[Pathogenesis, diagnosis, and extracorporeal correction of water-electrolytic imbalance in critically ill patients].

The review of literature is dedicated to some issues of the development, diagnosis, and extracorporeal correction of water electrolytic disorders in critically ill patients. It considers the main points concerning water-electrolytic metabolism and its regulation in health and disease. The authors describe the specific features of invasive and noninvasive methods for diagnosing water-sectoral disorders and the possibilities of their correction with medical measures. They consider the possibilities of correcting water-electrolytic and sectoral disorders in the use of currently available methods of extracorporeal detoxification (ultrafiltration, hemodialysis, hemofiltration, and hemodiafiltration).

[Insulin-like growth factor 1 in patients with multiple organ dysfunction during hemofiltration/hemodiafiltration].

Severe diseases of different etiology are generally accompanied by significant neurohumoral stress and catabolism. The use of insulin and insulin-like growth factor 1 (IGF-1) regulates the rate of protein and carbohydrate catabolism, retards increasing azotemia, thus normalizing protein metabolism. By taking into account the physicochemical properties of IGF-1 and the high resolving capacity of the modes of renal replacement therapy (RRT), it cannot be ruled out the possibility that the really significant amount of this polypeptide is eliminated, which may negatively affect the patient's metabolic adaptation. In this connection, the authors studied the levels of IGF-1 in patients with multiple organ dysfunction during hemofiltration/hemodiafiltration (HF/HDF). All the patients were found to have the maximum low content of IGF-1 both before and during RRT. There was a high elimination of this hormone with an effluent during RRT. The clearance of IGF-1, calculated for 24 hours of a procedure was equal to that of the proinflammatory cytokines TNFa and IL-Ibeta during HF/HDF. The results lead to the conclusion that early replacement therapy for hypercatabolism should be performed in patients with multiple organ dysfunction.

[Pharmacokinetic simulation of different modes of renal replacement therapy]. / Vozmozhnosti kineticheskogo modelirovaniia pri sravnenii éffektivnosti razlichnykh metodov zamestitel'noi pochechnoi terapii.

Based on the results of examination of patients with severe acute renal failure and multiorgan insufficiency, the authors give a comparative analysis of different modes of renal replacement therapy, such as intermittent hemofiltration, continuous arteriovenous hemofiltration, and continuous venovenous hemodiafiltration. Kinetic simulation in terms of urea and creatinine, by employing a one- and two-pool model for the disposition of these substances in the patient's body was taken as a basic method. The analysis led to the conclusion that continuous hemodiafiltration (CHDF) with an actually large volume of filtration and dialysis was the optimum technique for correcting uremic impairments of homeostasis in critically ill patients. CHDF failed to induce a significant metabolic stress and to noticeably affect the rate of urea and creatinine generation. Overall, all the filtration treatments are an effective means of eliminating low-molecular-weight nitrogenous metabolites that are characterized by the high rate of generation and the large volume of disposition in the organism. It is necessary only to correctly select a dose of renal therapy.

[The specific features of lipid metabolism and changes in the plasma activity of transaminases in patients with sepsis]. / Osobennosti lipidnogo obmena i dinamiki aktivnosti transaminaz plazmy krovi bol'nykh sepsisom.

A parallel study of changes in the activity of transaminases and the parameters of lipid metabolism was conducted in patients with sepsis or septic shock, receiving renal replacement therapy. The multiple baseline increase in the activity of gamma-glutamyltranspeptidase was observed in about 50% of the patients and the elevated level of triglycerides and very low density-lipoprotein cholesterol in all the examinees. In case of the baseline multiple increased activity of gamma-glutamyltranspeptidase as compared with the normal physiological values, the probability of a good clinical outcome was some 67%, in the survivors, the activity of the enzyme significantly increasing during therapy. In the absence of the baseline multiple increased activity of gamma-glutamyltranspeptidase, there was a good clinical outcome provided that there were positive changes in triglycerides and very low-density lipoprotein cholesterol during therapy and its probability was about 33%. It is concluded that the activity of gamma-glutamyltranspeptidase and the concentration of triglycerides and very low-density lipoprotein cholesterol may be used to evaluate the efficiency of treatment and as predictors of the outcome of treatment in patients with sepsis and septic shock.

[Basic characteristics of lipid metabolism in patients with sepsis during kidney replacement therapy]. / Osnovnye pokazateli lipidnogo obmena u bol'nykh sepsisom pri zamestitel'noi pochechnoi terapii.

The changing indices of lipid metabolism were studied in patients with sepsis who were undergoing the substitution renal therapy. A sharp reduction of high-density lipoproteins (HDLP) and a higher concentration of triglyceride (TG) and of an extremely low-density lipoproteins (ELDLP) were shown in the blood plasma of such patients irrespective of a clinical outcome. The positive dynamics of TG and ELDLP concentrations as observed in the process of treatment was considered to be a good prognostication sign in sepsis and septic shock.

[Renal replacement therapy in acute infectious renal insufficiency]. / Zamestitel'naia terapiia pri infektsionnoi ostroi pochechnoi nedostatochnosti.

A modern view on renal failure in patients with infectious diseases is presented and possibilities of various methods of renal replacement therapy are evaluated. The authors emphasize the obligatory combination of etiotropic and pathogenetic therapy. A clinical case is presented: a patient with tropical and 3-day malaria was effectively treated by high-flow intermittent hemofiltration.

[Systemic hemodynamics in constant hemofiltration in patients with septic shock]. / Sistemnaia gemodinamika pri postoiannoi gemofil'tratsii u bol'nykh s septichekim shokom.

Hemodiafiltration (HDF) is a method of pathogenetic therapy for the systemic inflammatory response syndrome in patients with sepsis and shock irrespective of renal failure. Systemic hemodynamics was examined in 18 patients with septic shock treated by HDF (2 groups). HDF was associated with stabilization of systemic hemodynamics in 50% patients (cardiac index, total peripheral resistance, index of the left heart work increased and the number of heart beats, central venous pressure, mean pressure in the pulmonary artery, pulmonary capillary wedging pressure decreased, oxygen consumption index increased, etc.), which allowed a reduction of the initial dopamine and norepinephrine doses 3-fold and lower by the end of days 3-4 of HDF treatment. An opposite tendency was observed in group 2 (refractory shock). Despite high (72.2%) mortality which was mainly caused by the progress of multiple organ dysfunction or untimely surgical intervention, it is obvious that HDF created conditions for surviving the critical period of disease in patients with progressive sepsis.

[Kinetic modeling during continuous hemodiafiltration in patients with sepsis and multiorgan failure]. / Kineticheskoe modelirovanie pri postoiannoi gemodiafil'tratsii u bol'nykh s sepsisom i poliorgannoi nedostatochnost'iu

Kinetic simulation in terms of urea and creatinine is the best way of prescribing a dialysis dose and assessing its quality as it considers differences in a patient's body weight, the level of catabolism, the rate of equilibration, including the recirculation phenomenon noticeably observed under shock. A 2-pool model of distribution of urea and creatinine was employed in the study. The latter was carried out in 31 patients (17 males and 14 females) with sepsis and multi-organ failure receiving 50 sessions of continuous hemodiafiltration (CHDF). The mean duration of CHDF was 73.8 +/- 7.0 (4.0-207.0) hours, the daily volumes of a substitute, a dialysate, and an effluent (filtrate + dialysate) were 33 +/- 1.0 (5.0-60.0), 43.9 +/- 0.8 (2.6-62.0), and 80.4 +/- 1.6 (12.0-122.3) liters a day, respectively. An analysis confirmed the high efficiency of CHDF close to that of the daily volume-body weight ratio and showed that such conditions of the procedure are optimal in maintaining azotemia at the subnormal level irrespective of the degree of cababolism.

[High-volume hemodiafiltration in the treatment of sepsis and multiple organ failure: 2 methods of the elimination of TNF-alpha]. / Vysokoob"emnaia gemodiafil'tratsiia v lechenii sepsisa i poliorgannoi nedostatochnosti: dva sposoba éliminatsii TNF-alpha.

Permanent hemodiafiltration (PHDF) as a method for treating patients with sepsis and multiple organ failure (MOF) corrects the severity of generalized inflammatory reaction, which is caused by hyperproduction of bioactive substances. Cytokines can be eliminated from circulation by 2 methods of kidney-replacing therapy: convection and adsorption on hemofilter membrane. Despite the slight adsorption clearance, our results indicate that experimental data not always correspond to the clinical situation. Pronounced cytokinemia persists in patients with sepsis and MOF during PHDF. In addition to correction of the main hemostasis parameters, kidney-replacing therapy eliminates an appreciable amount of TNF-alpha and other proinflammatory cytokines. Estimation of TNF-alpha balance indicates its good adsorption on the surface of hemodiafilter membrane.

[Acute lung injury syndrome and hemodiafiltration]. / Sindrom ostrogo povrezhdeniia legkikh i gemodiafil'tratsiia.

Acute lung injury syndrome is one of the most frequent components of polyorgan failure, particularly resultant from sepsis. Replacing renal therapy can correct uremic disorders in the hemostasis and gaseous exchange disorders in the lungs by eliminating excessive fluid in case of hyperhydration and by eliminating inflammation mediators. The present study demonstrated a favorable impact of hemodiafiltration on ventilation oxygen status of patients with acute lung injuries, which was confirmed by positive changes in blood oxygen pressure, intrapulmonary shunt, alveolar-arterial oxygen difference, etc. Changes in oxygen transport corresponded to those in patients with sepsis and shock without hemodiafiltration.

[Lactate kinetics during constant hemodiafiltration in critically severe patients with the systemic inflammatory response syndrome and multiple organ failure]. / Kinetika laktata pri postoiannoi gemodiafil'tratsii u kriticheski tiazhelykh bol'nykh s sindromom sistemnogo vospalitel'nogo otveta i poliorgannoi nedostatochnost'iu.

High-volume hemodiafiltration is a new approach to the treatment of critical patients with generalized inflammatory reaction and multiple organ failure. Increase of the liquid exchange during the procedure is fraught with the development of secondary metabolic disorders in cases when lactate-based buffer is used (with high amounts of lactate). This study was undertaken to evaluate the consequences for the acid-base balance in patients with hypoxia and circulatory failure. Twelve patients (6 men and 6 women) with APACHE II score 25 were examined. The major treatment modality was continuous hemodiafiltration. The results indicate that lactate-buffered solutions can be used in critical patients, because they do not cause a notable increase in the blood lactate levels due to its good utilization. Moreover, it is associated with correction of disorders in acid-base balance. No negative clinical consequences were observed after using lactate anion in high concentrations as the major buffer compound.

[Complement system during hemofiltration in patients with multiple organ failure]. / Sistema komplementa pri gemofiltratsii u bol'nykh s poliorgannoi nedostatochnost'iu.

Nine patients (8 men and 1 woman) were treated. Sepsis was diagnosed in 7 of them. All patients were subjected to forced ventilation of the lungs, 6 were in need of inotropic support. The severity of clinical status was 31 +/- 0.8 according to APACHE II score. One patient survived. The main method of substitute renal therapy (SRT) was permanent hemofiltration with spontaneous arteriovenous perfusion. The results indicate manifest depletion of the complement system augmenting with the progress of multiple organ failure (MOF). Extracorporeal perfusion in SRT had no additional negative effects on the complement system damaged by disease. Nonselective penetration of individual complement fractions into the filtrate in the course of perfusion was noted. Therefore, the complement system is severely damaged in patients with MOF; it can modulate the SRT because of penetration of its individual fractions.

[Metabolic effects of intermittent hemofiltration in patients with acute renal failure]. / Metabolicheskii éffekt intermittiruiushchei gemofil'tratsii u bol'nykh s ostroi pochechnoi nedostatochnost'iu.

AIM: Investigation of postaggressive reaction of metabolism on intermitten hemofiltration (IHF) in patients with acute renal failure (ARF). The speed of generation of urea, creatinine and oligopeptides was estimated in the course of (IHF) and in interval between the procedures. Hormonal stress was evaluated by concentration of hydrocortisone in plasma and and filtrate. MATERIALS AND METHODS: The trial covered 36 patients with oliguric ARF (21 males and 15 females) for whom IHF was the main method of replacement renal therapy. The kinetic modelling accounted for distinctive distribution of markers in body fluids. Statistical processing was made according to Student-Fisher T-criterion. RESULTS: IHF runs with intensive proteinolysis with acceleration of oligopeptides generation by 810%, degradation of large quantities of creatine triphosphate and 770%-accelerated production of creatinine, with protein catabolism and 440%-accelerated production of urea. Hydrocortisone blood levels rise about two-fold despite intensive elimination of the hormone with filtrate. Between speeds of IHF, generation of creatinine and secretion a direct correlation was found. This indicates the importance of the perfusion rate for induction of the stress and catabolism. Background hydrocortisone Irvrl has significant effects only on urea accumulation rates in IHF-free intervals. However, in the course of IHF, generation of urea and oligopeptides is to a great extent independent of hydrocortisone secretion. CONCLUSION: Application of IHF in ARF patients results in rather strong stress with enhanced proteinolysis and protein catabolism. To compensate protein loss associated with only urea generation, additional administration of minimum 60 g of plasma or amino acids is required.

[Plasma contents of cytokines (TNF-alpha, IL-1 beta, IL-6) and their clearance during continuous hemofiltration in patients with sepsis and multiple organ failure]. / Soderzhanie v plazme tsitokinov (TNF-alfa, IL-1beta, IL-6) i ikh klirens pri postoiannoi gemofil'tratsii u bol'nykh s sepsisom i poliorgannoi nedostatochnost'iu).

The total-systems inflammatory response was assessed in patients with sepsis and multiple organ failure by measuring plasma cytokines TNF-alpha, IL-1 beta, and IL-6 and their clearance and total elimination in the course of permanent hemofiltration (PHF). Sepsis and multiple organ failure were found to involve a stable circulation of numerous cytokines, their levels reaching the peaks in some cases. No correlation between the content of individual cytokines in the plasma were detected. Appreciable amounts of TNF-alpha and IL-1 beta were eliminated during PHF, their clearance being approximately 15 ml/min, whereas elimination of IL-6 was negligible. Hence, PHF affects the mediator component in the pathogenesis of sepsis and the multiple organ failure syndrome.

[Plasma myoglobin and continuous hemofiltration in patients with rhabdomyolysis and acute kidney failure]. / Mioglobin plazmy i postoiannaia gemofil'tratsiia u bol'nykh s rabdomiolizom i ostroi pochechnoi nedostatochnost'iu.

Plasma and filtrate levels of myoglobin, specific antibodies and immune complexes were measured by radioimmunoassay or enzyme immunoassay in patients with rhabdomyolysis and acute renal failure on continuous hemofiltration (CHF). 14 of them had crush syndrome, 7 had other forms of rhabdomyolysis. 11 patients died (52%) because of the underlying disease or its complications. Rhabdomyolysis was associated with marked and long-lasting myoglobinemia. Early amputation and restoration of diuresis combined with CHF resulted in a fall in myoglobin content. CHF provided elimination of large amounts of myoglobin with filtrate. In rhabdomyolysis in all cases there appeared specific antibodies and circulating immune complexes.

[Tumor necrosis factor-alpha kinetics during renal replacement therapy in patients with sepsis and multiple organ failure]. / Kinetika faktora nekroza opukholi al'fa pri zamestitel'noi pochechnoi terapii u patsientov sepsisom i s poliorgannoi nedostatochnost'iu.

Peptide TNF-alpha (tumor necrosis factor alpha) secreted by monocytes and resident macrophages is a key proinflammatory mediator. It can generate response systemic inflammation leading to shock and polyorganic insufficiency. Elimination of circulating TNF-alpha is pathogenetically perspective in respect to therapy of septic shock. Plasma level of TNF-alpha and its elimination with the filter/dialysate was traced in 23 patients with sepsis and polyorganic insufficiency receiving substitute renal therapy (continuous hemodiafiltration, intermittent hemodialysis) for acute renal failure. Sepsis and polyorganic insufficiency was associated with elevated plasma levels of TNF-alpha correlating in many cases with the disease severity. TNF-alpha was for the most part eliminated with the filter/dialysate. The degree of this elimination was related to the technique of blood perfusion and characteristics of the procedure.

[Evaluation of the effectiveness of continuous renal replacement therapy in critical patients after cardiovascular surgery]. / Otsenka éffektivnosti postoiannoi pochechnoi zamestitel'noi terapii u bol'nykh v kriticheskom sostoianii posle operatsii na serdtse i sosudakh.

The efficacy of continuous methods of renal substitute therapy (RST) in patients with multiple organ failure is assessed. The patients were divided in 2 groups administered different types of PST. Group 1 were 16 patients subjected to RST by peritoneal dialysis, in group 2 (n = 16) GP and/or GDP were used. Hemodynamics, hematological and biochemical values, and clearance of inflammation mediators were monitored and hemohydrobalance and complications of therapy assessed in the course of RST. Both RST methods proved to be highly effective. The possibility of differentiated use of peritoneal dialysis and GP/GDP permits an individual approach to treatment, and equally high efficacy of both methods solves the problem of treating total renal insufficiency in the majority of patients with multiple organ failure following cardiovascular surgery.