Blood Purification最新文献

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: High mortality rates among maintenance hemodialysis (MHD) patients necessitate more precise predictive tools. Existing models are limited by the accuracy and clinical usability. This study aimed to construct a precise and user-friendly machine learning (ML)-based mortality risk predictive model for MHD patients.

Methods: A total of 601 MHD patients from Shantou Central Hospital were enrolled in this study. Clinical and laboratory data were meticulously gathered and assessed. Patients were divided randomly into Training (70%) and Test (30%) cohort. Six types of ML algorithms based predictive models were constructed for prognostic prediction. The predictive accuracy of the model was evaluated by calculating the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC). Additionally, an online predictive model application was developed for practical clinical application.

Results: The Training and Test cohort exhibited comparable demographic and clinical traits. Age, body mass index, hemoglobin, cholesterol, aspartate aminotransferase, and serum albumin levels emerged as significant independent predictors of prognosis. The Extreme Gradient Boosting (XGBoost) based model predictive performance measures included with AUROC 0.831 and AUPRC 0.310 in the Test cohort. The XGBoost-based model was selected as the definitive predictive tool and was made accessible via a web application.

Conclusion: We successfully developed a machine ML predictive model to predict the risk factors of MHD patients, which was then integrated into a user-friendly web application. This predictive tool could help identify MHD patients at high risk of mortality in clinical practice.

Introduction: The selective cytopheretic device (SCD) is a cell-directed extracorporeal therapy approved for use in children with acute kidney injury (AKI) receiving continuous renal replacement therapy (CRRT) with sepsis/sepsis-like conditions. We compared outcomes for children treated with SCD to a contemporary cohort of children treated with CRRT alone.

Methods: Secondary analysis and comparison of patients ≤22 years old and ≥10 kg from a multicenter registry of patients receiving CRRT for AKI and/or fluid overload (WE-ROCK; 2015-2021) to patients from two multicenter, prospective, interventional studies of children with AKI and multiple organ dysfunction (MODS) receiving SCD (SCD-PED-01/SCD-PED-02; 2016-2022).

Results: Eighteen patients in the SCD cohort were compared to 178 in the CRRT cohort. There were no differences between cohorts at CRRT ± SCD initiation. SCD patients had shorter CRRT duration (6 [3, 11] vs. 10 [5, 18] days, p = 0.013) and shorter ICU length of stay (LOS) in survivors (16 [11, 25] vs. 27 [16, 46] days, p = 0.012). Survival to ICU discharge or day 60 was 94% in the SCD cohort vs. 74% in the CRRT cohort (p = 0.079). A Bayesian analysis demonstrated a >99% probability of improved survival with SCD. A sub-analysis in septic patients demonstrated greater survival (100% vs. 69%, p = 0.032), shorter CRRT duration (5 [3, 7] vs. 11 [6, 17] days, p = 0.006) and reduced ICU LOS in survivors (21 [10, 25] vs. 27 [16, 45] days, p = 0.027) in SCD-treated patients.

Conclusions: The addition of SCD therapy in children with AKI and MODS receiving CRRT may be beneficial, though larger prospective studies are needed.

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.