Toshio Naka

Myoglobin clearance by super high-flux hemofiltration in a case of severe rhabdomyolysis: a case report

ObjectiveTo test the ability of a novel super high-flux (SHF) membrane with a larger pore size to clear myoglobin from serum.SettingThe intensive care unit of a university teaching hospital.SubjectA patient with serotonin syndrome complicated by severe rhabodomyolysis and oliguric acute renal failureMethodInitially continuous veno-venous hemofiltration was performed at 2 l/hour ultrafiltration (UF) with a standard polysulphone 1.4 m2 membrane (cutoff point, 20 kDa), followed by continuous veno-venous hemofiltration with a SHF membrane (cutoff point, 100 kDa) at 2 l/hour UF, then at 3 l/hour UF and then at 4 l/hour UF, in an attempt to clear myoglobin.ResultsThe myoglobin concentration in the ultrafiltrate at 2 l/hour exchange was at least five times greater with the SHF membrane than with the conventional membrane (>100,000 μg/l versus 23,003 μg/l). The sieving coefficients with the SHF membrane at 3 l/hour UF and 4 l/hour UF were 72.2% and 68.8%, respectively. The amount of myoglobin removed with the conventional membrane was 1.1 g/day compared with 4.4–5.1 g/day for the SHF membrane. The SHF membrane achieved a clearance of up to 56.4 l/day, and achieved a reduction in serum myoglobin concentration from >100,000 μg/l to 16,542 μg/l in 48 hours.ConclusionsSHF hemofiltration achieved a much greater clearance of myoglobin than conventional hemofiltration, and it may provide a potential modality for the treatment of myoglobinuric acute renal failure.

Evaluation of Transcatheter Arterial Embolization with Gelatin Sponge Particles, Microcoils, and N-butyl Cyanoacrylate for Acute Arterial Bleeding in a Coagulopathic Condition

PURPOSE To evaluate the outcome of transcatheter arterial embolization with gelatin sponge particles, microcoils, and N-butyl cyanoacrylate (NBCA) for acute arterial hemorrhage in the setting of coagulopathy. MATERIALS AND METHODS Coagulopathy is defined by a platelet count less than 5 x 10(4)/microL and/or International Normalized Ratio (INR) greater than 1.5. Forty-six patients (31 male patients; mean age, 62 years) with acute arterial hemorrhage in a coagulopathic condition were treated by transcatheter arterial embolization with gelatin sponge particle, microcoils, and NBCA. RESULTS Because of failure of hemostasis or recurrent hemorrhage, 10 patients who underwent gelatin sponge particle embolization also received transcatheter arterial embolization with microcoils or NBCA embolization and two patients who underwent microcoil embolization also received transcatheter arterial embolization with NBCA. The gelatin sponge particle group consisted of 27 hemorrhagic arteries in 25 patients, the microcoil group had 20 in 20 patients, and the NBCA group had 16 in 13 patients. The mean platelet count and mean INR value were 5.8 x 10(4)/microL +/- 3.5 and 1.81 +/- 0.50, respectively. The primary hemostatic rate, recurrent hemorrhage rate, and mean treatment time for the gelatin sponge particle, microcoil, and NBCA groups were 67%, 23%, and 25 minutes +/- 10; 80%, 0%, and 37 min +/- 19; and 100%, 0%, and 9 min +/- 4, respectively. Primary and secondary hemostasis were achieved in 50 (80%) and 60 (95%) of the 63 hemorrhagic arteries, respectively. Three hemorrhagic arteries in which transcatheter arterial embolization failed were treated with surgical repair. CONCLUSIONS Although transcatheter arterial embolization with microcoils took a greater amount of time, transcatheter arterial embolization with NBCA or microcoils was more effective and feasible than that with gelatin sponge particle in terms of hemostasis and prevention of recurrent hemorrhage in a coagulopathic condition.

The effects of saline or albumin resuscitation on acid-base status and serum electrolytes*

Objective:To test whether fluid resuscitation with normal saline or 4% albumin is associated with differential changes in acid-base status and serum electrolytes. Design:Nested cohort study. Setting:Three general intensive care units. Patients:Six hundred and ninety-one critically ill patients. Interventions:Randomization of patients to receive blinded solutions of either 4% human albumin or normal saline for fluid resuscitation. Measurements and Main Results:Albumin was given to 339 patients and saline to 352. At baseline, both groups had a similar serum bicarbonate, albumin, and base excess levels. After randomization, bicarbonate and base excess increased significantly and similarly over time (p < .0001). On multivariate analysis, fluid resuscitation with albumin predicted a smaller increase in pH (p = .0051), bicarbonate (p = .034), and base excess (p = .015). The amount of fluid was an independent predictor of pH (p < .0001), serum chloride (p < .0001), calcium (p = .0001), bicarbonate (p = .0002), and base excess (p < .0001) on the first day of treatment. In patients who received >3 L of fluids in the first 24 hrs, albumin administration was associated with a significantly greater increase in serum chloride (p = .0026). Acute Physiology and Chronic Health Evaluation II score and the presence of sepsis also independently predicted changes in several electrolytes and acid-base variables. Conclusions:When comparing albumin and saline, the choice and amount of resuscitation fluid are independent predictors of acid-base status and serum electrolytes. When large volumes are given, albumin administration leads to a higher chloride concentration. However, overall differences between the types of fluid are minor, whereas the volume of fluid administered is a much stronger predictor of such changes, which are also influenced by illness severity and the passage of time.

A pilot randomized controlled comparison of extended daily dialysis with filtration and continuous veno-venous hemofiltration: fluid removal and hemodynamics.

Objectives Extended intermittent dialytic techniques are increasingly being reported in the treatment of ARF in the ICU but few randomized controlled trials exist. We compared one such technique to a technique of continuous renal replacement therapy with regard to fluid removal and hemodynamics. Methods Sixteen critically ill patients with ARF were enrolled in a randomized controlled trial at the ICU of a tertiary hospital. We randomized eight patients to three consecutive days of treatment with either Extended Daily Dialysis with filtration (EDDf) or Continuous Veno-Venous Hemofiltration (CVVH) and compared fluid removal and hemodynamics during treatment. Results A total of 16.6 liters of fluid were removed during EDDf (830 mL/day over 20 treatment days) compared with 15.4 liters (700 ml/day over 22 treatment days) during CVVH. Median fluid removal per day was 1837 mL in the EDDf group compared with 1410 mL per day in the CVVH group, p=0.674. Median hourly fluid removal rate was 252 mL for EDDf and 128 mL for CVVH (p<0.01). Mean arterial pressure in the EDDf group was lower at two hours after starting treatment (76 mmHg vs. 94 mmHg) in the CVVH group; p= 0.031. There was no significant difference between groups for heart rate, CVP and noradrenaline dose at all time intervals measured. Conclusions Adequate prescribed fluid removal was achieved with both techniques. However, as expected, fluid was removed at a faster rate during EDDf. This was initially associated with a lower blood pressure than during CVVH where blood pressure increased.

The Effect of Continuous Veno-Venous Hemofiltration or Direct Hemoperfusion With Polymyxin B-Immobilized Fiber on Neutrophil Respiratory Oxidative Burst in Patients With Sepsis and Septic Shock

Abstract:  Neutrophil activates and injures tissues and organs during sepsis or septic shock. Blood purification therapies such as continuous veno‐venous hemofiltration (CVVH) and direct hemoperfusion with polymyxin‐immobilized fiber (PMX‐DHP) have been used for the treatment of sepsis and septic shock, however, the effects of such therapies on neutrophil activation have previously been poorly understood. We sought to evaluate neutrophil reactive oxygen species (ROS), especially H2O2 production, in the pathophysiology of sepsis or septic shock and the effect of CVVH or PMX‐DHP on neutrophil ROS. Seven critically ill septic patients requiring CVVH (and 12 matched septic patients who did not require CVVH as control) and seven septic shock patients treated with PMX‐DHP were studied. We found that patients with sepsis or septic shock had significantly higher levels of neutrophil ROS compared with normal volunteers (183 ± 42, 292 ± 90, and 103 ± 30) (P < 0.05, and <0.005). Neutrophil ROS did not change over time in patients treated either with CVVH or without CVVH. In contrast, neutrophil ROS significantly inhibited PMX‐DHP treatment in patients with septic shock (pretreatment; 292 ± 88 vs. post‐treatment; 205 ± 93, P < 0.05). In conclusion, neutrophil ROS was significantly enhanced in the sepsis or septic shock affected patients. CVVH did not affect neutrophil ROS while PMX‐DHP significant inhibited neutrophil ROS.

Multicenter Study of Plasma Diafiltration in Patients With Acute Liver Failure

Plasma diafiltration (PDF) is a blood purification therapy in which simple plasma exchange (PE) is performed using a selective membrane plasma separator while the dialysate flows outside the hollow fibers. A prospective, multicenter study was undertaken to evaluate the changes in bilirubin, IL‐18, and cystatin C, as well as the 28‐day and 90‐day survival rates, with the use of PDF according to the level of severity as measured by the Model for End‐Stage Liver Disease (MELD) score. Twenty‐one patients with liver failure were studied: 10 patients had fulminant hepatitis and PDF therapies were performed 28 times; 11 had acute liver failure with the therapy performed 96 times. Levels of total bilirubin, IL‐18, and cystatin C decreased significantly after treatment. The 28‐day survival rate was 70.0% and that at 90 days was 16.7%. According to the severity of the MELD score, each of the results compared well with the use of Molecular Adsorbent Recirculating System or Prometheus therapy. In conclusion, PDF appears to be one of the most useful blood purification therapies for use in cases of acute liver failure in terms of medical economics and the removal of water‐soluble and albumin‐bound toxins.

Time to Initiation of Treatment with Polymyxin B Cartridge Hemoperfusion in Septic Shock Patients

Background: We investigated whether early initiation of hemoperfusion with a polymyxin B cartridge (PMX) after the diagnosis of septic shock could improve the clinical outcome. Methods: A prospective, open-labeled, multicenter cohort study was performed at intensive care units in Japan. 41 patients received PMX within 6 h after the diagnosis of septic shock (early group) and 51 patients were treated after 6 h (late group). Results: The early group had a significantly shorter duration of ventilator support and also had a lower catecholamine requirement. PMX was effective for improvement of hypotension, hypoperfusion, the sequential organ failure assessment score, and pulmonary oxygenation regardless of the timing of its initiation. The 28-day mortality rate did not differ between the two groups. Conclusions: Early initiation of PMX shortened the duration of ventilator support and also reduced the catecholamine requirement, so early treatment of septic shock should achieve a better outcome.

Amino Acid Balance with Extended Daily Diafiltration in Acute Kidney Injury

Background: The impact of hybrid dialysis therapies on amino acid (AA) balance in critically ill patients with acute kidney injury is unknown. Methods: We examined prospectively the AA balance with extended daily diafiltration (EDDF). Results: We studied 7 patients. AA clearances with EDDF ranged from 21.6 ml/min (tryptophan) to 66.9 ml/min (taurine). AA loss was 4.2 (IQR 1.4–12.3) g/day and 4.5% of daily protein intake for patients on enteral nutrition (EN). Percentage AA loss per hour on EDDF was highest for glutamine (32.1%) and lowest for glutamic acid (0.8%). Blood AA levels correlated with corresponding EDDF losses. Median total nitrogen appearance was 25.0 (IQR 20.6–29.3) g/day for patients on EN. This resulted in a negative nitrogen balance of –10.7 (IQR –16.6 to –1.4) g/day, of which 6.5% was attributable to AA loss. Conclusions: AA loss with EDDF was limited, but with much individual variability, and contributed to a strongly negative daily nitrogen balance.

Low-dose citrate continuous veno-venous hemofiltration (CVVH) and acid-base balance.

Objective To evaluate the acid-base effect of low-dose regional citrate anticoagulation (RCA) during continuous veno-venous hemofiltration (CVVH). Design Prospective observational study. Setting ICUs of tertiary public and private hospitals. Subjects Thirty critically ill patients with acute renal failure at risk of bleeding or with a major contraindication to heparin-CVVH and/or short filter life. Methods We used a commercial citrate-based fluid (11 mmol/L, sodium: 140 mmol/L, chloride: 108 mmol/L and 1 mol/L of potassium) as pre-dilution replacement fluid during CVVH. Further potassium was added according to serum potassium levels. We measured all relevant variables for acid-base analysis according to the Stewart-Figge methodology. Results Before treatment, study patients had a slight metabolic acidosis, which worsened over 6 hours of RCA-CVVH (pH from 7.39 to 7.38, p<0.005; bicarbonate from 23.2 to 21.6 mmol/L, p<0.0001 and base excess from −2.0 to −3.0 mEq/L, p<0.0001) due to a significant increase in SIG (from 5.8 to 6.6 mEq/L, p<0.05) and a decrease in SIDa (from 37.5 to 36.6 mEq/L, p<0.05). These acidifying effects were attenuated by hypoalbuminemia and a decrease in lactate (from 1.48 to 1.34 mmol/L, p<0.005) and did not lead to progressive acidosis. On cessation of treatment, this acidifying effect rapidly self-corrected within six hours. Conclusions Low dose RCA-CVVH induces a mild acidosis secondary to an increased strong ion gap and decreased SIDa which fully self-corrects at cessation of therapy. Clinicians need to be aware of these effects to correctly interpret changes in acid-base status in such patients.

Contents Vol. 33,2012

Annual Congress of the 245 Chinese Blood Purification Center Administration Committee April 20–23, 2011, Beijing Guest Editor: Tao Wei (Beijing) (available online only) S. Karger Medical and Scientifi c Publishers Basel • Freiburg • Paris • London • New York • New Delhi • Bangkok • Beijing • Tokyo • Kuala Lumpur • Singapore • Sydney Disclaimer Th e statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publisher and the editor(s). Th e appearance of advertisements in the journal is not a warranty, endorsement, or approval of the products or services advertised or of their eff ectiveness, quality or safety. Th e publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements. Drug Dosage Th e authors and the publisher have exerted every eff ort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant fl ow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. Th is is particularly important when the recommended agent is a new and/or infrequently employed drug. All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specifi ed fee to the Copyright Clearance Center (see ‘General Information’).