Blood Purification最新文献

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.

Background: Sodium management during hemodialysis session is based on the dialysate sodium (Na_D) prescription by the physician. However, the conflicting results of studies concerning the relationship between Na_D and mortality, and the sometimes significant difference between the Na_D prescribed and its actual value, are barriers to issuing on the optimal Na_D value. In the absence of any rational justification for preferring high or low dialysate sodium, prescribing Na_D remains empirical and quite intuitive.

Summary: From a clinical perspective, several arguments suggest prescribing the change in natremia (ΔNa) to be achieved at the end of the dialysis session rather than the Na_D value. Conductivity monitoring allows to calculate an online estimate (Na_Cond) of natremia and makes the hemodialysis monitor able to automatically adjust Na_D to achieve a Na_Cond target. From a technical standpoint, prescribing a Na_Cond-change target (ΔNa_Cond) rather than a Na_Cond target has the major advantage that the ΔNa_Cond value obtained at the end of the session may be unaffected by any lack of accuracy in the Na_D value. Key-Messages: Prescribing a target change (ΔNa) in natremia appears to be more rational and clinically relevant than prescribing a dialysate sodium. Conductivity monitoring makes it easier to implement this prescription in everyday clinical practice.

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: 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.

Background: The term adsorption is defined as the process in which molecules accumulate in the interfacial surface layer of a solid. The solid material is the sorbent, and the substance in the adsorbed state is called adsorbate. The basic principles and mechanisms involved in hemoadsorption include flow dynamics, chemical characteristics of synthetic materials, adsorption isotherms, mass transfer zone, and the Vroman effect. The development of devices and materials for hemoadsorption started in the 1970s, where activated charcoal coated in a plastic case was used as a sorbent for patients with drug overdose. Further developments of adsorbent materials led to the creation of several cartridges, which are now available for clinical use and are deployed for a myriad of purposes. Indications for hemoadsorption include sepsis, intoxication, drug overdose, acute kidney injury, rhabdomyolysis, cytokine release syndromes, acute liver failure, antibody-mediated autoimmune diseases, and uremia.

Summary: Herein, we aimed to describe the mechanisms involved in the adsorptive process and explore the singular properties of the commercially available devices for hemoadsorption.

Key messages: The devices deployed to adsorption are cartridges or filters. In cartridges, blood or plasma interacts with polymers in the form of beads, powder, flakes, granules, or a mesh of fibers. In filters, blood is exposed to a synthetic membrane in the form of hollow fibers. In research, clinical practice, and education, it is essential to specify the device and the adsorbent material used for hemoadsorption, since their properties and targets may vary entirely. Nephrologists and intensivists should be familiarized with the mechanisms and principles of hemoadsorption as these treatments are now being routinely applied.

Introduction: Chronic Kidney Disease (CKD) is a global public health issue. Bioelectrical impedance analysis (BIA) is a non-invasive and cost-effective method used for nearly three decades to assess the nutritional and volume status of dialysis patients. Despite its clinical utility, the quality of research and emerging trends in this field are not well understood. To address this gap, we conducted a bibliometric and visualization analysis from 1990 to 2024.

Methods: A comprehensive search in the Web of Science Core Collection on December 31, 2024, yielded 460 citations of reviews, articles, and publications in English. These were visualized and analyzed using VOSviewer, CiteSpace, and R-bibliometric techniques to identify trends related to authors, journals, countries, institutions, collaborative networks, keywords, and other relevant factors in BIA research in renal dialysis.

Results: Our study revealed the USA was the most productive country, followed by China. In terms of average citations per article, the USA led, followed by Italy and UK. Additionally,the USA, Brazil, and the UK exhibited high multiple country publications ratios, reflecting strong participation in international collaborations. The top three keywords are "hemodialysis", "body composition", and "peritoneal dialysis".

Conclusion: The USA, China, and UK emerged as the leading contributors in terms of publication output. Furthermore, the USA, Brazil, and the UK are highly active in international collaboration. Future research should aim to integrate long-term BIA data with patient-specific clinical factors to optimize dialysis treatment strategies and reduce complications. The field has made progress but needs improvement, especially in international collaborations.

Introduction Extracorporeal blood purification (EBP) devices are increasingly used in critically ill patients to manage sepsis, hyperinflammatory states, and other life-threatening conditions. However, these devices may unintentionally remove therapeutic medications, potentially compromising efficacy. Understanding these interactions is essential to optimize therapy and ensure patient safety. Methods A systematic search of PubMed, Cochrane, and manufacturer-specific databases was performed to identify literature on drug removal by current adsorptive EBP devices. Studies were screened for evidence of drug clearance, including both preclinical and clinical (in-vivo) data, using specific keywords related to drug removal and therapeutic drug monitoring (TDM). Results Out of 659 identified articles, 61 met the inclusion criteria. CytoSorb was the most extensively studied device, with 25 relevant publications-19 of which included in-vivo data. Data on drug removal were found for 43 substances with CytoSorb, 8 with Jafron, 12 with oXiris, 25 with Seraph, and 13 with PMX-HP. Antibiotics were the most commonly studied drug class, with vancomycin and meropenem being the most frequently investigated agents. While CytoSorb had the most comprehensive data, evidence for other devices was limited, especially regarding clinical studies. Conclusions Adsorptive EBP devices have the potential to unintentionally remove medications, which may compromise therapeutic effectiveness in critically ill patients if not properly accounted for. Among currently available devices, CytoSorb has the most comprehensive evidence base. However, additional clinical studies are required for all devices to confirm findings and establish dosing recommendations. The use of therapeutic drug monitoring, when available, is strongly advised to guide clinical decision-making.  .

Introduction: Dialysis-related amyloidosis (DRA) is a serious complication in patients undergoing long-term dialysis that leads to conditions such as carpal tunnel syndrome and destructive spondyloarthropathy. Improved removal of the precursor protein β₂-microglobulin (β₂-m) is considered an effective treatment strategy for DRA. Polymethylmethacrylate (PMMA) membranes have the capacity to adsorb β₂-m in dialysis filters, suggesting that direct hemoperfusion with PMMA in addition to standard dialysis may enhance β₂-m removal.

Methods: This prospective cohort study included 10 patients undergoing hemodialysis, who were diagnosed with DRA. The participants were treated with dialysis filter alone during visit 1, both standard dialysis filter and PMMA cartridges (FT-75, volume 75 cm3) during visits 2-4, and FT-145 PMMA cartridges (volume 145 cm3) during visits 5-7. The removal rates and clearances of β₂-m were quantified. We also assessed the removal of α₁-microglobulin (α₁-m), matrix metalloproteinase-3 (MMP-3), interleukin-6 (IL-6), and tumor necrosis factor-a (TNF-α), which may be associated with DRA symptoms.

Results: PMMA cartridge had increased β₂-m removal rates compared to dialysis filter alone for treatment duration of 240 min. Similarly, the removal rates of α₁-m and MMP-3 were higher with PMMA cartridges than with dialysis filter alone. β₂-m, α₁-m, and MMP-3 clearance improved with the addition of PMMA cartridges, depending on the cartridge size. The removal rates of IL-6 and TNF-α were higher with PMMA cartridges than with dialysis filter alone at 30 min, but not at 240 min.

Conclusion: Direct hemoperfusion with PMMA is an effective method for removing β₂-m in hemodialysis patients with DRA. Beneficial effects were also observed for the removal of α₁-m and MMP-3. Further research is required to evaluate the long-term efficacy of this approach in managing DRA.

Introduction: Sepsis is a life-threatening condition associated with high mortality due to an unregulated host immune response. Extracorporeal blood purification (EBP) therapies have been proposed as adjunctive treatments to immunomodulate patients; however, none have been consistently shown to be effective in reducing mortality. In several observational studies, Oxiris has been associated with cytokine reduction and a potential benefit in influencing inflammatory diseases. This meta-analysis explores the association between cytokine removal and clinical efficacy of the Oxiris membrane using interleukin-6 (IL-6) as a biomarker.

Methods: This review includes articles on EBP with Oxiris membranes in adult patients with sepsis/septic shock or COVID-19. No time or language restrictions were applied to the systematic literature search. Data extraction and statistical analysis were limited to the cytokines and clinical data reported in the included articles. The most representative cytokine was IL-6 and the selected outcomes included Vasoactive-Inotropic Score (VIS), SOFA score, procalcitonin (PCT) and C-reactive protein (CRP). The review used meta-analysis and unpaired t test to estimate differences between groups of patients treated with or without Oxiris.

Results: The study found no significant differences in demographics between the intervention and control groups at baseline. Intervention group showed a significant reduction in vasoactive inotropic score, norepinephrine dose, SOFA score, PCT, and CRP.

Conclusion: We reviewed 8 studies in which IL-6 was significantly reduced in the Oxiris group compared to the control. This meta-analysis found that the use of the Oxiris membrane resulted in significant clinical improvement during treatment.

Introduction: Endotoxin, also referred to as lipopolysaccharide (LPS), is a major stimulus of the inflammatory response capable of leading to sepsis and septic shock. Extracorporeal blood purification therapies are increasingly employed in the treatment of sepsis. Timely and thorough removal of endotoxin and cytokines can help mitigate the inflammatory cascade during septic shock. Hemoadsorption (HA) is a promising approach to achieve this goal. In this study, we analyzed different prototypes of a new CA cartridge: we performed in vitro circulations to define endotoxin and cytokine removal capacity.

Methods: In vitro HA was performed using GALILEO testing platform, and customized circuits with mini-modules of CA cartridge were prepared. A batch of 500 mL of blood preconditioned with LPS was utilized for each circulation. We collected samples at different time points: endotoxin activity and removal ratio (RR) of LPS, interleukin 6 (IL-6), and interleukin-1 beta (IL-1β) were assessed.

Results: The prototypes showed different performances, highlighting promising adsorption affinity toward the target molecules. A potentially clinically meaningful reduction of endotoxin activity by CA mini-module was observed. Concentration of the LPS, and cytokines IL-6 and IL-1β showed a significant reduction over time, as confirmed by the RRs.

Conclusion: Our experiments allowed to characterize the prototypes in terms of adsorption capacity for both endotoxin and cytokines. After this preliminary approach, the final CA mini-module was tested under the same experimental conditions and displayed excellent adsorption capacity, indicating its potential application for endotoxin removal.