Blood Purification最新文献

Hemoperfusion with the HA330/HA380 cartridge have markedly evolved during the past decade, and has thus been widely used in intensive care settings to treat critical or hyperinflammatory illnesses. A large number of clinical studies have demonstrated that HA330/HA380 hemoperfusion might mitigate systemic inflammatory response syndrome and organ dysfunction in ICU patients by removing inflammatory mediators and metabolic toxins from the blood. However, there is currently lacking a systematic evaluation on the safety and efficacy of HA330/HA380 hemoperfusion in intensive care settings. We are thus motivated to perform a state-of-the-art review of HA330/HA380 hemoperfusion to advance its use in daily critical care practice. In this paper, we first discuss the basic technique characteristics and ex vivo investigations of the HA330/HA380 cartridge. Then, we extensively summarize the latest clinical evidence regarding the use of HA330/HA380 hemoperfusion for the treatment of sepsis, severe COVID-19, cardiac surgery, acute pancreatitis, liver failure, and blunt trauma in sequence. Finally, drug clearance by the HA330/HA380 cartridge is also highlighted to address its safety concerns.

Introduction: This study aims to develop and validate a risk prediction model for predicting the likelihood of coagulation in patients undergoing anticoagulant-free hemodialysis (HD). Anticoagulant-free HD technique is necessary in patients with contraindications to systemic therapy. Coagulation is a complication of this technique. Unfortunately, no predictive model is currently available to assess the risk of coagulation in anticoagulant-free HD.

Methods: We retrospectively analyzed the clinical data from 299 HD sessions involving 164 patients who underwent anticoagulant-free HD between January 2022 and June 2023. To identify the risk factors for coagulation in anticoagulant-free HD, a univariate analysis was performed on 18 independent variables. Logistic regression was used to establish predictive models by identifying factors contributing to coagulation in anticoagulant-free HD. A calibration curve was drawn using regression coefficients and 1000 bootstrap repetitions to validate our model internally. The performance of the prediction model was evaluated using receiver operating characteristic (ROC), area under the curve (AUC), and decision curve analysis (DCA).

Results: The incidence of coagulation in patients on anticoagulant-free HD was 35.1%. Logistic regression analysis showed that platelet (PLT) hematocrit (HCT) levels, dialysate type, and age were risk factors for coagulation in anticoagulant-free HD patients (P<0.05). The Hosmer-Lemeshow test showed P= 0.29, and the AUC is 0.76 (95% CI 0.70-0.80). The optimal critical value was 0.40, yielding a sensitivity of 61.0%, a specificity of 80.4%, and a Youden index of 0.41.

Conclusion: In anticoagulant-free HD, there were numerous risk factors and a 35.1% occurrence of coagulation. The constructed coagulation risk prediction model exhibited good predictive and clinical utility and could serve as a reference for the initial assessment and screening of coagulation risk in anticoagulant-free HD.

Introduction: Paracetamol (acetaminophen) induced acute liver failure (ALF) with severe hyperammonemia (ammonia >100 µmol.L-1) is a life-threatening condition. A strategy based on high intensity continuous renal replacement therapy (CRRT) without early (up to day seven) transplantation may enable clinicians to safely identify which patients can recover and survive and which patients require transplantation.

Methods: We conducted a single-center, retrospective cohort study of patients with severely hyperammonemic paracetamol-induced ALF. The primary outcome was early transplant-free survival.

Results: We studied 84 patients (median age: 38; female sex: 79 [85%]) over a 12-year period (median ammonia level at ICU admission: 153 µmol.L-1; median peak aspartate aminotransferase (AST): 10,029 U.L-1, median lactate: 5.0 mmol.L-1 and median INR: 4.4) and 55 (65%) with King's College criteria for transplantation). Overall, 87% received high-intensity CRRT (92% in 2020-2023). Median CRRT intensity was 54 ml.kg-1.hr-1 within the first 48 hours and increased by 1.8 ml.kg-1.hr-1 per year during the study period (p = 0.002). Transplant-free survival to day 7 was 86% in 2011-2023 and 96% in 2020-2023. Overall, only 4 patients were transplanted and only 1 (4%) in 2020-223. On multivariable Cox analysis, factors independently associated with failure to achieve day seven transplant-free survival were higher APACHE III score (HR = 1.05, 95% CI [1.02-1.08]), higher lactate (HR = 1.27, 95% CI [1.12-1.44]) and lower platelet count at ICU admission (HR = 0.85, 95%CI [0.78-0.93]) and the median effluent dose applied within the first 48 hours of ICU admission (HR = 0.67, 95% CI [0.46-0.98]).

Conclusions: Early transplant-free survival is achievable in most patients with paracetamol-induced ALF and severe hyperammonaemia with a treatment based on high-intensity CRRT. Such transplant-free survival increased over time together with increased CRRT dose.

Introduction: Adsorption devices like CytoSorb® (CS) are increasingly used in critically ill patients. However, potential adverse effects have not been sufficiently investigated. The aim of this post-hoc analysis of the monocentric prospective Cyto-SOLVE study was to examine albumin concentration and platelet count during the application of CS in intensive care unit (ICU) patients with different indications for CS therapy.

Methods: 29 Adult ICU patients receiving continuous kidney replacement therapy and CS application for 12 hours were included. Albumin concentration and platelet count were measured before, during, and after application. Changes in albumin concentration and platelet count were investigated. Since 10/29 patients were substituted with platelets during CS therapy and 20/29 received albumin, subgroup analysis was performed in patients receiving no platelet concentrate and <20g albumin substitution during CS application. The dependent sample t-test was used to detect significant (p<0.05) changes over time and multivariate models were investigated.

Results: We observed a significant reduction in platelets (p=0.005, mean 14 G/l, 95% confidence interval (CI) 4 - 23G/l) during CS therapy with an even more pronounced drop in those 19 patients without platelet substitution (p=0.001, mean 22G/l, 95% CI 10 - 34). No significant change was detected in the albumin concentration of all patients. However, a significant albumin decrease was observed in those 17 patients with less than 20g albumin substitution during CS therapy (p=0.007, mean 0.17g/dL, 95% CI 0.05 - 0.29). No other potential covariates for the decrease could be identified in a multivariate model.

Conclusion: Since a drop in albumin and platelets occurred during the use of CS, an increased substitution might be necessary. Knowledge of potential side effects is of great importance to prevent harm during the use of extracorporeal procedures. This knowledge should be considered for a reliable risk-benefit assessment in the future.

Introduction: Fluid overload is a frequent and serious complication in hemodialysis patients. The combination of multiple point of care ultrasound (POCUS) measurements can identify significant venous congestion but its usefulness to determine ultrafiltration (UF) requirements and dry weight is unknown. Therefore, we evaluated prospectively patients in maintenance hemodialysis to establish the correlations between changes in venous congestion parameters and fluid removal.

Methods: This was a prospective, single-center, observational study. POCUS venous congestion measurments were performed in 22 patients during 32 online post-dilutional hemodiafiltration sessions and findings were correlated with UF volume, central venous pressure and body water composition determined by multifrequency bioelectric impedance analysis (BIA).

Results: The pre dialysis weight was on average 1.9 kg above the BIA estimated dry weight, the average initial IVC diameter was <2 cm. An initial abnormal Hepatic Vein (HV) waveform was present in 26% (8) of the measurements. The average UF volume was 2084 ± 655 ml and correlated with changes in inferior vena cava (IVC) diameter (R= 0.34, CI 95% (0.18, 0.56) p < 0.05) but not with any other POCUS venous congestion parameters. Normalization of the IVC diameter and HV waveform was observed during the first UF hour in all initially altered measurements. Diameter reduction in the IVC correlated with total body water volume reduction estimated with BIA when measured immediately after fluid removal (R= 0.34, CI 95% (0.08, 0.56) p<0.05) Conclusion. Reduction in IVC diameter had a modest but significant correlation with UF volume in our patients on maintenance hemodiafiltration. POCUS may be used to monitor patients during UF.

Introduction: We conducted a first-in-human trial evaluating safety and the potential for combined pathogen and CTC removal in patients with solid metastatic cancers.

Methods: The Seraph procedure was performed at a hemodialysis clinic on ten consecutive patients with metastatic cancer whose liquid biopsy was positive for the epithelial cell adhesion molecule (EpCAM). All of the patients exerted positive bacterial or fungal isolates.

Results: We have demonstrated the ability of Seraph100® Filter to remove both pathogens and circulating tumor cells, with median reduction of 71% within the 120 min, from patient blood.

Discussion: High yield CTCs clearance could potentially benefit patients in diagnostic and personalized treatment of cancer to be elucidated in further research.

Introduction: Hemoadsorption can be used as adjunctive therapy for sepsis. However, there is limited evidence regarding its antibiotic removal. In this in vivo preclinical study, we aimed to evaluate the removal of meropenem and piperacillin with the HA380 hemoadsorption cartridge.

Methods: Healthy adult sheep (n = 6) received 2 g of meropenem, and 4 g of piperacillin intravenously for 30 minutes followed by hemoadsorption with a HA380 cartridge at a blood flow rate of 120 mL/min for 4 hours. The sorbent-based removal ratio, clearance, and mass removal were calculated at multiple time points.

Results: The sorbent-based removal ratio of meropenem decreased from 95.4% (SD 1.8) at 10 minutes to less than 20% at 4-hours of hemoadsorption. Its cumulative sorbent-based mass removal was 386.6 mg (SD 78.8) over 4 hours with 65.6 % (SD 7.1) occurring in the first 60 minutes. In contrast, the sorbent-based removal ratio of piperacillin decreased more gradually from 98.4% (SD 0.6) at 10 minutes to 37.4% (SD 7.2) at 4 hours. Its cumulative sorbent-based mass removal was 647.4 mg (SD 191.3) over 4 hours with 63.4% (SD 4.2) occurring in the first 60 minutes. The overall sorbent-based clearance of piperacillin was significantly greater than meropenem (Pgroup < 0.0001).

Conclusion: Hemoadsoprtion with the HA380 cartridge removed meropenem and piperacillin throughout a 4-hour period, with high clearances at the start. Our findings can be used to inform dosing decisions during hemoadsorption in septic patients, there may be the need to consider increasing the doses of these antibiotics by 15-25 % to prevent underdosing.