Extracorporeal Ultrafiltration Research Articles

Development of a new miniaturized system for ultrafiltration.

Acute decompensated heart failure and fluid overload are the most common causes of hospitalization in heart failure patients, and often, they contribute to disease progression. Initial treatment encompasses intravenous diuretics although there might be a percentual of patients refractory to this pharmacological approach. New technologies have been developed to perform extracorporeal ultrafiltration in fluid overloaded patients. Current equipment allows to perform ultrafiltration in most hospital and acute care settings. Extracorporeal ultrafiltration is then prescribed and conducted by specialized teams, and fluid removal is planned to restore a status of hydration close to normal. Recent clinical trials and European and North American practice guidelines suggest that ultrafiltration is indicated for patients with refractory congestion not responding to medical therapy. Close interaction between nephrologists and cardiologists may be the key to a collaborative therapeutic effort in heart failure patients. Further studies are today suggesting that wearable technologies might become available soon to treat patients in ambulatory and de-hospitalized settings. These new technologies may help to cope with the increasing demand for the care of chronic heart failure patients. Herein, we provide a state-of-the-art review on extracorporeal ultrafiltration and describe the steps in the development of a new miniaturized system for ultrafiltration, called AD1 (Artificial Diuresis).

The Science of Extracorporeal Ultrafiltration: Introducing a Novel Miniaturized Device

Introduction: Fluid overload has been associated with untoward outcomes in a variety of clinical settings. Isolated extracorporeal ultrafiltration (UF) allows for mechanical extraction of excess fluid and optimization of volume status without the established risks associated with use of high-dose diuretics. Conventional machines for renal replacement therapy can be used to perform isolated UF. However, they typically need high blood flow rates with high circuit volumes and the therapy has to be performed by trained nurses. Herein, we describe a novel device, the Artificial Diuresis-1, or AD 1 (Medica S.p.A., Medolla, Italy), which is a portable technology designed to perform extracorporeal UF at bedside. Materials and Methods: The AD 1 uses a polysulfone mini-filter to generate ultrafiltrate with the help of two forces: blood flow (Qb) and gravity (based on the height at which the ultrafiltrate collection bag is placed). In vitro experiments were performed using human blood to evaluate vascular access pressures and ultrafiltrate volumes using various central venous catheters (CVCs; 12 Fr bilume, 10 Fr with 2 separate lumens, pediatric catheter 7 Fr). A variety of combinations were tested with Qb of 20, 35, 50 mL/min and collection bag height at 20, 40, 60 cm, measuring the UF rate per minute while monitoring the pressures in the venous and arterial lines and filtration fraction. Results: The device’s performance was as expected. Regarding the pediatric CVC, it was possible to perform measurements only with a Qb of 20 mL/min due to increased venous pressure. UF rates when lines were directly connected to the blood container as well as for CVC Tesio ranged from 3.7 to 11 mL/min, for the CVC Niagara™ from 4.5 to 12.5 mL/min, and for the CVC 7 Fr from 8.5 to 10 mL/min. The pressures of the vascular accesses were kept within a range of −5/-40 mm Hg for the artery and +10/+70 mm Hg for the vein. The highest venous pressure values were found with the CVC 7 Fr (+80/+100 mm Hg). Conclusions: This novel device allows to treat patients with fluid overload in a variety of settings, from low-intensity department such as long-term care facilities to the intensive care unit. The device is small and portable, has a simple design, and is user friendly. Future studies will be needed to evaluate whether gentle UF and treatment of volume overload will translate into improvement in clinical outcomes such as a reduction in congestion-related hospital admissions.

Artificial Diuresis: Animal Studies on Efficacy and Safety of a New Miniaturized Device for Extracorporeal Ultrafiltration

Introduction: We have recently developed a new miniaturized device for extracorporeal ultrafiltration (UF) to be used in patients with fluid overload: Artificial Diuresis-1 (AD1) (Medica S.p.A., Medolla, Italy). The device has a reduced priming volume, operates at very low pressures and flow regimes, and is designed to perform extracorporeal UF at bedside. After accurate experiments were carried out in vitro, we report in this paper the results of in vivo UF sessions carried out in selected animals according to veterinary best practice. Materials and Methods: The AD1 kit is pre-filled with sterile isotonic solution and operates with a polysulfone mini-filter, MediSulfone (polysulfone at 50,000 Dalton). A collection bag with a volumetric scale is connected to the UF line, and the ultrafiltrate is obtained by gravity based on the height at which the ultrafiltrate collection bag is placed. Animals were prepared and anesthetized. The jugular vein was cannulated with a double-lumen catheter. Three 6-h sessions of UF were scheduled with a target fluid removal of 1,500 mL. Heparin was used as anticoagulant. Results: In all treatments, the target value of UF was obtained in the absence of major clinical or technical problems with a maximum deviation from the scheduled UF rate lower than 10%. The device resulted to be safe, reliable, accurate, and easily usable thanks to a user-friendly interface and its very small dimensions. Conclusions: This study opens the way for clinical trials in different settings including departments with low intensity of care and even in ambulatory centers or patient’s home.

The Cardiorenal Syndrome in Heart Failure

Abnormal fluid handling leads to physiologic abnormalities in multiple organ systems. Deranged hemodynamics, neurohormonal activation, excessive tubular sodium reabsorption, inflammation, oxidative stress, and nephrotoxic medications are important drivers of harmful cardiorenal interactions in patients with heart failure. Accurate quantitative measurement of fluid volume is vital to individualizing therapy for such patients. Blood volume analysis and pulmonary artery pressure monitoring seem the most reliable methods for assessing fluid volume and guiding decongestive therapies. Still the cornerstone of decongestive therapy, diuretics' effectiveness decreases with progression of heart failure. Extracorporeal ultrafiltration, an alternative to diuretics, has been shown to reduce heart-failure events.

Chronic Peritoneal Drainage in Refractory Right Heart Failure and Ascites

Venous congestion (backward failure) plays an important role in the pathogenesis of cardiorenal syndrome. These patients develop ascites, which is associated with patient’s discomfort and increased intra-abdominal pressure,1 contributing to diuretic resistance. Paracentesis of cardiac ascites is associated with clinical and renal improvement.2,3 Owing to direct access to the peritoneal cavity and better hemodynamic stability, ascites can be better controlled with peritoneal dialysis (PD) compared with extracorporeal ultrafiltration.

In vitro use of standard fluid infusion central venous catheter for slow continuous ultrafiltration feasibility assessment.

Slow continuous ultrafiltration (SCUF) by central venous catheter (CVC) for hemodialysis is a simple extracorporeal ultrafiltration that can reduce and control fluid overload in patients with chronic or acute chronic heart failure unresponsive to medical therapy. In order to avoid complications and risks related to the catheterization with a standard CVC for hemodialysis to provide the SCUF, considering that hospitalized patients affected by congestive heart failure commonly undergo CVC placement for medications delivering, we tested an in vitro model to use a standard CVC for infusion to perform SCUF. We performed an in vitro SCUF experimental model through two different lumens of a triple (8Fr × 20 cm Tri-lumen catheter Kit-Envans Extra) and a quad-lumen CVC (8.5Fr × 20 cm Quad-lumen catheter kit-Benefis Medical Devices) commonly used in our Intensive Care Unit for fluids and medications infusions. We used Prismaflex with the HF-20 set (Baxter, IL, USA) to perform the SCUF treatment. Our in vitro data confirm the technical feasibility of the use of standard CVC for fluid infusion to perform a SCUF treatment with a theoretical weight loss of up to 200 ml/h by a blood flow ranging from 30 to 45 ml/min. The use of standard infusion CVC could be utilized in the intensive care unit to perform SCUF not exposing patients to the risks and complications related to the placement and permanence of CVC for hemodialysis.

COMPREHENSIVE TREATMENT OF COMPLICATED COURSE OF LIVER CIRRHOSIS IN CASE OF BLEEDING FROM THE VARICOS VEINS OF ESOPHAGUS, ENCEPHALOPATHY AND ASCITES

Aim: To develop a complex treatment for patients with decompensated cirrhosis in case of bleeding from the varicose veins of the esophagus. Material and methods: With bleeding from varicose veins of the esophagus for the period 2015–2020. in the clinic of the Transcarpathian Regional Clinical Hospital. A. Novak examined and treated 64 patients with C-class liver cirrhosis according to the Child-Turcotte-Pugh criteria. Results: In 17 patients they used extracorporeal ultrafiltration of ascitic fluid with it’s subsequent intravenous reinfusion. In the subgroup of 39 patients with effective sclerotherapy the mortality rate was 23.1%. In the subgroup of 25 patients where the ES was ineffective and the Blackmore tube was applied, the mortality rate was 32%. Among the 20 patients after laparocentesis with ascitic fluid evacuation 8 (40%) died. In the 17 patients after extracorporeal ultrafiltration of ascitic fluid with its subsequent intravenous reinfusion 2 (11.8%). In the subgroup where albumin peritoneal dialysis was applied 7 patients died (25.9%). Conclusions: The prognostic factors for the lethal outcome of bleeding from varicose veins of the esophagus in patients with decompensated liver cirrhosis are: the ineffectiveness of endoscopic sclerotherapy as a means of primary hemostasis, bleeding recurrence in the first 5 days. The use of staged treatment using extracorporeal methods can significantly improve the results of treatment, reduce mortality.

Abstract 9964: Influence of Worsening Heart Failure During Hospitalization on the Prognosis in Patients with Acute Decompensated Heart Failure

Introduction: Worsening heart failure (WHF) during hospitalization has been used as the one of endpoint in assessing treatments for acute decompensated heart failure (ADHF). However, there are few data on WHF and long-term prognosis, especially in Japanese population. Hypothesis: WHF during hospitalization can influence the long-term prognosis in patients with ADHF. Methods and Results: The Kyoto Congestive Heart Failure registry is a prospective multicenter cohort study enrolling 4056 consecutive patients hospitalized for ADHF in Japan. WHF was defined as additional intravenous inotropes, diuretics, respiratory management (noninvasive positive pressure ventilation or intubation), or extracorporeal ultrafiltration after 24 hours from admission. Among 4056 patients, 775 (19.4%) patients developed WHF during hospitalization. Inotropes use in emergency room was significantly higher (8.0% vs 2.7%, p<0.001), whereas diuretics use was significantly lower (45.6% vs 51.7%, p=0.002) in patients with WHF than those without WHF. In-hospital mortality was significantly higher in patients with WHF than in those without WHF (16.3% vs 4.0%, p<0.001). A composite of all-cause death and HF hospitalization at 1-year were compared in 3728 patients who were alive at discharge with available data. Patients with WHF (N=644, 18.3%) were younger (79 [70-85] vs 81 [7-85], p<0.001), more likely to be men (61.7 % vs 53.6%, p<0.001), and more likely to have diabetes (44.7% vs 35.2% p<0.001), chronic kidney disease (57.9% vs 41.3%, p<0.001), and ischemic etiology (41.6% vs 30.7%, p<0.001) than those without WHF (N=3084, 87.4%). After adjusting for confounders, the risk for primary outcome of WHF group remained significant (OR: 1.27, 95%CI: 1.02-1.58, p=0.03). Conclusions: The WHF during hospitalization was associated with worse 1-year clinical outcomes as well as in-hospital mortality in patients with ADHF.

Immersion pulmonary edema in a patient on maintenance dialysis: A case report

Immersion pulmonary edema (IPE) is a rare condition observed in divers. We report a case of a 66-year-old man on maintenance dialysis who developed acute dyspnea and blood-tinged sputum after scuba diving. Vital signs on admission were significant for elevated blood pressure at 209/63mmHg and hypoxia with an oxygen requirement of 6 L/min. Physical examination was remarkable for bilateral coarse crackles and systolic ejection murmur. Chest radiography revealed bilateral pulmonary edema. Echocardiography showed aortic stenosis and diffuse hypokinesis of left ventricular wall motion. We started bilevel positive airway pressure and administered nitroglycerin and nicardipine to maintain adequate oxygenation and reduce blood pressure. We started hemodialysis and extracorporeal ultrafiltration to remove excess fluid. His dyspnea subsided and oxygen was no longer required on Day 3. His long-standing hypertension, increased afterload due to vasoconstriction induced by cold water, increased capillary pressure due to impaired left ventricular motion and increased preload caused by exertion, and aortic stenosis probably contributed to pulmonary congestion. We propose maintenance dialysis as a novel risk factor for IPE due to its tendency to induce volume overload, increase pulmonary capillary pressure, and increase aortic stenosis risk. Patients on hemodialysis should refrain from diving to prevent this life-threatening condition.

Goal-directed dehydration therapy in sepsis and acute respiratory distress syndrome guided by volumetric hemodynamic monitoring

The aim of our study was to improve results of treatment of critically ill patients with sepsis and acute respiratory distress syndrome (ARDS) using the goal-directed dehydration therapy (DT).Sixty adult patients with sepsis and ARDS receiving mechanical ventilation for at least 24 hours were enrolled into a prospective randomized study. The patients were randomized into groups of dehydration guided either by extravascular (group of extravascular lung water index ‒ EVLWI,n= 30) or intravascular (group of global end-diastolic volume index ‒ GEDVI,n= 30) compartment. Dehydration was performed over 48 hours by administering diuretics or controlled extracorporeal ultrafiltration. We measured ventilation parameters, blood gases, and parameters of volumetric monitoring. The baseline characteristics of the patients did not differ between the groups. By 48 hours, the target fluid balance was achieved in both groups. In the EVLWI group at 48 hours, we found reduction of EVLWI by 15.4% (p< 0.001) and increase in PaO2/FiO2by 23.3% as compared with baseline (p< 0.001). In parallel, we observed decrease in creatinine and urea (p< 0.05). In the GEDVI group, PaO2/FiO2 rose by 12.5% (p = 0.021), whereas EVLWI remained unchanged (p= 0.4). Maximal decrease in EVLWI and improvement of PaO2/FiO2 were achieved in direct ARDS.Thus, in patients with sepsis and ARDS the de-escalation goal-directed therapy resulted in the improvement of arterial oxygenation and organ function. The efficacy of dehydration was increased in direct ARDS. The extravascular compartment dehydration algorithm attenuated pulmonary edema and acute kidney injury more efficiently. Therefore, sepsis-induced ARDS may require personalized therapeutic approach.

Usefulness of Peritoneal Ultrafiltration in Patients with Diuretic Resistant Heart Failure without End-Stage Renal Disease

Aim: This study aimed to explore the role of peritoneal ultrafiltration (UF) in cardiorenal syndrome (CRS) patients for fluid and metabolic control. Background: Peritoneal UF is safely and efficiently used for the management of CRS. It has been shown to provide efficient UF in hypervolemic patients. Methods: Thirty (20 males and 10 females) CRS patients were treated by peritoneal dialysis (PD) and UF. The baseline data of the patients (demographics, causes of heart failure, the presence of pacemaker or implantable cardioverter-defibrillator, the need for extracorporeal UF or paracentesis or thoracentesis, comorbidity, drugs, left ventricular ejection fraction [LVEF] and pulmonary artery systolic pressure [PAPs], pericardial effusion, physical examination, body weight, NYHA class, dialysis regime, urine output, N-terminal pro-B-type natriuretic peptide [NT-proBNP] level, hemoglobin, estimated glomerular filtration rate [eGFR], and other routine biochemical determinations) were recorded at the onset, every 6 months, and then annually. Echocardiograms were performed at baseline and after 6 and 12 months. The time points of complications associated with PD, the need for hemodialysis, the day of death, and causes of death were documented. Results: Mean age was 69 ± 8 years (range 49–84 years). The average PD duration was 18.25 ± 14.87 months. According to the CKD-EPI, initial mean GFR was 34.34 ± 11.9 mL/min/1.73 m² (range 16.57–59.0), and this increased to 45.48 ± 26.04, 45.10 ± 28.58, and 41.10 ± 25.68 mL/min/1.73 m² in the third, sixth, and twelfth months, respectively. There was a significant increase in the first 3 months and a significant decrease between the third and twelfth months (respectively, p = 0.018 and p = 0.043). There was no difference in eGFR levels between baseline and the end of the first year (p = 0.217). In the first 3 months, there was a significant decline in urea levels to 79.38 ± 36.65 from 109.92 ± 42.44 mg/dL and this was maintained until the end of the first year of PD therapy (after 3 months, p = 0.002; after 1 year, p = 0.024). However, there was no significant change in creatinine levels within the first year (p = 0.312). There was a significant increase in hemoglobin level up to the end of the first year of PD (after 3 months, p = 0.000; after 12 months, p = 0.013). There was a marked decrease in NT-proBNP levels in the first 6 months (p = 0.011). Functional capacity (according to NYHA classification) improved in all patients by the third month of PD treatment (p < 0.001). This early improvement was maintained in many patients during the following 12 months (p < 0.001). There was a marked decrease in NT-proBNP levels in the first 6 months (p = 0.011). At the end of the first year, there was an approximate 15% reduction in NT-proBNP levels (p = 0.647). Hospitalizations decreased to 6 ± 15 days/patient-year (range 18–122 days) from 62 ± 24 days/patient-year (p = 0.000). Conclusion: Peritoneal UF is a treatment method that maintains renal function and electrolyte balance, improves cardiac function, and reduces hospitalizations in CRS patients. We observed that this treatment significantly increased functional capacity and quality of life and significantly reduced hospital admissions.

Description and In-Vitro Test Results of a New Wearable/Portable Device for Extracorporeal Blood Ultrafiltration

This paper presents the design of Rene Artificiale Portatile (RAP), a novel wearable and portable device for extracorporeal blood ultrafiltration, capable of providing remote treatment of fluid overload in patients with kidney diseases and/or congestive heart failure. The development of the device is based on a new design paradigm, since the layout of the device is box-shaped, as to fit a backpack or a trolley case, differentiating it from other existing devices. The efficient layout and component placement guarantee minimalization and ergonomics, as well as an efficient and cost-effective use. The redundant control architecture of the device has been implemented to ensure a high level of safety and an effective implementation of the clinical treatment. The consistency of the design and its effective implementation are assessed by the results of the preliminary in-vitro tests presented and discussed in this work.

Acute Kidney Injury, Heart Failure, and Health Outcomes

Acute kidney injury in acute decompensated heart failure leads to increased readmissions regardless of being transient or sustained at the time of discharge. Timely identification of acute kidney injury and worsening heart failure in patients with acute decompensated heart failure is of utmost importance to optimize different components of heart failure treatment. Acute kidney injury is a strong predictor of poor outcomes and early death in patients with pulmonary artery hypertension and acute right-sided heart failure. Extracorporeal ultrafiltration should not be used as an initial or alternative to diuretic therapy. It should be reserved for diuretic-resistant individuals.

Інтенсивна терапія та малоінвазивні втручання в комплексному лікуванні крово-теч із варикозно розширених вен стравоходу у пацієнтів із декомпенсованим цирозом печінки

From January 2004 to December 2010 in the clinic of Transcarpathian Regional Clinical Hospital 64 patients with bleed-ing from esophageal varices with C-class liver cirrhosis by Child-Turcotte-Pugh criteria were examined and treated. The initial bleeding arrestin 39 (61%) patients was achieved with complex medical therapy and endoscopic sclerotherapy (ES). In 25 (39%) patients due to the inefficiency of the ES, authors used a Blakemore-Sengstaken tube. The III class of encephalopa-thy by West-Haven criteria was diagnosed in the in 37 (57.8%), in 27 it was of IV degree. In 3 (4.7%) patients ascites was transient and in 61 (95.3%) – refractory. In order to treat liver failure, as a major complication that caused bleeding adverse outcome in 27 patients with IV degree of encephalopathy authors used albuminperitoneal dialysis. Inorder to treat in-traabdominal hypertension at ascites in20 patients with III degree of hepatic encephalopathy authors applied laparocentesis with fluid evacuation. In17 patients they used extracorporeal ultrafiltration of asciticfluid with it’s subsequent intravenous reinfusion. In the subgroup of 39 patients with effective sclerotherapy the mortality rate was 23.1%. In the subgroup of 25 patients where the ES was ineffective and the Blackmore tube was applied, the mortality rate was 32%. Amongthe 20 pa-tients after laparocentesis with ascitic fluid evacuation 8 (40%) died. In the 17 patients after extracorporeal ultrafiltration of ascitic fluid with its subsequent intravenous reinfusion 2 (11.8%). In the subgroup where albumin peritoneal dialysis was applied 7 patients died (25.9%).A total of 17 (26.6%) patients died within the observation period of up to 5 days.

Extracorporeal Isolated Ultrafiltration for Management of Congestion in Heart Failure and Cardiorenal Syndrome.

Acute decompensated heart failure has the highest rate of hospital readmission among all medical conditions and portends a significant financial burden on health care system. Congestion, the hallmark of acute decompensated heart failure, represents the primary reason for hospitalization and the driver of adverse outcomes in these patients. Although diuretic-based medical regimens remain the mainstay of management of acute decompensated heart failure, they often show suboptimal efficacy and safety profiles in this setting. Mechanical extraction of excess fluid through extracorporeal ultrafiltration therapy has been proposed as a mechanistically relevant option in this setting. The advent of simplified, portable, and user-friendly devices that are dedicated to ultrafiltration therapy for these patients has renewed the interest in this therapeutic modality. In this article, we provide a brief overview of the initial mechanistic studies followed by the key clinical findings of the most recent landmark trials. The shortcomings of these studies are discussed in detail because not only do they provide the appropriate context in which the results are to be interpreted, but more importantly they also highlight the existing knowledge gaps that need to be addressed in future studies. Finally, selected practical and conceptual considerations and controversies are reviewed with regard to evidence-based ultrafiltration therapy.

Cardiorenal Syndrome Type 1: Definition, Etiopathogenesis, Diagnostics and Treatment

Abstract Cardiorenal Syndrome Type 1 (CRS-1) is defined as an acute worsening of heart function leading to acute kidney injury and/or dysfunction. It is an important cause of hospitalization which affects the diagnosis as well as the prognosis and treatment of patients. The purpose of this paper is to analyze causes that lead to the development of cardiorenal syndrome type 1 and its clinical consequences, as well as to emphasize the clinical importance of its early detection. The clinical studies and professional papers dealing with etiopathogenesis, diagnosis and treatment of cardiorenal syndrome type 1, have been analyzed. The most important role in the occurrence of cardio renal syndrome type 1 is played by hemodynamic mechanisms, activation of neurohumoral systems, inflammation and imbalance between the production of reactive oxygen species (ROS) and nitric oxide (NO). Diagnosis of cardiorenal syndrome type 1 involves biomarkers of acute renal injury among which the most important are: neutrophil gelatinaseassociated lipocalin (NGAL), cystatin C, kidney injury molecule 1 (KIM-1), liver-type fatty acid binding protein (L-FABP), IL-18 and the values of nitrogen compounds in serum. In addition to a pharmacological therapy, various modalities of extracorporeal ultrafiltration are applied in treatment of CRS-1, particularly if there is resistance to the use of diuretic therapy. As opposed to the experimental models, in clinical practice acute renal injury is often diagnosed late so that the measures taken do not give the expected results and the protective role shown in experimental conditions do not give the same results. For all these reasons, it is necessary to analyze the pathophysiology of renal impairment in cardiorenal syndrome as well as detect early indicators of kidney injury that could have clinical benefit and positive impact on reducing the cost of treatment.

Application of Extracorporeal Ultrafiltration Therapy Given to a Dog and a Cat with Pulmonary Edema and Renal Failure

A 13-year-old castrated male mixed breed dog and a 12-year-old castrated male mixed breed cat were referred to the hospital for the treatment of pulmonary edema and azotemia at the same time. To resolve the pulmonary edema and azotemia, intermittent hemodialysis (HD) was performed using ultrafiltration (UF), and the pulmonary edema, azotemia, other electrolyte and acid-base imbalances were improved. This case study demonstrated that when we encountered pulmonary edema patients with diuretic resistance, severe electrolyte imbalance, and impaired renal function complicated by decongestive therapy using diuretics, UF therapy can be considered a life-saving intervention.

Extracorporeal ultrafiltration therapy for acute decompensated heart failure

Congestion is the most common reason for hospitalization of patients with acute decompensated heart failure (ADHF) and adversely impacts their outcomes. Extracorporeal ultrafiltration (UF) therapy has re-emerged as an effective strategy for decongestion in this setting. This article is intended to discuss key concepts in UF and its technique, provide a brief historical view of UF application for decongestion in ADHF, review the hemodynamic and neurohormonal effects of UF and their positive effects on the pathophysiology of ADHF, discuss the findings of the landmark trials in this field, and explain key findings of these studies as well as the apparent discrepancies in their findings. In a separate section we discuss the intricacies of renal dysfunction in ADHF as it plays a very important role in understanding the current evidence and designing futures clinical trials of UF in ADHF. In the end, the authors provide their perspective on the future role of UF in management of patients with ADHF and congestion.

Dialysate with high dissolved hydrogen facilitates dissociation of indoxyl sulfate from albumin.

Background:Protein-bound toxins such as indoxyl sulfate (IS) are not efficiently removed by conventional hemodialysis (HD).Objectives:To improve the removal of IS, we performed an in vitro study to evaluate the effects of high dissolved hydrogen on the dissociation of IS from albumin using simulated HD.Materials and Methods:Wasted dialysate from peritoneal dialysis was concentrated a hundred times using extracorporeal ultrafiltration method. Dialysate with high dissolved hydrogen was made by mixing concentrated dialysis solution and electrolyzed-reduced water. The amounts of free fractions of IS were determined by high performance liquid chromatography.Results:IS was significantly dissociated from albumin using dialysate with high dissolved hydrogen compared with conventional dialysate (P < 0.05).Conclusions:Effective removal of IS is expected using a dialysate with high dissolved hydrogen.

Continuous ultrafiltration in acute decompensated heart failure: current issues and future directions.

Most patients hospitalized for acutely decompensated heart failure (ADHF) present with symptoms and signs of volume overload, which are also associated with high rates of death and re-hospitalization. Several studies have investigated the possible use of extracorporeal ultrafiltration in the management of ADHF, evaluating potential clinical benefits in terms of hospitalization and survival rates versus those of conventional diuretic therapy. Though ultrafiltration remains an extremely appealing therapeutic option for patients with AHDF, some of the most recent studies have reported conflicting results. Differences in the selection of study population, heterogeneity of the indications for the use of ultrafiltration, disparity in the ultrafiltration protocols, and high variability in the pharmacologic therapies used for the control group could explain some of these contradictory findings. The purpose of the present review is to provide an overview and an update on the mechanisms and clinical effects of ultrafiltration and on currently available evidence supporting its use in ADHF.