Blood Purification最新文献

Introduction: Adding a binder to dialysate improves the removal of protein bound toxins (PBTs). Systems that use dialysate with human serum albumin (HSA) to remove PBTs show promise for improving treatment in liver failure and other fields. HSA-based systems are difficult to scale due to scarce donor blood and expensive recombinant options. We investigate bovine serum albumin (BSA) as an alternative.

Methods: Computational modeling predicted the impact of dialysate side BSA concentration on the removal of three PBTs (bilirubin, cholic acid, and indoxyl sulfate). We validated our predictions using a blood analog solution with HSA and PBTs. This solution was dialyzed against dialysate with BSA at various concentrations. HSA dialysate was tested as a positive control.

Results: The model accurately predicts toxin removal. For bilirubin removal, the percent error of the prediction is less than 6%. For cholic acid and indoxyl sulfate, the percent error is higher because final concentration values are small. However, the square root of the sum of squares error of the prediction did not exceed 0.13 mg/g and 0.25 mg/g, respectively. PBT removal by BSA matched or exceeded results observed with HSA. The model accurately predicted the benefit of increased BSA concentration.

Conclusions: This model will allow binder dialysis optimization, enabling personalized dialysis dosing for maximum PBT removal. Using BSA can overcome the scarcity of HSA, enabling large scale treatment.

In the article "Protocol of the Comparison of Two Different Bicarbonate Replacement Fluids during Continuous Veno-Venous Hemofiltration with Regional Citrate Anticoagulation: A Prospective, Randomized, Controlled Trial" [Blood Purif. 2025;54:723-732; https://doi.org/10.1159/000547401] by Köglberger et al., the authors noticed an error in Table 2 of their article.The correct text should read: "3. LBF is reduced by 200 mL steps per hour (provided dose ≥25 mL/kg/h) to a target HCO3- of >22 mmol/L."

Introduction Hypercapnic respiratory failure is associated with high morbidity and mortality. Low-flow extracorporeal CO2 removal (ECCO2R) has been shown to facilitate lung protective ventilation or spontaneous breathing. However, three multicenter randomized trials have failed to show benefit which could potentially be a result of patient selection. In this study, we aimed to characterize prognostic scores developed for extracorporeal membrane oxygenation therapy which could potentially assist with the selection of patients for ECCO2R. Methods 70 patients admitted to the ICU at the University Hospital of Zurich between 10/2009 and 02/2017 with hypercapnic respiratory failure were treated with ECCO2R if pH ≤ 7.25 and/or PaCO2 ≥ 9kPa experiencing respiratory exhaustion during spontaneous breathing in obstructive lung disease or reaching the limits of lung protective ventilation (n=22 and n=48) in patients with restrictive lung pathologies. Data including baseline characteristics and respiratory parameters were collected prospectively. Scores were calculated retrospectively. Results The underlying diseases were ARDS (n=27), COPD (n=12), bronchiolitis obliterans syndrome (n=9), cystic fibrosis (n=10), pulmonary fibrosis (n=8) and other causes (n=4). 180-day mortality was 45.7% with the highest rate observed in PF and BOS patients as well as in patients who had been mechanically ventilated > 6 days before initiation of ECCO2R. The modified PRedicting dEath for SEvere hypercapnic Respiratory failure on vv-ECCO2R (PRESERVE-CO2) score differentiated well between survivors and non-survivors (4.3 ± 2.2 vs 6.9 ± 2.6, p < 0.01), whereas the modified Respiratory ECMO Survival Prediction (RESP-CO2) score showed no significant distinction. Receiver operating characteristics analysis of the PRESERVE-CO2 score revealed an area under the curve of 0.78, suggesting a cut-off of 7 points. Conclusion Careful selection of patients for ECCO2R therapy may help to improve outcomes. The proposed PRESERVE-CO2 score may serve as a guide. A score of 7 points or higher is associated with an unfavorable outcome regarding the 180-day mortality in the specific patient cohort of this study, but future studies to externally validate this score are required.

Introduction: Renal replacement therapy (RRT) is commonly used to manage metabolic disturbances in critically ill patients with acute kidney injury. While intraoperative RRT has been assessed in liver transplantation and cardiac surgery, its use in other surgical contexts remains unexplored. This study aimed to assess the feasibility of intraoperative continuous RRT (IoCRRT) in non-cardiac, non-liver transplant surgeries. Secondary objectives included evaluating safety and describing the patient population.

Methods: This retrospective study included all adult patients who underwent IoCRRT between January 2013 and January 2021 at Hospices Civils de Lyon (Lyon, France). Patients were classified as undergoing emergency or elective surgery. Data on IoCRRT indication, feasibility, safety, renal function at hospital discharge and mortality were analyzed.

Results: IoCRRT was successfully implemented in all 43 patients. Severe acidosis (pH < 7.2) was the main indication for IoCRRT in 27 patients (82%) of the emergency group, while IoCRRT was initiated to prevent metabolic complications and electrolyte imbalances in elective surgeries. Regional citrate anticoagulation was used in 36 (84%) cases. No adverse event was reported. At hospital discharge, no survivor progressed to end-stage renal disease; 4 (29%) patients exhibited a glomerular filtration rate (GFR) of 60-90 mL/min/1.73m², and 10 (71%) an GFR > 90 mL/min/1.73m². Twenty-seven patients (63%) died within 30 days.

Conclusion: IoCRRT seems to be a feasible and safe adjunctive therapy during emergency or elective surgery in patients with severe metabolic disorders. No IoCRRT-related complication was reported. Renal function appeared preserved. Further prospective studies are warranted to confirm these findings.

Introduction: Online hemodiafiltration (OLHDF) is associated to reduction in cardiovascular events and mortality when achieving high-dose convective volume. However, not all patients are able to reach the optimal volume of OLHDF or are not eligible for OLHDF. The aim of the present study is to compare expanded hemodialysis (HDx) and suboptimal post-dilution OLHDF in the reduction of solutes.

Methods: In this observational prospective study we included all the patients of our hemodialysis units with suboptimal (i.e. convective volume <19.2 litres) OLHDF. After a minimum of one month in OLHDF, patients were switched to HDx for another month. Removal ratio (RR) for small, medium and large molecules were calculated for each period. In addition, we compared the global removal score (GRS) with both techniques.

Results: Twelve patients were included (58% male, 68±16 years) and completed the study. OLHDF displayed higher RR of urea (p=0.011), prolactin (p<0.001), β2-microbloglulin (p=0.011), myoglobin (p=0.015), kappa free light chains (FLC) (p=0.04) and lambda FLC (p=0.012). In contrast, OLHDF and HDx presented similar RR of Creatinine, C-reactive protein, albumin, α2-macroglobulin, interleukin (IL)-1, IL-6, IL-8, IL-10, IL12, TNF-α, metalloproteinase-1 and p-cresol. The GRS was similar in OLHDF and HDx (55 [46-70]% vs 51 [41-59]%, NS).

Conclusion: In conclusion, HDx presents a similar GRS in comparison to OLHDF demonstrating that this technique can be prescribed in cases of suboptimal convective volume achievement.

Background: Antibiotic dosing in critically ill patients receiving continuous renal replacement therapy (CRRT) is challenging due to altered pharmacokinetics, variability in CRRT delivery, and limited dosing guidance. Optimizing therapy is essential, as underdosing may drive resistance and overdosing may increase toxicity, including cefepime-associated neurotoxicity.

Methods: We conducted a retrospective single-center study of ICU patients who received CRRT and at least one dose of cefepime, meropenem, or piperacillin-tazobactam between 2016 and 2020. Delivered CRRT dose was calculated from effluent rates. Daily antibiotic doses across CRRT phases were summarized, and resistance development was evaluated for Pseudomonas aeruginosa and Enterobacter cloacae using logistic regression.

Results: Of 954 eligible ICU patients, 661 met inclusion criteria. Median delivered CRRT dose was 29.5 mL/kg/h (IQR 25.0-33.5); 57.7% received ≥30 mL/kg/h, while only 9.6% were within the KDIGO-recommended 20-24.9 mL/kg/h. Median CRRT duration was 144 h (IQR 84-312), initiated a median of 2.3 days after ICU admission. Median daily doses during CRRT were 2.5 g for cefepime, 1.5 g for meropenem, and 10.8 g for piperacillin-tazobactam. Treatment-emergent resistance occurred in 17.6% of P. aeruginosa and 14.3% of E. cloacae isolates, while baseline resistance was common in E. coli (20.5%) and K. pneumoniae (27.3%). In multivariable models, longer treatment duration (OR 1.07/day, 95% CI 1.06-1.08), higher CRRT dose (OR 1.13 per 5 mL/kg/h, 95% CI 1.10-1.16), and lower daily antibiotic dose (OR 0.65 per g/day, 95% CI 0.61-0.70) were independently associated with cefepime resistance (AUC 0.73), with similar findings for meropenem (AUC 0.80).

Conclusion: Antibiotic dosing during CRRT was at the lower end of the therapeutic range and was associated with treatment-emergent resistance in exploratory analyses. These findings highlight the potential importance of CRRT-informed dosing strategies and underscore the need for careful balance between efficacy and toxicity.

Introduction: Socioeconomic and developmental diversity across Latin America (LA) significantly affects the availability of extracorporeal blood purification (EBP) therapies to treat acute kidney injury (AKI) and the training of nephrology fellows in these technologies. This survey assessed the availability of EBP therapies and perceived training needs of nephrologists and intensivists in the region.

Objective: To evaluate the availability of EBP therapies to treat AKI and identify training needs among LA nephrologists and intensivists.

Methods: Between March and December 2024, the AKI and extracorporeal organ support therapy committee of SLANH conducted an online survey targeting nephrologists and intensivists.

Results: 505 responses were collected, with 93% by nephrologists. Participants represented 20 LA countries, primarily from South America (58%), Mexico (23.6%), and the Caribbean (10.1%). Intermittent hemodialysis (IHD) was the most widely available therapy, accessible in 98% of centers. Peritoneal dialysis (PD) was available in 65% of hospitals, while continuous renal replacement therapy (CRRT) in 59% of centers but reported as unavailable in Haiti, Nicaragua, Paraguay, and Venezuela. Therapeutic plasma exchange (TPE) was available in 60% of hospitals, although accessibility varied significantly by country. Multi-organ support therapies showed limited regional availability, including liver support (11.9%), extracorporeal membrane oxygenation (ECMO, 16.7%), extracorporeal CO₂ removal (ECCO₂R, 7%), and hemoadsorption (20.6%). The greatest perceived training needs were identified for ECMO (54.2%), ECCO₂R (51.3%), CRRT (48.7%), and TPE (46.8%), whereas demand for further training in IHD and PD was comparatively lower. These findings underscore substantial disparities in therapy access and highlight urgent regional priorities for advanced EBP training.

Conclusion: This study highlights significant disparities in EBP therapy availability across LA, with advanced modalities like CRRT and multi-organ support inaccessible in several countries. Additionally, there is a high perceived need for training in ECMO, ECCO₂R, CRRT, and TPE. Addressing these gaps requires expanding access to EBP, implementing standardized training programs, establishing regional centers of excellence, and fostering international collaboration, patient outcomes across the region.