|
1
|
De Nitti C, Giordano R, Gervasio R, Castellano G, Podio V, Sereni L, Ghezzi P, Ronco C, Brendolan A, Inguaggiato P, Tonelli M, La Greca G, Tetta C. Choosing New Adsorbents for Endogenous Ultrapure Infusion Fluid: Performances, Safety and Flow Distribution. Int J Artif Organs 2018. [DOI: 10.1177/039139880102401102] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Adsorption may notably contribute to the removal of uremic toxins and to the efficiency of hemodialysis. We examined different uncoated stationary matrixes, charcoals and synthetic resins to establish their adsorptive capacities in relation to low (urea, creatinine) and high molecular weight (β2-microglobulin, myoglobin) compounds in in vitro conditions (steady state and flow-through) using isotonic solutions or uremic ultrafiltrate. Trace metal, particle release analyses and scanning electron microscopy of different adsorbents were performed. Dynamic flow-distribution studies were made using 99Technetium and analysing the different regions of interest by single head γ-camera. We show that adsorbents may differ greatly as to their adsorptive capacity depending on flow rate, nature, and total mass of the compounds to be removed from the ultrafiltrate. These studies suggest a methodological approach for screening stationary matrixes for possible application in hemodialysis.
Collapse
Affiliation(s)
- C. De Nitti
- Clinical and Laboratory Research Department, Bellco SpA, Mirandola - Italy
| | - R. Giordano
- Clinical and Laboratory Research Department, Bellco SpA, Mirandola - Italy
| | - R. Gervasio
- Clinical and Laboratory Research Department, Bellco SpA, Mirandola - Italy
| | - G. Castellano
- Nuclear Medicine Institute, Molinette Hospital, Turin - Italy
| | - V. Podio
- Nuclear Medicine Institute, Molinette Hospital, Turin - Italy
| | - L. Sereni
- Clinical and Laboratory Research Department, Bellco SpA, Mirandola - Italy
| | - P.M. Ghezzi
- Department of Nephrology and Dialysis, St Croce and Carle Hospital, Cuneo - Italy
| | - C. Ronco
- Department of Nephrology and Dialysis, St Bortolo Hospital, Vicenza - Italy
| | - A. Brendolan
- Department of Nephrology and Dialysis, St Bortolo Hospital, Vicenza - Italy
| | - P. Inguaggiato
- Clinical and Laboratory Research Department, Bellco SpA, Mirandola - Italy
| | - M. Tonelli
- Centro Interdipartimentale Grandi Strumenti, Modena and Reggio Emilia University - Italy
| | - G. La Greca
- Department of Nephrology and Dialysis, St Bortolo Hospital, Vicenza - Italy
| | - C. Tetta
- Clinical and Laboratory Research Department, Bellco SpA, Mirandola - Italy
| |
Collapse
|
|
2
|
Cubattoli L, Teruzzi M, Cormio M, Lampati L, Pesenti A. Citrate Anticoagulation during CVVH in High Risk Bleeding Patients. Int J Artif Organs 2018; 30:244-52. [PMID: 17417764 DOI: 10.1177/039139880703000310] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Regional citrate anticoagulation (RCA) is an effective form of anticoagulation for continuous renal replacement therapy (CRRT) in patients with contraindications to heparin. Its use has been very limited, possibly because of the need for special infusion solutions and difficult monitoring of the metabolic effects. Objective To investigate the safety and the feasibility of an RCA method for continuous veno-venous hemofiltration (CVVH) using commercially available replacement fluid. Methods We evaluated 11 patients at high risk of bleeding, requiring CVVH. RCA was performed using commercially available replacement fluid solutions to maintain adequate acid-base balance. We adjusted the rate of citrate infusion to achieve a post-filter ionized calcium concentration [iCa] <0.4 mmol/L when blood flow was <250 ml/min, or <0.6 mmol/L when blood flow was >250 ml/min. When needed, we infused calcium gluconate to maintain systemic plasma [iCa] within the normal range. Results Twenty-nine filters ran for a total of 965.5 h. Average filter life was 33.6±20.5 h. Asymptomatic hypocalcemia was detected in 6.9% of all samples. No [iCa] values <0.9 mmol/L were observed. Hypercalcemia (1.39±0.05 mmol/L) occurred in 2.5% of all samples. We observed hypernatremia (threshold 153 mmol/L) and alkalosis (threshold 7.51) in only 9.3% and 9.4% respectively of all samples, mostly concomitantly. No patient showed any signs of citrate toxicity. Conclusions: We developed a protocol for RCA during CVVH using commercially available replacement fluid that proved safe, flexible and applicable in an Intensive Care Unit (ICU) setting.
Collapse
Affiliation(s)
- L Cubattoli
- Department of Anesthesia and Intensive Care, University of Milan-Bicocca, San Gerardo Hospital, Via Donizetti 106, 20052 Monza, Italy.
| | | | | | | | | |
Collapse
|
|
3
|
Differences in CVVH vs. CVVHDF in the management of sepsis-induced acute kidney injury in critically ill patients. J Artif Organs 2017; 20:326-334. [PMID: 28676904 DOI: 10.1007/s10047-017-0970-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 06/25/2017] [Indexed: 01/08/2023]
Abstract
We hypothesized that patients with sepsis and AKI, especially patients without preserved renal function, and treated with continuous veno-venous hemodiafiltration (CVVHDF), have lower risk for mortality than patients treated with continuous veno-venous hemofiltration (CVVH). Patients were included if they fulfilled the diagnosis of severe sepsis or septic shock, suffered AKI and received continuous renal replacement therapy (CRRT) in intensive care unit. There were 62 patients treated by CVVH and 75 treated by CVVHDF. Mean survival time was longer in CVVHDF group with oliguric/anuric patients than in CVVH group. CVVH, and not classic risk factors, was associated with higher overall mortality in oliguric/anuric patients. In the linear regression model, hourly urine output was the strongest and positive predictor of longer survival. CVVHDF is according to our results a CRRT modality of choice for the treatment and lower mortality of septic patients with AKI where renal function is no longer preserved. CRRT has been associated with improved renal recovery, but it should be started earlier in AKI evolution with still preserved hourly urine output which is the most sensitive and prognostic marker of survival in septic patients with AKI.
Collapse
|
|
4
|
Inflammatory Biomarkers in Refractory Congestive Heart Failure Patients Treated with Peritoneal Dialysis. BIOMED RESEARCH INTERNATIONAL 2015; 2015:590851. [PMID: 26539513 PMCID: PMC4619815 DOI: 10.1155/2015/590851] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 05/04/2015] [Accepted: 05/05/2015] [Indexed: 12/14/2022]
Abstract
Proinflammatory cytokines play a pathogenic role in congestive heart failure. In this study, the effect of peritoneal dialysis treatment on inflammatory cytokines levels in refractory congestive heart failure patients was investigated. During the treatment, the patients reached a well-tolerated edema-free state and demonstrated significant improvement in NYHA functional class. Brain natriuretic peptide decreased significantly after 3 months of treatment and remained stable at 6 months. C-reactive protein, a plasma marker of inflammation, decreased significantly following the treatment. Circulating inflammatory cytokines TNF-α and IL-6 decreased significantly after 3 months of peritoneal dialysis treatment and remained low at 6 months. The reduction in circulating inflammatory cytokines levels may be partly responsible for the efficacy of peritoneal dialysis for refractory congestive heart failure.
Collapse
|
|
5
|
Wu B, Gong D, Xu B, He Q, Liu Z, Ji D. Decreased platelet count in patients receiving continuous veno-venous hemofiltration: a single-center retrospective study. PLoS One 2014; 9:e97286. [PMID: 24824815 PMCID: PMC4019530 DOI: 10.1371/journal.pone.0097286] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Accepted: 04/17/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A decreased platelet count may occur and portend a worse outcome in patients receiving continuous renal replacement therapy (CRRT). We aim to investigate the incidence of decreased platelet count and related risk factors in patients receiving CRRT. METHODS In this retrospective study, we screened all patients receiving continuous veno-venous hemofiltration (CVVH) at Jinling Hospital between November 2008 and October 2012. The patients were included who received uninterrupted CVVH for more than 72 h and had records of blood test for 4 consecutive days after ruling out pre-existing conditions that may affect the platelet count. Platelet counts before and during CVVH, illness severity, CVVH settings, and outcomes were analyzed. RESULTS The study included 125 patients. During the 3-day CVVH, 44.8% and 16% patients had a mild decline (20-49.9%) and severe decline (≥ 50%) in the platelet count,respectively; 37.6% and 16.0% patients had mild thrombocytopenia (platelet count 50.1-100 × 109/L) and severe thrombocytopenia (platelet count ≤ 50 × 10(9)/L), respectively. Patients with a severe decline in the platelet count had a significantly lower survival rate than patients without a severe decline in the platelet count (35.0% versus 59.0%, P=0.012), while patients with severe thrombocytopenia had a survival rate similar to those without severe thrombocytopenia (45.0% versus 57.1%, P=0.308). Female gender, older age, and longer course of the disease were independent risk factors for a severe decline in the platelet count. CONCLUSIONS A decline in the platelet count and thrombocytopenia are quite common in patients receiving CVVH. The severity of the decline in the platelet count rather than the absolute count during CVVH may be associated with hospital mortality. Knowing the risk factors for a severe decline in the platelet count may allow physicians to prevent such an outcome.
Collapse
Affiliation(s)
- Buyun Wu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Dehua Gong
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Bin Xu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Qunpeng He
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Daxi Ji
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
- * E-mail:
| |
Collapse
|
|
6
|
RONCO C, BELLOMO R, WRATTEN ML, TETTA C. Today's technology for continuous renal replacement therapies. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/tcic.7.4.198.205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
|
7
|
Romero CM, Downey P, Hernández G. [High volume hemofiltration in septic shock]. Med Intensiva 2010; 34:345-52. [PMID: 20153085 DOI: 10.1016/j.medin.2009.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Revised: 07/14/2009] [Accepted: 10/08/2009] [Indexed: 12/22/2022]
Abstract
Severe sepsis and septic shock are conditions associated with high morbidity and mortality. The disproportionate release of pro-inflammatory and anti-inflammatory mediators caused by the septic insult is the promoter of multiple organ dysfunction. Conventional hemodialysis, hemofiltration or a combination of both can be a good option to replace the deteriorating renal function in critically ill patients by the removal of nitrogen compounds (small molecules). However, this "renal dose" is insufficient for the removal of inflammatory mediators (medium molecules), and therefore contributes little to the cardiovascular stabilization of patients with septic shock. In this setting, a higher dose of ultrafiltration (> 50 ml/kg/h) or "septic dose" may be needed. In this review article, we have analyzed the clinical and pathophysiological rationale for the use of high volume hemofiltration in patients with septic shock.
Collapse
Affiliation(s)
- C M Romero
- Departamento de Medicina, Facultad de Medicina, Universidad de Chile, Santiago, Chile.
| | | | | |
Collapse
|
|
8
|
Ronco C, Ratanarat R, Bellomo R, Salvatori G, Petras D, Cal MD, Nalasso F, Bonello M, Brendolan A. Multiple organ support therapy for the critically ill patient in intensive care. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/17471060500233109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
|
9
|
Kojika M, Sato N, Yaegashi Y, Suzuki Y, Suzuki K, Nakae H, Endo S. Endotoxin adsorption therapy for septic shock using polymyxin B-immobilized fibers (PMX): evaluation by high-sensitivity endotoxin assay and measurement of the cytokine production capacity. Ther Apher Dial 2006; 10:12-8. [PMID: 16556131 DOI: 10.1111/j.1744-9987.2006.00340.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Because of its low sensitivity, the conventional measurement method for endotoxin (ET) is not the most appropriate for monitoring the effect of ET adsorption therapy. Thus, the efficacy of ET adsorption therapy was investigated using a newly developed high-sensitivity ET assay method. The changes in the cytokine production capacity of whole blood were also examined. We treated 24 peritonitis patients who had developed postoperative septic shock with ET adsorption therapy using a column of polymyxin B-immobilized fibers (PMX) and their serum ET levels were measured using the high-sensitivity ET assay based on the kinetic turbidimetric Limulus assay. In addition, the changes in the tumor necrosis factor-(TNF-alpha) production capacity of whole blood following lipopolysaccharide (LPS) stimulation and clinical outcome in the study patients were also examined. The 28-day mortality rate was 12%. PMX-direct hemoperfusion (PMX-DHP) was associated with elevation of the mean arterial pressure and urine output, reduction in the mean dose requirement of vasopressor agents, and recovery from the shock state in all the patients. The PaO2/FIO2 ratio also showed significant improvement. Using the high-sensitivity ET assay, ET was detected in the blood of 20 out of the 24 patients (80%) before the PMX-DHP, and a significant reduction in the ET level was noted after the PMX-DHP. The TNF-alpha production capacity of whole blood, which was found to be lower in the septic shock patients than in healthy subjects, was significantly increased after PMX-DHP. Elimination of ET by PMX-DHP in septic shock patients was confirmed by the high-sensitivity ET assay. PMX-DHP is thus considered to be a useful adjuvant therapeutic technique in the treatment of septic shock. Also, PMX-DHP might alleviate the immunosuppression associated with severe sepsis.
Collapse
Affiliation(s)
- Masahiro Kojika
- Department of Critical Care Medicine, Iwate Medical University, School of Medicine, Morioka, Japan.
| | | | | | | | | | | | | |
Collapse
|
|
10
|
Ratanarat R, Brendolan A, Ricci Z, Salvatori G, Nalesso F, de Cal M, Cazzavillan S, Petras D, Bonello M, Bordoni V, Cruz D, Techawathanawanna N, Ronco C. Pulse High-Volume Hemofiltration in Critically Ill Patients: A New Approach for Patients with Septic Shock. Semin Dial 2006; 19:69-74. [PMID: 16423184 DOI: 10.1111/j.1525-139x.2006.00121] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Mortality rates in septic shock remain unacceptably high despite advances in our understanding of the syndrome and its treatment. Humoral factors are increasingly recognized to participate in the pathogenesis of septic shock, giving a biological rationale to therapies that might remove varied and potentially dangerous humoral mediators. While plasma water exchange in the form of hemofiltration can remove circulating cytokines in septic patients, the procedure, as routinely performed, does not have a substantial impact on their plasma levels. More intensive plasma water exchange, as high-volume hemofiltration (HVHF)can reduce levels of these mediators and potentially improve clinical outcomes. However, there are concerns about the feasibility and costs of HVHF as a continuous modality--very high volumes are difficult to maintain over 24 hours and solute kinetics are not optimized by this regimen. We propose pulse HVHF (PHVHF)-HVHF of 85 ml/kg/hr for 6-8 hours followed by continuous venovenous hemofiltration (CVVH) of 35 ml/kg/hr for 16-18 hours-as a new method to combine the advantages of HVHFimprove solute kinetics, and minimize logistic problems. We treated 15 critically ill patients with severe sepsis and septic shock using daily PHVHF in order to evaluate the feasibility of the technique, its effects on hemodynamics, and the impact of the treatment on pathologic apoptosis in sepsis. Hemodynamic improvements were obtained after 6 hours of PHVHF and were maintained subsequently by standard CVVHas demonstrated by the reduction in norepinephrine dose. PHVHFbut not CVVHsignificantly reduces apoptotic plasma activity within 1 hour and the pattern was maintained in the following hours. PHVHF appears to be a feasible modality that may provide the same or greater benefits as HVHFwhile reducing the workload and cost.
Collapse
Affiliation(s)
- Ranistha Ratanarat
- Department of Nephrology, Dialysis and Transplantation, St. Bortolo Hospital, Vicenza, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
11
|
Balik M, Waldauf P, Plásil P, Pachl J. Prostacyclin versus citrate in continuous haemodiafiltration: an observational study in patients with high risk of bleeding. Blood Purif 2005; 23:325-9. [PMID: 16118487 DOI: 10.1159/000087770] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND The efficacy and safety of prostacyclin (PGI2) and citrate (ACD) anticoagulation were observed and compared during continuous haemodiafiltration. METHODS Mechanically ventilated patients received either the PGI2 analogue epoprostenol (group A, n = 17) in escalating doses of 4.5-10.0 ng.kg(-1).min(-1) in combination with heparin (6 IU.kg(-1).h(-1)) or 2.2% ACD (group B, n = 15). Blood flow was set to match the circuit-filling volume per unit time equal to the intravascular half-life of PGI2. RESULTS Median filter lifetimes were 26 h (interquartile range 16-37) in group A (39 filters) and 36.5 h (interquartile range 23-50) in group B (56 filters; p < 0.01). In group A, 4 patients (23.5%, p < 0.05) had the dose reduced due to hypotension. The final mean dose of PGI2 was 8.7 +/- 2.4 ng.kg(-1).min(-1). Four patients in group A (23.5%, p < 0.05) were switched to ACD due to a decrease in platelet count. No bleeding episodes, decrease in platelet count or adverse haemodynamic effects were encountered in group B. The cost of epoprostenol plus low dose heparin (EUR 204.73 +/- 53.04) was significantly higher than the cost of ACD-based anticoagulation (EUR 93.92 +/- 45.2, p < 0.05). CONCLUSION ACD offers longer filter survival, has no impact on platelet count and is less expensive. Increasing the dose of PGI2 up to the average of 8.7 ng.kg(-1).min(-1) did not increase the haemodynamic side effects.
Collapse
Affiliation(s)
- M Balik
- Department Anaesthesia and Intensive Care, University Hospital Kralovske Vinohrady, Prague, Czech Republic.
| | | | | | | |
Collapse
|
|
12
|
Jiang HL, Xue WJ, Li DQ, Yin AP, Xin X, Li CM, Gao JL. Influence of continuous veno-venous hemofiltration on the course of acute pancreatitis. World J Gastroenterol 2005; 11:4815-21. [PMID: 16097050 PMCID: PMC4398728 DOI: 10.3748/wjg.v11.i31.4815] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate whether continuous veno-venous hemofiltration (CVVH) in different filtration rate to eliminate cytokines would result in different efficiency in acute pancreatitis, whether the saturation time of filter membrane was related to different filtration rate, and whether the onset time of CVVH could influence the survival of acute pancreatitis.
METHODS: Thirty-seven patients were classified into four groups randomly. Group 1 underwent low-volume CVVH within 48 h of the onset of abdominal pain (early CVVH, n = 9). Group 2 received low-volume CVVH after 96 h of the onset of abdominal pain (late CVVH, n = 10). Group 3 underwent high-volume CVVH within 48 h of the onset of abdominal pain (early CVVH, n = 9). Group 4 received high-volume CVVH after 96 h of the onset of abdominal pain (late CVVH, n = 9). CVVH was sustained for at least 72 h. Blood was taken before hemofiltration, and ultrafiltrate was collected at the start of CVVH and every 12 h during CVVH period for the purpose of measuring the concentrations of TNF-α, IL-1β and IL-6. The concentrations of TNF-α, IL-1β and IL-6 were measured by swine-specific ELISA. The Solartron 1 255 B frequency response analyzer (British) was used to observe the resistance of filter membrane.
RESULTS: The survival rate had a significant difference (94.44% vs 68.42%, P<0.01) high-volume and low-volume CVVH patients. The survival rate had also a significant difference (88.89% vs 73.68%, P<0.05) between early and late CVVH patients. The hemodynamic deterioration (MAP, HR, CVP) was less severe in groups 4 and 1 than that in group 2, and in group 3 than in group 4. The adsorptive saturation time of filters membranes was 120-180 min if the filtration rate was 1 000-4 000 mL/h. After the first, second and third new hemofilters were changed, serum TNF-α concentrations had a negative correlation with resistance (r: -0.91, -0.89, and -0.86, respectively in group 1; -0.89, -0.85, and -0.76, respectively in group 2; -0.88, -0.92, and -0.82, respectively in group 3; -0.84, -0.87, and -0.79, respectively in group 4). The decreasing extent of TNF-α, IL-1β and IL-6 was significantly different between group 3 and group 1 (TNF-α P<0.05, IL-1β P<0.05, IL-6 P<0.01), between group 4 and group 2 (TNF-α P<0.05, IL-1β P<0.05, IL-6 P<0.01), between group 1 and group 2 (TNF-α P<0.05, IL-1β P<0.05, IL-6 P<0.05), and between group 3 and group 4 (TNF-α P<0.01, IL-1β P<0.01, IL-6 P<0.05), respectively during CVVH period. The decreasing extent of TNF-α and IL-1β was also significantly different between survival patients and dead patients (TNF-α P<0.05, IL-1β P<0.05). In survival patients, serum concentration of TNF-α and IL-1β decreased more significantly than that in dead patients.
CONCLUSION: High-volume and early CVVH improve hemodynamic deterioration and survival in acute pancreatitis patients. High-volume CVVH can eliminate cytokines more efficiently than low-volume CVVH. The survival rate is related to the decrease extent of TNF-α and IL-1β. The adsorptive saturation time of filter membranes are different under different filtration rate condition. The filter should be changed timely once filter membrane adsorption is saturated.
Collapse
Affiliation(s)
- Hong-Li Jiang
- Department of Hemodialysis Center, The First Hospital of Xi'an Jiaotong University, No.1 Jiankang Lu, Xi'an 710061, Shaanxi Province, China.
| | | | | | | | | | | | | |
Collapse
|
|
13
|
Ronco C, Bonello M, Bordoni V, Ricci Z, D'Intini V, Bellomo R, Levin NW. Extracorporeal therapies in non-renal disease: treatment of sepsis and the peak concentration hypothesis. Blood Purif 2004; 22:164-74. [PMID: 14732825 DOI: 10.1159/000074937] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In the setting of intensive care, patients with acute renal failure often present a clinical picture of the systemic inflammatory response syndrome (SIRS). SIRS can be caused by bacterial stimuli or by non-microbiological stimuli that induce a significant inflammatory response. When this response is exaggerated, the patient experiences multiple organ system failure and a condition of sepsis also defined as a systemic malignant inflammation. This is mostly characterized by an invasion of cytokines and other pro-inflammatory mediators into the systemic circulation where major biological effects take place, including vasopermeabilization, hypotension and shock. At the same time, the monocyte of the septic patient seems to be hyporesponsive to inflammatory stimuli to a certain extent. In this condition, the patient faces a situation of hyperinflammation but at the same time of immunodepression expressing a clinical entity defined as counter anti-inflammatory response syndrome. The general picture of the clinical disorder is therefore better characterized by an immunodysregulation than by a simple pro- or anti-inflammatory disorder. Due to the short half-life of cytokines and other mediators spilled over into the circulation, it is extremely difficult to approach the problem at the right moment with the right pharmacological agent. For these reasons, the peak concentration hypothesis suggests that continuous renal replacement therapies, due to their continuity and unspecific capacity of removal, might be beneficial in cutting the peaks of the concentrations of both pro- and anti-inflammatory mediators, restoring a situation of immunohomeostasis. Thus the patient may benefit from a lesser degree of immunodysregulation and he/she may restore a close-to-normal capacity of response to exogenous stimuli.
Collapse
Affiliation(s)
- Claudio Ronco
- Department of Nephrology, St. Bortolo Hospital, Vicenza, Italy.
| | | | | | | | | | | | | |
Collapse
|
|
14
|
Heering P, Grabensee B, Brause M. Cytokine removal in septic patients with continuous venovenous hemofiltration. Kidney Blood Press Res 2004; 26:128-34. [PMID: 12771539 DOI: 10.1159/000070996] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Despite the progress that has been made in intensive care medicine, multiple organ failure is still associated with high mortality. Apart from the prevention of infectious complications, numerous efforts are being made to improve the treatment of sepsis through adequate antibiotic therapy, the development of new respirator therapies, better control of the hemodynamic situation, and adequate renal replacement therapy. Some authors advocate continuous renal replacement therapy not only for acute renal failure but also for the elimination of inflammatory molecules such as cytokines. Continuous renal replacement therapy improves the cardiovascular hemodynamics in patients with multiple organ failure. Therapeutic options such as volume control, clearance of uremic toxins, correction of acid base disturbances and temperature control are improved. Suitable renal replacement therapy improves not only cardiovascular hemodynamics but also patient survival. In current practice, continuous renal replacement therapy is not used to eliminate mediators such as cytokines. In patients with multiple organ failure and compromised cardiovascular hemodynamics, renal replacement therapy should be carried out as early as possible. In the following review, experimental and clinical findings concerning mediator elimination by continuous and intermittent renal replacement therapy are summarized.
Collapse
Affiliation(s)
- P Heering
- Department of Medicine III, Solingen General Hospital, University of Cologne, Solingen, Germany.
| | | | | |
Collapse
|
|
15
|
Ronco C, Tetta C, Mariano F, Wratten ML, Bonello M, Bordoni V, Cardona X, Inguaggiato P, Pilotto L, d'Intini V, Bellomo R. Interpreting the mechanisms of continuous renal replacement therapy in sepsis: the peak concentration hypothesis. Artif Organs 2003; 27:792-801. [PMID: 12940901 DOI: 10.1046/j.1525-1594.2003.07289.x] [Citation(s) in RCA: 238] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Severe sepsis and septic shock are the primary causes of multiple organ dysfunction syndrome (MODS), which is the most frequent cause of death in intensive care unit patients. Many water-soluble mediators with pro- and anti-inflammatory action such as TNF, IL-6, IL-8, and IL-10 play a strategic role in septic syndrome. In intensive care medicine, blocking any one mediator has not led to a measurable outcome improvement in patients with sepsis. CRRT is a continuously acting therapy, which removes in a nonselective way pro- and anti-inflammatory mediators; "the peak concentration hypothesis" is the concept of cutting peaks of soluble mediators through continuous hemofiltration. Furthermore, there is evidence of increased efficacy of high-volume hemofiltration compared to conventional CVVH, and other blood purification techniques that utilize large-pore membranes or sorbent plasmafiltration are conceptually interesting.
Collapse
Affiliation(s)
- Claudio Ronco
- Department of Nephrology, St. Bortolo Hospital, Vicenza, Italy.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
16
|
Abstract
Both pro-inflammatory and anti-inflammatory mediators participate in the pathogenesis of sepsis and explain the failure of specific therapies to improve survival. Continuous extracorporeal therapies have been proposed as a therapeutic option in sepsis. We have studied the effects of plasma filtration associated with adsorption in patients with septic shock. We have shown that such treatment may lead to improved survival in a rabbit model of sepsis and to improved hemodynamics, reduced norepinephrine dose and restoration of near-to-normal responsiveness of blood leukocytes to endotoxin in humans. It is anticipated that treatment of plasma, as a device modular to conventional hemofiltration, may pave the way to innovative approaches to the extracorporeal treatment of septic patients.
Collapse
Affiliation(s)
- R Bellomo
- Department of Intensive Care, San Bortolo Hospital, Vicenza, Italy.
| | | | | | | |
Collapse
|
|
17
|
Ronco C, Bellomo R. Acute renal failure and multiple organ dysfunction in the ICU: from renal replacement therapy (RRT) to multiple organ support therapy (MOST). Int J Artif Organs 2003; 25:733-47. [PMID: 12296458 DOI: 10.1177/039139880202500801] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Renal replacement therapy (RRT) has evolved from the concept that we need to treat the dysfunction of a single organ (the kidney). As intensive care units have become more and more complex, it has become clear that the majority of patients with acute renal failure often have dysfunction of several other organs. In order to facilitate single organ support in this setting, continuous renal replacement therapy (CRRT) techniques have been developed. However, CRRT has opened the door to the concept that targeting renal support as the only goal of extracorporeal blood purification may be a simplistic view of our therapeutic aims. In this article we argue that it is now time to move from the simple goal of achieving adequate renal support. The proper goal of extracorporeal blood purification in ICU should be multi-organ support therapy (MOST). We explain why MOST represents the most logical future conceptual and practical evolution of CRRT and illustrates the biological rationale, supplying animal and clinical evidence that confirms the need to move rapidly in this direction theoretically, practically and technologically.
Collapse
Affiliation(s)
- C Ronco
- Department of Nephrology, Dialysis and Transplantation, St Bortolo Hospital, Vicenza, Italy.
| | | |
Collapse
|
|
18
|
Interpreting the Mechanisms of CRRT in Sepsis: The Peak Concentration Hypothesis. Intensive Care Med 2003. [DOI: 10.1007/978-1-4757-5548-0_62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
|
19
|
Yekebas EF, Strate T, Zolmajd S, Eisenberger CF, Erbersdobler A, Saalmüller A, Steffani K, Busch C, Elsner HA, Engelhardt M, Gillesen A, Meins J, The M, Knoefel WT, Izbicki JR. Impact of different modalities of continuous venovenous hemofiltration on sepsis-induced alterations in experimental pancreatitis. Kidney Int 2002; 62:1806-18. [PMID: 12371983 DOI: 10.1046/j.1523-1755.2002.00607.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Continuous venovenous hemofiltration (CVVH) is assumed to attenuate systemic complications in septic diseases. The impact of different treatment intensities of CVVH on immunologic and systemic alterations in experimental pancreatitis was evaluated. METHODS Eighty-four minipigs were allocated either to an untreated control group (group 1) or to one of six treatment groups (groups 2 to 7) that underwent CVVH in different modalities: (1): "late" CVVH, started after a decline of total peripheral resistance of 30% versus "prophylactic" CVVH started immediately after the induction of pancreatitis; (2) no change of hemofilters versus a periodic change of filters every 12 hours; (3) low-volume CVVH with a filtrate turnover of 20 mL/kg body weight (BW)/h versus high-volume CVVH (100 mL/kg/h). Pancreatitis was induced by intraductal injection of sodium-taurocholate (3%, 1 mL/kg BW) and enterokinase (2 U/kg BW). We focused on the occurrence of sepsis, serum cytokines, down-regulation of major histocompatibility complex II (MHC II) and the endotoxin receptor CD14 expression, bacterial translocation/endotoxemia, and pulmonary and renal histologic alterations. RESULTS CVVH delayed or definitively prevented the occurrence of sepsis. Pancreatitis was associated with a tremendous initial tumor necrosis factor-alpha (TNF-alpha) response prior to a return to near baseline levels in the late course of sepsis. Endotoxin hyporesponsiveness, suggested by the dissociation of decreasing TNF-alpha levels and increasing endotoxemia in end-stage sepsis, was favorably influenced by CVVH. Down-regulation of MHC II and CD14 expression was prevented in non-septic animals. CVVH-related sepsis-protection led to a significant attenuation of histological injury in lungs and kidneys. "Prophylactic" CVVH prevented histological changes more effectively than "late" CVVH. CONCLUSIONS CVVH offers a therapeutic option for supportive treatment in severe pancreatitis. The efficiency of CVVH is associated with the duration of filter use and cumulative plasma turnover. Since CVVH may lead to sepsis-protection and long-term survival, further evaluation in controlled, clinical trials is warranted.
Collapse
Affiliation(s)
- Emre F Yekebas
- Department of Surgery, University Hospital Eppendorf, Hamburg, Germany.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
20
|
Palevsky PM, Bunchman T, Tetta C. The Acute Dialysis Quality Initiative--part V: operational characteristics of CRRT. ADVANCES IN RENAL REPLACEMENT THERAPY 2002; 9:268-72. [PMID: 12382230 DOI: 10.1053/jarr.2002.35567] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This report represents the consensus statement of the ADQI workgroup addressing the operational characteristics of continuous renal replacement therapy (CRRT). Issues addressed included the specific operational characteristics of continuous hemofiltration (HF), continuous hemodialysis (HD), and continuous hemodiafiltration (HDF) and the impact of these different modalities on solute removal. The relative roles of arteriovenous (AV) and venovenous (VV) modalities of therapy were also evaluated. The workgroup also addressed the optimal components of a CRRT system from an operational standpoint.
Collapse
Affiliation(s)
- Paul M Palevsky
- VA Pittsburgh Healthcare System and Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. palevsky+@pitt.edu
| | | | | |
Collapse
|
|
21
|
Reiter K, D'Intini V, Bordoni V, Baldwin I, Bellomo R, Tetta C, Brendolan A, Ronco C. High-volume hemofiltration in sepsis. Theoretical basis and practical application. Nephron Clin Pract 2002; 92:251-8. [PMID: 12218300 DOI: 10.1159/000063325] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Karl Reiter
- Pediatric Intensive Care Unit, University Children's Hospital, Munich, Germany
| | | | | | | | | | | | | | | |
Collapse
|
|
22
|
Ronco C, Bellomo R, Kellum JA. Continuous renal replacement therapy: opinions and evidence. ADVANCES IN RENAL REPLACEMENT THERAPY 2002; 9:229-44. [PMID: 12382223 DOI: 10.1053/jarr.2002.35561] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Continuous arteriovenous haemofiltration (CAVH) is the first example of continuous renal replacement therapy (CRRT). CAVH was first applied for the treatment of diuretic unresponsive fluid overload. Subsequently, CRRT has undergone a remarkable growth, and it is now performed with pump technology (CVVH) and via double-lumen central venous catheters. In many intensive care units, especially in Australia and in Europe, CRRT has become the dominant, if not exclusive, form of artificial renal support. Continuous haemofiltration is now used beyond the original indications of blood purification, for the treatment of certain drug intoxications, for severe cardiac failure, for volume control during, after cardiopulmonary bypass, and to decrease the toxicity of chemotherapy. Furthermore, there is strong ongoing research into its role or that of derived techniques as possible adjuvant therapies during severe sepsis. Despite its large use, the current state of CRRT is surrounded by some controversies, and an effort should be made to give a dispassionate distillation of the literature for a final common definition of what is based on opinions and what carries sufficient evidence.
Collapse
Affiliation(s)
- Claudio Ronco
- Divisione di Nefrologia, Ospedale San Bortolo, Vicenza, Italy.
| | | | | |
Collapse
|
|
23
|
Ronco C, Brendolan A, Lonnemann G, Bellomo R, Piccinni P, Digito A, Dan M, Irone M, La Greca G, Inguaggiato P, Maggiore U, De Nitti C, Wratten ML, Ricci Z, Tetta C. A pilot study of coupled plasma filtration with adsorption in septic shock. Crit Care Med 2002; 30:1250-5. [PMID: 12072677 DOI: 10.1097/00003246-200206000-00015] [Citation(s) in RCA: 189] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To test the hypothesis that nonselective plasma adsorption by a hydrophobic resin (coupled plasmafiltration and adsorption) could improve hemodynamics and restore leukocyte responsiveness in patients with septic shock. DESIGN Prospective, pilot, crossover clinical trial. SETTING General intensive care unit in a teaching hospital. SUBJECTS Ten patients with hyperdynamic septic shock. INTERVENTIONS Patients were randomly allocated to 10 hrs of either coupled plasma filtration adsorption plus hemodialysis (treatment A) or continuous venovenous hemodiafiltration (treatment B) in random order. We measured the change in mean arterial pressure, norepinephrine requirements, and leukocyte tumor necrosis factor-alpha (TNF-alpha) production (both spontaneous and lipopolysaccharide-stimulated) after 10 hrs of each treatment. We also tested TNF-alpha production from normal human adherent monocytes incubated with patients' plasma obtained before and after the resin, both with or without incubation with an anti-interleukin-10 monoclonal antibody. RESULTS Mean arterial pressure increased after 10 hr by 11.8 mm Hg with treatment A and by 5.5 mm Hg with treatment B (p =.001). There was an average decrease of norepinephrine requirement of 0.08 microg/kg/min with treatment A and 0.0049 microg/kg/min with treatment B (p =.003). All patients but one survived. Spontaneous and lipopolysaccharide-induced TNF-alpha production from patients' whole blood increased over time with treatment A. This increase was more marked in blood drawn after the device (plasmafiltrate-sorbent plus hemodialyzer) (p =.009). Preresin plasma suppressed lipopolysaccharide-stimulated production of TNF-alpha by 1 x 10(6)cultured adherent monocytes from healthy donors. This suppressive effect was significantly reduced after passage of plasma through the resin (p =.019) and after incubation with anti-interleukin-10 monoclonal antibodies (p =.028). CONCLUSIONS In patients with septic shock, coupled plasmafiltration-adsorption combined with hemodialysis was associated with improved hemodynamics compared with continuous venovenous hemodiafiltration. This result might be related to its ability to restore leukocyte responsiveness to lipopolysaccharide. These findings suggest a potential role for blood purification in the treatment of septic shock.
Collapse
Affiliation(s)
- Claudio Ronco
- Department of Nephrology, St. Bortolo Hospital, Vicenza, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
24
|
Oda S, Hirasawa H, Shiga H, Nakanishi K, Matsuda KI, Nakamura M. Continuous hemofiltration/hemodiafiltration in critical care. Ther Apher Dial 2002; 6:193-8. [PMID: 12109942 DOI: 10.1046/j.1526-0968.2002.00431.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Continuous hemofiltration and continuous hemodiafiltration (CHF/CHDF) were developed as continuous renal replacement therapy for patients with severe conditons and has come to be widely performed mainly in critical care, taking the place of intermittent hemodialysis. The membrane pore size of a hemofilter used for CHF/CHDF allows passage of substances ranging from 30,000 to 50,000 Da, and the method for solute removal in CHF/CHDF employs the principle of convection, which is advantageous for removing middle- to high-molecular-weight substances. As apheresis therapy to remove pathogenic substances in blood, CHF/CHDF is therefore being investigated for its possible effect on various morbid conditions. It has recently been found that CHF/CHDF removes humoral mediators including cytokines, particularly in severe systemic inflammatory response syndromes such as septic shock and severe acute pancreatitis. CHF/CHDF is thus beginning to be performed for the prevention and treatment of organ dysfunction secondary to septic shock, trauma, or acute pancreatitis. CHF/CHDF is also efficacious as artificial liver support in preventing adverse effects caused by plasma exchange (PE) and for continuous removal of hepatic coma-inducing substances. CHF/CHDF is effective for various morbid conditions not only as renal replacement therapy, but also as apheresis therapy and is expected to be applied more widely in critical care in the future.
Collapse
Affiliation(s)
- Shigeto Oda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan.
| | | | | | | | | | | |
Collapse
|
|
25
|
Reiter K, Bellomo R, Ronco C. High Volume Hemofiltration in Sepsis. Intensive Care Med 2002. [DOI: 10.1007/978-1-4757-5551-0_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
|
26
|
Yekebas EF, Eisenberger CF, Ohnesorge H, Saalmüller A, Elsner HA, Engelhardt M, Gillesen A, Meins J, The M, Strate T, Busch C, Knoefel WT, Bloechle C, Izbicki JR. Attenuation of sepsis-related immunoparalysis by continuous veno-venous hemofiltration in experimental porcine pancreatitis. Crit Care Med 2001; 29:1423-30. [PMID: 11445702 DOI: 10.1097/00003246-200107000-00021] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES In light of evidence suggesting that hemofiltration favorably influences septic diseases by removing sepsis mediators, the impact of different modalities of continuous veno-venous hemofiltration (CVVH) on outcome and immunologic derangements in porcine pancreatogenic sepsis was evaluated. DESIGN Randomized, controlled intervention trial. SUBJECTS Forty-eight minipigs of either sex. INTERVENTIONS Pancreatitis was induced by intraductal injection of sodium taurocholate (4%, 1 mL/kg body weight [BW]) and enterokinase (2 U/kg BW). Animals were allocated either to untreated controls-group 1-or to one of three treatment groups-group 2: low-volume CVVH (20 mL/kg BW), no change of hemofilters; group 3: low-volume CVVH, filters changed every 12 hrs; and group 4: high-volume CVVH (100 mL/kg BW), filters changed every 12 hrs. Survival represented the major parameter of the study. Serum cytokine levels, sepsis-related down-regulation of major histocompatibility complex II and CD14 expression on leukocytes, bacterial translocation, and endotoxemia were further parameters evaluated in the study. MEASUREMENTS AND MAIN RESULTS High-volume CVVH combined with periodic filter change was significantly superior compared with less intensive treatment modalities (low-volume CVVH, no filter change) in sepsis protection. Long-term survival (>60 hrs) was found in 67% of group 4 and 33% of group 3 animals (p <.05), whereas in controls and group 2 no animal survived. CVVH ameliorated the initial serum tumor necrosis factor-alpha response and prevented sepsis-induced in vitro endotoxin hyporesponsiveness. Down-regulation of major histocompatibility complex II and CD14 expression on monocytes was significantly improved by CVVH. Improved oxidative burst and phagocytosis capacity in polymorphonuclear leukocytes suggested that leukocyte function was stabilized by CVVH. Also, CVVH significantly reduced bacterial translocation and endotoxemia. CONCLUSIONS Hemofiltration reversed sepsis-induced immunoparalysis in a porcine model of bile acid-induced pancreatitis. Implications for human pancreatitis must be validated in prospective, clinical protocols.
Collapse
Affiliation(s)
- E F Yekebas
- Department of Surgery, University Hospital Eppendorf, Hamburg, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
27
|
|
|
28
|
Meloni C, Morosetti M, Turani F, Palombo G, Meschini L, Zupancich E, Taccone-Gallucci M, Di Giulio S, Casciani CU. Cardiac function and oxygen balance in septic patients during continuous hemofiltration. Blood Purif 2000; 16:140-6. [PMID: 9681156 DOI: 10.1159/000014327] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The aim of this work was to study hemodynamic, oximetric and metabolic parameters in septic patients during continuous hemofiltration, in order to determine whether the changes in hemodynamic parameters can influence the oxygen utilization in peripheral tissues. 29 multiple organ failure patients with septic shock were studied during the first 48 h of continuous hemofiltration: 18 were submitted to CAVH and 11 patients were treated with CAVHD to correct ARF and fluid overload. Our data show that RVEF improves and REDVI reduces progressively during treatment, together with a significant reduction of the cardiac index after 48 h of CAVH(D). There were no significant variations in oxygen tissue parameters, while plasma lactate was reduced significantly. In conclusion, our data confirm that continuous hemofiltration may be useful in septic patients to correct fluid overload and ARF, without affecting hemodynamic stability and oxygen balance. Moreover, in septic patients, this technique improves hemodynamics, reduces the filling pressure in the right heart and reduces hyperdynamic response as CI and SVRI, without any negative effects on O2 balance.
Collapse
Affiliation(s)
- C Meloni
- Institute of Tissue Typing, NCR, L'Aquila, Italy
| | | | | | | | | | | | | | | | | |
Collapse
|
|
29
|
Marinez de Francisco AL, Ghezzi PM, Brendolan A, Fiorini F, La Greca G, Ronco C, Arias M, Gervasio R, Tetta C. Hemodiafiltration with online regeneration of the ultrafiltrate. KIDNEY INTERNATIONAL. SUPPLEMENT 2000; 76:S66-71. [PMID: 10936801 DOI: 10.1046/j.1523-1755.2000.07608.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The concept of regeneration of dialysis fluids and of ultrafiltrate in particular has been recently revisited. Hemodiafiltration with online regeneration of the ultrafiltrate allows the concomitant infusion of sodium, calcium, and bicarbonate. Here, we studied the adsorptive characteristics of an integrated two-step sorbent system relative to different solutes present in the ultrafiltrate: sodium, calcium, phosphate, bicarbonate, uric acid, creatinine, and beta2-microglobulin. In vitro studies were performed in order to differentiate the relative roles for each sorbent (mineral-activated charcoal or hydrophobic resin) in adsorbing a given solute. Ex vivo studies were performed in order to evaluate the presence of cytokines (interleukin-1 beta and tumor necrosis factor-alpha), of cytokine (interleukin-1 beta and tumor necrosis factor-alpha)-inducing activities, and of the cytokine release in response to exogenous bacterial lipopolysaccharide by normal whole blood incubated with ultrafiltrate samples obtained at 15, 120, and 240 minutes after the start of treatment. The results of the present studies show the presence of immunomodulatory substances in the ultrafiltrate and the significant (P < 0.01) increase in the lipopolysaccharide-induced release of both interleukin-1 beta and tumor necrosis factor-alpha. The biological relevance of the ultrafiltrate and the possible relevance of the online, endogenous reinfusion are discussed.
Collapse
|
|
30
|
Bellomo R, Kellum JA, Gandhi CR, Pinsky MR, Ondulik B. The effect of intensive plasma water exchange by hemofiltration on hemodynamics and soluble mediators in canine endotoxemia. Am J Respir Crit Care Med 2000; 161:1429-36. [PMID: 10806135 DOI: 10.1164/ajrccm.161.5.9809127] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
High volume hemofiltration (HVHF) (200 ml/kg/h) improves hemodynamics in experimental septic shock but is difficult to apply clinically. Accordingly, we studied whether less intensive HVHF (80 ml/kg/h) can still improve hemodynamics in experimental septic shock. We also investigated its effect on the serum concentrations of several inflammatory mediators, including endothelin (ET-1), endotoxin (LPS), tumor necrosis factor-alpha (TNF-alpha), and 6-keto prostaglandin F(1alpha) (6-kepto PGF(1alpha)). Sixteen anesthetized dogs were connected to a continuous veno-venous hemofiltration (CVVH) (filtration: 80 ml/kg/h) or sham circuit and endotoxin (0.5 mg/kg) was infused intravenously over 5 min. Hemodynamic variables were measured at baseline and at 15, 45, 90, and 180 min. The major hemodynamic finding was that endotoxin-induced hypotension was significantly attenuated by intensive CVVH (p < 0.04). Changes in cardiac output and right ventricular ejection fraction were equal in both groups. ET-1 levels, but not LPS, TNF-alpha, or 6-keto PGF(1alpha), were lower during CVVH (p = 0.042). Endotoxin or TNF-alpha were not found in the ultrafiltrate. Median clearances of ET-1 and 6-keto PGF(1alpha) during intensive CVVH were 8.8 and 25.9 ml/m, respectively. We conclude that intensive CVVH attenuates the early component of endotoxin-induced hypotension and reduces serum concentrations of endothelin-1. The effect of CVVH on blood pressure is not explained by convective clearance of the mediators in question.
Collapse
Affiliation(s)
- R Bellomo
- Department of Anesthesiology, University of Pittsburgh Medical Centre, Pittsburgh, Pennsylvania, USA
| | | | | | | | | |
Collapse
|
|
31
|
Abstract
While there is clear support for the use of continuous renal replacement therapy (CRRT) in critically ill acute renal failure patients, there are other illnesses without renal involvement where CRRT might be of value. These include sepsis and other inflammatory syndromes such as acute respiratory distress syndrome (ARDS) and cardiopulmonary bypass where removal of inflammatory mediators by hemofiltration is hypothesized to improve outcome. Adsorption appears to be the predominant mechanism of mediator elimination. However, the observed hemodynamic improvement can, at least partially, be attributed to a reduction of body temperature or to fluid removal, and the evidence for a clinically important removal of proinflammatory cytokines remains limited. Continuous and therefore smooth fluid removal may improve organ function in ARDS, after surgery with cardiopulmonary bypass, and in patients with refractory congestive heart failure. Continuous removal of endogenous toxins, eventually combined with intermittent hemodialysis, is probably beneficial in inborn errors of metabolism, severe lactic acidosis, or tumor lysis syndrome.
Collapse
Affiliation(s)
- M Schetz
- Department of Intensive Care Medicine, University Hospital Gasthuisberg, Leuven, Belgium.
| |
Collapse
|
|
32
|
Tetta C, Bellomo R, Brendolan A, Piccinni P, Digito A, Dan M, Irone M, Lonnemann G, Moscato D, Buades J, La Greca G, Ronco C. Use of adsorptive mechanisms in continuous renal replacement therapies in the critically ill. Kidney Int 1999. [DOI: 10.1046/j.1523-1755.56.s72.16.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
|
33
|
De Vriese AS, Colardyn FA, Philippé JJ, Vanholder RC, De Sutter JH, Lameire NH. Cytokine removal during continuous hemofiltration in septic patients. J Am Soc Nephrol 1999; 10:846-53. [PMID: 10203370 DOI: 10.1681/asn.v104846] [Citation(s) in RCA: 296] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
A potential application of the continuous renal replacement therapies is the extracorporeal removal of inflammatory mediators in septic patients. Cytokine elimination with continuous renal replacement therapies has been demonstrated in several clinical studies, but so far without important effects on their serum concentrations. Improved knowledge of the cytokine removal mechanisms could lead to the development of more efficient treatment strategies. In the present study, 15 patients with septic shock and acute renal failure were observed during the first 24 h of treatment with continuous venovenous hemofiltration (CVVH) with an AN69 membrane. After 12 h, the hemofilter was replaced and the blood flow rate (QB) was switched from 100 ml/min to 200 ml/min or vice versa. Pre- and postfilter plasma and ultrafiltrate concentrations of selected inflammatory and anti-inflammatory cytokines were measured at several time points allowing the calculation of a mass balance. Cytokine removal was highest 1 h after the start of CVVH and after the change of the membrane (ranging from 25 to 43% of the prefilter amount), corresponding with a significant fall in the serum concentration of all cytokines. The inhibitors of inflammation were removed to the same extent as the inflammatory cytokines. Adsorption to the AN69 membrane appeared to be the main clearance mechanism, being most pronounced immediately after installation of a new membrane and decreasing steadily thereafter, indicating rapid saturation of the membrane. A QB of 200 ml/min was associated with a 75% increase of the ultrafiltration rate and a significantly higher convective elimination and membrane adsorption than at a QB of 100 ml/min. The results indicate that optimal cytokine removal with CVVH with an AN69 membrane could be achieved with a combination of a high QB/ultrafiltration rate and frequent membrane changes.
Collapse
Affiliation(s)
- A S De Vriese
- Renal Division of the Department of Medicine, University Hospital, Gent, Belgium.
| | | | | | | | | | | |
Collapse
|
|
34
|
Yekebas EF, Treede H, Knoefel WT, Bloechle C, Fink E, Izbicki JR. Influence of zero-balanced hemofiltration on the course of severe experimental pancreatitis in pigs. Ann Surg 1999; 229:514-22. [PMID: 10203084 PMCID: PMC1191737 DOI: 10.1097/00000658-199904000-00010] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To examine the impact of continuous venovenous hemofiltration (CVVH) on the course of experimental pancreatitis in pigs. SUMMARY BACKGROUND DATA The activation of different mediator cascades is assumed to trigger multiple organ dysfunction or failure during necrotizing pancreatitis. CVVH has been suggested to be beneficial in those instances by eliminating several inflammatory mediators released in the circulation. METHODS Pancreatitis was induced by a combined intraductal injection of sodium taurocholate and enterokinase. Control group animals received no treatment after induction. A second group underwent "therapeutic" CVVH after a 20% decline of mean arterial pressure. In the third group, "prophylactic" CVVH was started simultaneously with the induction of pancreatitis. The concentrations of tumor necrosis factor-alpha, transforming growth factor-beta1, kinin, and phospholipase A2 were measured at different time points in blood (pre- and postfilter) and in the hemofiltrate to calculate the respective sieving coefficients that reflect most accurately the plasma clearance of mediators by CVVH. RESULTS Survival time was significantly prolonged both by therapeutic and prophylactic CVVH; it was more pronounced in the latter. CVVH did not influence the increase in transforming growth factor concentrations. However, 6 hours after induction, the increases of plasma concentrations of tumor necrosis factor, phospholipase, and kinin were significantly weakened by CVVH compared with controls. In the treatment groups, the plasma concentrations of tumor necrosis factor and phospholipase showed a significant negative correlation with the respective sieving coefficients, which decreased in the later course of the experiments. CONCLUSIONS Experimental necrotizing pancreatitis was associated with a tremendous increase of plasma concentrations of tumor necrosis factor, phospholipase, and kinin. The effective removal of these mediators by CVVH resulted in significantly improved survival time. Animals that received prophylactic CVVH had a longer survival period than those in which CVVH was started after clinical impairment. The decreasing efficiency of CVVH in eliminating inflammatory mediators in the later course of the experiments suggested that the filter membranes were compromised by long-term application. These findings provide further evidence that CVVH offers therapeutic options even in the absence of conventional indications for blood-purifying treatments.
Collapse
Affiliation(s)
- E F Yekebas
- Department of Surgery, University Hospital Eppendorf, Hamburg, Germany
| | | | | | | | | | | |
Collapse
|
|
35
|
Perouansky M, Oppenheim A, Sprung CL, Eidelman LA, Pizov R. Effect of haemofiltration on pathological fibrinolysis due to severe sepsis: a case report. Resuscitation 1999; 40:53-6. [PMID: 10321849 DOI: 10.1016/s0300-9572(99)00002-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Bleeding due to coagulopathy is a frequent complication of severe sepsis, especially in burn patients. The primary treatment is aimed at the underlying cause but additional supportive measures, consisting mainly of coagulation factor replacement, are frequently necessary. We describe the salutary effect of continuous veno-venous haemofiltration (CVVH) with predilution on diffuse haemorrhage in a patient with severe septic shock and renal failure. The diffuse haemorrhage was initially treated with replacement of coagulation factors. Prothrombin time and partial thromboplastin time became normal while diffuse bleeding continued and the thrombelastogram showed evidence of fibrinolysis. A short period of CVVH lead to the cessation of bleeding which was reflected by a normal thrombelastogram.
Collapse
Affiliation(s)
- M Perouansky
- Department of Anesthesiology and Critical Care Medicine, Hadassah University Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | | | | | | | | |
Collapse
|
|
36
|
Kellum JA, Johnson JP, Kramer D, Palevsky P, Brady JJ, Pinsky MR. Diffusive vs. convective therapy: effects on mediators of inflammation in patient with severe systemic inflammatory response syndrome. Crit Care Med 1998; 26:1995-2000. [PMID: 9875910 DOI: 10.1097/00003246-199812000-00027] [Citation(s) in RCA: 173] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare two forms of continuous renal replacement therapy, continuous venovenous hemofiltration (CVVH) vs. continuous venovenous hemodialysis (CVVHD), in terms of the removal of inflammatory mediators from the blood of patients with systemic inflammatory response syndrome and acute renal failure. DESIGN Randomized crossover, clinical study. SETTING University teaching hospital. PATIENTS Thirteen patients with systemic inflammatory response syndrome and acute renal failure receiving continuous renal replacement therapy. INTERVENTION Patients were randomized to receive either convective clearance using CVVH or diffusive clearance using CVVHD for the first 24 hrs, followed by the other modality for 24 hrs. All treatments utilized AN69 hemofilters. CVVH was performed with an ultrafiltration rate of 2 L/hr and CVVHD with a dialysis outflow rate of 2 L/hr. MEASUREMENTS AND MAIN RESULTS Plasma and ultrafiltrate concentrations of tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-10, and sL-selectin were measured at 0, 1, 3, 6, 12, and 24 hrs by radioimmunoassay. Plasma endotoxin concentrations were also measured at 0, 12, and 24 hrs by chromogenic assay. CVVH was associated with a 13% decrease in plasma TNF-alpha concentrations compared with a 23% increase while on CVVHD (p < .05). Mean plasma concentrations of IL-6, IL-10, and sL-selectin were unchanged over time and between therapies. Only minimal amounts of mediators were recovered in the effluents with either therapy except for IL-6. The clearances for IL-6 were different between therapies, 1.9+/-0.8 (SD) mL/min for CVVHD and 3.3+/-1.5 mL/min for CVVH, (p< .01). Plasma endotoxin concentrations were not different between therapies. CONCLUSION CVVH resulted in a decrease in plasma TNF-alpha concentrations as compared with CVVHD, while the type of transport mechanism used did not influence plasma concentrations of IL-6, IL-10, soluble L-selectin, or endotoxin. Differences in clearance for IL-6 between CVVH and CVVHD did not translate into significant changes in circulating IL-6 concentrations.
Collapse
Affiliation(s)
- J A Kellum
- Department of Anesthesiology/Critical Care Medicine, University of Pittsburgh Medical Center, PA, USA
| | | | | | | | | | | |
Collapse
|
|
37
|
Tetta C, Wratten M, Cristol J, Tarchini R, Bosc J, Canaud B, Camussi G. The Role of Platelet-Activating Factor in the Haemoincompatibility of Haemodialytic Treatments. Int J Artif Organs 1998. [DOI: 10.1177/039139889802101115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- C. Tetta
- Clinical and Laboratory Research Department, Bellco S.p.A., Mirandola - Italy
| | - M. Wratten
- Clinical and Laboratory Research Department, Bellco S.p.A., Mirandola - Italy
| | - J.P. Cristol
- Departments of Neprology and Biochemistry, Lapeyronie Hospital, Montpellier - France
| | - R. Tarchini
- Department of Nephrology, Carlo Poma Hospital, Mantova
| | - J.Y. Bosc
- Departments of Neprology and Biochemistry, Lapeyronie Hospital, Montpellier - France
| | - B. Canaud
- Departments of Neprology and Biochemistry, Lapeyronie Hospital, Montpellier - France
| | - G. Camussi
- Department of Nephrology, University of Pavia at Varese, Varese - Italy
| |
Collapse
|
|
38
|
Jones CH, Goutcher E, Newstead CG, Will EJ, Dean SG, Davison AM. Hemodynamics and survival of patients with acute renal failure treated by continuous dialysis with two synthetic membranes. Artif Organs 1998; 22:638-43. [PMID: 9702314 DOI: 10.1046/j.1525-1594.1998.06165.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Synthetic membranes are not identical and have specific interactions that may be harmful or beneficial. We have investigated the incidence of hypotension and the outcome of acute renal failure (ARF) in ventilated patients treated by continuous venovenous dialysis with 2 different synthetic membranes. In Study 1, the mean arterial pressure (MAP) and systemic vascular resistance (SVR) were monitored during the first 12 min of dialysis with polyacrylonitrile (PAN). In Study 2, the MAP and survival rates were compared in patients randomly assigned to either PAN or polysulfone. No subjects were receiving angiotensin converting enzyme inhibitors. In Study 1, the MAP decreased due to a reduction in the SVR during the first 6 min of dialysis but returned to the baseline value by 12 min in 22 patients during 27 dialysis treatments. In Study 2, the MAP was lower than the baseline value at 6 min during 233 dialysis treatments in 133 patients randomly assigned to PAN or polysulfone membranes (PAN group, 81.5 +/- 15 to 78.7 +/- 15.6 mm Hg, p = 0.001; and polysulfone group, 81.3 +/- 15.4 to 80.0 +/- 15.7 mm Hg, p = 0.06). Severe reductions in the MAP were seen during 13.2% of the PAN and 7.2% of the polysulfone treatments (chi 2, p = NS). The age, APACHE II score, MAP, inotrope requirement, and primary diagnosis did not differ according to membrane material in a total of 197 consecutive patients (PAN, n = 97; polysulfone, n = 100). Patients survival was 29% (PAN) and 27% (polysulfone). In multivariate analysis, APACHE II score, inotrope requirement, and liver failure were significant determinants of survival. In conclusion, PAN and polysulfone membranes were not different with respect to hypotensive reactions or survival in critically ill patients undergoing continuous venovenous hemodialysis.
Collapse
Affiliation(s)
- C H Jones
- Department of Renal Medicine, St. James's University Hospital, Leeds, West Yorkshire, U.K
| | | | | | | | | | | |
Collapse
|
|
39
|
Saborio P, Hahn S, Scheinman J, Chan J. Hemofiltration in Children. Int J Artif Organs 1998. [DOI: 10.1177/039139889802100710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- P. Saborio
- Nephrology Division, Department of Pediatrics and Department of Biochemistry and Molecular Biophysics, Virginia Commonwealth University's Medical College of Virginia, Richmond, VA -USA
| | - S. Hahn
- Nephrology Division, Department of Pediatrics and Department of Biochemistry and Molecular Biophysics, Virginia Commonwealth University's Medical College of Virginia, Richmond, VA -USA
| | - J.I. Scheinman
- Nephrology Division, Department of Pediatrics and Department of Biochemistry and Molecular Biophysics, Virginia Commonwealth University's Medical College of Virginia, Richmond, VA -USA
| | - J.C.M. Chan
- Nephrology Division, Department of Pediatrics and Department of Biochemistry and Molecular Biophysics, Virginia Commonwealth University's Medical College of Virginia, Richmond, VA -USA
| |
Collapse
|
|
40
|
Lee PA, Weger GW, Pryor RW, Matson JR. Effects of filter pore size on efficacy of continuous arteriovenous hemofiltration therapy for Staphylococcus aureus-induced septicemia in immature swine. Crit Care Med 1998; 26:730-7. [PMID: 9559612 DOI: 10.1097/00003246-199804000-00024] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the effect of hemofilter pore size on the efficacy of continuous arteriovenous hemofiltration (CAVH) in improving morbidity and mortality in an immature swine model of Staphylococcus aureus-induced septicemia. DESIGN Prospective, randomized study with age-matched controls. SETTING Biomedical research facility. SUBJECTS Fourteen 4 to 8-wk-old, weaned Poland-China swine, weighing 5 to 10 kg. INTERVENTIONS Spontaneously breathing, ketamine-sedated swine (4 to 8 wks of age) were given an intravenous lethal dose of live S. aureus. Animals were then filtered with either a 50-kilodalton (kD) pore size filter (control) or a 100-kD pore size filter (experimental). No animals received antibiotics. MEASUREMENTS AND MAIN RESULTS Physiologic, biochemical, and hematologic parameters were measured in all animals every 1 to 3 hrs. Animals were monitored continuously and survival time (hr) was recorded (permanent survival = 168 hrs/7 days). Animals filtered with the 100-kD filter survived significantly longer than control animals (103 +/- 18 [SEM] vs. 56 +/- 9 hrs). The 100-kD-filtered group had one permanent survivor (168 hrs). Protein concentration of the ultrafiltrate obtained from the 100-kD-filtered animals was eight-fold higher than control ultrafiltrate. The protein removed did not contain a high percentage of albumin (as determined by autoanalyzer methods). No significant differences were seen in any of the other measured parameters. CONCLUSIONS CAVH significantly improved survival in swine with S. aureus-induced sepsis. The superior performance of the 100-kD filter vs. the 50-kD filter suggests that higher molecular weight mediators that are not removed efficiently by the 50-kD filter may be responsible for the morbidity and mortality seen in this model of sepsis. These mediators may be removed in greater proportion by our customized (100-kD pore size) filter.
Collapse
Affiliation(s)
- P A Lee
- Department of Clinical Research, Medical City Dallas Hospital, TX, USA
| | | | | | | |
Collapse
|
|
41
|
Joy MS, Matzke GR, Armstrong DK, Marx MA, Zarowitz BJ. A primer on continuous renal replacement therapy for critically ill patients. Ann Pharmacother 1998; 32:362-75. [PMID: 9533067 DOI: 10.1345/aph.17105] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To characterize the multiple continuous renal replacement therapy (CRRT) techniques available for the management of critically ill adults, and to review the indications for and complications of use, principles of drug removal during CRRT, drug dosage individualization guidelines, and the influence of CRRT on patient outcomes. DATA SOURCES MEDLINE (January 1981-December 1996) was searched for appropriate publications by using terms such as hemofiltration, ultrafiltration, hemodialysis, hemodiafiltration, medications, and pharmacokinetics; selected articles were cross-referenced. STUDY SELECTION References selected were those considered to enhance the reader's knowledge of the principles of CRRT, and to provide adequate therapies on drug disposition. DATA SYNTHESIS CRRTs use filtration/convection and in some cases diffusion to treat hemodynamically unstable patients with fluid overload and/or acute renal failure. Recent data suggest that positive outcomes may also be attained in patients with other medical conditions such as septic shock, multiple organ dysfunction syndrome, and hepatic failure. Age, ventilator support, inotropic support, reduced urine volume, and elevated serum bilirubin concentrations have been associated with poor outcomes. Complications associated with CRRT include bleeding due to excessive anticoagulation and line disconnections, fluid and electrolyte imbalance, and filter and venous clotting. CRRT can complicate the medication regimens of patients for whom it is important to maintain drug plasma concentrations within a narrow therapeutic range. Since the physicochemical characteristics of a drug and procedure-specific factors can alter drug removal, a thorough assessment of all factors needs to be considered before dosage regimens are revised. In addition, an algorithm for drug dosing considerations based on drug and CRRT characteristics, as well as standard pharmacokinetic equations, is proposed. CONCLUSIONS The use of CRRT has expanded to encompass the treatment of disease states other than just acute renal failure. Since there is great variability among treatment centers, it is premature to conclude that there is enhanced survival in CRRT-treated patients compared with those who received conventional hemodialysis. This primer may help clinicians understand the need to individualize these therapies and to prospectively optimize the pharmacotherapy of their patients receiving CRRT.
Collapse
Affiliation(s)
- M S Joy
- Division of Nephrology and Hypertension, School of Medicine, University of North Carolina, Chapel Hill, USA
| | | | | | | | | |
Collapse
|
|
42
|
Affiliation(s)
- C H Jones
- Department of Renal Medicine, St. James's University Hospital, Leeds, United Kingdom
| |
Collapse
|
|
43
|
Sanchez-Izquierdo Riera JA, Alted E, Lozano MJ, Pérez JL, Ambrós A, Caballero R. Influence of continuous hemofiltration on the hemodynamics of trauma patients. Surgery 1997; 122:902-8. [PMID: 9369890 DOI: 10.1016/s0039-6060(97)90331-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The aim of this prospective randomized controlled study was to investigate the effects of continuous venovenous hemofiltration on the hemodynamics and respiratory function of critically ill trauma patients with multiple organ dysfunction syndrome. METHODS Thirty consecutive critically ill, mechanically ventilated, trauma patients with multiple organ dysfunction syndrome (without kidney failure) who had invasive hemodynamic monitoring for management of hypotension or hypoxemia were randomized to treatment with or without continuous venovenous hemofiltration. Hemodynamics profile was recorded immediately before and at 6, 12, 24, and 48 hours after the hemofiltration was started (mean of three set data each time). No changes in ventilatory parameters were performed during the study. RESULTS Thirty patients were analyzed (15 with and 15 without hemofiltration). Both groups were similar in age (36 +/- 18 versus 36 +/- 14 years) and severity scores (Injury Severity Score, 32 +/- 16 versus 30 +/- 11; Acute Physiology and Chronic Health Evaluation II score, 22 +/- 7 versus 21 +/- 6; Goris score, 5.2 +/- 1.7 versus 5.2 +/- 1.8) and received similar inotropic support. We found a significant improvement in mean arterial pressure (80 +/- 9 to 94 +/- 8 (mm Hg), p = 0.01) and partial pressure of oxygen in arterial blood/inspiratory oxygen supply index (124 +/- 40 to 204 +/- 44, p = 0.03) in the intervention group during the study period. We did not find any other significant change in variables studied. CONCLUSIONS Continuous venovenous hemofiltration is associated with a significant improvement in hemodynamic and respiratory variables in critically ill trauma patients with multiple organ dysfunction syndrome. This improvement can help in the management of these patients. Further work is necessary to define whether this technique can reduce the high mortality of this disease.
Collapse
|
|
44
|
Tetta C, Mariano F, Buades J, Ronco C, Wratten ML, Camussi G. Relevance of platelet-activating factor in inflammation and sepsis: mechanisms and kinetics of removal in extracorporeal treatments. Am J Kidney Dis 1997; 30:S57-65. [PMID: 9372980 DOI: 10.1016/s0272-6386(97)90543-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Sepsis can be considered a systemic inflammatory response syndrome (SIRS) caused by infection. When an excessive and/or persistent activation of humoral and cellular mechanisms of host defense is present, an exaggerated and generalized activation of inflammatory mechanisms can lead to a multiple organ dysfunction syndrome. Mediators thought to be involved in this syndrome include the major plasma cascade systems (complement, coagulation, and fibrinolytic systems) and soluble cell-derived mediators (cytokines, reactive oxygen species, platelet-activating factor (PAF), arachidonic acid metabolites, and nitric oxide and related compounds). Several findings indicate that among these mediators, PAF may exert an important role in the pathophysiology of septic shock. Evidence is accumulating that in human sepsis this scenario is far more complicated and that removal of inflammatory mediator excess from plasma, rather than blockade of their potentially beneficial local production, might provide a rationale for the use of continuous renal replacement therapy (CRRT). There is an emerging view that CRRT should be considered in the light of broader concept (ie, the use of blood purification for the treatment of sepsis). Recent studies, performed in an experimental model of continuous arteriovenous hemofiltration with exogenous PAF, demonstrated that polysulfone membranes can adsorb substantial amounts of biologically active PAF. These studies also showed that the removal of this mediator occurs by a two-step process involving early adsorption followed by ultrafiltration. Although the removal of cytokines, such as tumor necrosis factor-alpha (TNF-alpha), remains controversial, mainly because of differences in membrane used, operational conditions, and inter- and intra-assay variability, the crucial point is that no evidence has yet been given to show real benefit from CRRT in significantly reducing the plasma concentration of cytokines. The net advantage of CRRT, however, may not only be the removal of cytokines per se, but also the simultaneous elimination of cytokine-inducing substances. Experimental and human studies will be discussed as to whether extracorporeal treatments may remove an excess of circulating cytokines, either by increasing the turnover rate (the so-called high-volume hemofiltration), or by using sorbent systems to regenerate plasma filtrate.
Collapse
Affiliation(s)
- C Tetta
- Clinical and Laboratory Research Department, Bellco, Mirandola (Modena), Italy.
| | | | | | | | | | | |
Collapse
|
|
45
|
Abstract
The evolution of technology and biomaterials has permitted a parallel development of renal replacement therapies in the acute, critically ill patient. From the original description of continuous arteriovenous hemofiltration, new techniques such as continuous venovenous hemofiltration, hemodiafiltration, and high flux dialysis have been developed and clinically used. A parallel improvement in efficiency has been achieved with urea daily clearances as high as 50 L or more. The use of special highly permeable dialyzers has also permitted an increase in the clearances of larger solutes, thus leading to significant removals of chemical substances involved in acute inflammation and sepsis. In this field, recent observations have suggested using hemofiltration with high volumes of fluid exchange. The hardware and software of the newer CRRT systems are key in achieving these results and in safely performing such challenging techniques.
Collapse
Affiliation(s)
- C Ronco
- Department of Nephrology, St Bortolo Hospital, Vicenza, Italy.
| | | |
Collapse
|
|
46
|
van Bommel EF. Should continuous renal replacement therapy be used for 'non-renal' indications in critically ill patients with shock? Resuscitation 1997; 33:257-70. [PMID: 9044498 DOI: 10.1016/s0300-9572(96)01030-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Accumulating experience with the use of continuous renal replacement therapy (CRRT) in critically ill patients with acute renal failure suggests that these treatment modalities have distinct advantages relative to conventional dialysis in terms of solute clearances, fluid removal and hemodynamics, which may translate in improved renal and patient outcome. Recent data point to a possible beneficial effect of CRRT on the clinical course, independent from an impact on fluid balance, in critically ill patients with shock which is attributed to the continuous elimination of inflammatory mediators from the circulation. This has raised the question as to whether CRRT might be used for 'non-renal' indications such as the systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS). In some animal models of experimental septic and non-septic shock, (short-term) hemodialysis and hemofiltration were found to improve hemodynamics and/or gas exchange. However, data were inconsistent and the clinical relevance questionable. Observations from both uncontrolled and controlled clinical studies (comprising only a small number of patients) support the hypothesis that CRRT may exert beneficial effects on the clinical course in critically ill patients with SIRS and MODS, independent from volume removal. Although several mediators known to play a role in the development of SIRS/MODS may pass hemofiltration membranes, quantitative data on the extent of its extracorporeal clearance relative to the production rate and endogenous clearance is often lacking. In addition, this aspecific elimination with CRRT may also effect levels of anti-mediators, which may be harmful. Ultrafiltrate properties include depression of cardiac performance, induction of proteolysis and immunosuppressive activity suggesting that water-soluble factors responsible for these deleterious effects are removed from the circulation by convection. However, no significant survival advantage has yet been shown for critically ill patients with SIRS/MODS when treated with CRRT as an adjunct to conventional therapy. Only prospective controlled studies of appropriate sample size, which requires a multicenter approach, might answer the question whether use of CRRT may alter the clinical course and outcome in critically ill patients with SIRS and MODS. Until such studies are performed, the rationale for the use of CRRT in the absence of conventional indications for dialytic support remains unproven.
Collapse
Affiliation(s)
- E F van Bommel
- Department of Internal Medicine, Drechtsteden Hospital, Dordrecht, The Netherlands
| |
Collapse
|
|
47
|
Ronco C, Bellomo R, Wratten ML, Tetta C. Future technology for continuous renal replacement therapies. Am J Kidney Dis 1996. [DOI: 10.1016/s0272-6386(96)90091-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
|
48
|
|