ABSTRACT
Background: In critical patients with acute renal failure, intermittent diffusive renal replacement techniques cause hemodynamic problems due to their high depurative efficiency. This situation is avoided using continuous low efficiency therapies, which are expensive, prevent patient mobilization and add hemorrhagic risk due to systemic anticoagulation. Intermittent and prolonged hemodiafiltration (HDF) has the depurative benefits of diffusion, plus the positive attributes of convection in a less expensive therapy. Aim: To report our experience with intermittent and prolonged on-line HDF in critically ill patients. Patients and Methods: During 2016, HDF therapies performed on critical patients with indication of renal replacement therapy were characterized. The hemodynamic profile was evaluated (doses of noradrenaline, blood pressure, heart rate and perfusion parameters). Results: Fifty-one therapies were performed in 25 critical patients, aged 58 ± 11 years (28% women), with an APACHE II score of 22.1 ±10. The average time of the therapies was 4.15 hours (range 3-8 hours), the replacement volume was 75 ± 18 mL/kg/h and ultrafiltration rate was 226 ± 207 mL/h. The mean initial, maximum and final noradrenaline doses were 0.07 ± 0.1, 0.13 ±0.18 and 0.09 ±0.16 μg/kg/min respectively. No differences between patients with low, medium and high doses of noradrenaline or dose increases during therapy, were observed. The greatest decrease in mean arterial pressure was 15.3% and the maximum increase in heart rate was 12.8%. Anticoagulation was not required in 88% of therapies. Conclusions: High-volume intermittent or prolonged HDF is an effective therapy in critical patients, with good hemodynamic tolerability, lower costs and avoidance of systemic anticoagulation risks.
Subject(s)
Humans , Male , Female , Middle Aged , Aged , Critical Illness/therapy , Renal Replacement Therapy/methods , Hemodiafiltration/methods , Acute Kidney Injury/therapy , Norepinephrine/administration & dosage , Prospective Studies , Analysis of Variance , Treatment Outcome , APACHE , HemodynamicsABSTRACT
ABSTRACT Objective To investigate the impacts of continuous venovenous hemodiafiltration on the microcirculation in patients with acute kidney injury. Methods A prospective observational pilot study conducted in a 40-bed, open clinical-surgical intensive care unit of a private tertiary care hospital located in the city of São Paulo (SP), Brazil. Microcirculation was assessed using near-infrared spectroscopy by means of a 15mm probe placed over the thenar eminence. Vascular occlusion test was performed on the forearm to be submitted to near-infrared spectroscopy by inflation of a sphygmomanometer cuff to 30mmHg higher than the systolic arterial pressure. The primary endpoint was the assessment of near-infrared spectroscopy-derived parameters immediately before, 1, 4 and 24 hours after the initiation of continuous venovenous hemodiafiltration. Results Nine patients were included in this pilot study over a period of 2 months. Minimum tissue oxygen saturation measured during the vascular occlusion test was the only near-infrared spectroscopy-derived parameter to differed over the time (decrease compared to baseline values up to 24 hours after initiation of continuous venovenous hemodiafiltration). Conclusion The impacts of microcirculatory dysfunction on clinical outcomes of patients undergoing to continuous venovenous hemodiafiltration need to be further investigated.
RESUMO Objetivo Avaliar o impacto da hemodiafiltração venovenosa contínua na microcirculação de pacientes com lesão renal aguda. Métodos Estudo piloto, prospectivo e observacional conduzido em uma unidade de terapia intensiva clínico-cirúrgica aberta, com 40 leitos, localizada em um hospital terciário, privado, na cidade de São Paulo (SP), Brasil. A microcirculação foi avaliada empregando-se a espectroscopia no infravermelho próximo, por meio de uma sonda de 15mm posicionada sobre a eminência tenar. O teste de oclusão vascular foi realizado no antebraço a ser submetido à espectroscopia no infravermelho próximo, inflando-se o manguito de um esfigmomanômetro a um valor 30mmHg acima da pressão arterial sistólica. O desfecho primário foi a avaliação dos parâmetros derivados por espectroscopia no infravermelho próximo imediatamente antes, 1, 4 e 24 horas após o início da hemodiafiltração venovenosa contínua. Resultados Foram incluídos nove pacientes neste estudo piloto ao longo de 2 meses. A saturação de oxigênio tecidual mínima mensurada durante o teste de oclusão vascular foi o único parâmetro derivado por espectroscopia no infravermelho próximo que diferiu ao longo do tempo, com queda em relação aos valores iniciais nas primeiras 24 horas após o início da hemodiafiltração venovenosa contínua. Conclusão A influência da disfunção microcirculatória sobre os desfechos clínicos de pacientes submetidos à hemodiafiltração venovenosa contínua precisa ser melhor investigada.
Subject(s)
Humans , Male , Female , Hemodiafiltration/methods , Acute Kidney Injury/diagnostic imaging , Microcirculation/physiology , Pilot Projects , Prospective Studies , Spectroscopy, Near-Infrared , Acute Kidney Injury/physiopathology , Acute Kidney Injury/therapy , Middle AgedABSTRACT
RESUMO A hipercalcemia é um distúrbio metabólico raro em pediatria, potencialmente fatal, apresentando um vasto diagnóstico diferencial, incluindo neoplasias. Relatamos aqui o caso de uma criança de 3 anos, previamente saudável, admitida no serviço de urgência por fadiga, hiporreatividade, febre e claudicação da marcha com 5 dias de evolução, de agravamento progressivo. À observação, apresentava-se inconsciente (escore de coma Glasgow: 8). Laboratorialmente, apresentava hipercalcemia grave (cálcio total 21,39mg/dL, ionizado 2,93mmol/L) e anemia microcítica. Iniciou hiper-hidratação e foi transferido para a unidade de cuidados intensivos pediátricos. Instituiu-se hemodiafiltração venovenosa contínua com soluto livre de cálcio, ocorrendo a progressiva normalização da calcemia, com melhoria do estado de consciência. Administrou-se zolendronato. Excluíram-se causas metabólicas, infecciosas e intoxicação. O mielograma permitiu o diagnóstico de leucemia linfoblástica aguda. A hipercalcemia associada à malignidade em pediatria é rara, ocorrendo como forma de apresentação da neoplasia ou na recorrência desta. Em situações com risco de vida iminente, deve se considerar hemodiafiltração venovenosa contínua.
ABSTRACT Hypercalcemia is a rare metabolic disorder in children and is potentially fatal. It has a wide differential diagnosis, including cancer. Here, we report the case of a previously healthy 3-year-old who was admitted to the emergency room with fatigue, hyporeactivity, fever and limping gait that had evolved over 5 days and that was progressively worsening. On examination the patient was unconscious (Glasgow coma score: 8). Laboratory tests indicated severe hypercalcemia (total calcium 21.39mg/dL, ionized calcium 2.93mmol/L) and microcytic anemia. Hyperhydration was initiated, and the child was transferred to the pediatric intensive care unit. Continuous venovenous hemodiafiltration with calcium-free solution was instituted, which brought progressive normalization of serum calcium and an improved state of consciousness. Zoledronate was administered, and metabolic and infectious causes and poisoning were excluded. The bone marrow smear revealed a diagnosis of acute lymphoblastic leukemia. Hypercalcemia associated with malignancy in children is rare and occurs as a form of cancer presentation or recurrence. Continuous venovenous hemodiafiltration should be considered in situations where there is imminent risk to life.
Subject(s)
Humans , Male , Child, Preschool , Hemodiafiltration/methods , Williams Syndrome/etiology , Precursor Cell Lymphoblastic Leukemia-Lymphoma/diagnosis , Diphosphonates/therapeutic use , Bone Density Conservation Agents/therapeutic use , Precursor Cell Lymphoblastic Leukemia-Lymphoma/complications , Zoledronic Acid , Hypercalcemia/therapy , Imidazoles/therapeutic useABSTRACT
Introducción: La hemodiafiltración on line de alto volumen (HVHDF), ha demostrado mejorar los aclaramientos de medianas moléculas en los pacientes dializados a través de altos volúmenes de convección. El objetivo de este trabajo es valorar la eficacia de esta técnica en la depuración de la β2 microglobulina , comparando su concentración basal en pacientes hemodializados crónicos, con la del final del período analizado. Asimismo, se realizó al KDQOL-SF para valorar la calidad de vida de los pacientes participantes del estudio. Métodos: estudio de cohorte longitudinal de pacientes prevalentes en hemodiálisis de alto flujo - high flux- que pasaron a hemodiafiltración en línea de alto volumen. Se midió, entre otros, el clearance de β2 microglobulina y sus concentraciones a través del tiempo. Se utilizó paquete estadístico Stata 11. Resultados: El período de seguimiento total fue de 84 meses (promedio 23.4 ± 19 meses por paciente). Se realizaron 8978 tratamientos. Los niveles basales al ingreso a HVHDF de β2 fueron de 36,05 mg/l ± 10, y al final del período estudiado, fueron de 31,2 ±10 (p = 0,03). El clearance promedio de β2 fue de 71 ± 16 ml/min. Los niveles de β2 al inicio del estudio se asociaron con la antigûedad en diálisis de los pacientes (r 0,4 - p <0.02). Cinco años de permanencia en hemodiálisis convencional aumentan 11,2 mg/l los niveles de β2 micro globulina, y para obtener niveles por debajo de 30 mg/l en el 50% de nuestros pacientes, se requieren 5 años de High Volume HDF. Conclusión: Los valores de β2 microglobulina basal de los pacientes insuficientes renales crónicos en diálisis, tienen correlación con su antigûedad en hemodiálisis. Los niveles de β2 microglobulina séricas en estos pacientes, disminuyen lentamente y de forma progresiva con significación clínica, cuando la técnica indicada es la hemodiafiltración de alto volumen.
Background: On line high volume hemodiafiltration (HVHDF) has shown to improve the clearance of medium molecules in dialyzed patients through high volumes of convection. The objective of this work is to evaluate the effectiveness of this technique in β2 microglobulin depuration, comparing its basal concentration, in chronic hemodialyzed patients, with the final concentration of the analyzed period. Further more, the KDQOL-SF was performed in order to evaluate the quality of life of the patients who participated in the study. Methods: Longitudinal cohort study of prevalent patients in highflux hemodialysis who were changed to on line high volume hemodiafiltration. Among other, β2 microglobulin clearance and its concentrations changes over time were measured as indicators of efficiency and adequacy of treatment. A statistical package Stata 11 was used. Results: Total follow up period was of 84 months (average 23,4 ± 19 months per patient). 8978 treatments were performed. Basal levels of β2 were; 36.05 mg/l ± 10, when admitted and 31.2 ± 10 (p=0.03), at the end of the study. Clearance mean of β2 was of 71 ± 16ml/min. The levels of β2 at the beginning of the study were associated with elapsed time from the first dialysis of the patients (r 0.4 - p< 0,02). Five years of conventional hemodialysis increase 11.2 mg/l the levels of β2 seric microglobulin and to obtain levels below 30 mg/l in 50% of our patients, 5 years of High Volume HDF is required. Conclusion: Values of β2 basal microglobulin in patients with chronic renal failure undergoing dialysis, are related to the time spent under hemodialysis treatment. In these patients, levels of seric β2 microglobulin, decrease slowly and progressively and reach clinical significance when the technique is high volume hemodiafiltration.
Subject(s)
Humans , Male , Female , Renal Dialysis , Hemodiafiltration/methodsABSTRACT
Ultrafiltration failure in patients undergoing peritoneal dialysis is a condition with an incidence that increases over time. It is related to increased cardiovascular morbidity and mortality and is a major cause of the abandonment of the treatment technique. Because the number of patients undergoing renal replacement therapy is increasing with society aging and because approximately 10 percent of this population is treated with peritoneal dialysis, this matter is becoming more common in everyday practice for clinicians involved in the care of patients with chronic renal failure. In this review, we summarize the available measures used to prevent and treat ultrafiltration failure and the current state of research in the field, both in the experimental and clinical settings, focusing on the possible clinical applications of recent findings.
Subject(s)
Humans , Hemodiafiltration/adverse effects , Kidney Failure, Chronic/therapy , Peritoneal Dialysis/adverse effects , Hemodiafiltration/methods , Peritoneal Dialysis/methods , Treatment FailureABSTRACT
OBJECTIVE: To compare beta2-microglobulin (beta2M) clearance between on-line hemodiafiltration (HDF) and high flux hemodialysis (HFHD). MATERIAL AND METHOD: The total, convection/diffusion, and membrane adsorption components of beta2M clearance in 10 hemodialysis patients treated with on-line HDF at the replacement fluid rates of 75 (HDF75) and 125 (HDF125) mL/min, were determined and compared with HFHD. RESULTS: The total beta2M clearance in the HDF 125 group was significantly higher than the HDF75 group (124.5 +/- 4.4 vs 101.3 +/- 4.1 mL/min; p < 0.05); both values were much greater than the HFHD group (p < 0.01). The convection/diffusion was the major portion of total beta2M clearance in all three groups. The values of convection/diffusion and membrane adsorption in both HDF groups were about 2 and 3 times, respectively, of the HFHD group (p < 0.01). Both components of beta2M clearance in the HDF125 group did not statistically differ from the HDF75 group, however; the value of convection/diffusion clearance in HDF125 was more than in the HDF75 group. Regarding Kt/Vurea and phosphate clearance, there were no significant differences among the study groups. CONCLUSION: On-line HDF could provide more beta2M clearance than HFHD by increasing both the convection/ diffusion, and membrane adsorption clearances. HDF125 provided more total beta2M clearance than HDF75 from the convection/diffusion mechanism while the adsorptive mechanisms were equal.
Subject(s)
Analysis of Variance , Convection , Diffusion , Female , Hemodiafiltration/methods , Humans , Kidney Failure, Chronic/blood , Male , Middle Aged , Prospective Studies , Treatment Outcome , beta 2-Microglobulin/bloodABSTRACT
Antecedentes: La falla hepática es una causa importante de morbilidad y mortalidad en Unidades de Terapia Intensiva. Las terapias convencionales no son lo suficientemente efectivas. El trasplante hepático es el tratamiento definitivo para esta entidad, pero debido a la falta de donantes se hacía necesario desarrollar una "terapia puente" o de sostén de la vida hasta que aquél se realizara. La xenohemodiafiltración hepática extracorpórea pretende ser el soporte transitorio de un paciente con falla hepática fulminante. Objetivo: Presentamos el primer caso de xenohemodiafiltración hepática extracorpórea. Lugar de aplicación: Hospital Italiano de Buenos Aires. Diseño: Descripción del primer caso clínico de xenohemodialfiltración. Población: Mujer de 42 años portadora de falla hepática fulminante, con grave alteración de la coagulación, déficit de factor V y severa hipertensión intracraneana. Método: El sistema consiste en una circulación cruzada entre un hígado porcino y un paciente con falla hepática fulminante a través de una membrana de poliacrilonitril. Resultados: El procedimiento duró 5 horas y alcanzó mejoras hemodinámicas, bioquímicas y metabólicas. La presión intracraneana disminuyó de 34 a 5 cm H2O, el amoníaco sérico cayó de 673 a 370 ng/dl, ácido láctico de 11 a 5.3 mmol/L y la bilirrubina de 7.4 a 2.5 mg/dl. Los valores hemodinámicos se mantuvieron estables durante el procedimiento. La paciente pudo recibir el trasplante y continúa viva 11 meses después. Conclusiones: La xenohemodiafiltración hepática extracorpórea es un método clínico experimental que puede constituir una terapia clínica alternativa para soporte de pacientes con falla hepática fulminante hasta que se obtenga un órgano apto para trasplante.
Subject(s)
Humans , Female , Adult , Anesthesia, Local , Blood Coagulation Disorders/complications , Cross Circulation/methods , Life Support Care/methods , Factor V Deficiency , Hemodiafiltration/methods , Hepatic Insufficiency/etiology , Hepatic Insufficiency/physiopathology , Hepatic Insufficiency/mortality , Hepatic Insufficiency/therapy , Hepatic Insufficiency , Intracranial Hypertension , Perfusion , Liver Transplantation , Clinical Evolution , Complementary Therapies , Hemodynamics , Third-Party ConsentABSTRACT
Con la finalidad de evitar las obstrucciones del circuito extracorpóreo o la sobre-heparinización cuando se utiliza en pacientes el hemodiafilter, se diseñó un sistema de vigilancia de su funcionamiento basado en la colocación de 2 transductores de presión en el hemodiafilter (Diafilter-20S. Amicon), uno colocado en el circuito arterial (A) y otro en el venoso (V), cuantificándose continuamente estas presiones medias y obteniéndose sus diferencias, denominadas presión diferencial (D). Nuestros resultados evidencian que la presión óptima diferencial para el funcionamiento de hemodiafilter es de 45.292mmHg, manteniendose su margen de eficiencia entre 31.46 y 59.11mmHg
Subject(s)
Humans , Male , Female , Edema/therapy , Hemodiafiltration/methods , Hemodiafiltration , Kidney Diseases/therapy , Renal Insufficiency/therapy , VenezuelaABSTRACT
El artículo plantea las bases científicas y operativas de la técnica de Hemofiltración. Propone los aspectos destacados de la participación de enfermería en el monitoreo del procedimiento y la asistencia de enfermería al paciente