High-volume Venovenous Hemofiltration Research Articles

Treatment of patients with chronic liver failure according to disease etiology

Aim. Improving the efficiency of treatment of patients with chronic liver failure by optimizing the application of extracorporeal detoxification methods.Methods. The study included 292 patients with chronic liver failure (188 males and 104 females). The main causes of chronic liver failure were nutritional factor (alcohol abuse), viral liver diseases, and the combination of alcoholic and viral factors. All patients regardless of the disease etiology were divided into groups. Patients in group 1 received standard conservative therapy, aimed at relieving the symptoms of chronic liver failure. Patients in group 2 were additionally administered plasma exchange, in group 3 - PE and high-volume venovenous hemofiltration, and in group 4 - sessions of molecular adsorbent recirculating system (MARS).Results. Mortality of patients with chronic liver failure on conservative treatment accounted for 84.0% and was 1.5-2.1 times higher than in other groups (53% in plasma exchange group, 52% when using plasma exchange and high-volume venovenous hemofiltration and 40.6% in MARS group), these differences being statistically significant when compared with group 1 (χ2 from of 18.3 to 23.4, p 0.05). Indicators, reflecting the time of 50% mortality of patients with chronic liver failure of different etiology, suggest that in chronic liver failure of alcoholic origin plasma exchange and a combination of plasma exchange and high-volume venovenous hemofiltration are the most effective, and in chronic liver failure of viral and mixed etiology the best results are obtained when using MARS.Conclusion. The effectiveness of treatment of patients with chronic liver failure depends on the etiology of the disease: in alcoholic chronic liver failure plasma exchange and a combination of plasma exchange and high-volume venovenous hemofiltration are most rational, and in chronic liver failure of viral and mixed etiology MARS sessions are rational.

Assessing treatment efficiency in patients with hepatic encephalopathy

Aim. Comparative analysis of the efficacy of conservative and extracorporeal methods of treatment in patients with hepatic encephalopathy. Methods. The study included 117 patients with chronic liver failure. In all patients hepatic encephalopathy, registered in 100% of cases, was one of the major syndromes, with its severity ranging from stage 2 to 4. All patients were distributed to 4 groups, conservative treatment was continued in all groups. In the 2nd group plasma exchange, in 3rd - plasma exchange + high volume venovenous hemofiltration, in 4th - Molecular Adsorbent Recirculating System (MARS) were added. Treatment effect was assessed by the number of patients with positive changes in mental status (assessed by number connection test) and by the number of patients with varying degrees of hepatic encephalopathy regression (in points). Results. Data analysis showed that both conservative and extracorporeal methods of treatment leaded to the reduction of hepatic encephalopathy severity, as well as better results in number connection test, but the improvement was more significant in patients treated with extracorporeal methods. Among them, better effect was seen in patients treated with Molecular Adsorbent Recirculating System use. At the time of discharge, no signs of deterioration was seen in patients treated by Molecular Adsorbent Recirculating System and plasma exchange + high volume venovenous hemofiltration. Conclusion. Extracorporeal methods of treatment are more effective for hepatic encephalopathy severity reduction compared to conservative therapy, Molecular Adsorbent Recirculating System is the most effective method compared to other extracorporeal methods.

Response to Dr Spriet's Letter About the Article: “Disposition of Voriconazole During Continuous High Volume Veno-Venous Haemofiltration (CVVH) in A Critically Ill Patient”

Response to Dr Spriet's Letter About the Article: “Disposition of Voriconazole During Continuous High Volume Veno-Venous Haemofiltration (CVVH) in A Critically Ill Patient”

The Pharmacokinetic Profile of Voriconazole During Continuous High-volume Venovenous Hemofiltration in a Critically Ill Patient

In critically ill patients, dosage adjustment of voriconazole could be helpful when high-volume continuous venovenous hemofiltration is needed. Voriconazole pharmacokinetics were studied in an anuric critically ill patient, under high-volume continuous venovenous hemofiltration, over an interval period after a 4-mg/kg dose of voriconazole. Arterial and effluent voriconazole concentrations were measured after liquid phase extraction using a high-pressure liquid chromatography. The extrapolate area under the curve(0-12h) of voriconazole was 65 mg/h/L. The total body clearance of voriconazole was 5.4 L/h with a half-life of 16.5 hours and a distribution volume of 128.6 L. The estimated sieving coefficient was 0.58 and the filtration clearance 1.39 L/h. High-volume continuous venovenous hemofiltration could affect voriconazole disposition in contrast with other techniques. Besides, we observed voriconazole accumulation consequence of the saturation of the metabolic clearance resulting from multiple organ failure. Dosage adjustment seems to be required in these conditions, but this observation must be confirmed by a clinical study.

Cost-effectiveness analysis of early veno-venous hemofiltration for severe acute pancreatitis in China

To determine the most cost-effective hemofiltration modality for early management of severe acute pancreatitis (SAP) in China. We carried out a search of Pub-Medline and Chinese Biomedical Disk database. Controlled clinical trials on Chinese population were included in the analysis. The four decision branches that were analyzed were: continuous or long-term veno-venous hemofiltration (CVVH/LVVH), short-term veno-venous hemofiltration (SVVH), SVVH plus peritoneal dialysis (PD), and non-hemofiltration control group. The effectiveness of the technique was determined by survival rate, complications prevention and surgery preservation. The total cost of hospitalization was also assessed. The SVVH only technique was the least costly modality, $5809 (44449 RMB), and was selected as the baseline treatment modality. SVVH only arm achieved the lowest C/E ratio in terms of overall survival, complications prevention and surgery preservation. In incremental cost-effectiveness analysis, the CVVH/LVVH only and the control arms were inferior to other techniques. Sensitivity analysis showed SVVH only and SVVH plus PD arms overlapped in C/survival ratio. The role of early veno-venous hemofiltration as an alternative therapy for SAP remains controversial. However, we propose that early use of short-term high-volume veno-venous hemofiltration would have a beneficial impact on the management of SAP.

Severe lactic acidosis complicating metformin overdose successfully treated with high-volume venovenous hemofiltration and aggressive alkalinization

In this report of a near-fatal metformin ingestion successfully treated with alkalinization and high-volume hemofiltration, we discuss the management of severe lactic acidosis and demonstrate that early aggressive intervention resulted in a positive outcome. Case report. A tertiary pediatric intensive care unit. The patient was a healthy 14-yr-old female found by a sibling following a seizure of unknown duration, thought to be secondary to hypoglycemia as a consequence of a self-ingestion of metformin, atenolol, and diclofenac. She responded well to advanced resuscitation but progressively developed severe lactic acidosis, bradycardia, and hypotension in addition to persistent hypoglycemia. The peak lactate level was 37.5 mmol/L with an albumin corrected anion gap of 65 mmol/L. She was treated with high-volume venovenous hemofiltration and aggressive alkalinization therapy. The latter facilitated control of severe acidosis, whereas the hemofiltration removed the ingested drugs in addition to endogenously produced lactate precipitated by metformin. In this case, early and aggressive treatment of the acidosis and cardiovascular compromise with inotropes, venovenous hemofiltration, and large doses of sodium bicarbonate in metformin overdose resulted in a successful outcome even in the presence of severe acidosis and very high lactate levels.

Effects of high volume veno-venous hemofiltration on MODS with cerebral edema

目的 探讨高容量静脉静脉血液滤过(HV-CVVH)治疗合并严重脑水肿的多器官功能障碍(MODS)的临床效果.方法2 3例严重脑水肿(GCS评分5～6分)同时存在MODS但无合并肾功能衰竭患者(APACHE II评分19～26)分为两组:HV-CVVH组(12例),血流量为250～300ml,置换液为3.0～4.0L/h;对照组(1 3例)按常规治疗.持续监测生命体征,检测血气分析和细胞因子.结果HV-CVVH组治疗期间无死亡,与对照组比较,治疗后4～6 小时平均动脉压开始显著上升,多巴胺输注速度减少,电解质和酸碱平衡维持在正常水平,氧合指数(PO2/FiO2)显著上升,血浆乳酸、IL-1 β、IL-6、TNF-α水平较对照组显著下降(P＜0.05～0.01),GCS和APACHE II评分显著改善.三周后生存率比较,HV-CVVH组10例(10/12,83.3%),对照组5例(5/13,38.5%).结论高容量静脉静脉血液滤过(HV-CVVH)治疗MODS合并严重脑水肿有良好效果,这与其能较好地调节内环境、清除体内细胞因子和乳酸等炎性介质,改善的血流动力学、氧合功能有关。

Outcome of critically ill patients treated with intermittent high-volume haemofiltration: a prospective cohort analysis.

To evaluate intervention and outcome in critically ill patients treated with high-volume haemofiltration (HV-HF). Prospective cohort analysis. 18-bed closed format general intensive care unit (ICU) of a teaching hospital. 30-month cohort of ICU patients treated with HV-HF. Intermittent high-volume venovenous haemofiltration. Observed and predicted mortality in prospectively stratified prognostic groups. Clinical and filtration data, Acute Physiology and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score (SAPS) II and the Madrid Acute Renal Failure (ARF) score and predicted mortality. A total of 306 patients were haemofiltrated (140 medical, 166 surgical), 52 % were oliguric. Mean APACHE II score was 31 (SD 8) and mean SAPS II score 60 (SD 16). Mean ultrafiltrate rate was 63 ml/min (SD 20). A median total of 160 litres (90 % range 49 to 453) were filtrated per patient, material costs were 565 ECU (90 % range 199 to 1514). ICU mortality was 33 %, hospital mortality 40 % [95 % confidence interval (CI) 34 to 45], predicted mortality by the ARF score 67 % (CI 66 to 69). Non-cardiac surgery mortality was 47 % (CI 39 to 54), 73 % (CI 70 to 76) predicted by APACHE II and 67 % (CI 64 to 70) by SAPS II. Observed mortality was significantly lower than predicted in all prognostic groups. The standardised mortality ratio (SMR) was no higher than the SMR in the overall ICU population. Mortality in HV-HF patients was lower than that predicted by illness severity scores, as was the case in all patients in our ICU. Treatment with HV-HF appears to be safe and feasible. The efficacy of HV-HF should be tested in randomised, controlled trials of suitable power.

Acid—base responses to high-volume haemofiltration in the critically ill

We have studied the acid-base and cardiorespiratory effects of intermittent pumped high-volume venovenous haemofiltration (HVHF) using replacement fluid containing lactate as the source of bicarbonate in critically ill patients. We demonstrated significant hyperlactataemia throughout the procedure, but there was no deterioration in acid-base status, haemodynamics, or oxygen delivery. These observations suggest that the worsening of acidosis and the hypotension that have been described with this technique can be avoided by appropriate monitoring and resuscitation prior to haemofiltration, and may be due to unrecognized inadequacies in the oxygen transport system.

High-volume hemofiltration improves hemodynamics of endotoxin-induced shock in the pig

This study was designed to assess the influence of high-volume continuous hemofiltration on the hemodynamics of endotoxin-induced shock in pigs. Eighteen anesthetized and ventilated pigs were studied for 240 minutes following the start of a 30-minute infusion of 0.5 mg/kg endotoxin. They were randomly divided into three groups: group 1 served as a control group, receiving endotoxin only; group 2 received zero balance, high-volume, venovenous hemofiltration with the removal of 6,000 mL ultrafiltrate/hr; and group 3 was used to evaluate the hemodynamic effect of the extracorporeal circuit itself. The decline in mean arterial pressure for group 2 was less than for group 1 (24 ± 7.8 mm Hg [mean ± SEM] versus 60 ± 3.4 mm Hg; P < .001) as was the drop in cardiac output (0.35 ± 0.24 L/min versus 1.53 ± 0.59 L/min; P < .01). The decline in cardiac output was more pronounced in group 3 than in group 1 (3.98 ± 0.21 L/min versus 1.53 ± 0.59 L/min; P < .01). Left ventricular stroke work decreased by 61 ± 6.8 g in group 1 versus 14 ± 2.0 g in group 2 ( P < .01), while left ventricular stroke work in group 3 was lower than that in group 1 ( P < .02). Right ventricular stroke work increased further in group 2 than in group 1 (16 ± 2.1 g v 3 ± 0.8 g; P < .01). The pulmonary vascular resistance, systemic vascular resistance, right atrial pressure, and pulmonary artery wedge pressure in groups 2 and 3 did not differ from those in group 1. We conclude that in this model, high-volume venovenous hemofiltration significantly improves cardiac function but does not affect pulmonary vascular resistance or systemic vascular resistance, while the use of the extracorporeal circuit adversely affects cardiac function. The effect of hemofiltration was more pronounced in this study than in others, probably because of the higher ultrafiltrate volume.

High volume hemofiltration improves right ventricular function in endotoxin-induced shock in the pig.

This study assessed the influence of continuous high volume hemofiltration on right ventricular function of pigs with endotoxin induced shock. Eighteen anesthetized and ventilated pigs were studied for 240 min after the start of infusion of 0.5 mg/kg endotoxin over 30 min. Right ventricular ejection fraction (RVEF) was measured by rapid response thermodilution technique. After endotoxin infusion, the pigs were randomly divided into 3 groups: group 1 as a control group, receiving endotoxin only, group 2 to observe the effects of zero balance high volume veno-venous hemofiltration with removal of ultrafiltrate at a rate of 6000 ml/h, and group 3 to evaluate the effect of the extracorporeal circuit itself on RVEF. The decline of RVEF in group 2 was less than in group 1 (0.04 +/- 0.02 vs 0.21 +/- 0.03 (mean +/- SEM); p less than 0.001). The decline of RVEF in group 3 (0.24 +/- 0.02) was more pronounced than that in group 1 (p less than 0.05). The differences in the course of RVEF between group 1 and group 2 could not be explained by differences in heart rate, preload or afterload. Cardiac output and mean arterial pressure were significantly higher in group 2 than in group 1 (p less than 0.01). It is concluded that in this model, high volume hemofiltration improves RVEF and cardiac performance by removal of vasoactive mediators, responsible for myocardial depression.

The haemodynamic effects of intermittent haemofiltration in critically ill patients

The haemodynamic effects of intermittent high volume venovenous haemofiltration were studied in 13 critically ill patients. The mean negative fluid balance during filtration was 1.21 and the mean duration of treatment 3 h 40 min. The cardiac index fell initially (4.5 +/- 0.2 to 3.8 +/- 0.21/min/m2; p less than 0.05) but then remained stable throughout treatment before returning to baseline at the end of haemofiltration. The mean arterial pressure was unchanged with an increase in the systemic vascular resistance (651 +/- 33 to 765 +/- 65 dyne.s/cm5; p less than 0.05) suggesting that vascular responsiveness is maintained during haemofiltration.