Kazuya Nakanishi

Usefulness of plasma exchange plus continuous hemodiafiltration to reduce adverse effects associated with plasma exchange in patients with acute liver failure.

ObjectiveTo efficiently remove middle-molecular-weight substances such as hepatic toxins and minimize adverse effects associated with plasma exchange implementation, we have performed plasma exchange slowly in combination with continuous hemodiafiltration. This study was designed to determine the usefulness of plasma exchange with continuous hemodiafiltration in reducing the adverse effects associated with implementation of plasma exchange alone. DesignA retrospective clinical study. SettingUniversity teaching hospital. PatientsThe study involved 90 patients with liver failure who had been treated with plasma exchange in our department over the past 12 yrs. We examined these patients by dividing them into two groups (48 patients treated with plasma exchange alone and 42 patients treated with plasma exchange plus continuous hemodiafiltration at the time of plasma exchange implementation). Measurements and Main Results Baseline blood Na+ concentration, HCO3− concentration, and colloid osmotic pressure were followed after implementation of plasma exchange to compare the frequency of development of three adverse effects (hypernatremia, metabolic alkalosis, and sharp decrease in colloid osmotic pressure) in the two groups. Hypernatremia was found in 26.7% of treatments in the group with plasma exchange alone and 3.3% in the group of plasma exchange plus continuous hemodiafiltration, and metabolic alkalosis was found in 30.6% of treatments in the group with plasma exchange alone and 4.9% in the group of plasma exchange plus continuous hemodiafiltration; both percentages were significantly higher in the group with plasma exchange alone (p < .001). A sharp decrease in colloid osmotic pressure occurred in 13.3% of treatments in the group with plasma exchange alone but was not observed at all in the patients treated with plasma exchange plus continuous hemodiafiltration. ConclusionsWe conclude that adverse effects associated with plasma exchange for artificial liver support for liver failure can be alleviated with use of plasma exchange plus continuous hemodiafiltration instead of plasma exchange alone.

Cytokine Adsorptive Property of Various Adsorbents in Immunoadsorption Columns and a Newly Developed Adsorbent: An in vitro Study

Background/Aims: Cytokines play important roles in the pathophysiology of systemic inflammatory response syndrome (SIRS) and sepsis. Therefore, some effective measures to remove cytokines from the bloodstream could be effective in the treatment of SIRS and sepsis. The aim of this study was to evaluate the cytokine adsorptive property of various adsorbents for the purpose of the development of new selective cytokine adsorption columns. Methods: The cytokine adsorptive property of adsorbent in a CF-X column, which consists of cellulose beads cross-linked with hexamethylene-di-isocyanate, was compared with those of various adsorbents in currently available immunoadsorption columns, such as Immusorba TR®, Immusorba PH®, Selesorb®, and Lixelle®, in vitro batchwise test using patients’ plasma. A newly developed adsorbent, MPCF-X, which was modified by coating the surface of the adsorbent in CF-X with 2-methacryloyloxyethyl phosphorylcholine (MPC), was also tested for its cytokine adsorptive property. Results: The adsorbent in CF-Xshowed a significantly higher adsorption rate for TNF-α, interleukin (IL)-6 and IL-10 compared with other adsorbents (p < 0.05). Adsorbent in Lixelle® showed good affinity to TNF-α and IL-8. Especially, the adsorbent in CF-X almost completely removed TNF-α, whereas it also had considerable affinity to normal IgG. MPCF-X showed decreased affinity to IgG with considerable adsorptive properties to cytokines. Conclusion: Selective cytokine adsorption columns could be developed with improvement of currently available adsorbents. Such a new selective cytokine adsorption column could be clinically applied for the treatment of SIRS/sepsis.

The Change in Renal Replacement Therapy on Acute Renal Failure in a General Intensive Care Unit in a University Hospital and its Clinical Efficacy: A Japanese Experience

Abstract:  The aim of our study was to examine renal replacement therapies (RRT) that have been used for acute renal failure (ARF) in our intensive care unit (ICU) patients and to compare their outcomes. Sixteen patients who underwent intermittent hemodialysis (IHD), 14 patients who underwent continuous hemofiltration (CHF) in combination with IHD (CHF + IHD), and 38 patients who underwent continuous hemodiafiltration (CHDF) were evaluated. Regarding the effects of blood purification on hemodynamics and renal function, the percentage increase in blood pressure and percent rapid increase in urinary output were the greatest in the CHDF group. The hourly urinary output after the start of initial blood purification increased only in the CHDF group. The survival rate was significantly higher in the CHDF group. These results suggest that CHDF should be the first‐line therapy for patients with ARF and that we are moving in the right direction regarding the application of RRT to treat ARF in ICU patients.

Modulation of Polymorphonuclear Leukocyte Apoptosis in the Critically Ill by Removal of Cytokines with Continuous Hemodiafiltration

Delay of polymorphonuclear leukocyte (PMN) apoptosis caused by hypercytokinemia is considered to be a potential cause of tissue damage and resultant organ failure. We evaluated whether continuous hemodiafiltration using a polymethylmethacrylate membrane hemofilter (PMMA-CHDF), which can remove cytokines in the circulating blood, can modulate apoptosis in peripheral blood neutrophils and thereby reduce tissue damage and organ dysfunction in 25 critically ill patients. Following the completion of a 3-day PMMA-CHDF session, serum cytokine levels were significantly decreased and the percentage of apoptotic PMNs was significantly increased. A significant correlation was observed between the PMMA-CHDF-induced increase in the percentage of apoptotic PMNs and the degree of decrease in the serum interleukin-6 level. A significant correlation was also found between the increase in the percentage of apoptotic PMNs and improvement in sequential organ failure assessment score following PMMA-CHDF. These results suggest that PMMA-CHDF in critically ill patients with hypercytokinemia and concomitant delay in apoptosis of PMNs can alleviate the delay of PMN apoptosis through the removal of serum cytokines and thus may result in avoidance of organ dysfunction.

Efficacy of continuous hemodiafiltration for patients with congestive heart failure.

Background/Aims: The basic principle of treatment of congestive heart failure is achieving adequate control of preload and afterload through enhancement of cardiac contractility. In severe cases, however, we have usually applied continuous hemodiafiltration (CHDF) as a type of mechanical support. In this study, we investigated hemodynamic changes caused by CHDF in patients with congestive heart failure. Methods: We treated seven patients with congestive heart failure complicated by multiple organ failure by CHDF over 72 h, during which we measured hemodynamic parameters to determine their changes. Results: Implementation of CHDF resulted in a significant decrease in pulmonary artery occluded pressure and significant increases in cardiac index and left ventricular stroke work index. In addition, 72-hour cumulative water balance was found to be –1,791 ± 2,119 ml, and systemic vascular resistance index decreased significantly. Conclusion: Hemodynamics of patients were improved with CHDF through strict control of preload and consequently tissue oxygen metabolism was improved.

Intracranial Pressure Monitoring in Patients with Fulminant Hepatic Failure Treated with Plasma Exchange and Continuous Hemodiafiltration

Background/Aims: To study the influence of our artificial liver support (ALS) on intracranial pressure (ICP) and to evaluate the significance of ICP monitoring in fulminant hepatic failure (FHF) patients treated with ALS. Methods:ICP was measured in 13 consecutive FHF patients treated with ALS. Maximum value in ICP every day was employed as ICPmax of the day. We analyzed the correlation: (a) between ICPmax and consciousness level; (b) between ICP and colloid osmotic pressure (COP), and (c) between ICP and PaCO2. Results: ICP in 11 patients of 13 was controlled <20 mm Hg through our ALS. A significant positive correlation between ICPmax and consciousness level was found (p < 0.01). Although there was a significantly negative correlation between ICP and COP (p < 0.001), there was no correlation between ICP and PaCO2. Conclusions:We conclude that our ALS does not have any adverse effects on ICP and that ICP monitoring is one of the inevitable monitorings in the management of FHF.

Catheter-related infections in continuous hemodiafiltration in intensive care patients.

Background/Aims: Infection control is of key importance especially in the application of long-term continuous hemodiafiltration (CHDF) involving invasive vascular catheterization to critically ill patients. We investigated hemodialysis catheter-related infections in long-term CHDF. Methods: We examined catheter infections in 54 patients who were admitted to the intensive care unit and underwent CHDF for 2 weeks or longer. Results: With a total of 155 catheters (1,071 catheter days) studied, catheter colonization and catheter-related bloodstream infection were noted with an incidence rate of 4.8 and 2.7 per 1,000 catheter days, respectively. No difference in catheter colonization rate was observed depending on the catheterization sites or duration of catheterization. Infections were identified in 39 patients (72%) and blood culture positivity was noted in 25 patients (46%). Conclusions: Since the majority of cases requiring long-term CHDF are complicated with a variety of infections, it is difficult to control infections associated with hemodialysis catheters separately from infections of other types. Systemic infection control should serve as a strategy finally leading to successful control of catheter-related infection.

A successful salvage therapy with daptomycin and linezolid for right-sided infective endocarditis and septic pulmonary embolism caused by methicillin-resistant Staphylococcus aureus

Although vancomycin administration is recommended for the treatment of infective endocarditis (IE) caused by methicillin-resistant Staphylococcus aureus (MRSA), it is unclear whether an alternative agent, daptomycin, can be used to treat IE with pulmonary complications. A 26-year-old female who had undergone surgical repair of a ventricular septal defect as an early teenager presented with fever, headache, and vomiting. She was admitted to our hospital and diagnosed with right-sided IE with septic pulmonary embolism caused by MRSA. Vancomycin, rifampicin, and gentamicin were administered; however, exacerbation of drug eruption due to the antimicrobial agents on the 11th day led us to switch from vancomycin and rifampicin to daptomycin. Furthermore, we included linezolid to treat lung abscesses that accompanied the septic pulmonary embolism. We confirmed negative blood cultures on the 18th day. On the same day, a patch closure for the ventricular septal defect and tricuspid valve replacement were performed. She was discharged on the 65th day with an uneventful postoperative course. This experience suggests that daptomycin and linezolid are effective salvage therapies for right-sided IE caused by MRSA and accompanied by pulmonary complications.

Successful treatment of pulmonary embolism-induced cardiac arrest by thrombolysis and targeted temperature management during pregnancy

Thrombolysis for pulmonary embolism and targeted temperature management for cardiac arrest are controversial treatments in pregnancy.

Nutritional Support for the Patient with Multiple Organ Failure in Gastroenterological Surgery.

消化器外科領域の多臓器不全 (multiple organ failure;MOF) 70例を対象に, いかにして代謝動態を把握し, いかなる栄養管理を施行すればよいかを検討した.代謝動態の把握には, indirect calorimetryによるエネルギ-消費量, respiratory quotient, %FAT, 動脈血中ケトン体比 (arterial ketone body ratio; AKBR) およびケトン体量, 血中乳酸値などが有効であった.MOF患者はhypermetabolicで, 基礎エネルギー消費量の140～150%を消費しており, AKBRの低下している肝不全合併MOF症例では, エネルギー基質の利用制限や蛋白代謝の低下が観察された.全症例に対して中心静脈栄養法を施行した.消費エネルギー量相当のエネルギ-量の投与は肝不全合併MOFおよび腎不全合併MOFで困難であったが, 前者ではATP-Mgやplasma exchangeの併用が, 後者では持続的血液濾過や持続的血液濾過透析の併用が有効であった.また分枝鎖アミノ酸を多量に含む製剤は有用であった.