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Unlabelled: ♦, Background: Peritoneal dialysis (PD) has limited power for liquid extraction (ultrafiltration), so fluid overload remains a major cause of treatment failure. ♦, Methods: We present steady concentration peritonal dialysis (SCPD), which increases ultrafiltration of PD exchanges by maintaining a constant peritoneal glucose concentration. This is achieved by infusing 50% glucose solution at a constant rate (typically 40 mL/h) during the 4-hour dwell of a 2-L 1.36% glucose exchange. We treated 21 fluid overload episodes on 6 PD patients with high or average-high peritoneal transport characteristics who refused hemodialysis as an alternative. Each treatment consisted of a single session with 1 to 4 SCPD exchanges (as needed). ♦, Results: Ultrafiltration averaged 653 ± 363 mL/4 h - twice the ultrafiltration of the peritoneal equilibration test (PET) (300 ± 251 mL/4 h, p < 0.001) and 6-fold the daily ultrafiltration (100 ± 123 mL/4 h, p < 0.001). Serum and peritoneal glucose stability and dialysis efficacy were excellent (glycemia 126 ± 25 mg/dL, peritoneal glucose 1,830 ± 365 mg/dL, D/P creatinine 0.77 ± 0.08). The treatment reversed all episodes of fluid overload, avoiding transfer to hemodialysis. Ultrafiltration was proportional to fluid overload (p < 0.01) and inversely proportional to final peritoneal glucose concentration (p < 0.05). ♦, Conclusion: This preliminary clinical experience confirms the potential of SCPD to safely and effectively increase ultrafiltration of PD exchanges. It also shows peritoneal transport in a new dynamic context, enhancing the influence of factors unrelated to the osmotic gradient., (Copyright © 2016 International Society for Peritoneal Dialysis.)

Background/aims: Recent updates to the Nikkiso Aquarius continuous renal replacement therapy (CRRT) platform allowed us to develop a post-dilution protocol for regional citrate anticoagulation (RCA) using standard bicarbonate buffered, calcium containing replacement solution with acid citrate dextrose formula-A as a citrate source. Our objective was to demonstrate that the protocol was safe and effective., Methods: Prospective audit of consecutive patients receiving RCA for CRRT within intensive care unit, who were either contraindicated to heparin or had poor filter lifespan (<12 h for 2 consecutive filters) on heparin., Results: We present the first 29 patients who used 98 filters. After excluding 'non-clot' filter loss, 50% had a duration of >27 h. Calcium supplementation was required for 30 (30%) filter circuits, in 17 of 29 (58%) patients. One patient discontinued the treatment due to metabolic alkalosis, but there were no adverse bleeding events., Conclusion: Post-dilution RCA system is effective and simple to use on the Aquarius platform and results in comparable filter life for patients relatively contraindicated to heparin., (© 2016 The Author(s) Published by S. Karger AG, Basel.)

Development of extracorporeal blood purification acquires greater significance in the intensive care of multiple organ failures (MOF) with all the pathophysiological aspects of its constituent parts. MOF are the main cause of mortality among critically ill patients and treatment of these patients require significant investment. The purpose of the implementation of extracorporeal blood correction techniques today is multiple organ support therapy (MOST). Early extracorporeal therapy is used only in the treatment of renal failure. Today extracorporeal techniques are increasingly being used to replace the functions of various organs and systems. MOST includes diffusion, convection, filtration, sorption, apheresis methodic. They affect the molecular and electrolyte composition of blood, allow to correct, repair, replace, and maintain homeostasis in severe multiorgan dysfunction. Extracorporeal new molecular technologies have been successfully applied in the intensive care of severe heart and respiratory failure, acute kidney injury and acute hepatic dysfunction, in the treatment of severe sepsis, metabolic disorders, the correction of immune imbalance.

Objective . To investigate the effects of 72-hour early-initiated continuous venovenous hemofiltration (ECVVH) treatment in patients with septic-shock-induced acute respiratory distress syndrome (ARDS) (not acute kidney injury, AKI) with regard to serum E-selectin and measurements of lung function and hemodynamic stability. Methods . This prospective nonblinded single institutional randomized study involved 51 patients who were randomly assigned to receive or not receive ECVVH, an ECVVH group ( n = 24) and a non-ECVVH group ( n = 27). Besides standard therapies, patients in ECVVH group underwent CVVH for 72 h. Results . At 0 and 24 h after initiation of treatment, arterial partial pressure of oxygen/fraction of inspired oxygen (PaO 2 /FiO 2 ) ratio, extravascular lung water index (EVLWI), and E-selectin level were not significantly different between groups (all P > 0.05). Compared to non-ECVVH group, PaO 2 /FiO 2 is significantly higher and EVLWI and E-selectin level are significantly lower in ECVVH group (all P < 0.05) at 48 h and 72 h after initiation of treatment. The lengths of mechanical ventilation and stay in intensive care unit (ICU) were shorter in ECVVH group (all P < 0.05), but there was no difference in 28-day mortality between two groups. Conclusions . In patients with septic-shock-induced ARDS (not AKI), treatment with ECVVH in addition to standard therapies improves endothelial function, lung function, and hemodynamic stability and reduces the lengths of mechanical ventilation and stay in ICU., Competing Interests: The authors declare that there are no competing interests regarding the publication of this paper.

Unlabelled: The number of patients with acute pancreatitis and pancreatic necrosis has been steadily increasing. Mortality in infected pancreatic necrosis remains high., Aim: To develop measures to prevent infection of pancreatic necrosis by timely correction of intra-abdominal hypertension and the syndrome of intestinal failure., Material and Methods: Developed a package of measures, consisting of early intestinal lavage and enterosorption, intravenous highdoses of octreotide, epidural blockade, adequate detox and the start of effective antimicrobial therapy. Comparative evaluation of clinical, laboratory and instrumental data in the primary (n=50) and control (n=50) groups., Results: In the main group pancreatogenic sepsis occurred in 10%, control 18%. Mortality, respectively, was 8 and 16%.

Objective: This study is to evaluate the effect of high-volume hemofiltration (HVHF) and early goal-directed therapy (EGDT) on alveolar-arterial oxygen exchange in patients with refractory septic shock., Patients and Methods: Patients were classified into two groups by a prospective cohort study: 86 received both HVHF and EGDT (the HVHF group), and 81 treated with EGDT only (the control group). Alveolar-arterial oxygen pressure was taken at baseline and at days 1, 3, and 7, and respiratory index (RI, ratio of P(a)O2 alveolar-arterial oxygen pressure difference (P(A-a)DO2) to arterial oxygen pressure (P(a)O2) was calculated., Results: At day 7, the levels of central venous and arterial blood oxygen content were significantly higher in the HVHF vs. the control group (both with p < 0.05). The level of oxygen extraction ratio (O2ER) was significantly higher in the HVHF than the control group (p < 0.01). The levels of P(A-a)DO2 and RI were significantly lower in the HVHF than the control group (p < 0.05 and p < 0.01, respectively). RI and the ratio of P(a)O2 to the fraction of inspired oxygen were significantly higher in the HVHF than the control group (p < 0.05 and p < 0.01, respectively). The acute physiology and chronic health evaluation score and the sequential organ failure assessment score in the HVHF group were significantly lower compared to the control group (p < 0.01 and p < 0.05, respectively). At day 28, the mortality rate was lower in the HVHF vs. the control group (p < 0.01)., Conclusions: These findings demonstrated that HVHF, when used as an adjunctive therapy to the EGDP protocol, could improve alveolar-arterial oxygen exchange, clinical outcome and survival in patients with refractory septic shock.

Venovenous extracorporeal membrane oxygenation (vv-ECMO) is a highly invasive method for organ support that is gaining in popularity due to recent technical advances and its successful application in the recent H1N1 epidemic. Although running a vv-ECMO program is potentially feasible for many hospitals, there are many theoretical concepts and practical issues that merit attention and require expertise. In this review, we focus on indications for vv-ECMO, components of the circuit, and management of patients on vv-ECMO. Concepts regarding oxygenation and decarboxylation and how they can be influenced are discussed. Day-to-day management, weaning, and most frequent complications are covered in light of the recent literature.

The 1980s saw the use of continuous arteriovenous hemofiltration whose intensity hemofiltration rate was only 3 or 4 mL kg⁻¹ h⁻¹. With the installation of a blood pump, this dose went up to 8 or 10 mL kg⁻¹ h⁻1, and continued to increase, reaching about 20 mL kg⁻¹ h⁻¹ by the year 2000. Some studies found that a higher dose could be beneficial, and the world rapidly followed the trend, increasing the dose up to 35 mL kg⁻¹ h⁻¹. Then, two randomized control trials, namely the VA/NIH Acute Renal Failure Trial Network study and the RENAL study, came along in succession which changed the Kidney Disease: Improving Global Outcomes (KDIGO) recommendation to 20 to 25 mL kg⁻¹ h⁻¹. However, no good evidence exists to support this. Our recent multicenter retrospective studies from the JSEPTIC CRRT database show that the Japanese continuous renal replacement therapy dose of (14.3 mL kg⁻¹ h⁻¹) does not seem to have worse outcomes when compared with a higher dose.

Objective: Crush syndrome (CS) is a common critical condition. This study aimed to establish crush syndrome goat model through muscle injection of glycerol and test the effect of continuous veno-venous hemofiltraion (CVVH)., Methods: 12 male goats at 12-15 months age were randomly assigned into control, model, and CVVH groups. After 2 weeks of normal feeding, the goats were weighed and stripped off foods for 24 h. Goats in the model and CVVH groups were then injected with 50% glycerol athind legs. Diagnosis of CS was established based on serum creatine kinase (CK) > 1 000 U/L and serum creatinine (sCr) > 2 times of standard. No intervention was given to goats in the control group. A catheter was planted to get blood access. CVVH was administered using a Prisma-flex machine, with blood flow being set at 100 mL/min and replacement fluid with predilution at 35 mL/(kg x h). After 23 h of treatment, the goats were sacrificed. Plasma and kidney samples were taken., Results: Bloody urine hyperkalemia and decrease of urine volume were found in all of the goats injected with glycerol. Serum CK and sCr increased 1 h after the injection compared with the controls. After 23 h of CVVH treatment, serum CK and sCr decreased compared with goats in the model group. The light microscope revealed manifestation of tubular necrosis and interstitial edema, but the glomeruli were almost normal. The electronic microscope found prominent signs of cell apoptosis, such as chromatin aggregation, mitochondrial swelling, and endoplasmic reticulum expansion. Caspase12 expression in the goats with CS was significantly higher than that in the controls. The CVVH treated goats had lower level of expression than those in the model group (P < 0.05). TUNEL staining identified a higher proportion of renal cell apoptosis in the goats in the model group compared with those in the CVVH group., Conclusion: Muscle injection with glycerol can induce CS in goats. Early CVVH intervention improves renal function and alleviates renal tubular cell apoptosis.

Objective: To evaluate the effect of hemofiltration during cardiopulmonary bypass on lactate level in adult patients who underwent cardiac surgery., Design: An observational study., Setting: Prince Sultan cardiac center, Riyadh, Saudi Arabia., Participants: The study included 283 patients classified into two groups: Hemofiltration group (n=138), hemofiltration was done during CPB. Control group (n = 145), patients without hemofiltration., Interventions: Hemofiltration during cardiopulmonary bypass., Measurements and Main Results: Monitors included hematocrit, lactate levels, mixed venous oxygen saturation, amount of fluid removal during hemofiltration and urine output. The lactate elevated in group H than group C (P < 0.05), and the PH showed metabolic acidosis in group H (P < 0.05). The mixed venous oxygen saturation decreased in group H than group C (P < 0.05). The number of transfused packed red blood cells was lower in group H than group C (P < 0.05). The hematocrit was higher in group H than group C (P < 0.05). The urine output was lower in group H than group C (P < 0.05)., Conclusions: Hemofiltration during cardiopulmonary bypass leads to hemoconcentration, elevated lactate level and increased inotropic support. There are some recommendations for hemofiltration: First; Hemofiltration should be limited for patients with impaired renal function, positive fluid balance, reduced response to diuretics or prolonged bypass time more than 2 hours. Second; Minimal amount of fluids should be administered to maintain adequate cardiac output and reduction of priming volumes is preferable to maintain controlled hemodilution. Third; it should be done before weaning of or after cardiopulmonary bypass and not during the whole time of cardiopulmonary bypass.

Background: Cardiopulmonary bypass (CPB) is associated with morbidity and mortality. To reduce its adverse effect modified ultrafiltration is being increasingly employed. This study is planned to evaluate the benefits of modified ultrafiltration (MUF) in adult cardiac surgery., Methods: Eighty consecutive patients presenting to adult cardiac surgery as elective case were enrolled. These patients were randomly divided in to two groups. MUF group which received modified ultrafiltration after separation from CPB and control group which did not receive modified ultrafiltration. Postoperative mediastinal and chest drainage in 24 hrs, blood products requirement, reopening, ICU stay, and mortality in 30 days were recorded. These variables were compared between MUF group and control group., Results: Forty patients were randomized to control group and 40 in MUF group. Mean age was 51.15 ± 8.90 in control group as compared to 46.95 ± 13.24 MUF group (p = 0.1). Out of 40 patients in control group 7 (17.5%) were female while 11 (27.5%) out of total 40 were female in MUF group. (p = .284). Mean CBP time was 120.62 ± 20.97 in control group versus 117.37 ± 38.78 in MUF group (p = 0.64). Post-operative drain output ranged from 330 ml to 1300 ml in control group and 300 ml to 780 ml in MUF group. Mean postoperative drain output 554.25 ± 192.57 in control group versus 439.22 ± 89.59 in MUF group (p = .001). Three (7.5%) out of 40 patients required re-exploration in control group versus 1 (2.5%) in MUF group. (p = .305). Mean ICU stay was 52.80 ± 22.37 hours in control group versus 45.30 ± 21.82 hours in MUF group (p = 0.133). Three (7.5%) out of 40 patients died in control group versus 1 (2.5%) in MUF group. (p = 0.305)., Conclusion: Use of modified ultrafiltration is associated with low postoperative bleeding less requirements of blood and blood products.

Citrate has been recommended as the first-line anticoagulant for continuous renal replacement therapy (CRRT) in critically ill patients. Compared with heparin, citrate anticoagulation is safer and more efficacious. Citrate inhibits the coagulation cascade by lowering the ionized calcium (iCa) concentration in the filter. Monitoring of systemic iCa concentrations is inherent to the protocol, and monitoring of postfilter iCa is recommended to adjust citrate flow and optimize anticoagulation. While systemic iCa targets are in the physiological range, postfilter iCa concentrations are targeted between 0.20 and 0.35 mmol/l. In a previous issue of Critical Care, Schwarzer et al. compared systemic and postfilter iCa measurements of patients receiving citrate-based CRRT between six devices. They highlight the unreliability of iCa concentrations in the postfilter range, because the instruments cannot be validated in the low iCa range. The maximum mean difference between two instruments was as high as 0.33 mmol/l (range 0.21-0.50 mmol/l). The authors call for dialysis companies to revise their protocols. However, the first implication of their study is that the accuracy of blood gas analyzers to measure iCa in the low range needs to improve; and, secondly, clinicians using citrate anticoagulation need to be aware that the postfilter iCa result may be falsely high or low. This is particularly relevant when frequent premature filter clotting is observed despite postfilter iCa results in the seemingly target range. In these situations, citrate flow can be safely increased up to 4 mmol/l blood flow under monitoring of signs of citrate accumulation.

Objective: To implement hypothermia during blood purification to investigate its effect and risk in the treatment of postoperative cardiogenic shock in valvular heart disease., Methods: A non-blinded prospective randomized controlled trial (RCT) was conducted. Patients with valvular heart disease suffering from postoperative cardiogenic shock admitted to intensive care unit (ICU) of Wuhan Asian Heart Hospital from January 2011 to December 2014 were enrolled, and they were randomly divided into normothermic continuous blood purification (CBP) group (NT group) and hypothermia CBP group (HT group) according to random number table and envelope enclosed method. The patients in both groups were given continuous renal replacement therapy (CVVH), the blood temperature in NT group was remained at 36.5-37.3 °C , and it was controlled at 34.0-35.0 °C in HT group. The data were collected before and 1, 2, 3 days after treatment, including cardiac index (CI), the oxygen supply/oxygen consumption ratio (DO₂/VO₂), acute physiology and chronic health evaluation III (APACHE III) score, multiple organ dysfunction (MODS) score. The length of ICU stay, duration of mechanical ventilation, duration of CBP, ICU mortality and the incidence of complication were recorded., Results: A total of 95 patients were enrolled, with 47 patients in NT group, and 48 in HT group. There was no significant difference in gender, age, preoperative cardiac function, cardiothoracic ratio and type of valve replacement between two groups. Compared with those before treatment, no significant difference was found in CI, DO₂/VO₂ ratio, APACHE III score, MODS score on 1, 2, 3 days after treatment in NT group (all P > 0.05). But in HT group, DO₂/VO₂ ratio was significantly improved on 1 day after treatment (2.5 ± 0.7 vs. 1.8 ± 0.4, P < 0.05), CI (mL · s⁻¹ · m⁻²: 50.01 ± 8.34 vs. 31.67 ± 11.67), APACHE III score ( 50.6 ± 6.2 vs. 77.5 ± 5.5), and MODS score (6.0 ± 1.5 vs. 9.3 ± 3.4) were significantly improved 3 days after treatment (all P < 0.05). Compared with those in NT group, DO₂NO2 ratio in HT group was significantly increased from 1 day after treatment (2.5 ± 0.7 vs. 1.8 ± 0.4, P < 0.05), and CI (mL · s⁻¹ · m⁻²: 38.34 ± 10.00 vs. 35.01 ± 6.67), APACHE III score (68.9 ± 7.1 vs. 81.2 ± 7.3), and MODS score (8.9 ± 2.7 vs. 10.6 ± 2.4) were significantly improved from 2 days after treatment (all P < 0.05). In respect of clinical outcomes, compared with NT group, the length of ICU stay (days: 6.9 ± 3.4 vs. 12.5 ± 3.5, t = 2.024, P = 0.017) and duration of mechanical ventilation (days: 4.2 ± 1.3 vs. 7.5 ± 2.7, t = 1.895, P = 0.034) in HT group was significantly shortened, duration of CBP was also significantly shortened (days: 4.6 ± 1.4 vs. 10.5 ± 4.0, t = 2.256, P = 0.019), and ICU mortality was significantly lowered (12.50% vs. 23.40, χ² = 1.987, P = 0.024), but there was no significant difference in incidence of infection (54.17% vs. 53.19%, χ² = 0.689, P = 0.341), ventricular arrhythmia (31.25% vs. 36.17%, χ² = 0.772, P = 0.237), and muscle fibrillation (14.58% vs. 8.51%, χ² = 0.714, P = 0.346), and blood loss (mL: 617.0 ± 60.7 vs. 550.9 ± 85.2, t = 1.290, P = 0.203) between HT group and NT group. The incidence of bradycardia in HT group was significantly higher than that of the NT group (29.17% vs. 14.89%, χ² = 2.368 P = 0.029)., Conclusion: Blood purification under hypothermia is a safe and effective therapeutic procedure for postoperative cardiogenic shock in patients with valvular heart disease, and it may improve the prognosis of postoperative patients.

Purpose: We compared hemodynamic and biological effects of the Cascade system, which uses very high volume hemofiltration (HVHF) (120 mL kg(-1) h(-1)), with those of usual care in patients with septic shock., Methods: Multicenter, prospective, randomized, open-label trial in three intensive care units (ICU). Adults with septic shock with administration of epinephrine/norepinephrine were eligible. Patients were randomized to usual care plus HVHF (Cascade group), or usual care alone (control group). Primary end point was the number of catecholamine-free days up to 28 days after randomization. Secondary end points were number of days free of mechanical ventilation, renal replacement therapy (RRT) or ICU up to 90 days, and 7-, 28-, and 90-day mortality., Results: We included 60 patients (29 Cascade, 31 usual care). Baseline characteristics were comparable. Median number of catecholamine-free days was 22 [IQR 11-23] vs 20 [0-25] for Cascade vs control; there was no significant difference even after adjustment. There was no significant difference in number of mechanical ventilation-free days or ICU requirement. Median number of RRT-free days was 85 [46-90] vs 74 [0-90] for Cascade vs control groups, p = 0.42. By multivariate analysis, the number of RRT-free days was significantly higher in the Cascade group (up to 25 days higher after adjustment). There was no difference in mortality at 7, 28, or 90 days., Conclusion: Very HVHF using the Cascade system can safely be used in patients presenting with septic shock, but it was not associated with a reduction in the need for catecholamines during the first 28 days.

Objectives: To measure plasma nucleosome levels and expression of toll-like receptors (TLRs) in a pilot cohort of patients with severe acute kidney injury (AKI) within a randomised controlled trial of continuous venovenous haemofiltration with high cut-off filters (CVVH-HCO) v standard filters (CVVH-std)., Methods: We measured plasma nucleosome levels using the Cell Death Detection ELISA PLUS (10X) assay kit. We analysed plasma levels for correlation with disease severity and compared the effects of CVVH-HCO and CVVH-std on plasma nucleosome levels over the first 72 hours. We studied cell surface TLR expression on CD14-positive monocytes in a subcohort of CVVH-HCO patients., Results: We did not detect nucleosomes in normal human plasma, but found elevated nucleosome levels in patients with severe AKI. Nucleosome levels at randomisation correlated weakly with Acute Physiology and Chronic Health Evaluation III scores (Pearson ρ=0.475, P=0.016). Treatment with CVVH-HCO or CVVH-std had no effect on nucleosome levels over 72 hours. The mean fluorescence intensity (MFI) ratios of TLR2 and TLR4 expression were elevated throughout the 72-hour period (range for TLR2, 0.97-3.98; range for TLR4, 0.91-10.18) and did not appear to decrease as a result of treatment with CVVH-HCO., Conclusions: Nucleosome concentration was elevated in the plasma of patients with severe AKI and mildly correlated with disease severity, but was not affected by treatment with CVVH-HCO or CVVH-std. Similarly, levels of TLR2 and TLR4 expression did not decrease over time during CVVHCrit HCO treatment.

Objective: To assess the safety and efficacy of combining extracorporeal CO2 removal with continuous renal replacement therapy in patients presenting with acute respiratory distress syndrome and acute kidney injury., Design: Prospective human observational study., Settings: Patients received volume-controlled mechanical ventilation according to the acute respiratory distress syndrome net protocol. Continuous venovenous hemofiltration therapy was titrated to maintain maximum blood flow and an effluent flow of 45 mL/kg/h with 33% predilution., Patients: Eleven patients presenting with both acute respiratory distress syndrome and acute kidney injury required renal replacement therapy., Interventions: A membrane oxygenator (0.65 m) was inserted within the hemofiltration circuit, either upstream (n = 7) or downstream (n = 5) of the hemofilter. Baseline corresponded to tidal volume 6 mL/kg of predicted body weight without extracorporeal CO2 removal. The primary endpoint was 20% reduction in PaCO2 at 20 minutes after extracorporeal CO2 removal initiation. Tidal volume was subsequently reduced to 4 mL/kg for the remaining 72 hours., Measurements and Main Results: Twelve combined therapies were conducted in the 11 patients. Age was 70 ± 9 years, Simplified Acute Physiology Score II was 69 ± 13, Sequential Organ Failure Assessment score was 14 ± 4, lung injury score was 3 ± 0.5, and PaO2/FIO2 was 135 ± 41. Adding extracorporeal CO2 removal at tidal volume 6 mL/kg decreased PaCO2 by 21% (95% CI, 17-25%), from 47 ± 11 to 37 ± 8 Torr (p < 0.001). Lowering tidal volume to 4 mL/kg reduced minute ventilation from 7.8 ± 1.5 to 5.2 ± 1.1 L/min and plateau pressure from 25 ± 4 to 21 ± 3 cm H2O and raised PaCO2 from 37 ± 8 to 48 ± 10 Torr (all p < 0.001). On an average of both positions, the oxygenator's blood flow was 410 ± 30 mL/min and the CO2 removal rate was 83 ± 20 mL/min. The oxygenator blood flow (p <0.001) and the CO2 removal rate (p = 0.083) were higher when the membrane oxygenator was placed upstream of the hemofilter. There was no safety concern., Conclusions: Combining extracorporeal CO2 removal and continuous venovenous hemofiltration in patients with acute respiratory distress syndrome and acute kidney injury is safe and allows efficient blood purification together with enhanced lung protective ventilation.

Rationale: Post-cardiac surgery shock is associated with high morbidity and mortality. By removing toxins and proinflammatory mediators and correcting metabolic acidosis, high-volume hemofiltration (HVHF) might halt the vicious circle leading to death by improving myocardial performance and reducing vasopressor dependence., Objectives: To determine whether early HVHF decreases all-cause mortality 30 days after randomization., Methods: This prospective, multicenter randomized controlled trial included patients with severe shock requiring high-dose catecholamines 3-24 hours post-cardiac surgery who were randomized to early HVHF (80 ml/kg/h for 48 h), followed by standard-volume continuous venovenous hemodiafiltration (CVVHDF) until resolution of shock and recovery of renal function, or conservative standard care, with delayed CVVHDF only for persistent, severe acute kidney injury., Measurements and Main Results: On Day 30, 40 of 112 (36%) HVHF and 40 of 112 (36%) control subjects (odds ratio, 1.00; 95% confidence interval, 0.64-1.56; P = 1.00) had died; only 57% of the control subjects had received renal-replacement therapy. Between-group survivors' Day-60, Day-90, intensive care unit, and in-hospital mortality rates, Day-30 ventilator-free days, and renal function recovery were comparable. HVHF patients experienced faster correction of metabolic acidosis and tended to be more rapidly weaned off catecholamines but had more frequent hypophosphatemia, metabolic alkalosis, and thrombocytopenia., Conclusions: For patients with post-cardiac surgery shock requiring high-dose catecholamines, the early HVHF onset for 48 hours, followed by standard volume until resolution of shock and recovery of renal function, did not lower Day-30 mortality and did not impact other important patient-centered outcomes compared with a conservative strategy with delayed CVVHDF initiation only for patients with persistent, severe acute kidney injury. Clinical trial registered with www.clinicaltrials.gov (NCT 01077349).

Patients with severe hypernatremia who receive conventional treatment are often undertreated. Data on the management of acute hypernatremia using continuous venovenous hemofiltration (CVVH) are limited to anecdotes. This study aimed to evaluate the efficacy and safety of CVVH treatment for acute severe hypernatremia in critically ill patients in a retrospective cohort. A total of 95 patients who were admitted to our ICU between January 2009 and January 2014 were analyzed as the original cohort. These patients were divided into CVVH and conventional treatment groups. The patients in the conventional and CVVH groups were then matched by age, reason for ICU admission, vasopressor dependency, basic serum sodium concentration, and Glasgow scores. A Cox regression model was used to adjust the confounding variables. In the original cohort, the 28-day survival rates were 41.9% and 25.0% for the CVVH and conventional treatment groups, respectively. Conventional treatment (HR = 2.1, 95% CI 1.1-3.8, P = 0.019) was an independent predictor of patient mortality in the multivariate Cox regression model. In the matched cohort, the two groups were not significantly different in baseline characteristics. The CVVH group had a significantly greater reduction in the serum sodium concentration (0.78 [0.63-1.0] mmol/L/h versus 0.13 [0.009-0.33] mmol/L/h), P < 0.001) and an improved 28-day survival rate (34.8% vs. 8.7%, P = 0.002) compared with the conventional treatment group. The two groups did not differ significantly in treatment-related complications. CVVH treatment is possibly more effective than conventional treatment for the management of acute severe hypernatremia in critically ill patients.

Heart failure (HF) is a common and important cause of morbidity and mortality in the elderly, imposing a significant burden on healthcare systems. Better management of ischemic heart disease has resulted in increased survival and growth in the number of prevalent heart failure patients, but co-existing renal impairment complicates management and limits traditional therapeutic options. Ultrafiltration (UF) techniques have shown promise in the treatment of diuretic-resistant HF, but the early successes of extracorporeal treatments has not been confirmed by randomized trials. Peritoneal dialysis (PD) may be cheaper and provide more effective UF therapy in selected patients and this review examines the issues surrounding the use of PD for such patients. Whist many nephrologists are enthusiastic about the use of this technique, making a more cogent case for PD in this setting for cardiologists is likely to need a combined strategy of demonstrating improvement in individual cases and further study of potential medicoeconomic benefits., (Copyright © 2015 International Society for Peritoneal Dialysis.)

Extreme hypernatremia in intensive care unit are frequently associated with a poor prognosis and their treatment, when associated with acute renal failure, is not consensual. We report the case of a 39-year-old man admitted in our intensive care unit for coma who presented extreme hyperosmolar hypernatremia (sodium 180 mmol/L, osmolarity 507 mOsm/L) associated with acute renal failure (urea 139.3 mmol/L, creatinine 748 μmol/L) and many other metabolic abnormalities. He was treated with hypotonic fluid administration and continuous renal replacement therapy (veno-venous hemodiafiltration) using an industrial dialysate fluid. Natremia was controlled by modulating intravenous water and sodium intake according to biological data. After 10 days, continuous renal replacement therapy was stopped and neurological exam was normal. Continuous veno-venous hemodiafiltration may be useful for treatment of extreme hypernatremia by allowing gradual correction of fluid and electrolyte disorders., (Copyright © 2015 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.)

Background: The heparin requirement for coupled plasma filtration adsorption (CPFA) is usually high. Heparin administration often cannot be adherent to prescription, leading to a premature clotting of circuit and an insufficient volume of treated plasma. Regional citrate anticoagulation (RCA) could be an attractive alternative; however, no data are available on citrate pharmacokinetics at high levels of circuit citratemia., Methods: Fifteen septic shock patients with acute kidney injury undergoing CPFA with RCA at target circuit citratemia of 6 mmol/L were treated with CPFA-haemofiltration in pure predilution (CPFA-HF predilution group, n = 5 patients), or predilution haemodiafiltration (CPFA-HDF predilution group, n = 5 patients) or pre- and postdilution haemofiltration (CPFA-HF pre/postdilution group, n = 5 patients). Citrate pharmacokinetics was carried out through its determination in systemic and circuit blood, and effluent at time 0, 0.2, 1, 3, 6 and 9 h., Results: The systemic concentrations of citrate in the CPFA-HF predilution group significantly increased over the sessions (from basal level of 0.21 to 0.76 mmol/L at 3 h), whereas they did not change in CPFA-HDF predilution and CPFA-HF pre/postdilution groups. Circuit plasma citrate concentrations (from 3 to 8 mmol/L) correlated strongly with circuit iCa++ levels (Spearman R = -0.7022, P < 0.01). Sieving coefficients of citrate were near the unit in all three groups and unrelated to blood and infusion flow rates in predilution. However, the amount of citrate removed by effluent was ∼40% for the CPFA-HF predilution group and reached 60% for both the CPFA-HDF predilution and CPFA-HF pre/postdilution groups (P < 0.05). As for the efficiency of plasmafiltration, the plasmafiltrate volume (from 17 to 20 mL/kg/day) was not significantly different among the groups., Conclusions: These results demonstrated that in refractory septic shock patients on CPFA at circuit citratemia of 6 mmol/L both HDF predilution and HF pre/postdilution were the best dialysis modalities to maintain a normal systemic citratemia through a high rate of citrate loss in the effluent., (© The Author 2015. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.)

Background: Novel putative mediators of acute kidney injury (AKI) include immune-cell derived tumour necrosis factor-like weak inducer of apoptosis (TWEAK), angiopoietin-2 (Ang-2) and protein pentraxin-3 (PTX3). The effect of continuous venovenous hemofiltration (CVVH) and different anticoagulation regimens on plasma levels were studied., Methods: At 0, 10, 60, 180 and 720 min of CVVH, samples were collected from pre- and postfilter blood and ultrafiltrate. No anticoagulation (n = 13), unfractionated heparin (n = 8) or trisodium citrate (n = 21) were compared., Results: Concentrations of TWEAK, Ang-2 and PTX3 were hardly affected by CVVH since the mediators were not (TWEAK, PTX3) or hardly (Ang-2) detectable in ultrafiltrate, indicating negligible clearance by the filter in spite of molecular sizes (TWEAK, PTX3) at or below the cutoff of the membrane. Heparin use, however, was associated with an increase in in- and outlet plasma TWEAK., Conclusion: Novel AKI mediators are not cleared nor produced by CVVH. However, heparin anticoagulation increased TWEAK levels in patient's plasma whereas citrate did not, favouring the latter as anticoagulant in CVVH for AKI.

Objective: To explore the effects of high-volume hemofiltration (HVHF) on the plasma interleukin-6 (IL-6), pro-calcitonin (PCT), extra vascular lung water index (EVLWI) and alveolar-arterial oxygen exchange in patients with septic shock., Patients and Methods: 97 cases intensive patients with septic shock were enrolled  from Department of Intensive Care Unit (ICU) of the Provincial Hospital affiliated to Shandong University between January 2011 and December 2014. According to the puting into practice of high-volume hemofiltration (HVHF) or not, all the patients were divided in two groups (NHVHF group, group A, n = 46 cases) and (HVHF group, group B, n = 51 cases). The plasma IL-6, PCT intrathoracic blood volume index (ITBVI), extra-vascular lung water index (EVLWI) and pulmonary vascular permeability index(PVPI) was detected before treatment and after treatment 24h, 72h The Alveolar- arterial oxygen pressure difference P(A-a)DO2 was checked by arterial blood gas analysis (ABGA) at first and after treatment 24 hour, 72 hour, 7 day in two groups. The mortality at 28 day was compared between two groups., Results: After 72h treatment, the plasma IL-6, PCT in group B has a significant decrease. After 72h treatment, the level ITBVI, EVLWI and PVPI in group B had a significant improvement. The levels of P(A-a)DO2 in HVHF group were reduced more significantly than N-HVHF group after 7 day. The EVLWI and P(A-a)DO2 had a significant positive correlation (correlation ratio = 0.712, 95% confident interval [0.617, 0.773], p = 0.001). The mortality at 28 day had a significant decrease between groups (15.22% vs. 34.15% χ2 = 4.242, p = 0.038)., Conclusions: HVHF could decrease plasma inflammatory factors and EVLWI so that it could improve the levels of alveolar-arterial-oxygen exchange in patients with septic shock, so it could improve the survival rate of patients.

Introduction: Ionized calcium (iCa) concentration is often used in critical care and measured using blood gas analyzers at the point of care. Controlling and adjusting regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) involves measuring the iCa concentration in two samples: systemic with physiological iCa concentrations and post filter samples with very low iCa concentrations. However, modern blood gas analyzers are optimized for physiological iCa concentrations which might make them less suitable for measuring low iCa in blood with a high concentration of citrate. We present results of iCa measurements from six different blood gas analyzers and the impact on clinical decisions based on the recommendations of the dialysis' device manufacturer., Method: The iCa concentrations of systemic and post filter samples were measured using six distinct, frequently used blood gas analyzers. We obtained iCa results of 74 systemic and 84 post filter samples from patients undergoing RCA for CRRT at the University Medicine of Greifswald., Results: The systemic samples showed concordant results on all analyzers with median iCa concentrations ranging from 1.07 to 1.16 mmol/L. The medians of iCa concentrations for post filter samples ranged from 0.21 to 0.50 mmol/L. Results of >70% of the post filter samples would lead to major differences in decisions regarding citrate flow depending on the instrument used., Conclusion: Measurements of iCa in post filter samples may give misleading information in monitoring the RCA. Recommendations of the dialysis manufacturer need to be revised. Meanwhile, little weight should be given to post filter iCa. Reference methods for low iCa in whole blood containing citrate should be established.

Background and Objectives: The evidence for high-volume hemofiltration plus hemoperfusion (HVHF&HP) for hyperlipidemic severe acute pancreatitis (HL-SAP) is anecdotal. The purpose of our study was to evaluate the efficacy of HVHF&HP for HL-SAP in a prospective controlled study., Design and Setting: Prospective controlled pilot study between May 2010 and May 2013 in a hospital intensive care unit., Patients and Methods: HL-SAP patients chose conventional treatment alone (the control group) or conventional treatment combined with the experimental protocol (the HVHF&HP group) and were prospectively followed in our hospital. APACHE II score, SOFA score, ICU and hospital stay duration, and serum biomarkers were considered endpoints., Results: Ten HL-SAP patients accepted conventional treatment alone (the control group) and 10 patients underwent HVHF&HP combined with conventional treatment (the HVHF&HP group). The APACHE II score, SOFA score, systolic blood pressure, diastolic blood pressure, heart rate, serum amylase, and serum creatinine were significantly reduced after the HVHF&HP treatment. The changes in these variables were significantly different between the HVHF&HP and control group at 48 hours after the initiation of treatment. Patients in the HVHF&HP group had a significantly shorter ICU stay (P=.015). The reduction in serum triglyceride and cholesterol in the HVHF&HP group after 2, 6, 12, 24, and 48 hours was greater than the control group. All of the tested serum cytokines were significantly decreased after HVHF&HP treatment (P < .05). However, in patients who underwent conventional treatment alone, there was no significant change in the serum cytokines., Conclusion: This study suggests that the addition of HVHF&HP to conventional treatment for HL-SAP patients may be superior to conventional treatment alone for the improvement of serum biomarkers and clinical outcomes.

Objective: To improve the results of abdominal sepsis treatment by comprehensive application of extracorporeal detoxification methods controlled by tissue perfusion., Subject and Methods: Fifteen patients with abdominal sepsis were examined, septic shock was diagnosed to all of them. Patients were divided into two groups. The first group (n = 7) consists of patients with acute renal failure, who had undergone adsorption of Lipopolysaccharide. The second group (n = 8) consists of patients with acute renalfailure, who had undergone prolonged hemofiltration regardless of the products of nitrogen metabolism level to terminate systemic inflammatory response. Dynamic monitoring of tissue perfusion was performed using Doppler ultrasound flowmeter methods., Results: According to high frequency Doppler ultrasound results all the patients with abdominal sepsis have significant peripheral circulatory disorders maintaining in volumetric and linear blood flow velocity reduction. As a result of application extracorporeal detoxification methods indexes of tissue perfusion were improved. Performance of selective endotoxine hemosorbtion and hemofiltration provides substantially stabilizing effect on Doppler microcirculation indexes: average volumetric blood flow velocity (Qam) increased 4.5 times, end-diastolic linear blood flow velocity (Vakd)--increased to 85%, peripheral resistance index (RI) reduced 2.8 times. Doppler tissue perfusion indexes monitoring allows directly monitor extracorporeal detoxification methods effectiveness, supplementing system hemodynamic monitoring data., Conclusion: Timely application extracorporeal detoxification methods in abdominal sepsis can improve tissue perfusion.

Background: Variant Creutzfeldt-Jakob disease (vCJD) is a transmissible spongiform encephalopathy affecting humans, acquired initially through infection with bovine spongiform encephalopathy (BSE). A small number of vCJD cases have been acquired through the transfusion of blood from asymptomatic donors who subsequently developed vCJD. Filter devices that selectively bind the infectious agent associated with prion disease have been developed for removal of infection from blood. This study independently assessed one such filter, the P-CAPT filter, for efficacy in removing infectivity associated with the BSE agent in sheep blood. The sheep BSE model has previously been used to evaluate the distribution of infectivity in clinically relevant blood components. This is the first study to assess the ability of the P-CAPT filter to remove endogenous infectivity associated with blood components prepared from a large animal model., Study Design and Methods: Paired units of leukoreduced red blood cells (LR-RBCs) were prepared from donors at the clinical stage of infection and confirmed as having BSE. One cohort of recipients was transfused with LR-RBCs alone, whereas a parallel cohort received LR and P-CAPT-filtered RBCs (LR-RBCs-P-CAPT)., Results: Of 14 recipients, two have been confirmed as having BSE. These sheep had received LR-RBCs and LR-RBCs-P-CAPT from the same donor., Conclusions: The results indicate that, after leukoreduction and P-CAPT filtration, there can still be sufficient residual infectivity in sheep RBCs to transmit infection when transfused into a susceptible recipient., (© 2015 AABB.)

Objective: To investigate the effects of application of intermittent hemofiltration combined with hemoperfusion (HP) in the early stage of severe burn in the prevention and treatment of sepsis., Methods: Forty severely burned patients, admitted to our burn ward from June 2011 to March 2013, conforming to the study criteria, were divided into conventional treatment group (CT, n=20) and blood purification group (BP, n=20) according to the random number table. Patients in group CT received CT according to the accepted principles of treatment for a severe burn. Patients in group BP received CT and intermittent hemofiltration combined with HP once respectively on post injury day (PID) 3, 5, and 7, spanning 6 to 8 hours for each treatment. On PID 3, 5, 7, 10, and 14, body temperature, heart rate, and respiratory rate were recorded; white blood cell count (WBC), neutrophil granulocytes, blood urea nitrogen (BUN), and creatinine were determined; levels of IL-1, IL-6, TNF-α, and high-mobility group box 1 (HMGB1) in serum were determined by ELISA; level of LPS in serum was determined with the chromogenic substrate limulus amebocyte lysate method; level of procalcitonin (PCT) in serum was determined by double antibody sandwich immune chemiluminescence method. The symptoms and signs of sepsis were observed during the treatment. Data were processed with Fisher's exact test, chi-square test, analysis of variance for repeated measurement, and LSD-t test., Results: (1) Except for that on PID 5, the mean body temperature of patients in group BP was significantly lower than that of group CT at each of the rest time points (with t values from 1.87 to 2.97, P values below 0.05). The heart rate was significantly slower in patients of group BP than in group CT from PID 3 to 14 (with t values from 1.78 to 3.59, P values below 0.05). Except for that on PID 3, the respiratory rate of patients in group BP was significantly slower than that of group CT at each of the rest time points (with t values from 1.93 to 2.85, P values below 0.05). (2) The levels of WBC, neutrophil granulocytes, BUN, and creatinine of patients in group BP were significantly lower than those of group CT (with t values from 1.78 to 4.23, P values below 0.05). (3) Except for that on PID 3, the level of IL-1 of patients in group BP was significantly lower than that of group CT at each of the rest time points (with t values from 1.97 to 4.16, P values below 0.05). Except for that on PID 7, the level of IL-6 of patients in group BP was significantly lower than that of group CT at each of the rest time points (with t values from 2.11 to 6.34, P values below 0.05). The levels of TNF-α and HMGB1 of patients in group BP were significantly lower than those of group CT from PID 3 to 14 (with t values from 1.98 to 5.29, P values below 0.05). (4) On PID 3, 5, 7, 10, and 14, the levels of LPS and PCT of patients in group BP were respectively (0.23 ± 0.07), (0.27 ± 0.09), (0.22 ± 0.06), (0.20 ± 0.08), (0.15 ± 0.07) EU/mL, and (0.44 ± 0.12), (0.67 ± 0.13), (0.74 ± 0.13), (0.64 ± 0.12), (0.71 ± 0.10) ng/mL, and they were lower than those of group CT [(0.37 ± 0.08), (0.45 ± 0.09), (0.56 ± 0.09), (0.48 ± 0.08), (0.40 ± 0.08) EU/mL, and (0.74 ± 0.11), (1.16 ± 0.12), (1.40 ± 0.13), (1.55 ± 0.15), (1.49 ± 0.14) ng/mL, with t values from 1.88 to 3.43, P values below 0.05]. (5) The incidence of sepsis of patients in group BP was obviously lower than that of group CT (χ² = 6.94, P<0.01)., Conclusions: Intermittent hemofiltration combined with HP can effectively improve blood biochemical indexes and vital signs and reduce the occurrence of burn sepsis by decreasing the levels of proinflammatory cytokines, LPS, and PCT.

Objective: To investigate the molecular mechanisms of continuous venovenous hemofiltration (CVVH) combined with ulinastatin (ULI) (CVVH-ULI) for the treatment of septic shock., Methods: Human umbilical endothelial cells (HUVECs) were incubated with serums isolated from normal healthy people (control), septic shock patients treated with conventional therapy (CT) or treated with CVVH combined with ULI (CVVH-ULI). Endothelial permeability was evaluated by the leakage of FITC-labeled albumin. The morphological changes of F-actin was evaluated by Rhodamine-phalloidin. The phosphorylated levels of p38 were determined by Western blot. Cells were then treated with p38inhibitor (SB203580), or DMSO, followed by incubation with serum from septic shock patients treated with conventional therapy. Endothelial permeability and F-actin rearrangements were also evaluated as noted above., Results: Serum from CT group increased endothelial permeability, F-actin rearrangements, and phosphorylated levels of p38, which were inhibited by CVVH-ULI treatment. Moreover, in CT group, the serum-induced endothelial hyperpermeability and F-actin rearrangements were inhibited by SB203580, the inhibitor of p38., Conclusion: CVVH combined with ulinastatin decreases endothelial hyperpermeability induced by septic shock through inhibiting p38 MAPK pathways.

Background: Extended daily dialysis (EDD) has been suggested as an effective renal replacement therapy for acute kidney injury. However, results from studies comparing EDD to continuous renal replacement therapy (CRRT) are inconclusive., Study Design: A systematic review and meta-analysis was performed by searching in MEDLINE, EMBASE, the Cochrane Library, Google Scholar, and a Chinese database (SinsoMed)., Setting & Population: Patients with acute kidney injury., Selection Criteria for Studies: Randomized controlled trials (RCTs) and observational studies were included. EDD was defined as extended hemodialysis or hemodiafiltration for more than 6 but less than 24 hours per session using a conventional hemodialysis machine., Intervention: Renal replacement therapy comparing EDD with CRRT., Outcomes: Mortality, kidney recovery, and fluid removal., Results: We included 17 studies from 2000 to 2014: 7 RCTs and 10 observational studies involving 533 and 675 patients, respectively. Meta-analysis of RCTs showed no difference in mortality rates between EDD and CRRT (relative risk, 0.90; 95% CI, 0.74-1.11; P=0.3). However, EDD was associated with lower mortality risk compared with CRRT in observational studies (relative risk, 0.86; 95% CI, 0.74-1.00; P=0.05). There was no evidence of heterogeneity in RCTs (I(2)=0%) or observational studies (I(2)=15%). In both RCTs and observational studies, there were no significant differences in recovery of kidney function, fluid removal, or days in the intensive care unit, and EDD showed similar biochemical efficacy to CRRT during treatment (serum urea, serum creatinine, and serum phosphate)., Limitations: The survival benefit of EDD is dependent on only observational studies and might have been affected by allocation or selection bias., Conclusions: EDD is associated with similar outcomes to CRRT in RCTs. The finding that EDD is associated with a lower mortality rate relies on data from observational studies, which are potentially subject to allocation or selection bias, making further high-quality RCTs desirable., (Copyright © 2015 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Multiple organ dysfunction syndrome (MODS) is a rare complication of wasp stings. Currently, there is no standardized treatment for MODS secondary to multiple wasp stings, although blood purification techniques are often used. This study aimed to analyze our experiences of using intermittent hemodialysis (IHD) with or without high-volume hemofiltration (HVHF) for treating acute wasp stings complicated by MODS. In this retrospective study, 36 patients with wasp stings complicated by MODS received either IHD combined with hemoperfusion, or HVHF (ultrafiltration flow rate, 70 mL/kg/h) combined with hemoperfusion for 5 days followed by IHD. Clinical symptoms, blood biochemical parameters, duration of mechanical ventilation, use of vasoactive agents, duration of hospital stay and survival rate were recorded, and Acute Physiology and Chronic Health Evaluation II (APACHE II) and multiple organ dysfunction (MOD) scores estimated. Patients treated with HVHF followed by IHD appeared to exhibit a faster recovery than those receiving IHD alone, as evidenced by superior improvements in MOD (4.29±1.08 vs. 2.27±1.07) and APACHE II (7.09±2.62 vs. 4.20±1.69) scores (P < 0.05). Patients treated with HVHF had significantly lower myoglobin, creatine kinase-MB, lactate dehydrogenase, bilirubin and creatinine levels than patients treated with IHD alone. In addition, the durations of hospital stay (13.15±2.77 vs. 27.92±3.18 days), vasopressor use (1.76±0.24 vs. 3.43 ± 1.01 days), mechanical ventilation (3.02±1.63 vs. 5.94 ± 2.11 days) and oliguria (6.57±2.45 vs. 15.29 ± 3.51 days) were reduced, and renal function more often recovered (85.1% vs. 53.1%), in the HVHF group compared with the IHD group (P < 0.05). These results raise the possibility that HVHF plus IHD may be superior to IHD alone for the treatment of acute wasp stings complicated by MODS; additional prospective studies are merited to explore this further.

Inflammation is a key part in the etiology and progression of idiopathic nephrotic syndrome (INS), we hypothesize that removing pro-inflammatory cytokines with intermittent high-volume hemofiltration (IHVHF) could improve the outcome in INS patients. The purpose of the current study is to examine whether IHVHF promotes remission in steroid-resistant INS. Fifty-one steroid-resistant INS patients were followed up on an open-label basis with prospective evaluations. Thirty-five patients received mycophenolate mofetil (SRD group) and 16 patients received drugs and IHVHF due to volume overload despite of diuretics (SRDF group). The rate of complete remission (CR) was analyzed. We also recruited 30 healthy individuals and 36 steroid-sensitive (SS) INS patients as controls to investigate the correlation of interleukin (IL)-8, IL-10, IL-6 and IL-17 with INS activity. Compared with the patients in the SRD group, the 6-month CR rate was higher (44% vs. 9%, p < 0.001) and time to first CR was significantly shorter (7.3 ± 3.6 vs. 11.1 ± 5.3 months, p = 0.02) in the SRDF group. Serum IL-8 was highest in the SRDF group and reduced by IHVHF clearance. Serum IL-8 was lower during remission than at onset or recurrence of INS, whereas no significant difference was seen in the other cytokines. Receiver operating characteristic curve analysis demonstrated that serum IL-8 predicted steroid sensitivity with moderate accuracy (area under the curve = 0.79, 95% CI: 0.69-0.87). IHVHF promotes remission in patients with steroid-resistant INS and it may be partly due to serum IL-8 clearance.

Introduction: We have aggressively used continuous veno-venous hemofiltration (CVVH) on high model for end-stage liver disease (MELD) score liver transplant patients with acute kidney injury and hypothesized that the addition of intraoperative CVVH therapy would improve overall outcomes., Methods: We performed a retrospective review of all adult, single organ, liver transplant recipients requiring preoperative renal replacement therapy between January 1, 2011 and June 1, 2013. Intraoperative and perioperative records and laboratory values were collected and used to create a database of these patients. Patients were grouped according to whether or not they underwent CVVH at the time of liver transplantation., Results: Twenty-one patients with new-onset renal failure requiring preoperative renal replacement therapy received a liver transplant alone. Fourteen received intraoperative CVVH and 7 patients did not. The average MELD score was similar between groups (34 for intraoperative CVVH vs 35; P = .8). Preoperative sodium and potassium were higher for the group receiving intraoperative CVVH, but still fell within normal ranges. Preoperative lactate levels were higher in the group that received intraoperative CVVH (4.7 vs 2.0 mmol/L; P = .01). Intraoperative CVVH did not decrease intraoperative transfusion requirements or intensive care unit (ICU) and hospital lengths of stay. Differences in reoperative rates did not reach statistical significance. All patients were weaned off renal replacement therapy. One-year patient survival rate was 86% for intraoperative CVVH versus 71% without., Conclusion: The judicious use of intraoperative CVVH therapy may permit patients with increasing severity of illness to achieve outcomes comparable with less ill patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Rationale: In end-stage renal disease (ESRD), a condition characterized by fluid overload, both obstructive and central sleep apnea (OSA and CSA) are common. This observation suggests that fluid overload is involved in the pathogenesis of OSA and CSA in this condition., Objectives: To test the hypothesis that fluid removal by ultrafiltration (UF) will reduce severity of OSA and CSA in patients with ESRD., Methods: At baseline, on a nondialysis day, patients with ESRD on thrice-weekly hemodialysis underwent overnight polysomnography along with measurement of total body extracellular fluid volume (ECFV), and ECFV of the neck, thorax, and right leg before and after sleep. The following week, on a nondialysis day, subjects with an apnea-hypopnea index (AHI) greater than or equal to 20 had fluid removed by UF, followed by repeat overnight polysomnography with fluid measurements., Measurements and Main Results: Fifteen patients (10 men) with an AHI greater than or equal to 20 (10 OSA; 5 CSA) participated. Mean age was 53.5 ± 10.4 years and mean body mass index was 25.3 ± 4.8 kg/m(2). Following removal of 2.17 ± 0.45 L by UF, the AHI decreased by 36% (43.8 ± 20.3 to 28.0 ± 17.7; P < 0.001) without affecting uremia. The reduction in AHI correlated with the reduction in total body ECFV (r = 0.567; P = 0.027) and was associated with reductions in ECFV of the right leg (P = 0.001), overnight change in ECFV of the right leg (P = 0.044), ECFV of the thorax (P = 0.001), and ECFV of the neck (P = 0.003)., Conclusions: These findings indicate that fluid overload contributes to the pathogenesis of OSA and CSA in ESRD, and that fluid removal by UF attenuates sleep apnea without altering uremic status.

Objective: Extracorporeal life support has undergone a revolution in the past several years with the advent of new, miniaturized equipment and success in supporting patients with a variety of illnesses. Most experience has come with the use of extracorporeal membrane oxygenation, a modified form of cardiopulmonary bypass that can support the heart, lungs, and circulation for days to months at a time. To describe the recommendations for the use of extracorporeal membrane oxygenation in children with pediatric acute respiratory distress syndrome based on a review of the literature and expert opinion., Design: Consensus conference of experts in pediatric acute lung injury., Methods: A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The extracorporeal support subgroup comprised two international experts. When published data were lacking, a modified Delphi approach emphasizing strong professional agreement was used., Results: The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, 11 of which related to extracorporeal support. All recommendations had agreement, with 10 recommendations (91%) achieving strong agreement. These recommendations included the utilization of extracorporeal support for reversible causes of pediatric acute respiratory distress syndrome, consideration of quality of life when making the decision to use extracorporeal support, and the use of the Extracorporeal Life Support Organization registry to report all extracorporeal support activity, among others., Conclusions: Pediatric extracorporeal membrane oxygenation for pediatric acute respiratory distress syndrome could benefit from more specific data collection and collaboration of focused investigators to establish validated criteria for optimal application of extracorporeal membrane oxygenation and patient management protocols. Until that time, consensus opinion offers some insight into guidelines.

Background: Convective dialysis modalities (haemofiltration (HF), haemodiafiltration (HDF), and acetate-free biofiltration (AFB)) removed excess body fluid across the dialysis membrane with positive pressure and accumulated middle- and larger-size accumulated solutes more efficiently than haemodialysis (HD). This increased larger solute removal combined with use of ultra-pure dialysis fluid in convective dialysis is hypothesised to reduce the frequency and severity of symptoms during dialysis as well as improve clinical outcomes. Convective dialysis therapies (HDF and HF) are associated with lower mortality compared to diffusive therapy (HD) in observational studies. This is an update of a review first published in 2006., Objectives: To compare convective (HF, HDF, or AFB) with diffusive (HD) dialysis modalities on clinical outcomes (mortality, major cardiovascular events, hospitalisation and treatment-related adverse events) in men and women with end-stage kidney disease (ESKD)., Search Methods: We searched the Cochrane Renal Group's Specialised Register (to 18 February 2015) through contact with a Trials' Search Co-ordinator using search terms relevant to this review., Selection Criteria: We included randomised controlled trials comparing convective therapy (HF, HDF, AFB) with another convective therapy or diffusive therapy (HD) for treatment of ESKD., Data Collection and Analysis: Two independent authors identified studies, extracted data and assessed study risk of bias. We summarised treatment effects using the random effects model. We reported results as a risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous data together with 95% confidence intervals (CI). We assessed for heterogeneity using the Chi(2) test and explored the amount of variation in treatment estimates beyond that expected by chance using the I(2) statistic., Main Results: Twenty studies comprising 667 participants were included in the 2006 review. In that review, there was insufficient evidence of treatment effects on major clinical outcomes to draw clinically meaningful conclusions. Searching to February 2015 identified 40 eligible studies comprising 3483 participants overall. In total, 35 studies (4039 participants) compared HF, HDF or AFB with HD, three studies (54 participants) compared AFB with HDF, and three studies (129 participants) compared HDF with HF.Risks of bias in all studies were generally high resulting in low confidence in estimated treatment effects. Convective dialysis had no significant effect on all-cause mortality (11 studies, 3396 participants: RR 0.87, 95% CI 0.72 to 1.05; I(2) = 34%), but significantly reduced cardiovascular mortality (6 studies, 2889 participants: RR 0.75, 95% CI 0.61 to 0.92; I(2) = 0%). One study reported no significant effect on rates of nonfatal cardiovascular events (714 participants: RR 1.14, 95% CI 0.86 to 1.50) and two studies showed no significant difference in hospitalisation (2 studies, 1688 participants: RR 1.23, 95% CI 0.93 to 1.63; I(2) = 0%). One study reported rates of hypotension during dialysis were significantly reduced with convective therapy (906 participants: RR 0.72, 95% CI 0.66 to 0.80). Adverse events were not systematically evaluated in most studies and data for health-related quality of life were sparse. Convective therapies significantly reduced predialysis levels of B2 microglobulin (12 studies, 1813 participants: MD -5.55 mg/dL, 95% CI -9.11 to -1.98; I(2) = 94%) and increased dialysis dose (Kt/V urea) (14 studies, 2022 participants: MD 0.07, 95% CI -0.00 to 0.14; I(2) = 90%) compared to diffusive therapy, but results across studies were very heterogeneous. Sensitivity analyses limited to studies comparing HDF with HD showed very similar results. Directly comparative data for differing types of convective dialysis were insufficient to draw conclusions.Studies had important risks of bias leading to low confidence in the summary estimates and were generally limited to patients who had adequate dialysis vascular access., Authors' Conclusions: Convective dialysis may reduce cardiovascular but not all-cause mortality and effects on nonfatal cardiovascular events and hospitalisation are inconclusive. However, any treatment benefits of convective dialysis on all patient outcomes including cardiovascular death are unreliable due to limitations in study methods and reporting. Future studies which assess treatment effects of convection dose on patient outcomes including mortality and cardiovascular events would be informative.

Introduction: Although diuretics are mainly used for the treatment of acute decompensated heart failure (ADHF), inadequate responses and complications have led to the use of extracorporeal ultrafiltration (UF) as an alternative strategy for reducing volume overloads in patients with ADHF., Objective: The aim of our study is to perform meta-analysis of the results obtained from studies on extracorporeal venous ultrafiltration and compare them with those of standard diuretic treatment for overload volume reduction in acute decompensated heart failure., Methods: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases were systematically searched using a pre‑specified criterion. Pooled estimates of outcomes after 48 h (weight change, serum creatinine level, and all-cause mortality) were computed using random effect models. Pooled weighted mean differences were calculated for weight loss and change in creatinine level, whereas a pooled risk ratio was used for the analysis of binary all-cause mortality outcome., Results: A total of nine studies, involving 613 patients, met the eligibility criteria. The mean weight loss in patients who underwent UF therapy was 1.78 kg [95% Confidence Interval (CI): -2.65 to -0.91 kg; p < 0.001) more than those who received standard diuretic therapy. The post-intervention creatinine level, however, was not significantly different (mean change = -0.25 mg/dL; 95% CI: -0.56 to 0.06 mg/dL; p = 0.112). The risk of all-cause mortality persisted in patients treated with UF compared with patients treated with standard diuretics (Pooled RR = 1.00; 95% CI: 0.64-1.56; p = 0.993)., Conclusion: Compared with standard diuretic therapy, UF treatment for overload volume reduction in individuals suffering from ADHF, resulted in significant reduction of body weight within 48 h. However, no significant decrease of serum creatinine level or reduction of all-cause mortality was observed.

Continuous and intermittent renal replacement therapies are thought to be equally adequate approaches for the treatment of patients with acute kidney injury. Accordingly, current guidelines advocate the use of different modalities in a complementary fashion, i.e., to tailor therapy to the specific clinical situation. In patients with hemodynamic instability or at risk of cerebral edema, continuous renal replacement therapy or prolonged intermittent renal replacement therapy should, however, be preferred. Intermittent hemodialysis, on the other hand, remains the therapy of choice for the rapid correction of life-threatening electrolyte abnormalities or metabolic acidosis. During the further course of treatment, an individualized approach should be continued which may include a switch between modalities based on current therapeutic goals and potential risks for side effects of renal replacement therapy.