High-volume Hemofiltration Group Research Articles

A Retrospective Chart Review to Determine Hypophosphatemia Incidence and Phosphorus Supplementation Requirements in Patients With Severe Thermal Cutaneous Injuries Receiving High-Volume Hemofiltration.

Patients with severe thermal injuries have increased metabolic demands necessitating frequent phosphate supplementation. Patients with acute renal failure may have less requirements, due to reduced elimination. However, patients being supported with renal replacement therapy have varying degree of requirements. Little published evidence depicts the incidence of hypophosphatemia and repletion requirements in patients with severe thermal injuries treated with high-volume hemofiltration (HVHF) and a high-flux membrane. The objective of this retrospective chart review was to determine the incidence of hypophosphatemia and characterize repletion requirements and response in this population. Enrolled patients had at least 20% TBSA thermal injuries and required continuous hemofiltration with prefilter replacement fluid doses ≥35 mL/kg IBW/hr. A randomly selected cohort without acute kidney injury (AKI) and matched based on age and extent of TBSA was used to compare phosphorus requirements over an initial 14-day period. Demographics, diet, and variables affecting phosphorus concentrations were collected. Sixteen patients were included in the retrospective HVHF group and 16 patients in a case-control cohort to better depict the impact of HVHF. The average age was 60.2 ± 15.1 years and median TBSA was 30% (23.4, 56.3) in the HVHF group, compared to 53.3 ± 16.4 years (P = .22) and TBSA 29% (26.4, 33.9; P = .73). All patients in the HVHF group were started on HVHF with a 1.6 m2 polyethersulfone membrane for AKI. As expected, the HVHF group exhibited statistically higher than normal baseline potassium and phosphorous laboratory values. The HVHF group experienced more days with hypophosphatemia (49.6 ± 12.4% vs 29.3 ± 16.3%, P = .012), despite 0.75 mmol/kg/day phosphorous supplementation (compared to 0.66 mmol/kg/day for the control group, P = .45). Patients with longer durations of HVHF therapy experienced increasing risk of hypophosphatemia, reaching 100% by the end of the study period. This study demonstrates severe thermally injured patients receiving HVHF for AKI are at increased risk for hypophosphatemia, and require high phosphate supplementation.

516 Phosphorus Requirements in Patients with Severe Thermal Injuries Requiring High-Volume Hemofiltration

IntroductionPatients with thermal injuries have increased metabolic demands, requiring increased phosphate supplementation. Evidence is scant depicting incidence of hypophosphatemia and repletion requirements in patients with thermal injuries treated with high-volume hemofiltration (HVHF) and a high-flux membrane. The objective of this study was to determine the incidence of hypophosphatemia and characterize repletion requirements in this population.MethodsThis study was a case-control, retrospective chart review. Patients were included if sustained at least 20% total body surface area (TBSA) thermal injuries and required continuous HVHF (prescribed doses ≥ 35 mL/kg/hr). A randomly selected cohort (matched to age, TBSA, and inhalation injury) without acute kidney injury (AKI) was used to compare phosphorus requirements over an initial 14 day period. An a priori sample size was calculated (n = 26) to detect a minimum difference of 0.3 mmol/kg/day. Repeated measures ANOVA was used to compare requirements and concentrations. Demographics, diet, and variables affecting phosphorus concentrations were compared utilizing Fisher's exact, Student's t-test, or Mann-Whitney test depending on type and distribution.ResultsOne thousand sixty-six patients were screened. Most were excluded from the HVHF group for TBSA < 20% (58%) or not a burn injury (29%). Sixteen patients were included in each group. The average age was 60.2 ± 15.1 vs 53.3 ± 16.4 (p = 0.22) with median TBSA (p = 0.73) of 30% (23.4, 56.3) vs 29% (26.4, 33.9). All patients in the study group were started on HVHF for AKI, utilizing a 1.6m2 polyethersulfone membrane (mean delivered prefilter dose of 54.7 ± 1.5 ml/kg/hr), and had statistically higher potassium and phosphorous laboratory values at baseline. Parenteral phosphorus replacements were 2 fold higher in the HVHF group (p = 0.02), but not statistically different after accounting for estimated enteral intake. Despite providing 0.75 mmol/kg/day of phosphorous supplementation (vs 0.66 mmol/kg/day in control, p = 0.45), the HVHF group experienced more days with hypophosphatemia (49.6 ± 12.4 % vs 29.3 ± 16.3 %, p = 0.012). By 72h, every HVHF patient experienced at least one episode of hypophosphatemia. Patients on longer durations of therapy had increasing risk of hypophosphatemia. There was a significant difference in days requiring mechanical ventilation (p < 0.001)ConclusionsThis study demonstrates thermally injured patients receiving HVHF for AKI are at increased risk for hypophosphatemia and require higher phosphate supplementation to maintain lower average serum concentrations, as compared to the controls with similar burns but without acute kidney injury.

Effect of high-volume hemofiltration on children with sepsis.

BackgroundSepsis has always been a challenge in pediatric intensive care unit (PICU) with poor prognosis. In order to evaluate the effect between routine continuous renal replacement therapy (CRRT) and high-volume hemofiltration (HVHF) in children with sepsis, we performed out this prospective, randomized, controlled, open-label trial.MethodsForty-seven children with sepsis were enrolled from January 2015 to December 2016. Twenty-two patients in Control group received routine CRRT and 25 patients in HVHF group received HVHF within 6 hours after the diagnosis of sepsis. The oxygenation index, serum creatinine, urea, lactate, inflammatory cytokines (IL-6, IL-10, and TNF-α), pediatric risk of mortality III (PRISM III) and 28-day mortality rate were collected and compared.ResultsThe oxygenation index in HVHF group and Control group was significantly increased at 48 hours (P<0.01) and 72 hours after treatment (P<0.05). The same result of arterial lactate was observed. Serum creatinine, urea, IL-6, IL-10, TNF-α and PRISM III score were significantly ameliorated after 72 hours treatment in HVHF group (P<0.01), while there was no significant difference in Control group. After 72 hours of treatment, the oxygenation index, lactate, serum creatinine, urea, TNF-α, IL-6, IL-10 and PRISM III score in HVHF group were significantly improved compared with Control group (P<0.01). There is no significant difference on 28-day mortality between the two groups (P>0.05).ConclusionsHVHF might be an effective treatment for children with sepsis.

Effect of High-Volume Hemofiltration in Critically Ill Patients: A Systematic Review and Meta-Analysis.

BackgroundStudies have been carried out to assess the efficacy of high-volume hemofiltration (HVHF) among critically ill patients. However, it is currently unclear whether HVHF is really valuable in critically ill patients.Material/MethodsRandomized controlled trials evaluating HVHF for critically ill adult patients were included in this analysis. Three databases were searched up to July 27, 2018. The relative risk (RR), mean difference (MD), and 95% confidence intervals (CI) were determined.ResultsTwenty-one randomized controlled trials were included in this analysis. Overall, HVHF was associated with lower mortality compared with control measures (RR=0.88, 95% CI=0.81 to 0.96, P=0.004) in critically ill patients. Sub-analysis revealed HVHF reduced mortality in sepsis and acute respiratory distress syndrome patients, but no similar effect in other diseases. HVHF decreased levels of plasma tumor necrosis factor and interleukin 6. The heart rate of the HVHF group after treatment was slower than the control group, while we found higher mean arterial pressure in the HVHF group, but oxygenation index was not significantly different between the two groups. HVHF had no remarkable influence on acute physiological and chronic health evaluation score (APACHE II score) compared with the control group.ConclusionsHVHF might be superior to conventional therapy in critically ill patients.

High-volume hemofiltration in adult burn patients with septic shock and acute kidney injury: a multicenter randomized controlled trial

BackgroundSepsis and septic shock occur commonly in severe burns. Acute kidney injury (AKI) is also common and often results as a consequence of sepsis. Mortality is unacceptably high in burn patients who develop AKI requiring renal replacement therapy and is presumed to be even higher when combined with septic shock. We hypothesized that high-volume hemofiltration (HVHF) as a blood purification technique would be beneficial in this population.MethodsWe conducted a multicenter, prospective, randomized, controlled clinical trial to evaluate the impact of HVHF on the hemodynamic profile of burn patients with septic shock and AKI involving seven burn centers in the United States. Subjects randomized to the HVHF were prescribed a dose of 70 ml/kg/hour for 48 hours while control subjects were managed in standard fashion in accordance with local practices.ResultsDuring a 4-year period, a total of nine subjects were enrolled for the intervention during the ramp-in phase and 28 subjects were randomized, 14 each into the control and HVHF arms respectively. The study was terminated due to slow enrollment. Ramp-in subjects were included along with those randomized in the final analysis. Our primary endpoint, the vasopressor dependency index, decreased significantly at 48 hours compared to baseline in the HVHF group (p = 0.007) while it remained no different in the control arm. At 14 days, the multiple organ dysfunction syndrome score decreased significantly in the HVHF group when compared to the day of treatment initiation (p = 0.02). No changes in inflammatory markers were detected during the 48-hour intervention period. No significant difference in survival was detected. No differences in adverse events were noted between the groups.ConclusionsHVHF was effective in reversing shock and improving organ function in burn patients with septic shock and AKI, and appears safe. Whether reversal of shock in these patients can improve survival is yet to be determined.Trial registrationClinicaltrials.gov NCT01213914. Registered 30 September 2010.

Clinical Benefits of High-Volume Hemofiltration in Critically Ill Pediatric Patients with Severe Sepsis: A Retrospective Cohort Study

Aims: The study aimed to assess the clinical benefits of high-volume hemofiltration (HVHF) in pediatric patients with severe sepsis compared with standard-volume continuous veno-venous hemofiltration (CVVH). Methods: We retrospectively analyzed the medical records of 155 pediatric patients with severe sepsis admitted to the pediatric intensive care unit of Shanghai Children's Hospital from January 2010 to June 2016. A total of 93 patients were treated with HVHF and 62 patients were treated with CVVH. Results: HVHF treatment did not significantly reduce 28-day mortality. Moreover, there was no significant difference in reducing the plasma level of inflammatory mediators and improving hemodynamic variables between HVHF and CVVH group. However, the incidence of hyperglycemia was significantly higher in HVHF group than in CVVH group. Conclusions: There is no evidence to indicate that HVHF is superior to CVVH in reducing 28-day mortality as an adjunct to the treatment of severe sepsis in pediatric patients.

Effects and mechanisms of high-volume hemofiltration on endotoxin-induced acute lung injury of piglets

Objective: To compare the effects of high-volume hemofiltration (HVHF) and continuous veno-venous hemofiltration (CVVH) on cardiopulmonary functions, lung fluid balance, lung damage and cytokine expression in endotoxin-induced acute lung injury piglet model, and to further evaluate the value of high-volume hemofiltration in acute lung injury. Method: Eighteen piglets were randomly divided into the control group (6 piglets), the CVVH group (6 piglets) and the HVHF group (6 piglets). By general anesthesia, the intravenous infusion of 0.15 mg/kg endotoxin were received in all the animals and induced acute lung injury.High-volume hemofiltration and continuous veno-venous hemofiltration were addressed to different groups.Subsequently, hemodynamic parameters (heart rate, mean arterial blood pressure, central venous pressure, pulse contour cardiac index, systemic venous resistance index and extravascular lung water index) as well as gas exchange and lung mechanics parameters (respiratory rate, partial pressure of carbon dioxide, partial pressure of oxygen/fraction of inspired oxygen, dynamic lung compliance and airway resistance) were intermittently measured.Lung tissues were collected for further analysis (the lung wet-to-dry weight ratio, lung injury scoring). The plasma protein levels of cytokines (interleukin(IL) -6, 10 and tumor necrosis factors alpha(TNF-α)) were also assessed.Two-way analysis of variance (ANOVA) and Bonferroni post-test were conducted to identify significant differences among the control, CVVH and HVHF group. Result: Compared with CVVH, HVHF had the capacity to improve significantly the index of Cdyn(HVHF (2.3±0.5) vs. CVVH (1.5±0.5) ml/(cmH(2)O·kg), 1 cmH(2)O=0.098 kPa, P<0.05)and Rrs(HVHF (22.0±1.9) vs.CVVH (29.5±1.5) cmH(2)O/(L·s), P<0.05)at the time of 6 h, and decreased lung water accumulation(index of EVLWI in HVHF (22.7±2.1) vs.CVVH (39.5±2.6) ml/m(2,) P<0.01) at the time of 6 h, and the plasma concentration of cytokines(IL-6, IL-10, TNF-α)in the HVHF group had an obvious decline compared with those in the CVVH group at the time of 6 h( (200±55) vs. (280±61), (74±17) vs. (102±21), (54±13) vs. (73±21) pg/ml, all P<0.05). The lung injury scoring of HVHF group was significantly lower than those of CVVH group((7.8±1.9) vs. (11.3±2.2) scores, P<0.05). Although the plasma concentration of cytokines(IL-6, IL-10, TNF-α) in the CVVH group were lower than those in the control group at the time of 6 h((374±55), (137±25), (98±17) pg/ml, all P<0.05), the indexes of respiratory function were not improved (all P<0.05). Conclusion: Different doses hemofiltration can reduce plasma inflammatory mediators indicators in piglets.Early high volume hemofiltration can improve respiratory function of piglets with endotoxin-induced acute lung injury and reduce lung injury pathological score.

Emergent Triglyceride-lowering Therapy With Early High-volume Hemofiltration Against Low–Molecular-Weight Heparin Combined With Insulin in Hypertriglyceridemic Pancreatitis

To compare the value of emergent triglyceride (TG)-lowering therapies between early high-volume hemofiltration (HVHF) and low-molecular-weight heparin (LMWH) combined with insulin (LMWH+insulin) as well as their effects on the outcomes of hypertriglyceridemic pancreatitis (HTGP) patients. In this randomized controlled trial, 66 HTGP patients presenting within 3 days after the onset of symptoms from August 2011 to October 2013 were assigned randomly to receive either HVHF or LMWH+insulin as an emergent TG-lowering therapy. Thirty-three patients were included in each group, and the therapy was started as soon as possible after admission. TG levels, clinical outcomes, and inflammatory biomarkers were compared between the 2 groups. Thirty-two individuals in the HVHF group and 34 in the LMWH+insulin group were included in the final analysis. Characteristics of the patients in both groups were roughly comparable. HVHF could remove TG from the plasma and achieve its target (<500 mg/dL) in approximately 9 hours, whereas the target was not achieved within 48 hours in patients receiving the LMWH+insulin treatment (P<0.05). However, no differences were found in terms of the majority of the clinical outcomes, including local pancreatic complications (P>0.05), the requirement of surgical intervention (P=0.49), mortality (P=0.49), and the duration of hospitalization (P=0.144). Furthermore, an unexpectedly higher incidence of persistent organ failure was observed in the HVHF group compared with the LMWH+insulin group (risk ratio with HVHF, 2.42; 95% confidence interval, 1.15-5.11; P=0.01). Hospital charges for patients in the HVHF group were approximately 2-fold higher than those for patients in the LMWH+insulin group (5.20±4.90 vs. 2.92±3.21, P=0.03). We selected a systemic inflammatory response syndrome score of at least 2 at baseline as a predictor of SAP patients, and the subgroup analyses showed that HVHF cannot improve the prognosis of the predicted SAP patients compared with the LMWH+insulin group. HVHF can lower TG levels more efficiently than LMWH+insulin therapy, but it is not superior in terms of clinical outcomes and costs. Further multicenter studies with large samples are required to clarify the feasibility of administering the HVHF treatment to HTGP patients (ChiCTR-TRC-13003274).

Clinical Evaluation of High-Volume Hemofiltration with Hemoperfusion Followed by Intermittent Hemodialysis in the Treatment of Acute Wasp Stings Complicated by Multiple Organ Dysfunction Syndrome.

Multiple organ dysfunction syndrome (MODS) is a rare complication of wasp stings. Currently, there is no standardized treatment for MODS secondary to multiple wasp stings, although blood purification techniques are often used. This study aimed to analyze our experiences of using intermittent hemodialysis (IHD) with or without high-volume hemofiltration (HVHF) for treating acute wasp stings complicated by MODS. In this retrospective study, 36 patients with wasp stings complicated by MODS received either IHD combined with hemoperfusion, or HVHF (ultrafiltration flow rate, 70 mL/kg/h) combined with hemoperfusion for 5 days followed by IHD. Clinical symptoms, blood biochemical parameters, duration of mechanical ventilation, use of vasoactive agents, duration of hospital stay and survival rate were recorded, and Acute Physiology and Chronic Health Evaluation II (APACHE II) and multiple organ dysfunction (MOD) scores estimated. Patients treated with HVHF followed by IHD appeared to exhibit a faster recovery than those receiving IHD alone, as evidenced by superior improvements in MOD (4.29±1.08 vs. 2.27±1.07) and APACHE II (7.09±2.62 vs. 4.20±1.69) scores (P < 0.05). Patients treated with HVHF had significantly lower myoglobin, creatine kinase-MB, lactate dehydrogenase, bilirubin and creatinine levels than patients treated with IHD alone. In addition, the durations of hospital stay (13.15±2.77 vs. 27.92±3.18 days), vasopressor use (1.76±0.24 vs. 3.43 ± 1.01 days), mechanical ventilation (3.02±1.63 vs. 5.94 ± 2.11 days) and oliguria (6.57±2.45 vs. 15.29 ± 3.51 days) were reduced, and renal function more often recovered (85.1% vs. 53.1%), in the HVHF group compared with the IHD group (P < 0.05). These results raise the possibility that HVHF plus IHD may be superior to IHD alone for the treatment of acute wasp stings complicated by MODS; additional prospective studies are merited to explore this further.

Early Fluid Resuscitation and High Volume Hemofiltration Decrease Septic Shock Progression in Swine.

This study aimed to assess the effects of early fluid resuscitation (EFR) combined with high volume hemofiltration (HVHF) on the cardiopulmonary function and removal of inflammatory mediators in a septic shock swine model. Eighteen swine were randomized into three groups: control (n = 6) (extracorporeal circulating blood only), continuous renal replacement therapy (CRRT) (n = 6; ultrafiltration volume = 25 mL/Kg/h), and HVHF (n = 6; ultrafiltration volume = 85 mL/Kg/h). The septic shock model was established by intravenous infusion of lipopolysaccharides (50 µg/kg/h). Hemodynamic parameters (arterial pressure, heart rate, cardiac output, stroke volume variability, left ventricular contractility, systemic vascular resistance, and central venous pressure), vasoactive drug parameters (dose and time of norepinephrine and hourly fluid intake), pulmonary function (partial oxygen pressure and vascular permeability), and cytokines (interleukin-6 and interleukin-10) were observed. Treatment resulted in significant changes at 4–6 h. HVHF was beneficial, as shown by the dose of vasoactive drugs, fluid intake volume, left ventricular contractility index, and partial oxygen pressure. Both CRRT and HVHF groups showed improved removal of inflammatory mediators compared with controls. In conclusion, EFR combined with HVHF improved septic shock in this swine model. The combination decreased shock progression, reduced the need for vasoactive drugs, and alleviated the damage to cardiopulmonary functions.

Evaluation of high volume hemofiltration according to pulse-indicated continuous cardiac output on patients with acute respiratory distress syndrome

To study the effects of high volume hemofiltration (HVHF) according to pulse-indicated continuous cardiac output (PiCCO) on patients with acute respiratory distress syndrome (ARDS). A prospective randomly controlled trial was conducted. 163 patients with ARDS admitted to Taizhou People's Hospital, Medical College, Nantong University, between February 2011 and January 2014, were enrolled. The patients were randomly divided into conventional therapy group (n=50), HVHF group (n=55), and PiCCO + HVHF group (n=58) by random number table. The patients in conventional therapy group received routine treatment including mechanical ventilation and drug treatment according to ARDS treatment guideline. The patients in the HVHF group received HVHF treatment of 18 hours per day on 1, 3, 5, 7 days on the basis of conventional therapy. Patients in the PiCCO + HVHF group received HVHF treatment according to PiCCO. The indexes of lung function and PiCCO monitoring were recorded at intensive care unit (ICU) admission (before) and 4 days and 7 days after treatment. The serum levels of tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) were determined by enzyme linked immunosorbent assay (ELISA), and the prognosis of patients was recorded. In three groups, oxygenation index (PaO₂/FiO₂), static lung compliance (Cs) were gradually increased, and respiratory rate (RR), lactic acid (Lac) were gradually decreased. The indicators in HVHF and PiCCO + HVHF groups were significantly improved compared with conventional therapy group. The indexes in PiCCO + HVHF group were significantly increased or decreased compared with those in HVHF group, and the statistical differences were found on the 7th day after treatment [PaO₂/FiO₂(mmHg, 1 mmHg=0.133 kPa): 189.3 ± 36.8 vs. 166.3 ± 36.1, Cs (mL/cmH₂O): 76.7 ± 18.9 vs. 67.0 ± 18.2, RR (times/min): 16.4 ± 5.2 vs. 19.2 ± 5.4, Lac (mmol/L): 1.20 ± 0.41 vs. 1.41 ± 0.43, all P<0.01]. In PiCCO + HVHF group, cardiac index (CI) was gradually increased, and extra vascular lung water index (EVLWI) and intra thoracic blood volume index (ITBVI) were gradually decreased. There were significant differences in the indexes 4 days and 7 days after treatment compared with those before treatment [CI (L × min⁻¹ m⁻²): 4.62 ± 1.13, 4.83 ± 1.10 vs. 4.01 ± 1.02, EVLWI (mL/kg): 7.6 ± 2.7, 6.5 ± 2.6 vs. 12.4 ± 2.9, ITBVI (mL/m²): 801.3 ± 120.9, 785.4 ± 118.7 vs. 980.1 ± 168.6, all P<0.01]. After treatment, the serum levels of TNF-α and IL-1β in three groups were gradually decreased. Compared with the conventional therapy group, the serum levels of TNF-α and IL-1β on 4 days and 7 days in the HVHF and PiCCO + HVHF groups were significantly decreased, and the statistical differences were found on 7 days [TNF-α (ng/L): 68.35 ± 12.63, 67.54 ± 12.90 vs. 85.35 ± 13.70; IL-1β (ng/L): 424.6 ± 142.9, 412.2 ± 140.2 vs. 895.2 ± 187.7, all P<0.01]. Compared with the HVHF group, the serum levels of TNF-α and IL-1β in the PiCCO + HVHF group were slightly decreased without statistical differences. Compared with the conventional therapy group, the number of organ failure, duration of mechanical ventilation, the length of stay in ICU and hospital mortality in HVHF group and PiCCO + HVHF group were lowered, and the statistical differences were found in PiCCO + HVHF group compared with HVHF group [number of organ failure: 2.41 ± 0.79 vs. 2.72 ± 0.80, duration of mechanical ventilation (days): 4.8 ± 2.0 vs. 5.7 ± 2.1, the length of stay in ICU (days): 11.5 ± 3.4 vs. 13.1 ± 3.6, hospital mortality: 31.0% (18/58) vs. 41.8% (23/55), all P<0.05]. Levels of inflammatory factors in patients with ARDS could be reduced by HVHF. The oxygenation and compliance of lung can be improved, the number of organ failure can be lowered, the duration of mechanical ventilation and the length of stay in ICU can be shortened, and the hospital mortality could be declined by PiCCO guided HVHF.

Study of the effects of high volume hemofiltration on extra vascular lung water and alveolar-arterial oxygen exchange in patients with septic shock

To explore the effects of high volume hemofiltration (HVHF) on inflammatory factors, extra vascular lung water and alveolar-arterial oxygen exchange in patients with septic shock. The data of 87 patients with septic shock underwent fluid resuscitation admitted to intensive care unit (ICU) of Shandong Provincial Hospital Affiliated to Shandong University were retrospectively analyzed. According to whether HVHF was used or not, all the patients were divided into fluid resuscitation group (n=41) and HVHF group (n=46). The patients in HVHF group received bedside high volume continuous vein-vein hemofiltration for at least 3 days on the basis of fluid resuscitation. The inflammatory factors, indexes of heart function, hemodynamics monitored by pulse-indicated continuous cardiac output (PiCCO), oxygen exchange, the severity of the disease before and after treatment, and 28-day mortality were compared between the two groups. The relationship between extra-vascular lung water index (EVLWI) and alveolar-arterial oxygen pressure difference (P(A-a)DO₂) was analyzed. (1) After treatment, the serum levels of interleukin-6 (IL-6), procalcitonin (PCT), and N-terminal pro-B-type natriuretic peptide (NT(-pro)BNP) in both group were gradually decreased. The IL-6, PCT, and NT(-pro)BNP on the 3rd day after treatment in HVHF group were significantly lower than those in fluid resuscitation group [IL-6 (μg/L): 34.8 ± 15.8 vs. 63.3 ± 21.2, PCT (μg/L): 7.5 ± 6.4 vs. 17.3 ± 11.2, NT(-pro)BNP (μg/L): 561.8 ± 23.7 vs. 584.3 ± 56.7, P<0.05 or P<0.01]. (2) The hemodynamics indexes were improved after treatment in both groups. The levels of intrathoracic blood volume index (ITBVI), EVLWI and pulmonary vascular permeability index (PVPI) on the 3rd day after treatment in HVHF group were significantly lower than those in fluid resuscitation group [ITBVI (mL/m²): 634.2 ± 125.8 vs. 963.8 ± 321.0, EVLWI (mL/kg): 7.5 ± 2.4 vs. 12.3 ± 4.2, PVPI: 2.2 ± 1.2 vs. 4.2 ± 2.0, all P<0.01]. (3) The levels of PA-aDO₂and arterial blood lactic (Lac) were gradually decreased, and oxygenation index (PaO₂/FiO₂) was gradually increased in both groups. Compared with fluid resuscitation group, the P(A-a)DO₂and Lac on the 3rd and the 7th day were significantly declined[P(A-a)DO₂(mmHg, 1 mmHg=0.133 kPa) on the 3rd day: 252.37 ± 29.45 vs. 270.82 ± 38.07, on the 7th day: 181.08 ± 21.81 vs. 221.02 ± 29.13; Lac (mmol/L) on the 3rd day: 3.17 ± 2.03 vs. 4.07 ± 2.43, on the 7th day: 1.95 ± 0.97 vs. 2.45 ± 1.07, P<0.05 or P<0.01], and the PaO₂/FiO₂on the 7th day was significantly elevated (mmHg: 258 ± 41 vs. 178 ± 34, P<0.01). (4) A significant positive correlation was found between EVLWI and P(A-a)DO₂(r=0.693, P=0.001), with the 95% confident interval (95% CI) 0.617-0.773. (5) The condition was improved after treatment in the two groups. The acute physiology and chronic health evaluationII (APACHEII) scores and sepsis-related organ failure assessment (SOFA) scores on the 7th day after treatment in HVHF group were significantly reduced compared with those in fluid resuscitation group (APACHEII score on the 3rd day: 18.2 ± 7.7 vs. 22.4 ± 8.6, on the 7th day: 8.2 ± 3.8 vs. 17.2 ± 6.8; SOFA score on the 3rd day: 13.6 ± 3.4 vs. 15.8 ± 5.0, on the 7th day: 7.6 ± 3.3 vs. 12.8 ± 3.9, P<0.05 or P<0.01). The 28-day mortality in HVHF group was significantly lower than that in fluid resuscitation group [15.22% (7/46) vs. 34.15% (14/41), χ² = 4.242, P=0.038]. HVHF could decrease blood inflammatory factors, and reduce the vaso-permeability and extra vascular lung water with a result of the improvement of the levels of alveolar- arterial oxygen exchange in patients with septic shock and the prognosis at the same time.

Effects of high volume hemofiltration on hemodynamics and oxygen metabolism at early stage of septic shock in piglet models

To observe the effects of hemofiltration at early stage of septic shock with different ultrafiltration doses, including hemodynamics, oxygen metabolism, inflammatory mediator in piglet models, and to evaluate the therapeutic effects of HVHF. The 18 healthy young piglets (Shanghai species) were divided randomly into three groups:control group (n = 6), conventional volume hemofiltration (CVVH) group [n = 6, ultrafiltration volume = 30 ml/(kg·h)] and high volume hemofiltration (HVHF) group [n = 6, ultrafiltration volume = 50 ml/(kg·h)], the animal model of septic shock was established by injection of lipopolysaccharide (LPS) (150 µg/kg) O111: B4. During the experiment, the following observations were carried out for all groups:1) Changes of hemodynamics [heart rate (HR), mean arterial pressure (MABP), cardiac output (CO), systemic vascular resistance index (SVRI), intrathoracic blood volume (ITBV)] and oxygen metabolism [oxygen delivery (DO2), oxygen consumption (VO2), oxygen extraction rate (O2ER) ] at the time of B0h, 0 h, 2 h, 4 h and 6 h.2) changes of TNF-α, IL-6, IL-10 in plasma at different time points (B0h, 0 h, 2 h, 4 h, 6 h). Significant difference in circulatory parameters, inflammatory mediators in plasma were found at B0h and 0 h among three groups; the CO in two treatment groups were higher than that in control group at 4 h, 6 h after model establishment (P < 0.05), and SVRI in HVHF groups were higher than that in other two groups at 4 h, 6 h after model was established (P < 0.05). The MABP in HVHF group [4 h (82 ± 17) mm Hg, 6 h (80 ± 12) mm Hg](1 mm Hg = 0.133 kPa) were higher than that in CVVH group at 4 h [(67 ± 12) mm Hg], 6 h [(69 ± 14) mm Hg] after model was established (P < 0.05). The levels of IL-6, IL-10, TNF-α in two treatment groups were lower than that in control group at 4 h and 6 h after model was established (P < 0.05), and the IL-6 [(281 ± 51) pg/ml], TNF-α [(67 ± 13) pg/ml] level in HVHF group was lower than that in CVVH group [IL-6(281 ± 51) pg/ml, TNF-α (67 ± 13) pg/ml] at 6 h (P < 0.05). The DO2 and VO2 in two treatment groups were higher than that in control group at 4 h, 6 h (P < 0.05), the O2ER in HVHF group were higher than that in CVVH group at 4 h (44% ± 3% vs. 33% ± 4%), 6 h (43% ± 5% vs. 31% ± 3%, P < 0.05). High volume hemofiltration (HVHF) at early stage of septic shock piglet models was more effective in improving hemodynamics, oxygen metabolism than conventional CVVH. And HVHF eliminated blood inflammatory mediators more effectively than conventional CVVH.

High‐Volume Hemofiltration Reduces the Expression of Myocardial Tumor Necrosis Factor‐Alpha in Septic Shock Pigs

Increasing evidence indicates that the expression of tumor necrosis factor-α (TNF-α) in myocardium correlates with the severity of cardiac dysfunction in septic shock. The aim of this study was to investigate the impact of high-volume hemofiltration (HVHF) on the expression of TNF-α in myocardium in septic shock pigs. Sixteen male Landrace pigs weighing 31 ± 5 kg were randomly assigned to control group (n = 4), septic shock group (n = 6), and HVHF group (septic shock + HVHF, n = 6). All animals were anesthetized and mechanically ventilated. After baseline examinations, septic shock group and HVHF group underwent induction of peritonitis. One hour later, the animals in HVHF group received treatment with HVHF and the treatment was continued for 12 h. As the control of HVHF group, the animals in septic shock group received the same support but hemofiltration. Twelve hours after HVHF therapy, all the animals were sacrificed. TNF-α and nitric oxide (NO) levels in both circulation and myocardium were measured. Compared with those of septic shock animals, the levels of cardiac output, stroke volume, and mean arterial pressure were better maintained in HVHF group. The expression of TNF-α in myocardium in HVHF group was lower than that in septic shock group (44.17 ± 18.70 vs. 92.50 ± 33.89 pg/mg protein, P = 0.015). The difference of TNF-α in circulation between HVHF group and septic shock group was no significance at different time. However, circulating NO in HVHF group was lower than that in septic shock group. These results suggest that HVHF improves hemodynamics and heart dysfunction in septic shock pigs, which may be attributed to reduction of TNF-α in myocardium but not in circulation.

Effects of high volume hemofiltration on mortality in patients with septic shock: a meta-analysis

To evaluate the effect of high volume hemofiltration (HVHF) and its therapeutic timing on mortality in patients with septic shock. Randomized controlled trials (RCT), case-control studies and prospective cohort studies on HVHF treating septic shock patients from 1999 to 2009 were identified by electronic and manually retrieving related data. An Meta-analysis of HVHF on mortality in septic shock patients was conducted through the methods recommended by the Cochrane Collaboration. 3 RCTs, 1 case-control study and 5 prospective cohort studies were selected. A total of 167 cases in 4 studies (3 RCTs, 1 case-control study) involving 79 HVHF and 88 LVHF groups were included for a Meta-analysis. The mortalities of septic shock in HVHF and LVHF groups were 40.5% (32/79) and 72.7% (64/88) respectively. As compared with traditional LVHF, HVHF could reduce the mortality in patients with septic shock [OR 0.33, (95%CI, 0.17 - 0.64); P < 0.01]. For 170 patients with septic shock in 5 prospective cohort studies, their mortality rates were improved by HVHF [OR 0.31, (95%CI, 0.19 - 0.49); P < 0.01]. It was consistent with the results of 4 control studies. Only 2 studies indicated the early HVHF group versus the late HVHF group could improve the survival of septic shock. Since there was significant heterogeneity between them (P < 0.05), it was better not to perform a Meta-analysis. There is a beneficial effect of high volume hemofiltration on mortality in septic shock patients. Further studies of a larger sample of high quality RCTs should be carried out to guide its use.

Improvement of Immune Dysfunction in Patients with Severe Acute Pancreatitis by High-Volume Hemofiltration: A Preliminary Report

The aim of this study was to investigate the effect of high-volume hemofiltration (HVHF) on ameliorating immune dysfunction in patients with severe acute pancreatitis (SAP). Twelve patients diagnosed with SAP admitted to the intensive care unit of general surgery, Jinling Hospital, from January 2004 to December 2006 were included in this study. They were assigned to the standard medical therapy group (SMT group, n=4) or HVHF group (n=8) immediately after enrollment, in a 1:2 ratio. The SMT group were given standard treatment for SAP, while the HVHF group were given standard as well as 72-hour HVHF treatment initiated within 2 hours after enrollment. Patients in the 2 groups were comparable for the baseline clinical parameters. All patients were monitored over a 72-hour observation period for continuous clinical status, blood cell counts including monocytes, CD4+ and CD8+ T cells, and HLA-DR expression on monocytes. Blood samples were collected from those patients at 0, 6, 12, 24, 48, and 72 hour after enrollment for measurement of plasma Th1-type cytokines (interleukin-1 [IL-1], IL-2, interferon-gamma [IFN-gamma], and tumor necrosis factor-alpha [TNF-alpha]) and Th2-type cytokines (IL-4, IL-5, IL-6, IL-IO, and IL-13) using ELISA. Within 72 hours, all measured cytokines except IL-4 were maintained at high levels, accompanied with a low level of peripheral monocytes, CD4+ and CD8+ T cell counts, and HLA-DR expression. Seventy-two hours later, plasma cytokines IFN-gamma, IL-1, IL-2, IL-5, IL-10, and IL-13 (p<0.05), but not TNF-alpha and IL-6, in patients in the HVHF group were significantly reduced, while there was no change for these parameters in the SMT group. Plasma levels of IFN-gamma, TNF-alpha, IL-1, IL-2, IL-5, and IL-13 in the HVHF group were significantly lower than those in the SMT group. Peripheral CD4+ and CD8+ T cells, monocyte count, and HLA-DR expression were increased significantly (p<0.05) only in the HVHF group, not in the SMT group. HLA-DR expression in the HVHF group was significant higher than that in the SMT group (p<0.05). HVHF significantly reduced plasma inflammatory cytokine concentrations including those of IFN-gamma, TNF-alpha, IL-1, IL-2, IL-5, and IL-13, while it increased monocyte HLA-DR expression in patients with SAP. The association of plasma cytokine reduction and cellular immune function recovery and clinical outcome needs further investigation.

Clinic study on high volume hemofiltration in patients with heart failure combined with diuretic resistance and unstable homodynamic

Objective To investigate if high volume hemofiltration (HVHF) is safe and efficient in patients with heart failure combining diuretic resistance and unstable homodynamie,and if there are differences on outcomes between HVHF and diuretic.Methods Eighty congestive heart failure patients with Heart Function class Ⅳ (NYHA) treated in our hospital from April 2006 to January 2008 were divided into HVHF group and diuretic group.The patients in diuretic group (n=40)were treated with the diuretic(lasix is dropped in a speed of 1～5mg/h after 40～60mg is injected,the largest dose of lasix＜1g/d) to decrease the volume burden of heart;The patients in HVHF group (n=40) were carried on HVHF.Others treatments of using drugs were same in tow groups,and dopamine were given to both the tow groups to keep the blood pressure＞90/60 mmHg.Mean artery pressure (MAP),heart rate,the speed of dopamine's transfusion as well as the levels of TNF-α,IL-1β,IL-6、CRP in circumambient blood were recorded pre and post study;Because all of our patients were critical illand can not get up,we put Swan-Ganz catheters in their bodies to monitoring the varieties of homodynamic and evaluated the function of left ventricles straightly.Results There was a gradual increase in HVHF group and decrease in diuretic group of heart rate(P＜0.05).Compared with the diuretic group.the dose of dopamine was gradual decreased in HVHF group (P＜0.05 hand in diuretic group,we had to increase the dose of dopamine to maintain the blood pressure in normal levels.Both CVP and PCWP in two groups were decreased after treatment,but the decrease was more significant in HVHF group (P＜0.05);after treatment,the SV、CO、CL of both groups were increased but the increase was more significant and the patients's homodynamic were more stable in HVHF group compared with the diuretic group (P＜0.05).There were more significant decreases in the levels of TNF-α、IL-1β、IL-6、CRP in circumambient blood in HVHF group than in diuretic group (P＜0.05).Compared with the diuretic group,the levels of Bun、Cr in the plasma were significantly decreased in HVHF group after 12h,the hyponatremia and the hyperkalemia were corrected (P＜0.05).Conclusions HVHF can be effectively used to keep the homodynamic stable by clearing the inflammatory medium of cytokines、water and natrium away from the blood and adjusting the internal environment.Compared with the diuretic group,HVHF is more effective to decreasing the patient's volume burden and can ameliorate the function of heart.It is safe to apply HVHF in patients with heart failure combining diuretic resistance and unstable homodynamic:and has clinical significance to those patients. Key words: High volume hemofiltration; Treatment; Diuretic resjstance; Homodynamic; Congestive heart failure

Effect of continuous high-volume hemofiltration on patients with acute respiratory distress syndrome and multiple organ dysfunction syndrome

To investigate the effect of continuous high-volume hemofiltration (HVHF) on extravascular lung water and respiratory mechanics in patients with acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS). Forty-one patients with ARDS and MODS were randomized into control group (20 patients) and HVHF treatment group (21 patients). The patients in HVHF treatment group undergoing mechanical ventilation were treated with HVHF (6 L/h) for 24 hours. The pulse indicator continuous cardiac output (PiCCO) catheter was inserted for monitoring cardiac output (CO), the extravascular lung water index (EVLWI) and intrathoracic blood volume index (ITBVI). Arterial partial pressure of oxygen (PaO(2)), arterial partial pressure of carbon dioxide (PaCO(2)), oxygenation index (PaO(2)/FiO(2)), peak airway pressure (Ppeak) and dynamic compliance (Cdyn) were measured. Concentrations of tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) in blood were detected by enzyme linked immunosorbent assay (ELISA). All indexes in control group did not show significant improvement before and after treatment (all P>0.05). There was significant lowering of concentrations of TNF-alpha and IL-6 in blood after HVHF at 24 hours, and also true in CO and EVLWI (all P<0.05). Ppeak and Cdyn were improved significantly, PaO(2)/FiO(2) increased markedly, and compared with that before HVHF and control group, significant differences were found in all the indexes (all P<0.05). HVHF shows significant beneficial effects on pulmonary function of patients with ARDS and MODS as a result of removal of cytokines, decrease in EVLWI and amelioration of disturbance in oxygen metabolism.

A pilot randomized study comparing high and low volume hemofiltration on vasopressor use in septic shock

High volume hemofiltration (HVHF) has shown potential benefits in septic animals and a few reports suggested a hemodynamic improvement in humans. However, randomized studies are still lacking. Our goal was to evaluate the hemodynamic effects of HVHF in septic shock patients with acute renal failure (ARF). Prospective randomized study in an intensive care unit (ICU). Twenty patients with septic shock and ARF. Patients were randomized to either high volume hemofiltration [HVHF 65 ml/(kg h)] or low volume hemofiltration [LVHF 35 ml/(kg h). Vasopressor dose was adjusted to reach a mean arterial pressure (MAP) > 65 mmHg. We performed six hourly measurements of MAP, norepinephrine dose, PaO(2)/FiO(2) and lactate, and four daily urine output and logistic organ dysfunction (LOD) score. Baseline characteristics of the two groups were comparable on randomization. Mean norepinephrine dose decreased more rapidly after 24 h of HVHF treatment compared to LVHF treatment (P = 0.004) whereas lactate and PaO(2)/FiO(2) did not differ between the two treatment groups. During the 4-day follow-up, urine output was slightly increased in the HVHF group (P = 0.059) but the LOD score evolution was not different. Duration of mechanical ventilation, renal replacement therapy and ICU length of stay were also comparable. Survival on day 28 was not affected. HVHF decreased vasopressor requirement and tended to increase urine output in septic shock patients with renal failure. However, a larger trial is required to confirm our results and perhaps to show a benefit in survival.

Effects of Continuous High-Volume Hemofiltration on Experimental Severe Acute Pancreatitis in Pigs

To compare the effects of different doses of hemofiltration on severe acute pancreatitis (SAP) in pigs. The animal model of SAP was produced by intraductal injection of sodium taurocholate and trypsin. Animals in group 1 served as SAP control. Animals in group 2 received (20 mL/kg per hour) continuous low-volume hemofiltration (LVHF), and animals in group 3 received (100 mL/kg per hour) continuous high-volume hemofiltration (HVHF) immediately after the induction of SAP. After the instrumentation of the animals by arterial and Swan-Ganz catheters, hemodynamic indexes were monitored intermittently at different times. The rectal temperature and the concentration of amylase and cytokines in serum were measured at the same time. The survival time of HVHF group was significantly prolonged (P < 0.01). The initial elevation of body temperature and the hypothermia in the late course of experiments were significantly ameliorated by HVHF (P < 0.01). Six hours after the induction of pancreatitis, the urine output of animals in HVHF group was obviously higher than that in control group (P < 0.05), which stayed behind 36 hours later (P < 0.05). The major hemodynamic finding was that pancreatitis-induced hypotension was significantly attenuated by HVHF (P < 0.01). The development of hyperdynamic circulatory failure was simultaneously attenuated, as reflected by a limited increase in CI, an attenuated decrease in systemic vascular resistance index. Plasma amylases in the HVHF group were significantly lower than those in control and LVHF groups (P < 0.01). The serum concentrations of cytokines such as tumor necrosis factor alpha (TNF-alpha), interleukin (IL) 6, and IL-10 all decreased significantly in treatment groups (P < 0.01), and those of HVHF group were less significant than the HVHF group (P < 0.01). The HVHF was associated with a better hemodynamic profile, a less hyperkinetic state, and more prolonged survival than that of LVHF, which may result from the HVHF that can remove the inflammatory cytokines more efficiently.