[Treatment of septic shock with the use of CPFA (associated plasma filtration and adsorption): impact on hemodynamics monitored with PiCCO ]. / Trattamento dello shock settico con l'impiego della CPFA (plasmafiltrazione e adsorbimento associate): impatto sull'emodinamica valutata con sistema PiCCO

BACKGROUND: Septic shock represents an emerging pathology and sepsis and its complications are the main cause of death in medical and surgical intensive care units. Single-target therapeutic trials failed to demonstrate any benefit, suggesting that the unselective removal of different mediators may be a more appropriate approach. METHODS: We evaluated a new technique (CPFA) combining a plasma-adsorption (with plasma filter and sorbent cartridge) with a traditional 'slow' extracorporeal treatment on 10 patients, 7 men and 3 women (mean age 53.8+/-16.3), all on mechanical ventilation, with septic shock and multiorgan failure. To identify easily comparable clinical data, the hemodynamic parameters of the patients were monitored with a recently developed, minimally invasive technology, Pulsion PiCCO . RESULTS: We obtained significant improvement of pre- versus post-treatment mean arterial pressure 77.2+/-12.5 vs. 83.3+/-14.1 mmHg (p<0.0001), cardiac index 4.03+/-0.89 vs. 3.46+/-0.82 L/m2/min (p<0.0001), indexed systemic vascular resistances 1388+/-496 vs. 1753+/-516 dynes x sec/cm5 (p<0.0001), PaO2/FiO2 ratio 204+/-87 vs. 232+/-81 (p<0.0001), and norepinephrine requirements 0.13+/-0.07 vs. 0 y/kg/min after a mean of 5.3+/-2.7 consecutive treatments. The survival at day 28 was 90%. Seven patients were discharged from the intensive care unit after a mean of 37.8+/-24 days (range 10-93). CONCLUSIONS: Our data suggest a promising role for CPFA in improving hemodynamics and correcting vasoparalysis in septic shock. Moreover, the noninvasive monitoring of hemodynamic parameters with PiCCO could become a useful tool for estimating the effect of treatment and gaining easily comparable data in different patients.

[Contrast nephropathy in cardiac procedures: no advantages with prophylactic use of N-acetylcysteine (NAC)]. / Nefropatia da contrasto in cardiologia interventistica: assenza di vantaggi con impiego profilattico di N-Acetilcisteina.

BACKGROUND: Acute renal failure induced by contrast agents represents the third cause of acute nephropathy in hospitalized patients. Some mediators are potentially involved in this process: recent data underscored the role of oxidising agents and prophylactic administration of NAC showed a lower incidence of acute renal damage after using contrast agents. METHODS: We analyzed 100 patients consecutively undergoing coronary angiography and/or transluminal angioplasty: the study group was given NAC orally at a dose of 600 mg twice daily, on the day before and on the day of administration of the contrast agent, together with hydration, while the control group was given only the hydration protocol with hypotonic saline. RESULTS: Twenty patients had baseline serum creatinine concentrations > 1.2 mg/dL (mild renal insufficiency group). The mean dose of contrast agent (Iodixanol; Visipaque 320, Nycomed) was 203 mL/procedure, with no statistical difference between groups. Among the patients with normal renal function, 5.7% in the NAC group and 8.8% in the control group had baseline serum creatinine concentrations above 0.3 mg/dL after 48 hours (p=NS). In patients with mild renal failure, 16.6% in the NAC group and 0% in the control group had serum creatinine concentrations > 0.5 mg/dL at 48 h (p=NS). We found no significant differences in serum creatinine values at 48 hours vs. baseline in anyone (NAC group with normal renal function or mild renal insufficiency, control group with normal renal function or mild renal insufficiency). Similarly, serum creatinine values at either baseline or after 48 hours were not significantly different in patients with normal renal function (NAC vs. control group) and with mild renal failure. CONCLUSIONS: Our study showed no potential advantage in the prevention of acute nephropathy, induced by high volumes of contrast agent, through the administration of NAC in patients with normal renal function and mild renal failure. However, the NAC dose used in our study might not be sufficient in balancing the contrast agent volume employed in these procedures.

[Organohalogen contamination of a dialysis-water treatment plant]. / Contaminazione da organo-alogenati di un impianto di trattamento di acqua per dialisi.

On March 2001 the regular quality control test of the water used for dialysis in an urban centre using a reverse osmosis system revealed a high level of organo-halogenated contamination. The compounds implicated were: trichloroethylene (trielene) [M.Wt. 131 D], tetrachloroethylene, trichloromethane (chloroform) [M.Wt. 121 D], chlorodibromomethane. The dialysis unit was closed. Water samples were analysed in duplicate. The table shows the values (in ppm or microgram/l) obtained for chloroform at the given times: March 8th, altered sample; March 12th, confirmation sample; March 16th, after osmosis membranes change; March 22nd, after carbon filtration replacement; March 26th, after softener resins substitution. The AAMI doesn't recommend any value for organo-halogenated compounds in dialysis water. In the past, the European Pharmacopoeia and the Italian Health Ministry released some reference values for tap water, values which were extended to water used for dialysis. The values are 1 ppm as reference value, 30 ppm as maximum accepted value for the sum of all organo-halogenated compounds, and 10 ppm as the recommended value. In conclusion, the problem was solved by progressive replacement of the components of the water treatment system, even though the real cause remained undetermined. No clinical symptom was recorded and no level of chloroform or trielene was detected in patients' sera despite the low molecular weight and low protein binding of the compounds. A strict control of the water quality and a more comprehensive and updated reference guide are needed for better and safer dialysis delivery.

[Microbiological evaluation of two different disinfection protocols of a new hemodialysis monitor with an ultrafilter]. / Valutazione microbiologica di due diversi protocolli di disinfezione di un nuovo monitor di dialisi dotato di ultrafiltro sul dialisato.

BACKGROUND: Hemodialysis monitors represent a frequent site for bacterial contamination. METHODS: Two different disinfection protocols on a new device (Formula(R), Bellco) have been compared: only chemical or chemical plus heat disinfection by means of CFU, and LAL test. The endotoxin removing capacity of ultrafilter was tested with varying lipopolysaccharide concentrations. RESULTS: Similar results were obtained with heat disinfection compared to chemical disinfection (CFU and LAL test). The LAL test (chromogenic and gel-clot) showed that the ultrafilter performance decreased with use and was significant after 200 operating hours. CONCLUSIONS: Heat disinfection between dialysis shifts and chemical disinfection at the end of the day exclude bacterial contamination of the monitor as well as chemical disinfection; LAL test is a useful and simple tool to assess the ultrafilters performance in each Center.

Dialock(R)subcutaneous port for hemodialysis: A twelve-month experience in a single center.

Background.The arteriovenous fistula (AVF) is still considered the golden standard form of vascular access for hemodialysis. However, the increasing use of central venous catheters mirrors the growing difficulty in planning an AVF. A totally implantable new device, the Dialock(R)system (Biolink Corporation, Norwell, MA), allowed us to conduct the first Italian experience. Methods.From February 1st 2000 to January 31st 2001, we implanted 21 devices in 12 males and 9 females, median age 66+/-12 years, with a dialysis duration ranging from 0 to 22 years. In 6 cases the Dialock (R)was first choice access, in 5 it replaced a malfunctioning tunneled central venous catheter, and in 10 cases it was the rescue access after previous AVF failures. Results.On average, the device was accessed 3.5 days after implantation. Median duration of use was 142 days (range 29-365), for a global observation period of 118.2 pt-months. Nineteen devices are currently working with-out any problem. One port was removed after 60 days due to thrombosis, and another after 9 months of use due to sepsis. Another patient had a systemic infection with cardiac and vertebral involvement with complete remission after 4 months of antibiotic therapy and salvage of the device. The infection rate was 1.3 per 1000 catheter-days. Prescribed blood flow was achieved in 95.7% of the sessions. Conclusion.Our short-term results confirm the efficacy and reliability of the new device. In order to assess the true indication for implanting Dialock(R), a more prolonged observation period is needed.

Is vecuronium toxicity abolished by hemodialysis? A case report.

Vecuronium is a curaric agent, largely used in anesthesia. Indications as to its employ in uremic patients appear to be debated because of partial renal elimination of the drug. A 52-year-old hemodialyzed woman required transplantectomy for rejection. At awakeness after general anesthesia (induced with fentanyl, propofol, and 6 mg of vecuronium, repeated with a single 2 mg dose 30 min later), she presented diafragmatic and muscular limb weakeness that lasted 180 min in spite of prostigmine administration. A 2 h 30 min predilutional hemofiltration was then performed, which induced rapid disappearance of neuromuscular blockade. Even if vecuronium can be used in dialysis patients, one should remember its possible side effects, especially with repeated doses, in determining prolonged neuromuscular blockade. Cautious use of this drug in renal failure is mandatory. Low dosage must be employed and repeated administration avoided. Neuromuscular blockade seems to be rapidly reversible with dialytic treatment.

[Evaluation of urea recirculation and dialysis efficiency of central venous jugular catheters when the venous lumen is used as an arterial lumen]. / Valutazione del ricircolo dell'urea ed efficacia dialitica del catetere giugulare venoso centrale quando il lume venoso è utilizzato come lume arterioso.

BACKGROUND: The dual lumen internal jugular venous catheter has proven to be the most useful temporary vascular access for hemodialysis. According to this evidence it was decided to evaluate urea recirculation rate during hemodialysis performed by dual lumen internal jugular catheter (IJC) under normal condition (R1) and when the arterial lumen of the catheter is used as venous lumen, and the venous lumen as arterial lumen (R2). METHODS: In 71 patients who underwent hemodialysis using a dual lumen IJC, urea recirculation rate was measured during a conventional bicarbonate hemodialysis, under normal condition R1 and during the experimental condition R2. RESULTS: Urea recirculation rate < 5% was achieved for almost all patients under normal condition R1. In the different condition R2, urea recirculation rate increased in all patients, from an average value of 3.7 +/- 1.7 to 5.1 +/- 1.8 p < 0.0001. This increment was expected ut surprisingly low. CONCLUSIONS: In conclusion during hemodialysis with dual lumen IJC efficient treatment can be provided in normal condition and also when the venous lumen is used as arterial lumen.

[Critical review of renal transplantation data from the Piedmontese Regional Dialysis and Transplantation Registry]. / Revisione critica dei dati riguardanti il trapianto renale nel Registro Regionale Piemontese di Dialisi e Trapianto (RPDT).

On 31/12/1995 a total of 1,128 Piedmontese uremic patients had undergone kidney transplantation, with 65% of operations performed by the Regional Reference Centre and 35% by extra-regional centres. Waiting time for dialysis was less than 5 years in over half of the patients most of whom were aged between 40 and 60 years old. In overall terms, the patient survival rate was 94%, 87%, 75% at 24, 60, 120 months respectively, with a statistically significant improvement when the curve was evaluated in the patient-pool treated with cyclosporine (84% versus 87% at 7 years). Organ survival was 76% at 21 years and 42% at 10 years, and results were again improved by the use of cyclosporine. Pathologies affecting the transplanted organ represent the main cause of morbidity; drop-out during dialysis is caused above all by immunological diseases. Infectious pathologies were responsible for the majority of deaths in this population.

[Glomerulonephritis in the elderly]. / Le glomerulonefriti nell'anziano.

The authors present a clinical analysis of the literature data regarding aged patients affected with glomerulonephritis (GN) and of 115 GN patients aged more than 65 years, biopsied in their own Center. Complications of renal biopsy, including the subclinical ones, were found in 19.1% of old patients compared to 19.2% of younger patients (p = NS), major complications in 5 and 1.4% respectively (p = NS). The most frequent GN was membranous GN (MGN) (27.8%), followed by IgA-GN (12%) and rapidly progressive GN (RPGN), idiopathic (8.6%) or secondary to vasculitis (8.6%). Eighteen out of 32 old MGN patients treated with alternated courses of steroids and immunosuppressive drugs for 6 months were compared to 32 MGN patients aged < 65 years identically treated. Complete remission was observed in 27.7% of cases and partial remission in 38.8% (p = NS). Complications of treatment were similar in the two groups of patients (p = NS). Patients with RPGN were treated with steroids (17 patients) plus immunosuppressive drugs (15 patients) and plasma exchange (13 patients). Systemic symptoms disappeared in 13/14 patients; ANCA became negative in all the 5 patients in whom they were detected; a 50% reduction of serum creatinine was obtained in 12 patients. These patients were compared to a control group of 26 patients aged < 65 years. Amelioration of renal function was evidenced more frequently among old patients with vasculitis (p < 0.05). Complications of treatment were more frequent among old patients with idiopathic RPGN (p < 0.05), but severe in only 1 case. Our data and data from the literature support the opportunity to perform renal biopsy in aged people, because it is as safe as in the younger population and allows a rational basis for treatment of GN. Clinical responses are similar to those of younger patients. Complications of treatment seem to be more frequent in old patients, but can be limited by some technical precautions and careful clinical monitorization.