Blood Purification最新文献

Background: Poisonings can harm through their direct effect or determining organ dysfunction. Extracorporeal blood purification therapies (EBPT) have been used for decades in case of poisonings. Although poisoning remains a major public health issue, focusing on organ dysfunction rather than the poison itself has significantly reduced mortality rates.

Summary: This review explores the complex and dynamic interactions among poisons, patients, and EBPT and describes specific poisonings where EBPT may be indicated.

Key messages: EBPT are indicated in many cases of intoxication, either to enhance clearance or for organ support. A thorough understanding of the interactions between poisons, patients, and EBPT is mandatory for proper management of each specific intoxication.

Background: Metabolic alkalosis is very common in hospitalized patients, and it is due to a negative H+ balance with base gain, especially HCO3-. When metabolic alkalosis is severe (pH ≥7.55) or extreme (pH >7.6), it is associated with extremely high morbidity and mortality, since, in addition to the underlying pathology, alkalemia itself generates serious organic repercussions and must be corrected promptly. Specifically, severe metabolic alkalosis is associated with increased adrenergic sensitivity, ionic hypocalcemia, hypokalemia, neuromuscular complications, myocardial and cerebral ischemia.

Summary: This narrative review explores literature reports where renal replacement therapy has been used to control severe metabolic alkalosis. It also analyzes side effects and response to therapy and attempts to provide recommendations regarding how to manage severe metabolic alkalosis with hemodialysis (HD).

Key messages: In severe and extreme metabolic alkalosis, in addition to diagnosing and treating the underlying cause, it is necessary to promptly remove excess bases, which can be achieved through renal replacement therapy. Intermittent HD with low bicarbonate in the dialysate has proven to be very effective for its management.

Introduction: The standard dialysate flow (Qd) for hemodialysis (HD) is currently set at 500 mL/min. One potential, sustainable, and cost-effective solution for eco-friendly HD may involve reducing Qd to limit wastewater. However, the effect of reduced Qd on small molecule and middle molecule (MM) removal remains to be investigated.

Methods: In this prospective observational study, 74 patients on different maintenance dialysis modalities with Qd set at 500 mL/min (Qd500) were assigned to receive Qd at 400 mL/min (Qd400) for 3 months. Dialysis adequacy, including small solute removal and MM reduction ratio (RR), was evaluated at enrollment and after 3 months.

Results: Compared to Qd500, Qd400 after 3 months achieved similar single-pool Kt/V (1.41 ± 0.30 vs. 1.43 ± 0.33, p = 0.58), equilibrated KT/V, urea RR, creatinine RR, and phosphate RR. Qd400 vs. Qd500 provided significantly higher beta2-microglobulin RR (77.0 [71.4-81.7] vs. 74.7 [68.4-79.4] %, p = 0.009) and lower kappa free light chain (FLC) RR (54.2 [42.1-64.4] vs. 57.6 [41.6-65.0] %, p = 0.03), whereas myoglobin and lambda FLC RR were similar. Qd400 resulted in higher pre-dialysis urea (20.2 ± 5.5 vs. 18.2 ± 6.2 mmol/L, p = 0.002), creatinine (694.0 ± 179.5 vs. 665.6 ± 220.4 µmol/L, p = 0.029), beta2-microglobulin (26.5 [23.0-30.0] vs. 23.5 [20.0-28.0] mg/L, p = 0.0001), and myoglobin (174.0 [122.0-251.0] vs. 159.5 [119.0-195.0] µg/L, p = 0.033) levels. Pre-dialysis levels of albumin, potassium, bicarbonate, phosphate, and calcium were similar between Qd400 and Qd500.

Conclusion: Three months of Qd at 400 mL/min appears to provide similar small molecule and MM removal, but with an increase in pre-dialysis urea, creatinine, beta2-microglobulin, and myoglobin levels. Although this strategy could help preserve water, its potential impact on long-term clinical outcomes deserves further evaluation.

Introduction: Reducing dialysate flow (Qd) to 400 mL/min has proven to be sufficient, safe, and effective in meeting dialysis adequacy requirements in adults, with the added advantage of decreasing water consumption per dialysis session. Expanded hemodialysis (HDx), which uses dialyzers with membranes capable of enhanced clearance of medium-sized molecules due to expanded pore capacity, has higher efficiency and reduces the importance of the dialysate-to-blood flow ratio (Qd/Qb) for molecule removal. The objective of this study was to evaluate dialysis effectiveness by analyzing the reduction rate of medium-sized molecules in patients weighing ≤70 kg, comparing Qd 400 mL/min vs. 500 mL/min in HDx using Theranova® membrane.

Methods: A post hoc analysis of the COREXH study population was performed. This observational, analytical, retrospective cohort study included 23 patients, of whom 11 (47%) had Qd 400 mL/min and 12 (52.1%) had Qd 500 mL/min.

Results: No statistically significant differences were observed in the reduction rate of medium-sized molecules between the Qd 400 mL/min and 500 mL/min groups. Additionally, water consumption was lower in the Qd 400 mL/min group, with an average saving of 24 L per patient per session and 13,824 L over 12 weeks.

Conclusion: Using Qd 400 mL/min in HDx vs. 500 mL/min did not affect dialysis effectiveness in terms of molecule reduction rates and resulted in substantial water savings in Qd 400 mL/min group.

Introduction: Premature circuit clotting remains a major limitation of pediatric continuous kidney replacement therapy (CKRT). While anticoagulation with heparin or citrate has been well studied, the risk factors for circuit failure under nafamostat mesylate (NM) use have not been well characterized.

Methods: This retrospective cohort study included pediatric patients aged <16 years who underwent CKRT in a single tertiary care center in Japan. Circuits that were discontinued within 48 h due to clotting were defined as those with a shorter circuit lifespan. Patient demographics, laboratory parameters, and CKRT settings were compared between the circuits with short and long lifespans. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for a short circuit lifespan, and Kaplan-Meier analysis was employed to assess circuit survival over time.

Results: After excluding circuits associated with extracorporeal membrane oxygenation or elective discontinuation within 48 h, the final analysis comprised 162 CKRT circuits, including 52 circuits (32%) with a short lifespan. By multivariate analysis, low antithrombin III (ATIII) activity before CKRT initiation (odds ratio [OR] 0.97, 95% confidence interval [CI]: 0.95-0.99), NM monotherapy without heparin (OR 0.23, 95% CI: 0.059-0.88), and small filter size (OR: 0.23, 95% CI: 0.077-0.67) were independently associated with a short circuit lifespan. By Kaplan-Meier analysis, circuit survival was significantly longer in patients with an ATIII activity of ≥59% and in those treated with heparin.

Conclusions: Low ATIII activity, NM monotherapy without heparin, and small filter size were independent risk factors for a shorter circuit lifespan in pediatric CKRT.

Introduction: Intravascular hemolysis is a significant complication of extracorporeal membrane oxygenation (ECMO), associated with adverse outcomes such as kidney failure and increased mortality. There is wide variability in the cited incidence of this complication. This survey study aimed to characterize the variability in hemolysis monitoring practices across ECMO centers.

Methods: The survey, distributed via the Extracorporeal Life Support Organization (ELSO) newsletter, received 26 responses from various healthcare professionals, including nurses, perfusionists, respiratory therapists, and physicians. Respondents represented both pediatric and adult ECMO units, primarily from academic centers in the USA (46%).

Results: Findings revealed that 92% of these centers use centrifugal pumps, with heparin and bivalirudin being the preferred anticoagulants. While 68% of respondents reported having a standard protocol for hemolysis monitoring, the specific protocols varied widely. Plasma-free hemoglobin was the most commonly monitored laboratory test. Definitions for what were considered significant hemolysis varied as well and were primarily identified by red urine and elevated plasma hemoglobin levels. Interventions to address hemolysis included adjusting pump speed, repositioning cannulas, replacing pump heads or oxygenators, and performing plasmapheresis.

Conclusion: The study highlights the variability in hemolysis monitoring practices among ECMO centers. Further research is warranted to establish optimal monitoring protocols to detect and potentially treat the complication of hemolysis.

Introduction: Neonatal acute kidney injury disproportionately affects extremely low birthweight (ELBW) infants (<1,000 g), who are especially vulnerable to fluid imbalance and its consequences. Current renal replacement therapy options are not optimized for patients under 2.5 kg. The Brophy Kit™, a cost-conscious, manual single-lumen dialysis device, may address this gap.

Methods: A preclinical feasibility study was conducted using eight healthy male Sprague Dawley rats (600-800 g), approximating the weight and blood volume of ELBW neonates. Each rat underwent 3-French catheter placement and sequential ultrafiltration (UF) cycles with the Brophy Kit™, targeting 5% and 10% blood volume removal. Respiratory rate was monitored as a surrogate for procedural tolerance.

Results: All eight animals tolerated the procedure and survived to UF completion. One rat was excluded due to catheter clotting before UF initiation. Respiratory rates remained stable throughout. Observed UF volumes deviated from prescribed volumes at the end of each experiment day by 11-12%.

Conclusion: This proof-of-concept study demonstrates the feasibility of using the Brophy Kit™ for manual UF in a preclinical model approximating ELBW neonates. The device shows potential as an accessible solution for fluid management in resource-limited settings.

Introduction: Chronic kidney disease (CKD) significantly impacts global health, with dialysis patients often experiencing reduced quality of life. Incremental start peritoneal dialysis (INPD) has emerged as a promising individualized treatment strategy, offering potential benefits for both patient outcomes and environmental sustainability compared to the standard peritoneal dialysis (STPD). This study aimed to evaluate the impact of incremental start continuous ambulatory peritoneal dialysis (CAPD) on quality of life, clinical outcomes, and environmental metrics, such as plastic waste generation, compared to conventional CAPD.

Methods: A multicenter study involving two groups (incremental start CAPD - INPD and standard dose conventional CAPD - STPD groups) was conducted. The baseline and 6-month follow-up data were collected, including laboratory parameters, treatment-related plastic waste, glucose load, residual renal function, and quality of life assessed using the Kidney Disease Quality Of Life Short Form (KDQOL-SF).

Results: There was no statistically significant difference in median age and gender between the two groups (p > 0.05). In the third month of the study, a significant difference was observed in peritoneal equilibrium test ultrafiltration volume, with higher values in the STPD group (p = 0.020). There were no statistically significant differences between study groups according to permeability groups (p = 0.714) or KtV (p = 0.743). In the sixth month of the study, the INPD group demonstrated significantly better residual renal function (p < 0.001) and reduced weekly polypropylene and polyvinyl chloride plastic waste (p < 0.001) and glucose load (p < 0.001) in both the baseline and sixth months of the study. KDQOL-SF scores were significantly higher in the INPD group (p < 0.001).

Conclusion: INPD demonstrated superior outcomes in maintaining residual renal function, reducing treatment burden, and improving quality of life while significantly lowering environmental impact compared to STPD. These findings support the adoption of INPD as an individualized and sustainable strategy in CKD management. Further research is needed to validate these findings in larger cohorts and explore long-term outcomes.

Introduction: Sleep disturbances are common in hemodialysis (HD) patients. We examined the excessive ultrafiltration rate (UFR), which is associated with poor outcomes, for its possible impact on sleep quality.

Methods: Only oligo-anuric patients with a three-times-weekly HD schedule were included in the study. Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality and a score >5 indicated poor sleepers. Ultrafiltration values refer to the month preceding the PSQI survey. Patients were divided into three categories: optimal UFR group (<10 mL/kg/h), borderline UFR group (10-13 mL/kg/h), and high UFR group (≥13 mL/kg/h).

Results: A total of 102 patients were included, with a median age of 60 (46-67) years. Median dialysis vintage was 44.5 (22-77) months. Average interdialytic weight gain (IDWG) percentage was 4.7 (3.7-5.7) and UFR was 11.6 ± 3.5 mL/kg/h. A total of 37 patients (36.3%) had optimal UFR, 29 patients (28.4%) had borderline UFR, and 36 patients (35.3%) had high UFR. Average PSQI score was 7 (4-10) points and 61 patients (59.8%) was identified as poor sleepers. Mean UFR was 11.7 ± 3.4 mL/kg/h in poor sleepers and 11.5 ± 3.7 mL/kg/h in non-poor sleepers (p = 0.819). PSQI score and poor sleeper prevalence were not significantly different between UFR groups. There was no significant correlation between PSQI and UFR (p = 0.325). In multivariate regression analysis, UFR was not an independent predictor of sleep quality. Additionally, younger age and a long HD vintage were independent predictors of high UFR.

Conclusion: Excessive and rapid fluid removal does not constitute a risk for poor sleep quality. Also, current findings underscore the increased frequency and complexity of sleep disorders in dialysis patients.

Introduction: Continuous renal replacement therapy (CRRT) is often performed for critically ill patients in intensive care units (ICUs), but its optimal indication and settings have yet to be determined. Thus, we aimed to describe the current status of CRRT in Japan through a multicenter retrospective observational study.

Methods: Adult ICU patients receiving CRRT at 18 tertiary hospitals in Japan (up to 100 patients from each hospital over the past year) were retrospectively enrolled. Patients receiving CRRT for <24 h or intermittent renal replacement therapy together with CRRT were excluded. The primary outcomes were the temporal changes in the electrolyte levels, acid-base balance, and uremia-related small solute concentrations. The secondary outcomes included potassium (K) and phosphate (P) supplementations during CRRT.

Results: Altogether, 1,045 patients were enrolled. The median CRRT duration and dose were 4.4 days and 17.3 mL/kg/h, respectively. The electrolyte levels, acid-base balance, and uremia-related small solute concentrations returned to normal by day 4 of treatment. A total of 732 (70.0%) patients received K supplementation, and only a few patients had hypokalemia until day 5. Moreover, 414 (39.6%) patients received P supplementation, and approximately 30%-50% of the patients had hypophosphatemia until day 5.

Conclusion: The CRRT dose in Japan was lower than that was recommended by the Kidney Disease: Improving Global Outcomes guideline. The electrolyte level abnormalities and acid-base imbalances of the studied patients were improved within 72-96 h of CRRT. Contrarily, K and P supplementations were common, indicating that the current CRRT solutions need to be modified.