Blood Purification最新文献

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: We report an Intervention/outcome study of 33 severe COVID-19 subjects who received Seraph 100 Microbind Affinity Blood Filter (Seraph 100) hemoperfusion therapy (15 survivors, 18 non-survivors) under emergency authorization from the FDA. Our objective was to determine if Seraph 100 hemoperfusion reduces SARS-CoV-2 RNA titers and/or markers of inflammation and/or epi/endothelial damage.

Methods: Viral RNA and 78 protein analytes related to endothelial/epithelial damage and/or inflammation were quantified in systemic blood samples from 33 severe COVID-19 subjects collected upon intensive care unit (ICU) admission and then immediately before and after blood passed through the heparin-based Seraph 100 filter at two time points on the first day of hemoperfusion. Viral RNA titers were quantified using droplet digital PCR. Protein analytes were quantified using multiplex/multi-analyte panels on MesoScale Discovery and ProteinSimple Ella platforms.

Results: A total of 15/33 subjects had detectable viral RNA in baseline samples (shortly after ICU admission). These initial viremia levels were low, and they did not change uniformly post-perfusion. Five of 55 protein analytes that were upregulated 1.4-120X at ICU admission relative to healthy controls showed significant decreases across the filter during the indicated time points on the first day of hemoperfusion: IP-10/CXCL10, fms-like tyrosine kinase 1, MIG/CXCL9, hepatocyte growth factor (HGF), and receptor for advanced glycosylation end products (RAGE). Paired t tests identified 25 additional analytes that showed significant decreases (p < 0.05) only without Bonferroni correction.

Conclusion: Initial freely circulating SARS-CoV-2 RNA levels of ICU-admitted subjects were low or undetectable. The Seraph 100 filter did not significantly reduce viral RNA titers in their plasma. However, multiple circulating proteins with roles in inflammation, endothelial/epithelial damage, and/or angiogenesis decreased significantly across the filter. Larger prospective trials will be required to determine if such transient reductions translate into improved patient outcomes. However, this study did not demonstrate a direct reduction of free SARS-CoV-2 viral RNA by the Seraph 100.

Introduction: The improvement of waste management constitutes a critical component of green nephrology initiatives. Hemodialysis circuits represent a substantial proportion of medical waste generated in dialysis units, yet standardized industry protocols for optimizing the disposal of discarded hemodialysis circuits remain underdeveloped. This study aimed to validate the effectiveness of Quality Control Circle (QCC) methodology in reducing the total mass of discarded hemodialysis circuits.

Methods: A multidisciplinary QCC task force was established with the explicitly defined objective: "reduce residual fluid volume in discarded hemodialysis circuits." The QCC methodology was systematically implemented to drive process improvements. Residual fluid mass from decommissioned hemodialysis circuits served as the primary quality metric, with comparative analyses conducted pre- and post-intervention.

Results: Implementation of QCC interventions resulted in a 29.7% reduction in mean circuit mass, decreasing from 0.64 ± 0.015 kg to 0.45 ± 0.012 kg (p < 0.01) across the sampled hemodialysis apparatus.

Conclusion: The implementation of QCC activities has significantly reduced residual waste from hemodialysis circuits, leading to environmental conservation and lower waste disposal costs. QCC serves as an effective management tool for hemodialysis units to promote the concept of green nephrology.

Introduction: Continuous renal replacement therapy (CRRT) is one of the most critical interventions in the intensive care unit, and anticoagulation is essential to ensure its efficacy. Regional citrate anticoagulation (RCA) has been widely adopted in clinical practice due to its reduced risk of bleeding complications. However, the suitability of RCA for CRRT in patients with hyperlactatemia remains controversial.

Methods: This study aimed to evaluate the efficacy and safety of different anticoagulation strategies (heparin systemic anticoagulation, RCA, and no anticoagulation) during CRRT in critically ill patients with hyperlactatemia. Using a retrospective cohort design, we analyzed clinical data from the MIMIC-IV v3.0 database, employing propensity score matching and multivariable Cox regression models to adjust for confounding factors.

Results: Our findings demonstrated that compared to the no-anticoagulation group, the citrate group exhibited significantly lower 28-day, 60-day, and 90-day mortality risks, with hazard ratios (HRs) of 0.623, 0.650, and 0.657, respectively. In contrast, the heparin group showed a significant reduction only in 28-day mortality risk (HR = 0.625). These results were further validated in the matched cohort, indicating that RCA significantly improves clinical outcomes and reduces mortality in hyperlactatemia patients requiring CRRT.

Conclusion: In summary, our study indicates that citrate anticoagulation significantly improves the prognosis of CRRT in patients with hyperlactatemia, suggesting its potential as a preferred anticoagulation strategy in this clinical setting.

Introduction: For patients requiring renal replacement therapy, peritoneal dialysis (PD) offers an alternative to maintain quality of life. The long-term success of PD depends on using a safe, functional, and durable peritoneal catheter (PC). This study aimed to assess the outcomes of a training program for nephrologists on PD catheter insertion in South American dialysis centers.

Methods: This longitudinal, retrospective, multicenter study was conducted in Colombia, Chile, Ecuador, and Bolivia. Patients who underwent PC insertion between January 2022 and May 2023 were included, with procedures performed by nephrologists trained in a specialized program. Data on population characteristics, procedural details, and catheter function at the first, third, and sixth months were collected.

Results: A total of 117 subjects were included (median age 59 years, 50.4% men). Hypertension and diabetes were the primary causes of kidney disease (34.19% and 49.57%, respectively). Bladder emptying and prophylactic antibiotics were administered before the procedure. Most PC insertions (86.32%) were performed under local anesthesia, with the modified Seldinger technique. Catheter implantation was successful in 96.58% of cases. Elective PD was performed in 69.91% of patients, while 30.01% required urgent PD. Within the first 2 weeks, complications occurred in 7.08% of patients, including catheter tip migration and flow failure. At one, three, and 6 months of follow-up, complications were observed in 1.79%, 3.77%, and 11.00% of patients, respectively. Catheter patency was maintained in 99.10%, 96.22%, and 96.00% of patients at 1, 3, and 6 months, respectively.

Conclusions: Optimal peritoneal access can be achieved through educational programs for nephrologists on catheter insertion, ensuring proper placement and maintenance, and resulting in low complication rates in PD patients.

Introduction: All dialysis modalities can potentially improve physical activity levels and patient well-being, primarily through better toxin clearance. We sought to assess the impact of medium cut-off hemodialysis (MCO-HD), high-flux hemodialysis (HF-HD), and high-flux hemodiafiltration (HF-HDF) on quantitative physical performance measures, which are prognostic for quality of life and mortality risk.

Methods: Ten maintenance hemodialysis patients received MCO-HD, HF-HD, and HF-HDF, each for a duration of 6 months. Outcomes encompassed alterations in physical activity levels, assessed with the International Physical Activity Questionnaire, and physical performance, evaluated through the 5-times sit-to-stand, 4-meter gait speed, grip strength tests, and bioelectrical impedance analysis.

Results: The cohort comprised 7 men and 3 women with a median dialysis vintage of 96 months (IQR: 36). Dialysis adequacy (single-pool KtV ≥1.2) was attained across all modalities for 18 months, with no notable alterations in nutritional and inflammation markers, including serum albumin. Self-reported physical activity improved during MCO-HD (total MET min/week 234.5 [IQR: 1,188] vs. 1,229.5 [IQR: 1,683], p = 0.019). There were no significant changes in handgrip strength, gait speed, or muscle mass in either group, nor were there any notable differences between the groups. The 5-times sit-to-stand test has shown stability in the MCO-HD group, whereas a substantial enhancement over 6 months observed with the HF-HDF (12.34 [IQR: 3.88] vs. 10.18 [IQR: 3.14] seconds, p = 0.022]).

Conclusion: The MCO-HD group reported elevated physical activity levels, while the HF-HDF group demonstrated considerable enhancement in low extremity strength. The patient-centered selection of dialysis modality, including the implementation of exercises and nutritional interventions, may improve physical performance and patient outcomes.

Introduction: Current evidence indicates that for patients requiring renal replacement therapy, USPD may correlate with reduced complications and lower mortality rates compared to USHD. However, there is a lack of literature specifically addressing its application and results in individuals with ESRD. A comprehensive examination and synthesis of existing research were conducted to compare fellow-up outcomes of USPD versus USHD in ESRD patients.

Methods: A comprehensive search was conducted in PubMed, Web of Science, and the Cochrane Library, and SpringerLink databases for that compare USPD to USHD before November 1, 2024. Mortality, all complications, noninfectious complications, infectious complications, bacteremia, and peritonitis were used as outcomes to compare USPD and USHD.

Results: This meta-analysis incorporated seven studies involving a total of 1,338 patients. Our findings showed no notable distinctions in peritonitis between USPD and USHD. urgent-start PD was linked to a reduced mortality rate "(OR: 0.48, 95% CI: 0.24-0.95, p < 0.05), lower all complications (OR: 0.27, 95% CI: 0.20-0.37, p < 0.05), lower noninfectious complications (OR: 0.32, 95% CI: 0.23-0.45, p < 0.05), lower infectious complications (OR: 0.29, 95% CI: 0.17-0.51, p < 0.05), lower bacteremia (OR: 0.18, 95% CI: 0.07-0.42, p < 0.05)" compared to USHD.

Conclusions: Our findings indicate that among patients with ESRD, those undergoing urgent-start PD have lower risks during the follow-up period compared to those receiving USHD. USPD is associated with significantly reduced all-cause mortality, overall complications, infectious complications, noninfectious complications, and bacteremia incidence. The results indicate that USPD could potentially function as an appropriate replacement for USHD. However, further high-quality clinical studies still are necessary to substantiate this conclusion.

Introduction: Septic shock (SS) is defined as sepsis-induced hypotension persisting despite adequate fluid resuscitation. Modified double filtration plasmapheresis (M-DFPP) is a promising therapeutic approach designed to selectively remove small-to-medium molecular weight inflammatory mediators while preserving essential plasma proteins, potentially restoring immune balance and stabilizing hemodynamics in patients with SS.

Methods: Eligible patients diagnosed with SS will be enrolled in this randomized controlled trial. Inclusion criteria include completion of early goal-directed therapy resuscitation standards within 12 h following admission to the intensive care unit and norepinephrine administration exceeding 0.5 µg/min/kg. The intervention group will receive treatment using the M-DFPP multivariate model. The primary endpoint is all-cause mortality at 28 days. Secondary endpoints will assess the efficacy of M-DFPP in reducing inflammatory mediators, evaluate changes in vasoactive drug requirements on the third day post-enrollment, and quantify improvement in organ dysfunction.

Conclusion: Validation through well-designed, large-scale randomized controlled trials is required to clarify the optimal patient selection criteria, treatment timing, frequency, and standardized protocols for M-DFPP. This is an experimental protocol of a randomized, open-label, multicenter, parallel-controlled trial aiming to evaluate whether M-DFPP can improve survival rates in patients with SS.