Blood Purification最新文献

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 min followed by hemoadsorption with a HA380 cartridge at a blood flow rate of 120 mL/min for 4 h. 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 min to less than 20% at 4 h of hemoadsorption. Its cumulative sorbent-based mass removal was 386.6 mg (SD 78.8) over 4 h with 65.6% (SD 7.1) occurring in the first 60 min. In contrast, the sorbent-based removal ratio of piperacillin decreased more gradually from 98.4% (SD 0.6) at 10 min to 37.4% (SD 7.2) at 4 h. Its cumulative sorbent-based mass removal was 647.4 mg (SD 191.3) over 4 h with 63.4% (SD 4.2) occurring in the first 60 min. The overall sorbent-based clearance of piperacillin was significantly greater than meropenem (pgroup < 0.0001).

Conclusion: Hemoadsorption with the HA380 cartridge removed meropenem and piperacillin throughout a 4-h 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.

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: Twenty-nine adult ICU patients receiving continuous kidney replacement therapy and CS application for 12 h 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 <20 g 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) 4-23 G/L) during CS therapy with an even more pronounced drop in those 19 patients without platelet substitution (p = 0.001, mean 22 G/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 20 g 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: 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 h 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 2020-2023. 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 h 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 hyperammonemia with a treatment based on high-intensity CRRT. Such transplant-free survival increased over time together with increased CRRT dose.

Introduction: Patients with end-stage renal disease (ESRD) are known to have reduced structural and functional brain connectivity in the brain regions associated with cognitive function. However, the effect of dialysis on brain connectivity remains unclear. This study aimed to evaluate the effects of dialysis on structural brain connectivity in patients with ESRD.

Methods: This prospective study included 20 patients with ESRD in the pre-dialysis stage and 35 healthy controls. The patients underwent T2-weighted and three-dimensional T1-weighted magnetic resonance imaging before and 3 months after dialysis initiation. Moreover, the cortical thickness was calculated. We applied graph theoretical analysis to calculate the structural covariance network based on cortical thickness. We compared the cortical thickness and structural covariance network of patients with ESRD in the pre-dialysis stage with those of healthy controls and with those of patients with ESRD in the post-dialysis stage.

Results: The mean cortical thickness in both hemispheres was lower in patients with ESRD in the pre-dialysis stage than in healthy controls (2.296 vs. 2.354, p = 0.030; 2.282 vs. 2.362, p = 0.004, respectively) and was higher in patients with ESRD in the post-dialysis stage than in those in the pre-dialysis stage (2.333 vs. 2.296, p = 0.001; 2.322 vs. 2.282, p = 0.002, respectively). Analysis of the structural covariance network revealed that the assortative coefficient was lower in patients with ESRD in the pre-dialysis stage than in healthy controls (-0.062 vs. -0.031, p = 0.029) and was higher in patients with ESRD in the post-dialysis stage than in those in the pre-dialysis stage (-0.002 vs. -0.062, p = 0.042).

Conclusion: We observed differences in the cortical thickness and structural covariance networks before and after dialysis in patients with ESRD. This indicates that dialysis affects structural brain connectivity, contributing to the understanding of the pathophysiological mechanism of cognitive function alterations resulting from dialysis in patients with ESRD.

Introduction: Arteriovenous fistula (AVF) maturation assessment is essential to reduce venous catheter residence. We introduced central venous oxygen saturation (ScvO2) and estimated upper body blood flow (eUBBF) to monitor newly created fistula maturation and recorded catheter time in patients with and without ScvO2-based fistula maturation.

Methods: From 2017 to 2019, we conducted a multicenter quality improvement project (QIP) in hemodialysis patients with the explicit goal to shorten catheter residence time post-AVF creation through ScvO2-based maturation monitoring. In patients with a catheter as vascular access, we tracked ScvO2 and eUBBF pre- and post-AVF creation. The primary outcome was catheter residence time post-AVF creation. We compared catheter residence time post-AVF creation between QIP patients and controls. One control group comprised concurrent patients; a second control group comprised historic controls (2014-2016). We conducted Kaplan-Meier analysis and constructed a Cox proportional hazards model with variables adjustment to assess time-to-catheter removal.

Results: The QIP group comprised 44 patients (59 ± 17 years), the concurrent control group 48 patients (59 ± 16 years), the historic control group 57 patients (58 ± 15 years). Six-month post-AVF creation, the fraction of non-censored patients with catheter in place was 21% in the QIP cohort, 67% in the concurrent control group, and 68% in the historic control group. In unadjusted and adjusted analysis, catheter residence time post-fistula creation was shorter in QIP patients compared to either control groups (p < 0.001).

Conclusion: ScvO2-based assessment of fistula maturation is associated with shorter catheter residence post-AVF creation.

Background: Hemoperfusion with the HA330/HA380 cartridge has markedly evolved during the past decade and has thus been widely used in intensive care settings to treat critical or hyperinflammatory illnesses. Numerous 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.

Summary: We searched the PubMed database, Chinese Clinical Trial Registry, and ClinicalTrials.gov for articles published from inception to June 20, 2024 (updated on September 10, 2024) to perform a state-of-the-art review of HA330/HA380 hemoperfusion in daily critical care practice. We discuss the basic technique characteristics and ex vivo investigations of the HA330/HA380 cartridge and 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. Ex vivo studies suggest that the HA330/HA380 cartridge demonstrates satisfactory biocompatibility and substantial adsorption capacity for inflammatory cytokines, such as interleukin-6, interleukin-10, and tumor necrosis factor-α. Small-scale clinical studies indicate that HA330/HA380 hemoperfusion may help reduce plasma levels of inflammatory mediators, alleviate organ dysfunction, and improve survival in some critically ill patients with sepsis, severe COVID-19, acute pancreatitis, and blunt trauma.

Key messages: (i) The HA330/HA380 cartridge contains abundant, coated, biocompatible sorbent beads made of styrene-divinylbenzene copolymers. (ii) HA330/HA380 hemoperfusion, with or without combined continuous renal replacement therapy, is a promising treatment option for some critically ill patients by removing proinflammatory mediators and alleviating organ dysfunction. (iii) The HA330/HA380 cartridge may adversely adsorb antibiotics, and appropriate antibiotic dosing adjustment and plasma drug level monitoring is recommended. (iv) There are currently numerous ongoing clinical trials evaluating the safety and efficacy of HA330/HA380 hemoperfusion in critically ill patients who develop sepsis or undergo cardiopulmonary bypass, which will certainly sharpen our future practice of HA330/HA380 hemoperfusion in ICU.

Introduction: The factors contributing to blood loss during hemodialysis (HD) procedures remain underexplored. This study aimed to quantify blood loss during HD and identify the potential factors associated with it.

Methods: The study included 70 ESRD patients undergoing HD. After dialysis, the extracorporeal blood circuits were rinsed with 1,000 mL of 0.05% NH3 solution in distilled water, and hemoglobin levels were measured. Univariate regression was used to assess the linear relationship between residual red blood cell (RBC) volume and various parameters, including HD mode, dialyzer surface area, ultrafiltration goal, hypotension during HD, blood flow rate, activated partial thromboplastin time, and C-reactive protein. Multivariate regression was also conducted to explore the relationships among these parameters.

Results: The mean RBC volume remaining in the extracorporeal blood circuit after HD was 1.6 ± 0.9 mL (mode: 1.0, range: 0.3-6.5 mL). When converted to whole blood volume per patient, the mean blood volume was 5.3 ± 3.0 mL (median: 4.1 mL, mode: 4.0 mL, range: 1.0-19.0 mL). Multivariate analysis identified the dialyzer surface area as the only significant determinant of residual RBC volume.

Conclusion: After HD, the remaining RBC volume in the extracorporeal blood circuit varies from 1.6 to 6.5 mL. When the RBC volume was converted to whole blood volume for each case, the blood loss ranged from 1.0 to 19.0 mL. Dialyzer surface area was the only significant determinant of residual RBC volume.

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 measurements 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 inferior vena cava (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 2,084 ± 655 mL and correlated with changes in IVC diameter (R = 0.34, 95% CI: [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, 95% CI: [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.