Successful Application of a Hemoperfusion Machine in Separated System CRRT: Evaluating Effectiveness and Safety in Critically Ill Patients With AKI in Resource-Limited Settings.

BACKGROUND: It is imperative to note that integrated system continuous renal replacement therapy (CRRT) necessitates a sophisticated and costly apparatus, potentially limiting its availability within resource-limited settings. The introduction of a separated system for continuous veno-venous hemofiltration (CVVH), characterized by uncomplicated setup procedures with a hemoperfusion machine, holds promise as a feasible alternative to CRRT for critically ill patients with acute kidney injury (AKI). METHODS: We aimed to retrospectively analyze the effectiveness and safety of separated CRRT applied from a hemoperfusion machine in critically ill patients with AKI during the January 2015 to December 2021 period. We also examine the in-hospital mortality rate and multivariate logistic regression analysis to uncover the factors that affect mortality. RESULTS: We included a total of 129 critically ill patients who received separated system CRRT. The SOFA score at CRRT initiation was 12.6 ± 3.8. The fluid accumulation at the day of CRRT initiation was 3900 mL (622-8172 mL) All patients received pre- and postdilution CVVH. The mean prescribed CRRT dose was 22.4 ± 3.1 mL/kg/h. We found no serious complications including circuit explosion and air embolism. The in-hospital mortality rate was 68.9%. High SOFA score and positive fluid accumulation at CRRT initiation serve as predictors of survival. CONCLUSIONS: Separated system CRRT using a hemoperfusion machine provides a simplified system to operate and is proven to be effective and safe in real-life practice, especially in resource-limited areas.

Comparison of different intensive triglyceride-lowering therapies in patients with hyperlipidemic acute pancreatitis.

OBJECTIVES: The goal of this study was to investigate the clinical value of emergent triglyceride (TG)-lowering therapies for hyperlipidemic acute pancreatitis (HLAP). METHODS: 126 HLAP patients were assigned randomly to receive either conventional treatment (CT), normal saline (NS) alone, or continuous veno-venous hemofiltration (CVVH) as an intensive TG-lowering therapy. TG levels, clinical outcomes, and inflammatory biomarkers were compared among the three groups. RESULTS: Baseline characteristics did not differ significantly among the groups. CVVH removed TG from the plasma and achieved its target TG (<500 mg/dL) in approximately 25 h, compared to 40 h in the NS alone group and no targeted effect within 48 h in the CT group (P < 0.05). Although the majority of clinical outcomes did not differ significantly, an unexpectedly higher incidence of organ failure occurred in the CVVH group compared to the others. Hospital costs, severe AP patients and length of stay were significantly higher in the CVVH group compared to the other groups (P < 0.005). CONCLUSIONS: Early CVVH lowers TG levels more efficiently than NS alone or CT therapy, but is not superior in terms of clinical outcomes and costs. NS also lowers TG levels and is significantly less costly than the other two treatments. Further multicenter studies are needed to determine the feasibility of NS alone treatment for HLAP patients.

[Clinical application of plasma exchange combined with continuous veno-venous hemofiltration dialysis in children with refractory Kawasaki disease shock syndrome]. / 血浆置换联合连续性静脉-é™è„‰è¡€æ¶²æ»¤è¿‡é€æžæ²»ç–—åœ¨å„¿ç«¥å·å´Žç— ä¼‘å ‹ç»¼åˆå¾ä¸­çš„ä¸´åºŠåº”ç”¨.

OBJECTIVES: To study the role of plasma exchange combined with continuous blood purification in the treatment of refractory Kawasaki disease shock syndrome (KDSS). METHODS: A total of 35 children with KDSS who were hospitalized in the Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, from January 2019 to August 2022 were included as subjects. According to whether plasma exchange combined with continuous veno-venous hemofiltration dialysis was performed, they were divided into a purification group with 12 patients and a conventional group with 23 patients. The two groups were compared in terms of clinical data, laboratory markers, and prognosis. RESULTS: Compared with the conventional group, the purification group had significantly shorter time to recovery from shock and length of hospital stay in the pediatric intensive care unit, as well as a significantly lower number of organs involved during the course of the disease (P<0.05). After treatment, the purification group had significant reductions in the levels of interleukin-6, tumor necrosis factor-α, heparin-binding protein, and brain natriuretic peptide (P<0.05), while the conventional group had significant increases in these indices after treatment (P<0.05). After treatment, the children in the purification group tended to have reductions in stroke volume variation, thoracic fluid content, and systemic vascular resistance and an increase in cardiac output over the time of treatment. CONCLUSIONS: Plasma exchange combined with continuous veno-venous hemofiltration dialysis for the treatment of KDSS can alleviate inflammation, maintain fluid balance inside and outside blood vessels, and shorten the course of disease, the duration of shock and the length of hospital stay in the pediatric intensive care unit.

Extracorporeal blood purification benefits in post-caesarean patient with severe acute respiratory distress syndrome due to miliary tuberculosis: a case report.

BACKGROUND: Miliary tuberculosis is a life-threatening disease caused by the hematogenous spread of Mycobacterium tuberculosis. It is uncommon in pregnancy. Mortality rates for patients with miliary tuberculosis who require mechanical ventilation are high (60-70%). CASE PRESENTATION: We reported a rare and challenging case, a 35-year-old Asian woman with 34 weeks of pregnancy, and miliary tuberculosis with acute respiratory distress syndrome and septic shock. The patient presented with severe acute respiratory distress syndrome, necessitating mechanical ventilation, vasopressor, and pregnancy termination with caesarean section. The patient underwent blood purification with continuous veno-venous hemofiltration using an oXiris filter for 24 hours. After continuous veno-venous hemofiltration, the patient's condition was greatly improved, and the patient was successfully extubated and was able to breathe spontaneously without vasopressor on the third day. High levels of interleukin-6, interleukin-10, procalcitonin, C-reactive protein, interferon-γ, and tumor necrosis factor-α were found postoperatively. CONCLUSION: The bacterial infection of tuberculosis, acute respiratory distress syndrome, and the stress response from the caesarean section contributed to the high levels of cytokines, which correlated with the patient's severe inflammatory condition. The cytokine levels were greatly reduced after the blood purification procedure and this might be associated with the patient's clinical improvement. Extracorporeal blood purification could help to disrupt the vicious cycle of inflammation.

Clinical effects of continuous veno-venous hemofiltration combined with hemoperfusion for the treatment of multiple myeloma complicated with acute kidney injury.

Objective: To evaluate the clinical efficacy of continuous veno-venous hemofiltration (CVVH) combined with hemoperfusion for the treatment of multiple myeloma (MM) complicated with acute kidney injury (AKI). Methods: Medical records of 73 patients with MM complicated with AKI admitted to the First People's Hospital of Huzhou from January 2019 to January 2021 were retrospectively analyzed. According to the treatment records, 35 patients received simple chemotherapy (control group), and 38 patients received CVVH combined with HP on the basis of chemotherapy (observation group). We compared the clinical efficacies, renal function indexes, and the serum globulin and erythrocyte sedimentation rate (ESR) values between the two groups. Results: After the treatment, the total efficacy of the observation group was significantly higher (81.58%) than that in the control group (57.14%; p <0.05). Serum cystatin C (CysC), urea nitrogen (BUN), ß2 macroglobulin (ß2-MG) and creatinine (SCr) levels were significantly lower in the observation group than in the control group (p <0.05). Serum globulin level and ESR values in the observation group after the treatment were also significantly lower than in the control group (p <0.05). Conclusions: The outcomes of patients with MM complicated with AKI treated with CVVH and hemoperfusion differ significantly from those of the patients treated only with CVVH. Combining CVVH and hemoperfusion helps to improve the efficacy of the treatment, promotes renal function recovery, and improves the levels of serum globulin and ESR.

Hemoperfusion for Clinically Suspected Organophosphate and Carbamate Poisoning in Critically Ill Patients: A Randomized Trial.

INTRODUCTION: Organophosphate poisoning occurs frequently, and despite treatment, increased severity and intensive care unit (ICU) admissions have been observed. We hypothesized that early hemoperfusion/hemadsorption (HA) therapy would change the clinical course of the disease. METHODS: We performed a prospective, open, randomized controlled study at an academic ICU. Adult patients referred for an acute cholinergic toxidrome were screened. Patients meeting inclusion and exclusion criteria were randomized to standard of care (SoC) or HA therapy plus SoC, which included 2 6-h cycles of HA 12 h apart beginning within the first 24 h of ICU admission. The primary outcome was a comparison of ICU length of stay (LOS). RESULTS: There were no significant baseline differences between the groups. The median ICU LOS was 6.5 days (IQR 4.5-10) in the HA group compared to 8 days (IQR 3.5-17) for the control group, p = 0.58. Among patients with an excess ICU LOS ≥7 days, the median ICU LOS was significantly shorter for the HA group, 10 days (IQR 8-12) compared to 17 days (IQR 14-22) for the control group, p = 0.001, resulting in a cost saving of EUR 7308 per patient. Duration (8 days vs. 13.5 days) and cumulative dosage (316 mg vs. 887 mg) of atropine among patients with excess ICU LOS were significantly lower in the HA group compared to the SoC group, respectively. A similar reduction in the duration of mechanical ventilation (HA = 6 days vs. SoC = 15 days, p = 0.001) was found. The combination of day 28 mortality and severe complications was lower in the HA group (10%, n = 2/20) compared to the SoC group (42%, 14/33) p = 0.01. CONCLUSION: HA therapy resulted in significant cost savings driven by a reduced LOS among patients with excess ICU LOS ≥7 days. This therapy was also associated with a significant reduction in the combination of day 28 mortality and severe complications including cardiac arrest, organ dysfunction, reintubation, and tracheostomy.

Clinical application of plasma exchange combined with continuous veno-venous hemofiltration dialysis in children with refractory Kawasaki disease shock syndrome / 中国当代儿科杂志

OBJECTIVES@#To study the role of plasma exchange combined with continuous blood purification in the treatment of refractory Kawasaki disease shock syndrome (KDSS).@*METHODS@#A total of 35 children with KDSS who were hospitalized in the Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, from January 2019 to August 2022 were included as subjects. According to whether plasma exchange combined with continuous veno-venous hemofiltration dialysis was performed, they were divided into a purification group with 12 patients and a conventional group with 23 patients. The two groups were compared in terms of clinical data, laboratory markers, and prognosis.@*RESULTS@#Compared with the conventional group, the purification group had significantly shorter time to recovery from shock and length of hospital stay in the pediatric intensive care unit, as well as a significantly lower number of organs involved during the course of the disease (P<0.05). After treatment, the purification group had significant reductions in the levels of interleukin-6, tumor necrosis factor-α, heparin-binding protein, and brain natriuretic peptide (P<0.05), while the conventional group had significant increases in these indices after treatment (P<0.05). After treatment, the children in the purification group tended to have reductions in stroke volume variation, thoracic fluid content, and systemic vascular resistance and an increase in cardiac output over the time of treatment.@*CONCLUSIONS@#Plasma exchange combined with continuous veno-venous hemofiltration dialysis for the treatment of KDSS can alleviate inflammation, maintain fluid balance inside and outside blood vessels, and shorten the course of disease, the duration of shock and the length of hospital stay in the pediatric intensive care unit.

Micronutrient deficiencies in critically ill patients receiving continuous renal replacement therapy.

BACKGROUND & AIMS: Continuous renal replacement therapy (CRRT) is essential to the management of acute kidney injury (AKI) in critical illness. Unfortunately, large quantities of micronutrients are shown to be lost in CRRT effluent. Current literature describes serum micronutrient values in CRRT patients to be below-reference range, yet seldom compares such values to other critically ill populations unexposed to CRRT. The aim of this study was to describe and compare the prevalence of micronutrient and carnitine deficiencies in critically ill patients at high malnutrition risk exposed to CRRT to a group of patient unexposed to CRRT. METHODS: A retrospective chart review was conducted at Duke University Hospital using the electronic medical record. The study group consisted of patients at high malnutrition risk requiring intensive care unit (ICU) admission from 01/01/2017-12/31/2018 with one or more of the following serum micronutrient levels checked: carnitine, copper, zinc, selenium, and vitamins B1, B6, B9, and C. Micronutrient deficiencies were defined as below the reference range and carnitine deficiencies were interpreted as an acyl to free carnitine ratio (ACFR) of >0.4. RESULTS: 106 ICU patients met inclusion criteria and 46% were exposed to CRRT. At least one micronutrient deficiency was reported in 90% of CRRT patients compared to 61% patients unexposed to CRRT (p = 0.002). A greater percentage of copper (p < 0.001) and carnitine (p < 0.001) deficiencies were found among patients exposed to CRRT, while more zinc deficiencies were noted among non-CRRT patients (p = 0.001). CONCLUSIONS: The vast majority of CRRT patients presented with micronutrient deficiencies. Clinicians should have a heightened awareness of the risk for serum copper, carnitine, and vitamin B6 deficiencies among CRRT patients. Further prospective and randomized-controlled trials are needed to better define this new category of malnutrition and test supplementation strategies to address and prevent these clinically-relevant deficiencies.

Early high-dose continuous veno-venous hemofiltration alleviates the alterations of CD4+ T lymphocyte subsets in septic patients combined with acute kidney injury.

BACKGROUND: This study aims to determine whether early high-dose continuous venous-venous hemofiltration (CVVH) alleviates the alterations in CD4+ T lymphocyte subsets in septic patients combined with acute kidney injury. METHODS: Enrolled septic patients combined with acute kidney injury were randomized into CVVH (n = 50) and conventional treatment (non-CVVH, n = 53) groups. Healthy volunteers (n = 21) were enrolled. CVVH was initiated within 12 h of intensive care unit (ICU) admission with doses of 35~60 ml/kg/h and maintained for at least 72 h. Th1, Th2, Th17, and Treg were measured by flow cytometry on days 1, 3, and 7 of ICU admission. Sequential organ failure assessment (SOFA) scores were calculated. RESULTS: Th1 percentages and Th1/Th2 ratios were lower, and Th2, Th17, and Treg percentages and Th17/Treg ratios were higher in septic patients compared to healthy volunteers. CVVH significantly increased Th1 percentages and Th1/Th2 ratios, and significantly decreased Th2, Th17, and Treg percentages and Th17/Treg ratios compared to non-CVVH. Th1 percentages and Th1/Th2 ratios were negatively correlated with SOFA scores, while Th2, Th17, and Treg percentages and Th17/Treg ratios were positively correlated with SOFA scores. Patients with CVVH had significantly lower SOFA scores on day 7 of ICU admission and a shorter ICU stay compared to those with non-CVVH. CONCLUSIONS: Septic patients combined with acute kidney injury exhibit different alterations of CD4+ T lymphocyte subsets. Early high-dose CVVH alleviates the alterations, which may be one of the factors associated with improved sepsis severity.

Prognostic risk factors in patients with refractory heart failure treated with continuous veno-venous hemofiltration.

INTRODUCTION: Investigation of the prognostic factors in patients with refractory heart failure (HF) undergoing continuous veno-venous hemofiltration (CVVH). METHODS: Clinical data of 146 patients with refractory HF between May 2018 and December 2020 were retrospectively analyzed and divided into survival and death groups according to the prognosis. Vital signs, inflammatory markers, and renal function parameters were compared before and after treatment. RESULTS: Central venous pressure levels were lower, whereas serum levels of brain natriuretic peptide, oxygen saturation, and cardiac output were higher after treatment (p < 0.05). Heart rate, systolic and diastolic blood pressures, serum levels of C-reactive protein, interleukin-6, tumor necrosis factor-α, interleukin-8, blood urea nitrogen, creatinine, and 24-h urinary protein were lower after treatment (p < 0.05). CONCLUSION: CVVH improved renal function and regulated blood pressure and vital signs in patients with refractory HF. Age, APACHE II score, disease duration, and hypotension were risk factors affecting the prognosis.

Effects and significance of continuous hemoperfusion on patients with diquat poisoning / 中华危重病急救医学

Objective:To investigate the effect of continuous hemoperfusion (HP) on the levels of soluble CD14 isoform (sCD14-st) and neutrophil gelatinase-associated lipocalin (NGAL) on patients with diquat (DQ) poisoning and its significance.Methods:A total of 86 patients with acute DQ poisoning admitted to the department of emergency medicine, Harrison International Peace Hospital Affiliated to Hebei Medical University from May 2018 to August 2021 were enrolled and divided into the intermittent HP group (40 cases) and the continuous HP group (46 cases) according to the random number table method. All patients received basic treatment and continuous veno-venous hemofiltration (CVVH) within 24 hours after admission. On this basis, the intermittent HP group received HP treatment within 2 hours, lasting 2 hours each time for every 8 hours, 3 times in all; the continuous HP group received continued HP treatment until there was no DQ component in urine samples. Serum NGAL levels were detected in all patients before treatment and at 3 hours, 12 hours, 24 hours, 2 days, 3 days, 5 days, and 7 days after treatment. At the same time, serum sCD14-st, blood lactate (Lac), arterial partial pressure of oxygen (PaO 2), serum creatinine (SCr), MB isoenzyme of creatine kinase (CK-MB) and interleukin-18 (IL-18) levels were detected before treatment and at 24 hours, 3 days, and 7 days after treatment. Kaplan-Meier survival curve was drawn to analyze the 28-day survival of patients. Results:Before treatment, there was no significant difference in serum NGAL, sCD14-st, Lac, PaO 2, SCr, CK-MB and IL-18 levels between the two groups. With the prolongation of treatment, the serum levels of NGAL, sCD14-st, Lac, SCr, CK-MB and IL-18 in the intermittent HP group increased at first and then decreased. Serum levels of NGAL, sCD14-st, CK-MB and IL-18 reached their peaks at 24 hours after treatment, and the Lac and SCr levels reached their peaks at 3 days after treatment. In addition, the levels of the above indexes at each time point in the continuous HP group were all significantly lower than those in the intermittent HP group [after 24 hours of treatment: NGAL (μg/L) was 345.90±30.75 vs. 404.24±38.79, sCD14-st (ng/L) was 1 941.88±298.02 vs. 2 656.35±347.93, CK-MB (U/L) was 30.67±9.11 vs. 43.28±8.06, IL-18 (ng/L) was 139.49±16.29 vs. 177.98±27.85; 3 days of treatment: Lac (mmol/L) was 2.98±0.26 vs. 3.72±0.49, SCr (μmol/L) was 125.01±24.24 vs. 156.74±28.88; all P < 0.05]. However, there was no significant difference in PaO 2 levels between the two groups at each time point after treatment. The Kaplan-Meier survival curve showed that the 28-day mortality of patients in the continuous HP group was significantly lower than that in the intermittent HP group [26.09% (12/46) vs. 52.50% (21/40); Log-Rank test: χ2 = 7.288, P = 0.007]. Conclusion:Continuous HP could effectively reduce serum sCD14-st, NGAL levels and 28-day mortality in patients with DQ poisoning, with good curative effect.

Post-transplant inotrope score is associated with clinical outcomes after adult heart transplantation.

BACKGROUND: Inotrope score has been proposed as a marker of clinical outcome after adult heart transplantation (HTx) but is rarely used in practice. METHODS: Inotrope score during the first 48 h after HTx was calculated in 81 patients as: dopamine + dobutamine + amrinone + milrinone (dose × 15) + epinephrine (dose × 100) + norepinephrine (dose × 100) + enoximone + isoprenaline (dose × 100), with each drug in µg/kg/min. Determinants of inotrope score were identified with linear regression. Cox regression was used to determine the association of inotrope score with mortality. RESULTS: The mean recipient age was 52 ± 11 years, and 32 (39.5%) patients were female. Determinants of inotrope score were preoperative C-reactive protein, serum urea, congenital heart disease, and donor cardiac arrest (R2  = .30). Inotrope score was associated with 5-year mortality, independent of recipient age and gender (HR 1.03, 95% CI 1.00-1.07). This association was attenuated when adjusting for female-to-male transplant and ischemia time. Inotrope score was also strongly associated with continuous veno-venous hemofiltration (OR 1.07, 95% CI 1.03-1.12). CONCLUSION: High inotrope score post-HTx was observed in recipient congenital heart disease and was associated with a higher risk of mortality and acute kidney injury.

Low bicarbonate replacement fluid normalizes metabolic alkalosis during continuous veno-venous hemofiltration with regional citrate anticoagulation.

BACKGROUND: Metabolic alkalosis is a frequently occurring problem during continuous veno-venous hemofiltration (CVVH) with regional citrate anticoagulation (RCA). This study aimed to evaluate the effectiveness of switching from high to low bicarbonate (HCO3-) replacement fluid in alkalotic critically ill patients with acute kidney injury treated by CVVH and RCA. METHODS: A retrospective-comparative study design was applied. Patients who underwent CVVH with RCA in the ICU between 09/2016 and 11/2017 were evaluated. Data were available from the clinical routine. A switch of the replacement fluid Phoxilium® (30 mmol/l HCO3-) to Biphozyl® (22 mmol/l HCO3-) was performed as blood HCO3- concentration persisted ≥ 26 mmol/l despite adjustments of citrate dose and blood flow. Data were collected from 72 h before the switch of the replacement solutions until 72 h afterwards. RESULTS: Of 153 patients treated with CVVH during that period, 45 patients were switched from Phoxilium® to Biphozyl®. Forty-two patients (42 circuits) were available for statistical analysis. After switching the replacement fluid from Phoxilium® to Biphozyl® the serum HCO3- concentration decreased significantly from 27.7 mmol/l (IQR 26.9-28.9) to 25.8 mmol/l (IQR 24.6-27.7) within 24 h (p < 0.001). Base excess (BE) decreased significantly from 4.0 mmol/l (IQR 3.1-5.1) to 1.8 mmol/l (IQR 0.2-3.4) within 24 h (p < 0.001). HCO3- and BE concentration remained stable from 24 h till the end of observation at 72 h after the replacement fluid change (p = 0.225). pH and PaCO2 did not change significantly after the switch of the replacement fluid until 72 h. CONCLUSIONS: This retrospective analysis suggests that for patients developing refractory metabolic alkalosis during CVVH with RCA the use of Biphozyl® reduces external HCO3- load and sustainably corrects intracorporeal HCO3- and BE concentrations. Future studies have to prove whether correcting metabolic alkalosis during CVVH with RCA in critically ill patients is of relevance in terms of clinical outcome.

Feasibility and efficacy of modified fixed citrate concentration protocol using only commercial preparations in critically ill patients: a prospective cohort study with a historical control group.

BACKGROUND: The cumbersome program and the shortage of commercial solution hindered the regular application of regional citrate anticoagulation (RCA). It is urgent to simplify the protocol using only commercial preparations. The aim of this study was to explore the feasibility and efficacy of the modified protocol for continuous veno-venous hemofiltration (CVVH) in unselected critically ill patients. METHODS: A prospective cohort study was conducted in 66 patients who received a new protocol combining fixed citrate concentration with modified algorithm for supplements (i.e., fixed protocol), and compared the efficacy, safety and convenience for this group to a historical control group with a traditional protocol (n = 64), where citrate was titrated according to the circuit ionized calcium concentration (i.e., titrated protocol). The convenience was defined as the demand for monitoring test and dose adjustment of any supplement. RESULTS: The filter lifespan was 63.2 ± 16.1 h in the fixed group and 51.9 ± 17.7 h in the titrated group, respectively. Kaplan-Meier survival analysis demonstrated longer circuit lifetime for fixed group (log-rank, p = 0.026). The incidence of circuit clotting was lower in the fixed protocol (15.2% vs. 29.7% in the titrated protocol, p = 0.047). Moreover, compared with the titrated group, patients with fixed protocol had less demand for monitoring test and dose adjustment of any supplement (the number of times per person per day) (3.3 [IQR 2.3-4.5] vs. 5.7 [IQR 3.3-6.9], p = 0.001 and 1.9 [IQR 0.5-2.7] vs. 6.3 [IQR 4.2-7.9], p < 0.001; respectively). No new onset bleeding complications occurred in all patients. The overall incidence of suspected citrate accumulation was 4.6% and there was no difference between the two groups (p = 0.969), yet a lower rate of metabolic alkalosis was found in the fixed group (3.0% vs. 14.1%, p = 0.024). CONCLUSIONS: Our modified fixed citrate concentration protocol is feasible, safe and effective to enhance the circuit lifespan and the convenience of implementation while maintaining a similar safety when compared to the traditional protocol. Using only commercial preparations may be helpful for widespread application of RCA. TRIAL REGISTRATION: Clinicaltrials.gov. NCT02663960 . Registered 26 January 2016.

Does hemofiltration protect the brain after head trauma? An experimental study in rabbits.

BACKGROUND: Traumatic brain injury (TBI) is one of the most frequent and severe neurological diseases. In the last few decades, significant advances have been made in TBI pathophysiology and monitoring, however new treatments have not emerged. Although the central nervous system (CNS) has been historically defined as an immunologically privileged organ, recent studies show the increasingly predominant role of inflammatory and apoptotic phenomena in the pathogenesis of TBI. Inflammatory response mediators can be eliminated with continuous renal replacement therapies (CRRT). Our aim was to investigate whether hemofiltration protects the brain after head trauma in an experimental study in animals. METHODS AND RESULTS: A model of TBI and CVVH was performed in anesthetized New Zealand white rabbits without acute renal failure. The experimental group TBI ( +)-CVVH ( +) was compared with a TBI ( +)-CVVH (-) and a TBI (-)-CVVH ( +) control groups. Rabbits were assessed immediately (NES1) and 24 h hours after (NES2) TBI and/or CVVH using a functional Neurological Evaluation Score (NES) and histology of the brains after sacrifice. There was evidence to support a difference of NES1 comparing with the TBI (-)-CVVH ( +), but not with TBI ( +)-CVVH (-) with only 15% of the rabbits treated with CVVH and TBI showing a favorable neurological course. The final neurological outcome (mortality at 24 h) was 0%, 22% and 53% in the TBI(-) + CVVH( +), TBI( +)-CVVH(-) and TBI( +)-CVVH( +) groups respectively. The use of hemofiltration before or after TBI did not make a difference in regards the outcome of the rabbits. There was evidence in the histology to support an increase of mild ischemia, hemorrhage and edema in the experimental group compared with the other two groups. CONCLUSIONS: CVVH in rabbits without renal failure used with the intention to protect the brain may worsen the prognosis in TBI.

Iliopsoas hematoma associated with low-molecular-weight heparin use: A case report.

Iliopsoas hematoma is an uncommon clinical entity that may develop in association with anticoagulation states, coagulopathies and hemodialysis, or anticoagulant therapy. Here, we report a case of unilateral iliopsoas hematoma in a 60-year-old man who received low-molecular-weight heparin for anticoagulation due to continuous veno-venous hemofiltration. The patient presented with fever and productive cough for 2 days. He received continuous veno-venous hemofiltration due to rising blood urea nitrogen (22.7 mmol/L; normal references: 3.2-7.1 mmol) and creatinine (1345 µmol/L; normal references: 53-106 µmol/L). Low-molecular-weight heparin (enoxaparin, 3500-5500 Da, 5-10 IU/kg/h) was delivered continuously by pumps for anticoagulation therapy. At day 12 post heparin treatment, the patient complained left back pain. Platelet count (243 × 109/L) was normal, but both activated partial thromboplastin time (67.5 s) and prothrombin time (17.3 s) were prolonged. Abdominal computed tomography scan revealed left iliopsoas swelling with an indistinct border. Low-molecular-weight heparin was discontinued. Anti-Xa was not monitored throughout the treatment. No improvement was seen, and 3 days later, the patient died after his family decided to terminate therapy. This case highlights the needs for careful anticoagulation as well as close monitoring, and particularly the use of anti-Xa to guide the treatment.

Fulminant Acute Kidney Injury in a Young Patient with Novel Coronavirus 2019.

Coronavirus disease 2019 (COVID-19) is a global pandemic affecting more than 200 countries and 180,000 cases in the United States. While the outbreak began in China, the number of cases outside of China exceeded those in China on March 15, 2020 and are currently rising at an exponential rate. The number of fatalities in the United States are expected to exceed more than Italy and China. The disease is characterized predominantly as an acute respiratory illness. However, preliminary data suggests that kidney is a target for the virus and deterioration of renal function was associated with poor outcomes including in-hospital mortality. We pre-sent a report of a patient with COVID-19 who presented with acute onset of symptoms and normal renal function at baseline but rapidly deteriorated resulting in death. The timing of decline in renal function correlated with his worsening clinical status. He was started on continuous veno-venous hemofiltration without signs of clinical benefit. We also present the possible mechanisms for acute kidney injury in these patients. We performed a review of the emerging literature by searching PubMed, Google Scholar, and EMBASE for studies and/or case series published on this topic. Acute kidney injury might help risk stratify critically ill patients on a fatal course of COVID-19.

MECCIAS trial: Metabolic consequences of continuous veno-venous hemofiltration on indirect calorimetry.

BACKGROUND: and aims: Caloric prescription based on resting energy expenditure (REE) measured with indirect calorimetry (IC) improves outcome and is the gold standard in nutritional therapy of critically ill patients. Until now continuous renal replacement therapy (CRRT) precluded the use of IC due to several mechanisms. We investigated the impact of CRRT on V̇CO2, V̇O2 and REE to facilitate indirect calorimetry during CRRT. METHODS: In 10 critically ill ventilated patient in need of continuous veno-venous hemofiltration (CVVH) using citrate predilution we performed IC in 4 different states: baseline, high dose, baseline with NaCl predilution and without CVVH. CO2 content of effluent fluid was measured by a point of care blood gas analyzer. Carbon dioxide production (V̇CO2) measured with IC was adapted by adding the CO2 flow of effluent and deducing CO2 flow in postdilution fluid to calculate a true V̇CO2. True REE was calculated with the Weir equation using the true V̇CO2. RESULTS: CO2 removal in effluent during baseline, high dose and NaCl predilution was respectively 24 mL/min, 38 mL/min and 23 mL/min. Together with the CO2 delivery by the postdilution fluid this led to an adaptation of REE respectively by 34 kcal/d or 2% (p = 0,002), 44 kcal/d or 3% (p = 0,002) and 33 kcal/d or 2% (p = 0,002). Compared to the true REE during baseline of 1935 ± 921 kcal/d, true REE during high dose was 1723 ± 752 kcal/d (p = 0.65), during NaCl predilution it was 1604 ± 633 kcal/d (p = 0.014) and without CRRT it was 1713 ± 704 kcal/d (p = 0.193). CONCLUSIONS: CO2 alterations due to CVVH are clinically of no importance so no correction factor of REE is needed with or without CVVH. IC must be performed during CVVH as CVVH seems to alter metabolism. These changes may be mainly explained by the use of citrate predilution.

ECMO as a Platform for Rapid Ammonia Removal in a Neonate with Multienzyme Urea Cycle Disorder.

Since the initial deployment of neonatal extracorporeal membrane oxygenation (ECMO) for respiratory failure, the use of ECMO in this population has diversified. We present a term female infant with carbamoyl phosphate synthetase 1 and partial N-acetylglutamate synthase deficiencies who developed severe hyperammonemia refractory to medical management requiring venoarterial ECMO-driven continuous veno-venous hemodiafiltration for ammonia detoxification. This case report illustrates a subpopulation where neonatal ECMO may improve survival and neurodevelopmental outcomes. To our knowledge, this is the first reported case of a urea cycle defect arising from two proximal enzyme deficiencies. Also, this is one of the few reported patients with UCD associated with peak ammonia levels >2,000 µmol/L who survived to hospital discharge after the successful use of ECMO for ammonia reduction. This case will add to the existing scant literature supporting the use of ECMO as a platform for rapid removal of serum ammonia.