with metabolic disorders, especially dangerous in such severe patients, and does not outweigh the risk of an increase in hemostasis disorders characteristic of heparin anticoagulation. Probably, ECD with citrate anticoagulation has to be carried out at an earlier stage of the disease, and in cases of severe MOF already present in the patient, it is advisable to use traditional heparin anticoagulation.

Evaluation of the use of combined extracorporeal detoxification in patients with severe acute pancreatitis: a retrospective cohort study

INTRODUCTION: Morbidity and mortality of severe acute pancreatitis (SAP) remains high. The most important direction of therapy is the relief of endotoxicosis. The use of extracorporeal detoxification (ECD) is a debatable problem. OBJECTIVE: Improving the results of treatment of patients with SAP, through the use of ECD methods. MATERIALS AND METHODS: The study included 25 patients. Group 1: ECD included 9 patients who used standard therapy with selective hemoperfusion (HP) and continuous veno-venous hemofiltration (CVVHF). Group 2 (control) 16 patients received standard therapy. We performed a comparative analysis of the main clinical and laboratory parameters and treatment outcomes between the groups. RESULTS: The use of ECD allowed to reduce the number of leukocytes from 14.9 to 8.6 × 109/l by 5 days of therapy in group 1, and from 17.6 to 16.1 × 109/l in group 2, respectively. The dynamics of CRP concentration from 1 to 5 days changed from 315.6 to 184.6 mg/ml and 274.2 to 352.9 mg/ml in groups 1 and 2, respectively. The level of PCT concentration on days 1–5 decreased from 4.5 to 2.1 ng/ml and 3.95 to 6.9 ng/ml in groups 1 and 2, respectively. The concentration of IL-6 decreased from 1624.3 to 914.3 pg/ml in group 1, and increased from 1529.8 to 1861.8 pg/ml in group 2, respectively. The dynamics of pH in group 1 was from 7.14 to 7.4 by the 5th day of therapy and 7.13 to 7.22 in group 2, respectively. SOFA by day 5 in group 1 was 4 points and 11 points in group 2, respectively. CONCLUSIONS: The use of HP and CVVHF in complex intensive care is accompanied by a significant regression of markers of endogenous intoxication, resolution of the acid-base state and reduces the severity of organ dysfunction and the risk of adverse outcomes, compared with standard treatment.

ВЛИЯНИЕ ГЕМОСОРБЦИИ С ЭКCТРАКОРПОРАЛЬНОЙ АУТОГЕМОМАГНИТОТЕРАПИЕЙ В СРАВНЕНИИ С МЕДИКАМЕНТОЗНОЙ ТЕРАПИЕЙ АНТАГОНИСТАМИ РЕЦЕПТОРОВ ИЛ-6 НА КЛИНИКО-ЛАБОРАТОРНЫЕ ПАРАМЕТРЫ ПАЦИЕНТОВ С ТЯЖЕЛЫМ ТЕЧЕНИЕМ COVID-19

Background: SARS-CoV-2 infection in 10-20% of cases is characterized by hypercytokinemia, and in this context, the use of interleukin-6 (IL-6) receptor blockers, in particular tocilizumab and levilimab, is pathogenetically justified, but anticytokine hemosorption is also used in such cases. It is impossible to determine which method is preferable in patients with severe COVID-19 due to the lack of large comparative studies of medical and extracorporeal anticytokine therapies. Purpose: To evaluate the effect of hemosorption through the Нemo-Рroteasosorb hemorosorbent in combination with extracorporeal autohemomagnetic therapy and medical therapy with IL-6 receptor antagonists on the respiratory status, hemostasis, acid-base state of the blood, the detoxification function of the liver and kidneys in patients with severe COVID-19 infection. Material and methods: The clinical and laboratory findings of 102 patients with a severe course of coronavirus infection, who developed cytokine storm, were evaluated. All patients were divided into three groups: hemosorption with magnetic blood treatment («HS+MBT») (41 patients), Tocilizumab group (40 patients) and Levilimab group (20 patients). The following indicators were studied: erythrocyte count and platelet count; hemoglobin level; concentration of total protein, creatinine, urea, total bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), fibrinogen, D-dimers; acid-base state and blood gas composition. To assess the respiratory status, the respiratory index (RI), ROX index, total oxygen flow, and dynamics of the level of respiratory support were evaluated. To assess hemodynamics, mean arterial pressure and heart rate were determined, the body temperature of the patients was also measured. Results: The results obtained demonstrate that with the combined use of MBT and hemosorption through the Hemo-Proteasosorb sorbent in patients with severe COVID-19, there were no significant fluctuations in hemodynamic parameters, levels of urea, creatinine, total bilirubin, AST and ALT. At the same time, the use of tocilizumab was associated with an increase in the levels of urea, total bilirubin and ALT. In the Levilimab group there was an increase in the concentration of urea. The use of HS+MBT was associated with a decrease in the level of fibrinogen, which was noted on the next day, as well as a tendency to a decrease in D-dimers. At the same time, during the treatment with IL-6 receptor blockers, a significant decrease in the level of fibrinogen was noted only on days 6-8. The number of thromboembolic complications was also lower in the patients with extracorporeal detoxification. With HS+MBT, an increase in the respiratory status indicators (RI, ROX-index, decrease in total oxygen flow) was observed already on the next day, while in the Tocilizumab and Levilimab groups, an increase in these indicators was noted only on days 6-8. A decrease in the ROX index and the absence of dynamics in the total oxygen flow were found on the next day in both groups. In the HS+MBT group, the obtained results indicated that the given technique both prevents more significantly the transition to the next level of respiratory support and contributes to its decrease as compared to IL-6 receptor blockers. Analysis of the acid-base state of the blood following HS + MBT showed a decrease in the level of lactate and an increase in HCO3, as well as deficiency/excess of bases, which indicated compensation for metabolic acidosis. Similar results with the use of IL-6 receptor blockers were obtained only on the 6th-8th day of the study, but no normalization of the lactate concentration in the blood of patients was found at any stage. Conclusion: The use of HS+MBT has a number of advantages over the treatment with IL-6 receptor blockers, which is manifested by the absence of cardio, hepato- and nephrotoxicity, as well as more significant positive effect on hemostasis, respiratory status and acid-base status of patients.

Extracorporeal Detoxification Methods and Hemostasis System for Ovarian Cancer Patients. Clinical Case

Introduction. Malignant tumors dominate in the picture of disability and mortality worldwide. One of the most frequent and dangerous comorbid conditions is kidney injury. At the same time, the most unfavorable incidence of acute kidney injury is recorded in multiple myeloma, leukemia, lymphoma and kidney and/or liver cancer and malignant ovarian neoplasms. In this regard, of vital importance is the choice of tactics in the prevention of thrombosis and thromboembolic complications, as well as the individual approach to of the anticoagulant therapy regimen during renal replacement therapy sessions, depending on the underlying disease and the state of the hemostatic system. Aim. To evaluate the effect of calcium citrate veno-venous hemodiafi ltration sessions on the hemostatic system of a patient with progressive organ dysfunctions associated with malignant ovarian neoplasm. Materials and methods. The methodology involved literature review and a case study to assess the effect of veno-venous hemodiafi ltration on hemostasis. Results and discussion. The clinical case was assessed in terms of P-selectin (CD62), which characterizes platelet activation processes. It should be noted that in this patient, the expression of P-selectin increased with each session of renal replacement therapy, while the platelet aggregation values remained at the level of the lower thresholds, which indicates a low probability of coagulation initiation. However, due to aggressive regulation of ovarian cancer by the hemostatic system in the form of production of inflammatory mediators, microvesicles, tissue factor expression and endothelial activation, attention should be paid to the molecular aspects of platelet activation in renal replacement therapy with regional citrate coagulation. Conclusion. The widespread use of extracorporeal detoxification methods is an independent risk factor not only for bleeding events, but may potentially contribute to thrombosis and thromboembolic complications, which requires a further detailed study of molecular mechanisms of hemostasis regulation by tumor and clinical evaluation of various anticoagulation methods.

#5130 THE EXPERIENCE OF SELECTIVE PLASMA EXCHANGE THERAPY IN PATIENTS WITH MULTIPLE MYELOMA

Abstract Background and Aims High concentrations of free light chains (FLCs) in multiple myeloma lead to cast-nephropathy and obstructive acute renal failure in 18-56% of patients. The aim of this research is to estimate the efficiency of extracorporeal free light chains of immunoglobulin elimination under this pathological condition during plasma exchange therapy using selective filters. Method Selective plasma exchange therapy (SEPET) was carried out in 11 patients with multiple myeloma. The patients were 61 [47-69] years old. Paraproteinemia level at primary examination varied from 1.6 to 78.8 g/liter. All patients exhibited proteinuria of 0.56 to 12.7 g/day, Bence Jones protein excretion (from 0.4 to 11.2 g/day) was detected in 9 cases. Blood creatinine levels ranged from 272 μmol/L to 534 μmol/L. None of the patients required renal replacement therapy. FLCs levels above 500 mg/L, irrespective of azotemia level, served as an indication for starting the procedure. All patients received VMP induction chemotherapy after sessions of selective plasma exchange therapy. SEPET was carried out on a “Multifiltrate” (Fresenius) hemodialysis machine in hemofiltration mode. «Evaclio 2C20» plasmafilter (Japan) was used. Patients underwent one procedures of SEPET in a dose of 3 volumes of circulating plasma. Blood flow velocity during varied from 40 to 60 ml/min, the duration of each procedure was 5-6 hours. Plasma substitution was performed with «Prismasol K4» solution - 10.0 L and albumin solution 20%-400 ml. Regulated clotting by nonfractionated heparin was calculated individually from the APTT values. No early or delayed complications of extracorporeal hemocorrection were recorded. FLCs, creatinine levels, and coagulogram results of patients were examined before and after the procedure. Results Analysis of serum FLC values before treatment showed a significant increase of κ- or λ-FLC levels, significantly surpassing normal values: 3-21.5 mg/liter κ-FLC and 5-27 mg/liter λ-FLC, with κ/λ-FLC proportion of 0.25-1.65. The primary levels of involved FLC medians in the group were 472 [312;44700] mg/L for κ-FLC and 163 [ 473; 24673] mg/L for λ-FLC, κ/λ-FLC proportions were 2.89. Through the membrane of the plasma filter “Evaclio 2C20” are sieved and removed substances with a molecular weight less than the molecular weight of albumin (65 kD). Kappa FLCs circulate as monomers of 22 kDa but may assemble into dimers of 45 kDa, particularly lambda FLCs. There is a partial loss of albumin. High molecular weight substances do not pass through this membrane. During SEPET the κ-FLC level in the plasmafiltrate was 272 mg/L, the λ-FLC level was 94 mg/L. After SEPET median serum κ-FLC was 231 mg/L, median serum λ-FLC was 96 mg/L. Compared with baseline data, serum FLC levels decreased after 24 hours, so that median serum κ-FLC was 281 mg/L, median serum λ-FLC was 101 mg/L. Clinical tolerance of extracorporeal detoxification was satisfactory and hemodynamically stable in all patients; and there were no were traumas of blood elements or decrease of serum albumin. Renal function recovered in 3 patients in the course of therapy, improved in 5 patients with renal insufficiency, and remained unchanged in 3 patients. Conclusion The Selective plasma exchange therapy directly removes FLCs excess from circulating blood. Rapid reduction of FLCs level in the course of selective extracorporeal elimination can prevent the development of irreversible renal failure and make it possible to carry out adequate antitumor therapy.

Mixed infection with COVID-19 and tropical malaria (case report)

This article describes a clinical case of mixed infection with COVID-19 and tropical malaria. Patient Z., 37 years old, arrived from the Central African Republic with a diagnosis of New coronavirus infection COVID-19, confirmed (PCR RNA SARS-CoV-2+ from January 27, 2022) mild form. During an objective examination, the subictericity of the sclera and skin integument attracted attention. During thermometry, an increase in body temperature to 39.0C was found. Consciousness at the level of somnolence was observed. Hemodynamics was unstable, with episodes of arterial hypotension; heart rate was 96 beats per minute. Respiratory rate was 24 breaths in 1 minute, SpO2 95%, and with inspiratory dyspnea. According to the patients laboratory study results, severe thrombocytopenia, apparent signs of hepatic and renal insufficiency, hyperbilirubinemia, increased concentrations of C-reactive protein, and procalcitonin were revealed. A differential diagnostic search was performed between acute viral hepatitis and malaria. Blood microscopy revealed young trophozoites of Plasmodium falciparum (++++) using the thick drop method. Antimalarial therapy with Malacur was prescribed, which was then replaced with parenteral Quinine followed by mefloquine. In parallel, extracorporeal detoxification operations were performed. The patients condition was stabilized against adequate etiotropic therapy and complex intensive care measures. On the 40th day, the patient was discharged restored health.
 The purpose of demonstrating a clinical case is to attract increased attention to the problem of imported cases of malaria, which, when combined with COVID-19 infection, may remain unrecognized for a long time, especially in cases where the diagnosis of COVID-19 receives rapid laboratory confirmation.
 Adequate and timely antimalarial therapy, including a complex of intensive care measures supplemented with extracorporeal detoxification methods, is the basis for a successful outcome in patients with severe malaria with the development of severe complications.

СЕРИЯ КЛИНИЧЕСКИХ СЛУЧАЕВ ТЯЖЕЛОГО ТЕЧЕНИЯ ИНФЕКЦИИ COVID-19 У РЕЦИПИЕНТОВ ПОЧЕЧНЫХ ТРАНСПЛАНТАТОВ

Coronavirus infection has had a significant impact on people around the world, however, there is a category of patients who are at high risk of severe disease - kidney transplant recipients. The high risk is due to the presence of a pronounced comorbid background, long-term background immunosuppression, a high risk of secondary infection, and graft dysfunction as a result of a severe infection. This paper presents a series of clinical cases of severe COVID-19 infection in kidney transplant recipients. We have demonstrated that timely diagnosis and intensive therapy, including both adequate drug therapy and the use of renal replacement therapy in the form of hemodialysis and extracorporeal detoxification methods, can not only save the lives of such patients, but also preserve a functioning kidney transplant.

Hemostasis disorders during extracorporeal detoxification and the possibility of their prevention. Literature review

A significant proportion of surgical patients requiring extracorporeal detoxification (ECD) initially have various hemostasis disorders and associated risks. Extracorporeal treatment can lead to the progression of such pathological conditions, including the development of clinically significant bleeding. The work analyzes modern literature, covering the development of hemostasis disorders during ECD and the possibility of their prevention. Currently, there is no consensus on the most significant causes and mechanisms of coagulation disorders in ECD, often leading to serious bleeding and deterioration in patient outcomes. Researchers agree that a significant influence on the risk of occurrence of coagulopathy is not exerted by the severity of the underlying disease, but by the presence of coagulation disorders before treatment. In patients who initially had coagulopathy and/or thrombocytopenia, bleeding after ECD sessions is observed in 40–50 % of cases. The role of heparin anticoagulation in the development of hemorrhagic complications has not yet received a final assessment. In the majority of publications in the literature, the authors conclude that citrate anticoagulation is effective and safe in various types of extracorporeal detoxification, noting that the use of citrate instead of heparin allows not only significantly extending the life of the filter, but also reducing the risk of developing coagulopathy and bleeding after the procedure. Questions of use, risks, and benefits of citrate anticoagulation over heparin for ECD in surgical patients with coagulopathy require further study.

ACUTE DESTRUCTIVE PANCREATITIS IN CHILDREN

Unlike adults, acute pancreatitis in children is a rare disease. The absence of unified standards for the diagnosis, treatment and rehabilitation of children with acute destructive pancreatitis, as well as high rates of complications and mortality, determined the relevance of our study.Materials and methods. Materials and methods. The results of treatment of 11 children with acute destructive pancreatitis were studied. The age of the patients ranged from 2 to 16 years. Laboratory examination in all patients included general and biochemical analyzes of blood, urine, peritoneal and thoracic exudate. All children underwent an ultrasound examination of the abdomen, chest cavity and mediastinum, and plain radiography of the chest and abdominal cavity. Computed tomography was performed in 6 patients (54.5%). Fibrogastroduodenoscopy (FGDS) was performed in 3 patients (27.3%). All patients underwent surgery. In 8 cases (72.7%), a median laparotomy was performed initially. In 3 observations (27.3%), surgical treatment began with video surgical revision of the abdominal organs, and then switched to conversion. Three patients (27.3%) subsequently underwent cystopancreatic jejunostomy. In one child, transcutaneous drainage of a false pancreatic cyst was performed under video surgical control. Synthetic somatostatin analogs and proteinase inhibitors were used as targeted therapy. All patients received long-term antibacterial therapy. Various methods of extracorporeal detoxification were used in 6 patients (54.5%).Statistical processing of the research results was carried out using standard methods with the calculation of relative values (absolute number of observations, % ratio).The approval of the scientific work was received from the Bioethical Commission of the Donetsk National Medical University (Ukraine).The work is a fragment of proactive research work of the Department of General and Children's Surgery of the Donetsk National Medical University (Ukraine). Results. Complications in the early postoperative period were noted in 8 children (72.7%). The group of the most severe complications included progressive enzymatic bacterial peritonitis, early adhesive intestinal obstruction, failure of cystopancreatic ileal anastomosis, profuse arrosive hemorrhage from the pancreas, cystopancreaticodigestive fistula and eventation. In the early postoperative period, 1 child aged 14 years (9.1%) died, and the rest of the patients were discharged in satisfactory condition. The average hospital stay for children was 23.1 days. In 7 patients (63.6%), complaints characterized by "enteric" discomfort occurred later.Conclusions. The principles of surgical and therapeutic tactics in children with acute destructive pancreatitis are based on a differentiated approach depending on the form of pancreatic necrosis and the development of purulent and destructive complications. Further study requires determination of situational surgical tactics, assessment of the effectiveness of combined therapy with somatostatin and proteinase inhibitors, selection of the optimal regimen of nutritional therapy and rehabilitation.

Early onset of veno-venous hemodiafiltration in treatment of severe combined trauma (clinical observation)

Severe combined trauma is characterized by high mortality both among young people (above 20 %) and among the older age group (about 45 %). Correction of metabolic disorders is the most difficult task, especially in the first hours after injury.Objective. To demonstrate the effectiveness of early initiation of veno-venous hemodiafiltration on the example of successful treatment of a patient with severe combined trauma (ISS is 57 points).Clinical observation. Patient A., 19 years old, was taken to the surgical intensive care unit by an ambulance team with a directional diagnosis of ‘severe combined injury’ as a result of falling from a height of the 6th floor in a state of alcoholic intoxication. Considering the impossibility of correcting waterelectrolyte and metabolic disorders by conservative methods, it was decided to start extracorporeal treatment early in the volume of prolonged venovenous hemodiafiltration with citrate-calcium anticoagulation (Ci-Ca CVVHD). In addition, the patient received therapy within the framework of the current recommendations for the treatment of severe combined trauma. Against the background of the ongoing treatment, there was a distinct positive trend. Vasopressor support was discontinued on day 3, and on day 15 the patient was transferred to independent breathing. In total, one CVVHD session was conducted, with a total duration of 62 hours. The patient’s stay in the intensive care unit was 29 days, in the profile distance – 4 days with subsequent discharge.Conclusions. The use of the CVVHD method in a patient with severe combined trauma in the early period without the phenomena of acute kidney injury contributed to the relief of metabolic disorders with the stabilization of the homeostasis system. However, in order to form conclusions and expand indications for the use of extracorporeal detoxification methods in patients with severe combined trauma, further study of this issue is necessary.

Практичні аспекти застосування методів екстракорпоральної детоксикації у лікуванні гострих отруєнь хімічної етіології

Abstract. The structure of xenobiotics that cause poisoning and the need for hospitalization is constantly changing. Today, psychotropic and narcotic substances and their precursors have become the main cause of severe poisonings that require emergency medical care. At the same time, another problem is the combined use of narcotic substances and alcohol, which often causes multiorgan dysfunction and prompts doctors to search for new treatment approaches, using traditional methods of afferent and efferent therapy in combination with modern extracorporeal detoxification technologies. Aim. Study of the peculiarities of the use of extracorporeal detoxification methods in the treatment of patients with acute chemical poisoning, which are associated with the change in the structure of poisons for 1990-2020. Materials and Methods. A cohort retrospective analysis of 1,685 charts of hospitalized patients with acute poisoning (Form No. 003/0) and 5,025 protocols of artificial detoxification procedures was conducted. Data from the reports of the Toxicological department and the Intensive care and extracorporeal detoxification unit of the Kyiv City Clinical Emergency Medical Center (hereinafter referred to as the Toxicological Center) for the period 1990-2020, with information on the structure of medical technologies (membrane, centrifugal, sorption and other) and the number of artificial detoxification methods used during the study period. Results. On average, the Kyiv Toxicological Center provides medical care to about 2,500 adult patients with chemical poisonings per year, of which about 1,500 patients will receive assistance in the Intensive care and extracorporeal detoxification unit. About 64,000 patients were treated in the period 1990-2020. It was established that the structure of acute poisonings has undergone significant changes: the number of poisonings by pesticides (organophosphorus substances, carbamates, and pyrethroids), technical fluids and solvents (ethylene glycol, dichloroethane, hydrogen tetrachloride, and methanol), metals (lead, mercury), corrosive substances (acids, alkalis). At the same time, a significant number of poisonings with alcohol and its surrogates, plant toxins and mushrooms, and household chemicals remained. The share of domestic, suicidal and criminal drug poisonings increased. However, after 2015, the number of poisonings by drugs, psychotropic substances (methadone, heroin, synthetic opioids) and their precursors, including in combination with benzodiazepines, meth- and amphetamine, cocaine and ethanol, has increased rapidly. In general, the part of drug poisonings has increased 3.5 times over the past 30 years. In accordance with the change in the structure of acute poisoning, the structure of extracorporeal detoxification technologies has also gradually undergone changes. The annual number of sorption technologies (hemosorption, plasmasorption) decreased. At the same time, there was an increase in the number of centrifuge technologies and membrane plasmapheresis. Significant changes have taken place in the direction of the application of blood oxygenation methods: the use of HBO in the treatment of acute poisoning has almost stopped, but the number of ozone therapy procedures and ultraviolet irradiation of the blood is increasing. During the study period, membrane technologies (hemodialysis, ultrafiltration, hemoperfusion) are the most common in the treatment of poisoning. Conclusions. The structure of toxic substances that cause household poisoning has undergone significant changes over the past 30 years: the number of poisonings by narcotic, psychotropic substances, medicines and alcohol has increased. There was a need to improve the existing approaches to the application of extracorporeal detoxification methods, in particular, a promising direction of research is the study of the effectiveness of various technologies for removing toxicants from the blood in case of poisoning with "new" narcotic, psychotropic substances and their precursors. The clinical effectiveness of hemodialysis, plasmapheresis, ozone therapy and ultraviolet irradiation of blood and their combination in the program of complex treatment of poisoning in adults are demonstrated. Key Words: acute poisoning, drugs, extracorporeal detoxification.

Оцінка виживання за методом Каплана-Майєра серед пацієнтів з отруєннями опіоїдними наркотиками, ускладненими гострим пошкодженням нирок

RESUME. Despite the fact that opioids do not have direct nephrotoxicity, a significant overdose, or their combination with alcohol and other psychotropic substances, contributes to the development of critical changes in many organs and systems of the body, which leads, in particular, to acute kidney injury (AKI). Aim. Using comparative analysis and the Kaplan-Meier method, to investigate the survival rates of patients with opioid drug poisoning complicated by acute respiratory distress syndrome treated with hemodialysis. Materials and Methods. A cohort retrospective analysis of the medical data of 128 patients (107 men, 21 women) aged 18 to 39 years who received treatment in the intensive care and extracorporeal detoxification department of the "Kyiv City Emergency Hospital" in the period 2017–2021 with a diagnosis of "Acute drug poisoning" (МКХ-10:Т40.0-Т40.3), complicated by the development of acute renal failure. Statistical analysis of the study results was performed using the Kaplan-Meier survival estimate; p≤0.05; the statistical analysis application package from Microsoft Excel 2019 was used. Results. Kaplan-Meier graphs indicated that patients with AKI due to morphine, heroin, and methadone poisoning have a statistically significant difference in survival rates (p < 0.05). The highest survival rates were shown by patients with morphine poisoning (100 %), the lowest were in groups with methadone (82.7 %) and heroin poisoning (48.3 %). Kaplan-Meier curves showed that all deaths occurred within 3–18 days of starting treatment, with most deaths (90 %) occurring within 3–12 days. Cumulative survival rates among patients with methadone-induced AKI stratified by blood alcohol content showed that among patients with methadone poisoning where alcohol was not detected, the survival rate was 100 %, and among patients with combined methadone and alcohol poisoning it was 75.2 %. Conclusions. Despite the similarity of the clinical picture in poisoning with natural and synthetic opioids (opioid syndrome), the causes of development of AKI and its course differ in patients with poisoning by different groups of drugs. Survival rates among patients with methadone poisoning are adversely affected by the presence of alcohol in the blood. Key Words: combined drug poisoning, renal failure.

Use of Selective Hemosorption and Hemodiafiltration in a Patient with Toxic Rhabdomyolysis Complicated by Acute Kidney Injury

Rhabdomyolysis ( RM ) is a clinical and laboratory syndrome accompanied by systemic endotoxicosis, a consequence of myocyte destruction and is manifested by acute kidney injury ( AKI ). The use of extracorporeal detoxification in the early stages of AKI is currently not recognized due to the lack of proven effectiveness. The objective: to demonstrate the effectiveness of selective hemoperfusion ( HP ) and hemodiafiltration ( HDF ) in a patient with toxic RM complicated by AKI . Subjects and methods. The article presents a clinical observation of an 1 8-y ea r-o ld patient after the use of 4-m ethylmethcathinone (mephedrone) with development of AKI . Clinical, laboratory, diagnostic, toxicological and instrumental methods of examination were used. HP and HDF were used together with standard intensive therapy. Results. Combined use of HP and HDF was accompanied by regression of markers of endotoxicosis and AKI . A decrease in myoglobin level was noted by 50.3%, 80.3% and 94.1%, respectively, after the 1st and 2nd procedures and by the 5th day. CPK (creatine phosphokinase) decreased by 47.7%, 81.5% and 97.8%, respectively. Cystati n-C went down by 19.3%, 39.9% and 69.9%, respectively. Conclusions. Earlier and justified use of HP and HDF was accompanied by a rapid improvement of clinical and laboratory parameters, which is reflected in the duration of ICU stay, hospital stay and the outcome of the disease in general.