Blood Purification最新文献

Background: Burns are a common injury affecting thousands of people worldwide each year. Clinical severity varies according to the total body surface area burned, which is in turn associated with morbidity and mortality. The management of a severe burn patient requires admission to a referral center. Patients with severe burns exhibit a complex and dysregulated immuno-inflammatory response. This leads to the loss of immune homeostasis, which is a source of infectious complications and organ dysfunctions. This loss of control of immune mechanisms plays a key role in the morbidity and mortality of severe burn patients.

Summary: Currently, several strategies, such as hemoadsorption, have been developed to modulate this host response. Modern hemoadsorption is based on new highly biocompatible sorbent cartridges of neutral macroporous resin beads. We propose herein a review of the immune pathways in burn injury and the rationale and potential applications of extracorporeal blood purification techniques, such as hemoadsorption, in the management of burn patients.

Key messages: Severe burns trigger an uncontrolled immuno-inflammatory response, leading to high morbidity and mortality. Immune homeostasis loss is central to complications such as infections and organ failure. Hemoadsorption may represent a potential therapeutic option to help modulate the immune response in burn patients.

Background: Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection, and where underlying circulatory, cellular, and metabolic abnormalities contribute to a greater risk of mortality than that posed by sepsis alone, this may be considered septic shock where circulatory support is needed in the face of a raised lactate level. The main pillars of therapy remain source control and appropriate timely antibiotics, resuscitation where needed, and adequate source control. However, in the setting of organ failure further support may be needed.

Summary: Here, we discuss the potential benefits from removal of pathogens using available extracorporeal techniques. Although randomized controlled trials supporting such an approach remain elusive, this is due to change in the next few years with current studies being performed. The use of extracorporeal blood purification therapies is a promising therapeutic strategy for critically ill ICU patients with high pathogen load refractory to conservative treatment or with elevated endotoxin levels.

Key messages: By targeting specific inflammatory mediators and pathogens, extracorporeal blood purification can help mitigate the severe inflammatory response associated with sepsis which should translate into improved patient survival. This approach may be particularly beneficial in cases where traditional treatments fail highlighting the need for further data to optimize the use of blood purification therapies in sepsis management.

Background: The recognition of syndromes has been a pillar of medical education and knowledge. However, treatment of syndromes is challenging because there is a disconnect between the underlying mechanisms that lead to organ injury and the clinical expression of this injury. This is an important barrier to identifying effective treatments in sepsis which may be resolved by the identification of sepsis endotypes.

Summary: In this review, we discuss the rationale for considering endotoxic septic shock as a true endotype; the mechanisms by which endotoxin induce cell and organ injury and dysfunction, the strategies to recognize when it occurs and the potential treatments, focusing on endotoxin removal through extracorporeal blood purification.

Key messages: There is sufficient preclinical and clinical evidence to support the notion that endotoxin is a relevant mechanism of injury in human sepsis that drives poor patient outcomes that can be identified using clinical criteria and biomarkers and that may respond to specific targeted therapies, strongly suggesting that endotoxemic septic shock is a bona fide endotype.

Background: Haemoadsorption (HA) is increasingly recognized as a valuable extracorporeal blood purification technique in paediatric intensive care. Although initially developed for adult patients, HA's application in paediatric critical care, particularly for conditions such as septic shock, liver failure, and rhabdomyolysis, has gained significant attention due to promising clinical outcomes.

Summary: HA has demonstrated efficacy in managing paediatric septic shock by reducing vasopressor requirements and lowering inflammatory markers. In liver failure, HA complements continuous renal replacement therapy (CRRT) by removing albumin-bound toxins and cytokines, mitigating systemic inflammation. Emerging evidence also supports HA as a rescue therapy in rare paediatric conditions like rhabdomyolysis and acute intoxications, preventing organ damage and reducing morbidity. Despite its benefits, HA in paediatrics presents technical challenges, including concerns over extracorporeal circuit volumes, vascular access, and anticoagulation. Paediatric-specific devices, such as the HA60, BS80, and PMX-05R, are addressing these limitations by offering lower priming volumes suitable for small children. Recent studies have highlighted improvements in haemodynamic stability, cytokine reduction, and organ function, reinforcing HA's potential as a critical adjuvant therapy. This review underscores the evolving landscape of HA in paediatric critical care, advocating for further research to optimize its application across diverse clinical scenarios.

Key messages: (1) HA shows significant promise in paediatric septic shock, liver failure, and rhabdomyolysis. (2) Technical advancements are expanding HAs applicability to neonates and small infants. (3) More multicentre studies are needed to establish HA's role in reducing mortality and improving quality of life post-PICU.

Introduction Sepsis and sepsis-associated acute kidney injury (AKI) are associated with increased patient morbidity and mortality. The immediate host response aimed at combating infection can become dysregulated, leading to uncontrolled inflammation and multi-organ failure, including AKI. Therapies targeting one protein component of the sepsis pathway have largely failed to improve patient outcomes, and currently only organ support therapies are used clinically to provide time for innate organ recovery to occur. The Selective Cytopheretic Device (SCD) is a continuous cell processing immunomodulatory device that attracts activated neutrophils and monocytes its biomimetic membrane surface. The activated leukocytes are transformed to a less pro-inflammatory phenotype and released back into the circulation when exposed to low ionized calcium concentration established in the SCD by standard regional citrate anticoagulation protocols used in continuous renal replacement therapy. Review In this review, we detail the history of the SCD and our experience with it, from discovery to pre-clinical testing to translational research application at the bedside. We discuss the SCD mechanism of action, its immunomodulatory effect, and the human studies involving critically ill adult pediatric patients with AKI who require continuous renal replacement therapy as part of the standard of care. We conclude discussing ongoing and future application of the SCD in both acute and chronic inflammatory states that would benefit from immunomodulation.

Background: There is growing interest in hemoadsorption (HA) therapies in critically ill patients although their precise indications remain to be established. Several devices are available on the market with heterogeneous properties and capabilities.

Summary: Due to the nonspecific removal associated with most HA techniques, concerns have been raised on their unintended removal of drugs such as anti-infectives in sepsis. On the other hand, drug removal might be beneficial in certain situations for instance antithrombotic medications in patients requiring emergency surgery or in case of accidental or self-induced intoxication. In this review, we summarize available in vitro, in vivo, and clinical studies reporting on the influence of various HA techniques on drugs pharmacokinetics.

Key message: We conclude that further studies should aim at providing drug dosing recommendations during HA and confirm its safety, efficacy, and practicalities when used for intoxications.

Background: Despite significant efforts to improve outcomes for patients with sepsis and septic shock, mortality rates remain alarmingly high.

Summary: Beyond standard management, novel adjuvant treatments seek to improve outcomes through a personalized approach. Among these, immunomodulation strategies aim to reestablish a balance in the dysregulated immune system, managing both pro-inflammatory and anti-inflammatory mediators. In recent years, various techniques utilizing extracorporeal circuits equipped with filters or cartridges, collectively referred to as blood purification therapies, have been developed and introduced to the market. Hemoadsorption, whether used alone or in conjunction with hemofiltration, may clear a broad range of substances from the blood, including inflammatory mediators, drugs, trace elements, bacteria, and viruses.

Key messages: Understanding the fundamental principles of blood purification techniques is essential for enhancing survival probabilities, keeping in mind the principle of primum non nocere as a guiding tenet of our daily practice. This review aimed to give an overview of hemoadsorption techniques by presenting current evidence and highlighting key areas that require further investigation.

Introduction: The air trap chamber used in continuous renal replacement therapy (CRRT) often causes clot formation due to gas interface, blood stasis and turbulent flow. The designs of this chamber vary widely. Few studies have quantitatively evaluated ex vivo quasi-blood stasis for different chamber types.

Methods: Flow retention characteristics at 20, 30, 40, 50, and 60 s in a top-feed chamber (where blood flow enters vertically from the top and passes through a mesh within the air trap chamber with a chamber 12 mL in volume) and a side-feed chamber (where blood flow enters from the side and bottom, without a mesh filter, with a flow deviator and 6 mL chamber volume) were evaluated using a 30% glycerin and iodine povidone-solution. Still images of the chambers at each time point were converted to 8-bit grayscale using Image J software (ver.1.54, Maryland, USA), with a brightness threshold in the range of 1-80 to compare the two chamber designs.

Results: Both chambers showed a decrease in the values of the highlighted areas over time; however, from 20 s, the side-feed chamber showed significantly lower values of the highlighted areas compared with the top-feed chamber. Similar to the findings at 20 s, significant differences in the values of the highlighted areas favored the side-feed chamber and persisted at 30, 40, 50, and 60 s. Furthermore, pseudo blood remained superficially in the top-feed chamber, while the side-feed chamber exhibited vortex flow, less stasis, turbulence, and stagnation.

Conclusion: The two chambers tested emptied of pseudo blood at different rates, with varying retention characteristics, with the side-feed chamber showing less pseudo-blood retention at all-time points assessed.

Introduction: Sepsis is a life-threatening condition characterized by dysregulated inflammatory responses, often leading to multiple organ dysfunction and high mortality rates. Continuous renal replacement therapy (CRRT) and extracorporeal blood purification therapies have emerged as vital adjuncts to manage fluid overload and modulate immune responses in septic shock. This study evaluates the impact of daily fluid balance variation on 90-day mortality and hospital length of stay in ICU patients undergoing CRRT for septic shock with endotoxin activity.

Methods: A post hoc analysis of the EUPHAS 2 project was conducted on 61 ICU patients with nonresponsive endotoxin shock at San Bortolo Hospital (2016-2021). Bayesian joint models assessed the relationship between fluid balance and mortality. Mediation analysis explored the impact of CRRT on mechanical ventilation duration and hospital stay.

Results: Fluid overload and excessive ultrafiltration were associated with prolonged mechanical ventilation and extended hospital stays. Targeted fluid balance management reduced 90-day mortality risk by 50%. CRRT reduced hospital length of stay directly by 5.31 days but indirectly extended it by 11.78 days due to mechanical ventilation. Optimal fluid balance was critical for minimizing mortality and complications.

Conclusions: Careful and tailored fluid management in CRRT is essential for improving survival rates and clinical outcomes in septic shock patients. Continuous monitoring of fluid dynamics is necessary to optimize hemodynamic stability and avoid complications. Future multicenter studies are needed to validate these findings and refine fluid management protocols.