|
1
|
Zhang Y, Ma J, Zheng A, Ming J, Huang Y, Cheng C, Ding X, Xiao M, Zhang P. Comparison of unplanned treatment interruption during CRRT in ICU patients under CVVH (pre + post dilution) or CVVHDF (post-dilution) mode: A retrospective cohort study. Nurs Crit Care 2025; 30:e70025. [PMID: 40123215 DOI: 10.1111/nicc.70025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2024] [Revised: 01/22/2025] [Accepted: 03/07/2025] [Indexed: 03/25/2025]
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) often becomes prematurely interrupted before the planned dose is reached for various reasons. This not only hampers therapeutic efficacy but also escalates blood loss for patients, thereby increasing the nursing workload and patient costs. AIM To assess the incidence and filter lifespan of unplanned interruptions in ICU patients undergoing CRRT, continuous veno-venous hemofiltration (CVVH) (pre + post dilution) mode was compared with continuous veno-venous haemodiafiltration (CVVHDF) (post dilution) mode. STUDY DESIGN We conducted a retrospective study involving 256 patients: 75 in the CVVH group and 181 in the CVVHDF group. Outcomes such as filter lifespan, unplanned treatment interruptions and catheter complications were compared across the three anticoagulation methods. RESULTS A greater proportion of unplanned interruptions was observed in the CVVHDF group. Specifically, filter coagulation led to more frequent interruptions in CVVHDF (p < .05). With citrate anticoagulation, the filters in the CVVH group lasted significantly longer (p = .025). However, under low-molecular-weight heparin or no anticoagulation, filter survival rates were statistically similar between the groups (p > .05). Anticoagulation method (95% CI 1.163-44.95, p = .034), venous pressure (95% CI 0.001-0.004, p = .027) and total serum calcium (95% CI -0.936 to -0.042, p = .033) affect the incidence rate of unplanned treatment interruptions in CVVH (pre- and post-dilution) (p < .05). Venous pressure (95% CI 0.001-0.002, p < .001) and BMI (95% CI -0.936 to -0.042, p = .033) affect the incidence rate of unplanned treatment interruptions in CVVHDF (post-dilution) (p < .05). The adjusted results indicate that PT (HR = 1.09, 95% CI 1.011-1.176, p = .025), venous pressure (HR = 1.013, 95% CI 1.004-1.022, p = .003) and blood flow rate (HR = 1.028, 95% CI 1.002-1.054, p = .034) are potential risk factors for filter lifespan in CVVH (pre- and post-dilution). Venous pressure (HR = 1.005, 95% CI 1.003-1.007, p < .001) is a potential risk factor for filter lifespan in CVVHDF (post-dilution). CONCLUSION Using the CVVH mode with citrate anticoagulation significantly prolongs CRRT filter life and reduces unplanned treatment interruptions. Further prospective, randomised controlled studies are needed to confirm these findings. RELEVANCE TO CLINICAL PRACTICE Exploring the reasons for unplanned treatment interruptions in ICU patients undergoing CRRT under common modes is crucial, serving as an important measure to ensure the quality of treatment. Nurses are the main implementers throughout the entire CRRT process. Understanding the risk factors for unplanned treatment interruptions and filter lifespan can help reduce the economic burden on patients, decrease the workload of medical staff and contribute to the development of plans aimed at improving the quality of care for critically ill patients receiving CRRT.
Collapse
Affiliation(s)
- Yanting Zhang
- Department of Critical Care Medicine, Hubei Clinical Research Center for Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jing Ma
- Department of Critical Care Medicine, Hubei Clinical Research Center for Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Anlong Zheng
- Department of Critical Care Medicine, Hubei Clinical Research Center for Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jing Ming
- Department of Critical Care Medicine, Hubei Clinical Research Center for Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yuting Huang
- Department of Critical Care Medicine, Hubei Clinical Research Center for Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Chong Cheng
- Department of Critical Care Medicine, Hubei Clinical Research Center for Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xinbo Ding
- Department of Critical Care Medicine, Hubei Clinical Research Center for Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Meng Xiao
- Department of Critical Care Medicine, Hubei Clinical Research Center for Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Pu Zhang
- Department of Critical Care Medicine, Hubei Clinical Research Center for Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| |
Collapse
|
|
2
|
Zhao Y, Li K, Wang L, Kuang G, Xie K, Lin S. Dexmedetomidine Mitigates Acute Lung Injury by Enhancing M2 Macrophage Polarization and Inhibiting RAGE/Caspase-11-Mediated Pyroptosis. FRONT BIOSCI-LANDMRK 2024; 29:409. [PMID: 39735987 DOI: 10.31083/j.fbl2912409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 09/14/2024] [Accepted: 09/25/2024] [Indexed: 12/31/2024]
Abstract
BACKGROUND Acute lung injury (ALI) significantly impacts the survival rates in intensive care units (ICU). Releasing a lot of pro-inflammatory mediators during the progression of the disease is a core feature of ALI, which may lead to uncontrolled inflammation and further damages the tissues and organs of patients. This study explores the potential therapeutic mechanisms of Dexmedetomidine (Dex) in ALI. METHODS In present study, cecal ligation puncture (CLP)-established ALI model mice and lipopolysaccharide (LPS)-stimulated RAW264.7 cell line were established to discover the influence of Dex. The evaluation of lung injury in vivo using histopathology, TUNEL assay, and analysis of inflammatory factors in bronchoalveolar lavage fluid (BALF) and serum. The receptor for advanced glycation end products (RAGE)/Caspase-11-dependent pyroptosis-related proteins and macrophage polarization markers were analyzed using western blot, immunofluorescence, and flow cytometry. Finally, the mechanism of Dex in macrophages was further verified in vitro. RESULTS In vivo, Dex alleviated lung injury and decreased TUNEL-positive cell expression in CLP group. Dex decreased tumor necrosis factor-alpha (TNF-α), interleukin (IL)-6 and IL-17A levels in BALF and serum, while increasing IL-10 expression. Dex treatment decreased the protein levels of RAGE, caspase-11, IL-1β and Gasdermin-D (GSDMD) in both in cells and in mice. Dex also down-regulated the synthesis of inducible nitric oxide synthase (iNOS) of classical activation phenotype (M1) markers, and up-regulated the synthesis of CD206 and Arg-1 of alternate activation phenotype (M2) markers. CONCLUSIONS Dex treatment can inhibit inflammation and reduce lung injury caused by CLP. It could be associated with mediating M1 and M2 polarization and suppressing RAGE/Caspase-11-depended pyroptosis.
Collapse
Affiliation(s)
- Yisi Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, 400016 Chongqing, China
- The Chongqing Key Laboratory of Translation Medicine in Major Metabolic Diseases, The First Affiliated Hospital of Chongqing Medical University, 400016 Chongqing, China
| | - Kefeng Li
- The Chongqing Key Laboratory of Translation Medicine in Major Metabolic Diseases, The First Affiliated Hospital of Chongqing Medical University, 400016 Chongqing, China
- Department of Critical Care Medicine, People's Hospital of Fengjie, 404600 Chongqing, China
| | - Liuyang Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, 400016 Chongqing, China
| | - Gang Kuang
- The Chongqing Key Laboratory of Translation Medicine in Major Metabolic Diseases, The First Affiliated Hospital of Chongqing Medical University, 400016 Chongqing, China
- Department of Critical Care Medicine, Dazu Hospital of Chongqing Medical University, 402360 Chongqing, China
| | - Ke Xie
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, 400016 Chongqing, China
| | - Shihui Lin
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, 400016 Chongqing, China
| |
Collapse
|
|
3
|
Nielsen ND, Jackson DB, Teixeira JP. Plasma exchange in septic shock: are we ready for prime time? CON. Intensive Care Med 2024; 50:1900-1902. [PMID: 39259295 DOI: 10.1007/s00134-024-07572-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 07/25/2024] [Indexed: 09/13/2024]
Affiliation(s)
- Nathan D Nielsen
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA.
- Section of Transfusion Medicine and Therapeutic Pathology, Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM, USA.
| | - David Bradley Jackson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Joao Pedro Teixeira
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| |
Collapse
|
|
4
|
Moury J, Nendumba G, Robert A, Hauquiert B, Vornicu O, Blackman S, Perriens E, De Lissnyder N, Shchukin A, El Yaakoubi F, Saad C, Schmit C, Dincq AS, Evrard P, Bulpa P, Michaux I, Honore PM. Has the CONVINCE trial convinced the nephrology and dialysis community? ANNALS OF TRANSLATIONAL MEDICINE 2024; 12:99. [PMID: 39507453 PMCID: PMC11534750 DOI: 10.21037/atm-24-50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 08/08/2024] [Indexed: 11/08/2024]
Affiliation(s)
- Julien Moury
- ICU, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
| | - Gauthier Nendumba
- ICU, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
| | - Arnaud Robert
- ICU, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
| | | | - Ovidiu Vornicu
- ICU, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
- ICU and Anesthesiology Departments, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
| | - Sydney Blackman
- Department of gynecology, Centre Hospitalier interregional Edith Cavell (Chirec Hospital), Brussels, Belgium
| | | | | | | | | | - Clara Saad
- Faculty of Medicine, ULB University, Brussels, Belgium
| | - Cyril Schmit
- Faculty of Medicine, ULB University, Brussels, Belgium
| | - Anne-Sophie Dincq
- ICU, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
- ICU and Anesthesiology Departments, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
| | - Patrick Evrard
- ICU, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
| | - Pierre Bulpa
- ICU, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
| | - Isabelle Michaux
- ICU, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
| | - Patrick M. Honore
- ICU, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
| |
Collapse
|
|
5
|
Sharma J, Khatav SK. Polymyxin B Hemoperfusion in Sepsis: A Possible Silver Lining to the Dark Clouds? Indian J Crit Care Med 2024; 28:903-905. [PMID: 39411302 PMCID: PMC11471985 DOI: 10.5005/jp-journals-10071-24816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2024] Open
Abstract
How to cite this article: Sharma J, Khatav SK. Polymyxin B Hemoperfusion in Sepsis: A Possible Silver Lining to the Dark Clouds? Indian J Crit Care Med 2024;28(10):903-905.
Collapse
Affiliation(s)
- Jeetendra Sharma
- Department of Critical Care, Artemis Health Institute, Gurgaon, Haryana, India
| | - Shivangi K Khatav
- Department of Critical Care, Artemis Health Institute, Gurgaon, Haryana, India
| |
Collapse
|
|
6
|
Li J, Yao Y, Lei X, Bao J, An S, Hu H, Sha T, Huang Q, Li T, Zeng Z, Wang X, Cai S. SIRTUIN 5 ALLEVIATES EXCESSIVE MITOCHONDRIAL FISSION VIA DESUCCINYLATION OF ATPASE INHIBITORY FACTOR 1 IN SEPSIS-INDUCED ACUTE KIDNEY INJURY. Shock 2024; 62:235-244. [PMID: 38754030 DOI: 10.1097/shk.0000000000002392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
ABSTRACT Sepsis-induced acute kidney injury (SAKI) poses a significant clinical challenge with high morbidity and mortality. Excessive mitochondrial fission has been identified as the central pathogenesis of sepsis-associated organ damage, which is also implicated in the early stages of SAKI. Sirtuin 5 (SIRT5) has emerged as a central regulator of cellular mitochondrial function; however, its role in the regulation of sepsis-induced excessive mitochondrial fission in kidney and the underlying mechanism remains unclear. In this study, SAKI was modeled in mice through cecal ligation and puncture, and in human renal tubular epithelial (HK-2) cells stimulated with lipopolysaccharide (LPS), to mimic the cell SAKI model. Our findings revealed that septic mice with a SIRT5 knockout exhibited shortened survival times and elevated levels of renal injury compared to wild-type mice, suggesting the significant involvement of SIRT5 in SAKI pathophysiology. Additionally, we observed that SIRT5 depletion led to increased renal mitochondrial fission, while the use of a mitochondrial fission inhibitor (Mdivi-1) reversed the detrimental effects caused by SIRT5 depletion, emphasizing the pivotal role of SIRT5 in preventing excessive mitochondrial fission. In vitro experiments demonstrated that the overexpression of SIRT5 effectively mitigated the adverse effects of LPS on HK-2 cells viability and mitochondrial fission. Conversely, downregulation of SIRT5 decreased HK-2 cells viability and exacerbated LPS-induced mitochondrial fission. Mechanistically, the protective function of SIRT5 may be in part, ascribed to its desuccinylating action on ATPase inhibitory factor 1. In conclusion, this study provides novel insights into the underlying mechanisms of SAKI, suggesting the possibility of identifying future drug targets in terms of improved mitochondrial dynamics by SIRT5.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Qiaobing Huang
- Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Tao Li
- Department of Critical Care Medicine, The First People's Hospital of Chenzhou, Southern Medical University, Chenzhou, China
| | - Zhenhua Zeng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiang Wang
- Department of Critical Care Medicine, The First People's Hospital of Chenzhou, Southern Medical University, Chenzhou, China
| | - Shumin Cai
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| |
Collapse
|
|
7
|
Papamichalis P, Oikonomou KG, Xanthoudaki M, Valsamaki A, Skoura AL, Papathanasiou SK, Chovas A. Extracorporeal organ support for critically ill patients: Overcoming the past, achieving the maximum at present, and redefining the future. World J Crit Care Med 2024; 13:92458. [PMID: 38855267 PMCID: PMC11155504 DOI: 10.5492/wjccm.v13.i2.92458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/17/2024] [Accepted: 03/26/2024] [Indexed: 06/03/2024] Open
Abstract
Extracorporeal organ support (ECOS) has made remarkable progress over the last few years. Renal replacement therapy, introduced a few decades ago, was the first available application of ECOS. The subsequent evolution of ECOS enabled the enhanced support to many other organs, including the heart [veno-arterial extracorporeal membrane oxygenation (ECMO), slow continuous ultrafiltration], the lungs (veno-venous ECMO, extracorporeal carbon dioxide removal), and the liver (blood purification techniques for the detoxification of liver toxins). Moreover, additional indications of these methods, including the suppression of excessive inflammatory response occurring in severe disorders such as sepsis, coronavirus disease 2019, pancreatitis, and trauma (blood purification techniques for the removal of exotoxins, endotoxins, or cytokines), have arisen. Multiple organ support therapy is crucial since a vast majority of critically ill patients present not with a single but with multiple organ failure (MOF), whereas, traditional therapeutic approaches (mechanical ventilation for acute respiratory failure, antibiotics for sepsis, and inotropes for cardiac dysfunction) have reached the maximum efficacy and cannot be improved further. However, several issues remain to be clarified, such as the complexity and cost of ECOS systems, standardization of indications, therapeutic protocols and initiation time, choice of the patients who will benefit most from these interventions, while evidence from randomized controlled trials supporting their use is still limited. Nevertheless, these methods are currently a part of routine clinical practice in intensive care units. This editorial presents the past, present, and future considerations, as well as perspectives regarding these therapies. Our better understanding of these methods, the pathophysiology of MOF, the crosstalk between native organs resulting in MOF, and the crosstalk between native organs and artificial organ support systems when applied sequentially or simultaneously, will lead to the multiplication of their effects and the minimization of complications arising from their use.
Collapse
Affiliation(s)
| | | | - Maria Xanthoudaki
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Greece
| | - Asimina Valsamaki
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Greece
| | | | | | - Achilleas Chovas
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Greece
| |
Collapse
|
|
8
|
Girardis M, Coloretti I, Antonelli M, Berlot G, Busani S, Cortegiani A, De Pascale G, De Rosa FG, De Rosa S, Donadello K, Donati A, Forfori F, Giannella M, Grasselli G, Montrucchio G, Oliva A, Pasero D, Piazza O, Romagnoli S, Tascini C, Viaggi B, Tumbarello M, Viale P. Adjunctive immunotherapeutic agents in patients with sepsis and septic shock: a multidisciplinary consensus of 23. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:28. [PMID: 38689337 PMCID: PMC11059820 DOI: 10.1186/s44158-024-00165-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 04/18/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND In the last decades, several adjunctive treatments have been proposed to reduce mortality in septic shock patients. Unfortunately, mortality due to sepsis and septic shock remains elevated and NO trials evaluating adjunctive therapies were able to demonstrate any clear benefit. In light of the lack of evidence and conflicting results from previous studies, in this multidisciplinary consensus, the authors considered the rational, recent investigations and potential clinical benefits of targeted adjunctive therapies. METHODS A panel of multidisciplinary experts defined clinical phenotypes, treatments and outcomes of greater interest in the field of adjunctive therapies for sepsis and septic shock. After an extensive systematic literature review, the appropriateness of each treatment for each clinical phenotype was determined using the modified RAND/UCLA appropriateness method. RESULTS The consensus identified two distinct clinical phenotypes: patients with overwhelming shock and patients with immune paralysis. Six different adjunctive treatments were considered the most frequently used and promising: (i) corticosteroids, (ii) blood purification, (iii) immunoglobulins, (iv) granulocyte/monocyte colony-stimulating factor and (v) specific immune therapy (i.e. interferon-gamma, IL7 and AntiPD1). Agreement was achieved in 70% of the 25 clinical questions. CONCLUSIONS Although clinical evidence is lacking, adjunctive therapies are often employed in the treatment of sepsis. To address this gap in knowledge, a panel of national experts has provided a structured consensus on the appropriate use of these treatments in clinical practice.
Collapse
Affiliation(s)
- Massimo Girardis
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy.
| | - Irene Coloretti
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Massimo Antonelli
- Dipartimento Di Scienze Biotecnologiche Di Base, Cliniche Intensivologiche E Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento Di Scienze Dell'Emergenza, Anestesiologiche E Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giorgio Berlot
- Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Stefano Busani
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
- Department of Anaesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - Gennaro De Pascale
- Dipartimento Di Scienze Biotecnologiche Di Base, Cliniche Intensivologiche E Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento Di Scienze Dell'Emergenza, Anestesiologiche E Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Silvia De Rosa
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS, Trento, Italy
| | - Katia Donadello
- Department of Surgery, Dentistry, Ginaecology and Paediatrics, University of Verona, and Anesthesia and Intensive Care Unit B, University Hospital Integrated Trust of Verona, Verona, Italy
| | - Abele Donati
- Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Delle Marche, Ancona, Italy
| | - Francesco Forfori
- Anesthesia and Intensive Care, Anesthesia and Resuscitation Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Maddalena Giannella
- Department of Medical and Surgical Sciences Infectious Diseases Unit, IRCCS Azienda Ospedaliero Universitaria Di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giorgia Montrucchio
- Department of Surgical Sciences, Departement of Anesthesia, Resuscitation and Emergency Torino, University of Turin, Turin, Italy
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Daniela Pasero
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Ornella Piazza
- University Hospital "San Giovanni Di Dio E Ruggi d'Aragona", Salerno, Italy
| | - Stefano Romagnoli
- Department of Health Science, Department of Anesthesia and Intensive Care, University of Florence, Careggi University Hospital, Florence, Italy
| | - Carlo Tascini
- Department of Medicine (DAME), Infectious Diseases Clinic, University of Udine, Udine, Italy
| | - Bruno Viaggi
- Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Mario Tumbarello
- Infectious and Tropical Diseases Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences Infectious Diseases Unit, IRCCS Azienda Ospedaliero Universitaria Di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| |
Collapse
|
|
9
|
Cortina G, Daverio M, Demirkol D, Chanchlani R, Deep A. Continuous renal replacement therapy in neonates and children: what does the pediatrician need to know? An overview from the Critical Care Nephrology Section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). Eur J Pediatr 2024; 183:529-541. [PMID: 37975941 PMCID: PMC10912166 DOI: 10.1007/s00431-023-05318-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/13/2023] [Accepted: 10/28/2023] [Indexed: 11/19/2023]
Abstract
Continuous renal replacement therapy (CRRT) is the preferred method for renal support in critically ill and hemodynamically unstable children in the pediatric intensive care unit (PICU) as it allows for gentle removal of fluids and solutes. The most frequent indications for CRRT include acute kidney injury (AKI) and fluid overload (FO) as well as non-renal indications such as removal of toxic metabolites in acute liver failure, inborn errors of metabolism, and intoxications and removal of inflammatory mediators in sepsis. AKI and/or FO are common in critically ill children and their presence is associated with worse outcomes. Therefore, early recognition of AKI and FO is important and timely transfer of patients who might require CRRT to a center with institutional expertise should be considered. Although CRRT has been increasingly used in the critical care setting, due to the lack of standardized recommendations, wide practice variations exist regarding the main aspects of CRRT application in critically ill children. Conclusion: In this review, from the Critical Care Nephrology section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC), we summarize the key aspects of CRRT delivery and highlight the importance of adequate follow up among AKI survivors which might be of relevance for the general pediatric community. What is Known: • CRRT is the preferred method of renal support in critically ill and hemodynamically unstable children in the PICU as it allows for gentle removal of fluids and solutes. • Although CRRT has become an important and integral part of modern pediatric critical care, wide practice variations exist in all aspects of CRRT. What is New: • Given the lack of literature on guidance for a general pediatrician on when to refer a child for CRRT, we recommend timely transfer to a center with institutional expertise in CRRT, as both worsening AKI and FO have been associated with increased mortality. • Adequate follow-up of PICU patients with AKI and CRRT is highlighted as recent findings demonstrate that these children are at increased risk for adverse long-term outcomes.
Collapse
Affiliation(s)
- Gerard Cortina
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Marco Daverio
- Pediatric Intensive Care Unit, University Hospital of Padua, Padua, Italy
| | - Demet Demirkol
- Pediatric Intensive Care Unit, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - Akash Deep
- Pediatric Intensive Care Unit, Kings College London, London, UK.
| |
Collapse
|
|
10
|
Greenhalgh DG, Hill DM, Burmeister DM, Gus EI, Cleland H, Padiglione A, Holden D, Huss F, Chew MS, Kubasiak JC, Burrell A, Manzanares W, Gómez MC, Yoshimura Y, Sjöberg F, Xie WG, Egipto P, Lavrentieva A, Jain A, Miranda-Altamirano A, Raby E, Aramendi I, Sen S, Chung KK, Alvarez RJQ, Han C, Matsushima A, Elmasry M, Liu Y, Donoso CS, Bolgiani A, Johnson LS, Vana LPM, de Romero RVD, Allorto N, Abesamis G, Luna VN, Gragnani A, González CB, Basilico H, Wood F, Jeng J, Li A, Singer M, Luo G, Palmieri T, Kahn S, Joe V, Cartotto R. Surviving Sepsis After Burn Campaign. Burns 2023; 49:1487-1524. [PMID: 37839919 DOI: 10.1016/j.burns.2023.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/02/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes. METHODS The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported. RESULTS The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis. CONCLUSION Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.
Collapse
Affiliation(s)
- David G Greenhalgh
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA.
| | - David M Hill
- Department of Clinical Pharmacy & Translational Scre have been several studies that have evaluatedience, College of Pharmacy, University of Tennessee, Health Science Center; Memphis, TN, USA
| | - David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Eduardo I Gus
- Division of Plastic & Reconstructive Surgery, The Hospital for Sick Children; Department of Surgery, University of Toronto, Toronto, Canada
| | - Heather Cleland
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Alex Padiglione
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Dane Holden
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Fredrik Huss
- Department of Surgical Sciences, Plastic Surgery, Uppsala University/Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - John C Kubasiak
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Aidan Burrell
- Department of Epidemiology and Preventative Medicine, Monash University and Alfred Hospital, Intensive Care Research Center (ANZIC-RC), Melbourne, Australia
| | - William Manzanares
- Department of Critical Care Medicine, Universidad de la República (UdelaR), Montevideo, Uruguay
| | - María Chacón Gómez
- Division of Intensive Care and Critical Medicine, Centro Nacional de Investigacion y Atencion de Quemados (CENIAQ), National Rehabilitation Institute, LGII, Mexico
| | - Yuya Yoshimura
- Department of Emergency and Critical Care Medicine, Hachinohe City Hospital, Hachinohe, Japan
| | - Folke Sjöberg
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Wei-Guo Xie
- Institute of Burns, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan, China
| | - Paula Egipto
- Centro Hospitalar e Universitário São João - Burn Unit, Porto, Portugal
| | | | | | | | - Ed Raby
- Infectious Diseases Department, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | | | - Soman Sen
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - Chunmao Han
- Department of Burn and Wound Repair, Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
| | - Asako Matsushima
- Department of Emergency and Critical Care, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Moustafa Elmasry
- Department of Hand, Plastic Surgery and Burns, Linköping University, Linköping, Sweden
| | - Yan Liu
- Department of Burn, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Carlos Segovia Donoso
- Intensive Care Unit for Major Burns, Mutual Security Clinical Hospital, Santiago, Chile
| | - Alberto Bolgiani
- Department of Surgery, Deutsches Hospital, Buenos Aires, Argentina
| | - Laura S Johnson
- Department of Surgery, Emory University School of Medicine and Grady Health System, Georgia
| | - Luiz Philipe Molina Vana
- Disciplina de Cirurgia Plastica da Escola Paulista de Medicina da Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | | | - Nikki Allorto
- Grey's Hospital Pietermaritzburg Metropolitan Burn Service, University of KwaZulu Natal, Pietermaritzburg, South Africa
| | - Gerald Abesamis
- Alfredo T. Ramirez Burn Center, Division of Burns, Department of Surgery, University of Philippines Manila - Philippine General Hospital, Manila, Philippines
| | - Virginia Nuñez Luna
- Unidad Michou y Mau Xochimilco for Burnt Children, Secretaria Salud Ciudad de México, Mexico
| | - Alfredo Gragnani
- Disciplina de Cirurgia Plastica da Escola Paulista de Medicina da Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Carolina Bonilla González
- Department of Pediatrics and Intensive Care, Pediatric Burn Unit, Clinical Studies and Clinical Epidemiology Division, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Hugo Basilico
- Intensive Care Area - Burn Unit - Pediatric Hospital "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina
| | - Fiona Wood
- Department of Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - James Jeng
- Department of Surgery, University of California, Irvine, CA, USA
| | - Andrew Li
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Mervyn Singer
- Department of Intensive Care Medicine, University College London, London, United Kingdom
| | - Gaoxing Luo
- Institute of Burn Research, Southwest Hospital, Army (Third Military) Medical University, Chongqing, China
| | - Tina Palmieri
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Steven Kahn
- The South Carolina Burn Center, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Victor Joe
- Department of Surgery, University of California, Irvine, CA, USA
| | - Robert Cartotto
- Department of Surgery, Sunnybrook Medical Center, Toronto, Ontario, Canada
| |
Collapse
|
|
11
|
Forin E, Lorenzoni G, Ferrer R, De Cal M, Zanella M, Marchionna N, Gregori D, Forfori F, Lorenzin A, Danzi V, Ronco C, De Rosa S. Endotoxin removal therapy with Polymyxin B immobilized fiber column: a single center experience from EUPHAS2 registry. Sci Rep 2023; 13:17600. [PMID: 37845296 PMCID: PMC10579294 DOI: 10.1038/s41598-023-44850-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 10/12/2023] [Indexed: 10/18/2023] Open
Abstract
Although the precise clinical indication for initiation of PMX-HA is widely debated in the literature, a proper patient selection and timing of treatment delivery might play a critical role in the clinical course of a specific subphenotype of septic shock (endotoxic shock). In light of this view, since 2019, we have introduced in our clinical practice a diagnostic-therapeutic flowchart to select patients that can benefit the most from the treatment proposed. In addition, we reported in this study our experience of PMX-HA in a cohort of critically ill patients admitted to our intensive care unit (ICU). We analyzed a single centre, retrospective, observational web-based database (extracted from the EUPHAS2 registry) of critically ill patients admitted to the ICU between January 2016 and May 2021 who were affected by endotoxic shock. Patients were divided according to the diagnostic-therapeutic flowchart in two groups: Pre-Flowchart (Pre-F) and Post-Flowchart (Post-F). From January 2016 to May 2021, 61 patients were treated with PMX-HA out of 531 patients diagnosed with septic shock and of these, fifty patients (82%) developed AKI during their ICU stay. The most common source of infection was secondary peritonitis (36%), followed by community-acquired pneumonia (29%). Fifty-five (90%) out of 61 patients received a second PMX-HA treatment, with a statistically significant difference between the two groups (78% of the Pre-F vs. 100% of the Post-F group, p = 0.005). In both groups, between T0 and T120, the Endotoxin Activity Assay (EAA) decreased, while the SOFA score, mean arterial pressure (MAP), and Vasoactive Inotropic Score (VIS) improved with no statistically significant difference. Furthermore, when performing a propensity score matching analysis to compare mortality between the two groups, statistically significant lower ICU and 90-day mortalities were observed in the Post-F group [p = 0.016]. Although in this experienced centre data registry, PMX-HA was associated with organ function recovery, hemodynamic improvement, and current EAA level reduction in critically ill patients with endotoxic shock. Following propensity score-matched analysis, ICU mortality and 90-day mortalities were lower in the diagnostic-therapeutic flowchart group when considering two temporal groups based on strict patient selection criteria and timing to achieve PMX. Further Randomised Control Trials focused on centre selection, adequate training and a flowchart of action when assessing extracorporeal blood purification use should be performed.
Collapse
Affiliation(s)
- Edoardo Forin
- International Renal Research Institute of Vicenza Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
- Department of Anesthesiology and Intensive Care, San Bortolo Hospital, Vicenza, Italy
| | - Giulia Lorenzoni
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Ricard Ferrer
- Shock, Organ Dysfunction, and Resuscitation Research Group (SODIR), Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain
- Intensive Care Department, Hospital Universitari Vall d́'Hebron, Barcelona, Spain
| | - Massimo De Cal
- International Renal Research Institute of Vicenza Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Monica Zanella
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Nicola Marchionna
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Francesco Forfori
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, The University of Pisa, Pisa, Italy
| | - Anna Lorenzin
- International Renal Research Institute of Vicenza Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Vinicio Danzi
- Department of Anesthesiology and Intensive Care, San Bortolo Hospital, Vicenza, Italy
| | - Claudio Ronco
- International Renal Research Institute of Vicenza Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Silvia De Rosa
- International Renal Research Institute of Vicenza Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy.
- Department of Anesthesiology and Intensive Care, San Bortolo Hospital, Vicenza, Italy.
- Centre for Medical Sciences - CISMed, University of Trento, Via S. Maria Maddalena 1, 38122, Trento, Italy.
| |
Collapse
|
|
12
|
Zhang B, Xiao Q, Ma Q, Han L. Clinical treatment for persistent inflammation, immunosuppression and catabolism syndrome in patients with severe acute pancreatitis (Review). Exp Ther Med 2023; 26:495. [PMID: 37753297 PMCID: PMC10519614 DOI: 10.3892/etm.2023.12194] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 07/28/2023] [Indexed: 09/28/2023] Open
Abstract
Severe acute pancreatitis (SAP) is a severe disease with a high prevalence and a 3-15% mortality worldwide, and premature activation of zymogen for any reason is the initial factor for the onset of SAP. Gallstone disease and heavy alcohol consumption are the two most common etiologies of SAP. Persistent inflammation, immunosuppression and catabolism syndrome (PICS) is a life-threatening illness, and there are no effective treatments. The relapse state of PICS mainly leads to high mortality due to septic shock or severe trauma, both of which are dangerous and challenging conditions for clinicians. Thus, it is important for medical staff to identify patients at high risk of PICS and to master the prevention and treatment of PICS in patients with SAP. The present review aims to increase the understanding of the pathogenesis of PICS, produce evidence for PICS diagnosis and highlight clinical treatment for PICS in patients with SAP. With this information, clinical workers could implement standardized and integrated measures at an early stage of SAP to stop its progression to PICS.
Collapse
Affiliation(s)
- Bo Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Qigui Xiao
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Qingyong Ma
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Liang Han
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| |
Collapse
|
|
13
|
Gao Y, Huang X, Yang Y, Lei Z, Chen Q, Guo X, Tian J, Gao X. Clinical analysis of AN69ST membrane continuous venous hemofiltration in the treatment of severe sepsis. Open Med (Wars) 2023; 18:20230784. [PMID: 37724124 PMCID: PMC10505301 DOI: 10.1515/med-2023-0784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 09/20/2023] Open
Abstract
We aimed to investigate the clinical efficacy of blood purification technology based on cytokine adsorption in the treatment of sepsis. Sixty patients with sepsis were randomly divided into control (n = 30) and experimental (n = 30) groups. Both groups were given routine treatment and continuous venovenous hemofiltration, and on this basis, the experimental group received acrylonitrile/sodium methacrylate (AN69ST) blood purification. The levels of C-reactive protein, procalcitonin, white blood cell count, albumin, platelets, total bilirubin, creatinine, lactic acid, and APACE II score, as well as secretion of inflammatory factors interleukin (IL)-6 and tumor necrosis factor (TNF-α) were compared. The hospitalization time, mechanical ventilation (MV) time, drug use time, and mortality were analyzed. After treatment, the secretion levels of IL-6 and TNF-α were decreased, and other indicators were significantly improved compared with those before treatment (P < 0.05), especially in the experimental group (P < 0.05). The hospitalization time, MV time, and drug use time in the experimental group were significantly lower than those of the control group (P < 0.05), and the mortality was lower than that in the control group (P < 0.05). In conclusion, blood purification technology based on cytokine adsorption can significantly improve various indicators of sepsis patients, reduce hospitalization time, reduce mortality, and improve the prognosis.
Collapse
Affiliation(s)
- Yuqiang Gao
- Intensive Medical Unit, Hainan Medical University, 571199Haikou, China
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, 570311, Haikou, China
| | - Xiaohong Huang
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, 570311, Haikou, China
| | - Yanan Yang
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, 570311, Haikou, China
| | - Zhenlin Lei
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, 570311, Haikou, China
| | - Qingan Chen
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, 570311, Haikou, China
| | - Xu Guo
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, 570311, Haikou, China
| | - Jia Tian
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, No. 19 Xiuhua Road, 570311Haikou, China
| | - Xiaoxin Gao
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, No. 19 Xiuhua Road, 570311Haikou, China
| |
Collapse
|
|
14
|
De Rosa S, Marengo M, Fiorentino M, Fanelli V, Brienza N, Fiaccadori E, Grasselli G, Morabito S, Pota V, Romagnoli S, Valente F, Cantaluppi V. Extracorporeal blood purification therapies for sepsis-associated acute kidney injury in critically ill patients: expert opinion from the SIAARTI-SIN joint commission. J Nephrol 2023; 36:1731-1742. [PMID: 37439963 PMCID: PMC10543830 DOI: 10.1007/s40620-023-01637-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 07/14/2023]
Abstract
Sepsis-Associated Acute Kidney Injury is a life-threatening condition leading to high morbidity and mortality in critically ill patients admitted to the intensive care unit. Over the past decades, several extracorporeal blood purification therapies have been developed for both sepsis and sepsis-associated acute kidney injury management. Despite the widespread use of extracorporeal blood purification therapies in clinical practice, it is still unclear when to start this kind of treatment and how to define its efficacy. Indeed, several questions on sepsis-associated acute kidney injury and extracorporeal blood purification therapy still remain unresolved, including the indications and timing of renal replacement therapy in patients with septic vs. non-septic acute kidney injury, the optimal dialysis dose for renal replacement therapy modalities in sepsis-associated acute kidney injury patients, and the rationale for using extracorporeal blood purification therapies in septic patients without acute kidney injury. Moreover, the development of novel extracorporeal blood purification therapies, including those based on the use of adsorption devices, raised the attention of the scientific community both on the clearance of specific mediators released by microorganisms and by injured cells and potentially involved in the pathogenic mechanisms of organ dysfunction including sepsis-associated acute kidney injury, and on antibiotic removal. Based on these considerations, the joint commission of the Italian Society of Anesthesiology and Critical Care (SIAARTI) and the Italian Society of Nephrology (SIN) herein addressed some of these issues, proposed some recommendations for clinical practice and developed a common framework for future clinical research in this field.
Collapse
Affiliation(s)
- Silvia De Rosa
- Centre for Medical Sciences-CISMed, University of Trento, Trento, Italy.
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy.
| | - Marita Marengo
- Nephrology and Dialysis Unit, Department of Specialist Medicine, Azienda Sanitaria Locale (ASL) CN1, Cuneo, Italy
| | - Marco Fiorentino
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari, Bari, Italy
| | - Vito Fanelli
- Anesthesia, Critical Care and Emergency Unit, Department of Surgical Sciences, Città della Salute e della Scienza di Torino, University of Torino, Turin, Italy
| | - Nicola Brienza
- Unit of Anesthesia and Resuscitation, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
| | - Enrico Fiaccadori
- Dipartimento di Medicina e Chirurgia, UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Università di Parma, Parma, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Santo Morabito
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università di Roma, Rome, Italy
| | - Vincenzo Pota
- Department of Women, Child, General and Specialty Surgery, L. Vanvitelli University of Campania, Naples, Italy
| | - Stefano Romagnoli
- Department of Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, University of Firenze, Florence, Italy
| | - Fabrizio Valente
- Nephrology and Dialysis Unit, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine (DIMET), SCDU Nefrologia e Trapianto Renale, University of Piemonte Orientale (UPO), Azienda Ospedaliero-Universitaria Maggiore della Carità, via Solaroli 17, 28100, Novara, Italy.
| |
Collapse
|
|
15
|
Papamichalis P, Oikonomou KG, Valsamaki A, Xanthoudaki M, Katsiafylloudis P, Papapostolou E, Skoura AL, Papamichalis M, Karvouniaris M, Koutras A, Vaitsi E, Sarchosi S, Papadogoulas A, Papadopoulos D. Liver replacement therapy with extracorporeal blood purification techniques current knowledge and future directions. World J Clin Cases 2023; 11:3932-3948. [PMID: 37388799 PMCID: PMC10303607 DOI: 10.12998/wjcc.v11.i17.3932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 06/12/2023] Open
Abstract
Clinically, it is highly challenging to promote recovery in patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF). Despite recent advances in understanding the underlying mechanisms of ALF and ACLF, standard medical therapy remains the primary therapeutic approach. Liver transplantation (LT) is considered the last option, and in several cases, it is the only intervention that can be lifesaving. Unfortunately, this intervention is limited by organ donation shortage or exclusion criteria such that not all patients in need can receive a transplant. Another option is to restore impaired liver function with artificial extracorporeal blood purification systems. The first such systems were developed at the end of the 20th century, providing solutions as bridging therapy, either for liver recovery or LT. They enhance the elimination of metabolites and substances that accumulate due to compromised liver function. In addition, they aid in clearance of molecules released during acute liver decompensation, which can initiate an excessive inflammatory response in these patients causing hepatic encephalopathy, multiple-organ failure, and other complications of liver failure. As compared to renal replacement therapies, we have been unsuccessful in using artificial extracorporeal blood purification systems to completely replace liver function despite the outstanding technological evolution of these systems. Extracting middle to high-molecular-weight and hydrophobic/protein-bound molecules remains extremely challenging. The majority of the currently available systems include a combination of methods that cleanse different ranges and types of molecules and toxins. Furthermore, conventional methods such as plasma exchange are being re-evaluated, and novel adsorption filters are increasingly being used for liver indications. These strategies are very promising for the treatment of liver failure. Nevertheless, the best method, system, or device has not been developed yet, and its probability of getting developed in the near future is also low. Furthermore, little is known about the effects of liver support systems on the overall and transplant-free survival of these patients, and further investigation using randomized controlled trials and meta-analyses is needed. This review presents the most popular extracorporeal blood purification techniques for liver replacement therapy. It focuses on general principles of their function, and on evidence regarding their effectiveness in detoxification and in supporting patients with ALF and ACLF. In addition, we have outlined the basic advantages and disadvantages of each system.
Collapse
Affiliation(s)
| | - Katerina G Oikonomou
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Thessaly, Greece
| | - Asimina Valsamaki
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Thessaly, Greece
| | - Maria Xanthoudaki
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Thessaly, Greece
| | | | | | - Apostolia-Lemonia Skoura
- Department of Transfusion Medicine, University Hospital of Larissa, Larissa 41110, Thessaly, Greece
| | - Michail Papamichalis
- Department of Cardiology, University Hospital of Larissa, Larissa 41110, Thessaly, Greece
| | | | - Antonios Koutras
- 1st Department of Obstetrics and Gynecology, General Hospital of Athens “ALEXANDRA”, National and Kapodistrian University of Athens, Athens 11528, Greece
| | - Eleni Vaitsi
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Thessaly, Greece
| | - Smaragdi Sarchosi
- Department of Anesthesiology, University Hospital of Larissa, Larissa 41110, Thessaly, Greece
| | | | | |
Collapse
|
|
16
|
Mehta Y, Paul R, Ansari AS, Banerjee T, Gunaydin S, Nassiri AA, Pappalardo F, Premužić V, Sathe P, Singh V, Vela ER. Extracorporeal blood purification strategies in sepsis and septic shock: An insight into recent advancements. World J Crit Care Med 2023; 12:71-88. [PMID: 37034019 PMCID: PMC10075046 DOI: 10.5492/wjccm.v12.i2.71] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/05/2023] [Accepted: 02/17/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Despite various therapies to treat sepsis, it is one of the leading causes of mortality in the intensive care unit patients globally. Knowledge about the pathophysiology of sepsis has sparked interest in extracorporeal therapies (ECT) which are intended to balance the dysregulation of the immune system by removing excessive levels of inflammatory mediators.
AIM To review recent data on the use of ECT in sepsis and to assess their effects on various inflammatory and clinical outcomes.
METHODS In this review, an extensive English literature search was conducted from the last two decades to identify the use of ECT in sepsis. A total of 68 articles from peer-reviewed and indexed journals were selected excluding publications with only abstracts.
RESULTS Results showed that ECT techniques such as high-volume hemofiltration, coupled plasma adsorption/filtration, resin or polymer adsorbers, and CytoSorb® are emerging as adjunct therapies to improve hemodynamic stability in sepsis. CytoSorb® has the most published data in regard to the use in the field of septic shock with reports on improved survival rates and lowered sequential organ failure assessment scores, lactate levels, total leucocyte count, platelet count, interleukin- IL-6, IL-10, and TNF levels.
CONCLUSION Clinical acceptance of ECT in sepsis and septic shock is currently still limited due to a lack of large random clinical trials. In addition to patient-tailored therapies, future research developments with therapies targeting the cellular level of the immune response are expected.
Collapse
Affiliation(s)
- Yatin Mehta
- Institute of Critical Care and Anesthesiology, Medanta the Medicity, Gurugram 12201, India
| | - Rajib Paul
- Department of Internal Medicine, Apollo Hospitals, Jubilee Hills, Hyderabad 500033, India
| | - Abdul Samad Ansari
- Department of Critical Care, Nanavati Max Super Specialty Hospital, Mumbai 400065, India
| | - Tanmay Banerjee
- Department of Internal Medicine & Critical Care, Medica Institute of Critical Care Medicine, Medica Superspecialty Hospital, Kolkata 700099, India
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital Campus, Ankara 06933, Turkey
| | - Amir Ahmad Nassiri
- Department of Nephrology, Shahid Beheshti University of Medical Sciences, Tehran 19839-63113, Iran
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria 15121, Italy
| | - Vedran Premužić
- Department of Nephrology, Clinical Hospital Zagreb, Clinic for internal diseases, Zagreb 10000, Croatia
| | - Prachee Sathe
- Department of Critical Care Medicine, D.Y. Patil Medical College, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Pune 411018, India
| | - Vinod Singh
- Department of Critical Care Medicine, Institute of critical care Medicine, Hospital Name - Sir Ganga Ram Hospital, New Delhi 110001, India
| | - Emilio Rey Vela
- Cardiac Surgery Intensive Care Unit, Samaritan University Hospital, Bogotá 11, Colombia
| |
Collapse
|
|
17
|
Stasi A, Franzin R, Caggiano G, Losapio R, Fiorentino M, Alfieri C, Gesualdo L, Stallone G, Castellano G. New Frontiers in Sepsis-Induced Acute Kidney Injury and Blood Purification Therapies: The Role of Polymethylmethacrylate Membrane Hemofilter. Blood Purif 2023; 52 Suppl 1:71-84. [PMID: 36693337 PMCID: PMC10210082 DOI: 10.1159/000528685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 11/17/2022] [Indexed: 01/25/2023]
Abstract
Acute kidney injury (AKI) is a common consequence of sepsis with a mortality rate of up to 40%. The pathogenesis of septic AKI is complex and involves several mechanisms leading to exacerbated inflammatory response associated with renal injury. A large body of evidence suggests that inflammation is tightly linked to AKI through bidirectional interaction between renal and immune cells. Preclinical data from our and other laboratories have identified in complement system activation a crucial mediator of AKI. Partial recovery following AKI could lead to long-term consequences that predispose to chronic dysfunction and may also accelerate the progression of preexisting chronic kidney disease. Recent findings have revealed striking morphological and functional changes in renal parenchymal cells induced by mitochondrial dysfunction, cell cycle arrest via the activation of signaling pathways involved in aging process, microvascular rarefaction, and early fibrosis. Although major advances have been made in our understanding of the pathophysiology of AKI, there are no available preventive and therapeutic strategies in this field. The identification of ideal clinical biomarkers for AKI enables prompt and effective therapeutic strategy that could prevent the progression of renal injury and promote repair process. Therefore, the use of novel biomarkers associated with clinical and functional criteria could provide early interventions and better outcome. Several new drugs for AKI are currently being investigated; however, the complexity of this disease might explain the failure of pharmacological intervention targeting just one of the many systems involved. The hypothesis that blood purification could improve the outcome of septic AKI has attracted much attention. New relevant findings on the role of polymethylmethacrylate-based continuous veno-venous hemofiltration in septic AKI have been reported. Herein, we provide a comprehensive literature review on advances in the pathophysiology of septic AKI and potential therapeutic approaches in this field.
Collapse
Affiliation(s)
- Alessandra Stasi
- Renal, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari, Bari, Italy
| | - Rossana Franzin
- Renal, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari, Bari, Italy
| | - Gianvito Caggiano
- Renal, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari, Bari, Italy
| | - Rosa Losapio
- Renal, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari, Bari, Italy
| | - Marco Fiorentino
- Renal, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari, Bari, Italy
| | - Carlo Alfieri
- Nephrology, Dialysis and Renal Transplant Unit, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Loreto Gesualdo
- Renal, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari, Bari, Italy
| | - Giovanni Stallone
- Nephrology Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, Advanced Research Center on Kidney Aging (A.R.K.A.), University of Foggia, Foggia, Italy
| | - Giuseppe Castellano
- Nephrology, Dialysis and Renal Transplant Unit, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| |
Collapse
|
|
18
|
Mann L, Ten Eyck P, Wu C, Story M, Jenigiri S, Patel J, Honkanen I, O’Connor K, Tener J, Sambharia M, Fraer M, Nourredine L, Somers D, Nizar J, Antes L, Kuppachi S, Swee M, Kuo E, Huang CL, Jalal DI, Griffin BR. CVVHD results in longer filter life than pre-filter CVVH: Results of a quasi-randomized clinical trial. PLoS One 2023; 18:e0278550. [PMID: 36630406 PMCID: PMC9833553 DOI: 10.1371/journal.pone.0278550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 11/11/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Filter clotting is a major issue in continuous kidney replacement therapy (CKRT) that interrupts treatment, reduces delivered effluent dose, and increases cost of care. While a number of variables are involved in filter life, treatment modality is an understudied factor. We hypothesized that filters in pre-filter continuous venovenous hemofiltration (CVVH) would have shorter lifespans than in continuous venovenous hemodialysis (CVVHD). METHODS This was a single center, pragmatic, unblinded, quasi-randomized cluster trial conducted in critically ill adult patients with severe acute kidney injury (AKI) at the University of Iowa Hospitals and Clinics (UIHC) between March 2020 and December 2020. Patients were quasi-randomized by time block to receive pre-filter CVVH (convection) or CVVHD (diffusion). The primary outcome was filter life, and secondary outcomes were number of filters used, number of filters reaching 72 hours, and in-hospital mortality. RESULTS In the intention-to-treat analysis, filter life in pre-filter CVVH was 79% of that observed in CVVHD (mean ratio 0.79, 95% CI 0.65-0.97, p = 0.02). Median filter life (with interquartile range) in pre-filter CVVH was 21.8 (11.4-45.3) and was 26.6 (13.0-63.5) for CVVHD. In addition, 11.8% of filters in pre-filter CVVH were active for >72 hours, versus 21.2% in the CVVHD group. Finally, filter clotting accounted for the loss of 26.7% of filters in the CVVH group compared to 17.5% in the CVVHD group. There were no differences in overall numbers of filters used or mortality between groups. CONCLUSIONS Among critically patients with severe AKI requiring CKRT, use of pre-filter CVVH resulted in significantly shorter filter life compared to CVVHD. TRIAL REGISTRATION ClinicalTrials.gov, NCT04762524. Registered 02/21/21-Retroactively registered, https://clinicaltrials.gov/ct2/show/NCT04762524?cond=The+Impact+of+CRRT+Modality+on+Filter+Life&draw=2&rank=1.
Collapse
Affiliation(s)
- Lewis Mann
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Patrick Ten Eyck
- University of Iowa Institute for Clinical and Translational Science, Iowa City, Iowa, United States of America
| | - Chaorong Wu
- University of Iowa Institute for Clinical and Translational Science, Iowa City, Iowa, United States of America
| | - Maria Story
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Sree Jenigiri
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Jayesh Patel
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Iiro Honkanen
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Kandi O’Connor
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Janis Tener
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Meenakshi Sambharia
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Mony Fraer
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Lama Nourredine
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Douglas Somers
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Jonathan Nizar
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Lisa Antes
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Sarat Kuppachi
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Melissa Swee
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Elizabeth Kuo
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Chou-Long Huang
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
| | - Diana I. Jalal
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, United States of America
| | - Benjamin R. Griffin
- Division of Nephrology & Hypertension, University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States of America
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, United States of America
| |
Collapse
|
|
19
|
Savioli G, Zanza C, Longhitano Y, Nardone A, Varesi A, Ceresa IF, Manetti AC, Volonnino G, Maiese A, La Russa R. Heat-Related Illness in Emergency and Critical Care: Recommendations for Recognition and Management with Medico-Legal Considerations. Biomedicines 2022; 10:2542. [PMID: 36289804 PMCID: PMC9599879 DOI: 10.3390/biomedicines10102542] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/22/2022] [Accepted: 10/06/2022] [Indexed: 11/30/2022] Open
Abstract
Hyperthermia is an internal body temperature increase above 40.5 °C; normally internal body temperature is kept constant through natural homeostatic mechanisms. Heat-related illnesses occur due to exposure to high environmental temperatures in conditions in which an organism is unable to maintain adequate homeostasis. This can happen, for example, when the organism is unable to dissipate heat adequately. Heat dissipation occurs through evaporation, conduction, convection, and radiation. Heat disease exhibits a continuum of signs and symptoms ranging from minor to major clinical pictures. Minor clinical pictures include cramps, syncope, edema, tetany, and exhaustion. Major clinical pictures include heatstroke and life-threatening heat stroke and typically are expressed in the presence of an extremely high body temperature. There are also some categories of people at greater risk of developing these diseases, due to exposure in particular geographic areas (e.g., hot humid environments), to unchangeable predisposing conditions (e.g., advanced age, young age (i.e., children), diabetes, skin disease with reduced sweating), to modifiable risk factors (e.g., alcoholism, excessive exercise, infections), to partially modifiable risk factors (obesity), to certain types of professional activity (e.g., athletes, military personnel, and outdoor laborers) or to the effects of drug treatment (e.g., beta-blockers, anticholinergics, diuretics). Heat-related illness is largely preventable.
Collapse
Affiliation(s)
- Gabriele Savioli
- Emergency Department, IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Doctoral Program Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Christian Zanza
- Foundation “Ospedale Alba-Bra”, Department of Emergency Medicine, Anesthesia and Critical Care Medicine, Michele and Pietro Ferrero Hospital, 12060 Verduno, Italy
| | - Yaroslava Longhitano
- Foundation “Ospedale Alba-Bra”, Department of Emergency Medicine, Anesthesia and Critical Care Medicine, Michele and Pietro Ferrero Hospital, 12060 Verduno, Italy
| | - Alba Nardone
- Department of Internal Medicine, Università degli Studi of Pavia, 27100 Pavia, Italy
| | - Angelica Varesi
- Department of Internal Medicine, Università degli Studi of Pavia, 27100 Pavia, Italy
| | | | - Alice Chiara Manetti
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy
| | - Gianpietro Volonnino
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University, 00185 Rome, Italy
| | - Aniello Maiese
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy
| | - Raffaele La Russa
- Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy
| |
Collapse
|
|
20
|
Wald R, Beaubien-Souligny W, Chanchlani R, Clark EG, Neyra JA, Ostermann M, Silver SA, Vaara S, Zarbock A, Bagshaw SM. Delivering optimal renal replacement therapy to critically ill patients with acute kidney injury. Intensive Care Med 2022; 48:1368-1381. [PMID: 36066597 DOI: 10.1007/s00134-022-06851-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
Critical illness is often complicated by acute kidney injury (AKI). In patients with severe AKI, renal replacement therapy (RRT) is deployed to address metabolic dysfunction and volume excess until kidney function recovers. This review is intended to provide a comprehensive update on key aspects of RRT prescription and delivery to critically ill patients. Recently completed trials have enhanced the evidence base regarding several RRT practices, most notably the timing of RRT initiation and anticoagulation for continuous therapies. Better evidence is still needed to clarify several aspects of care including optimal targets for ultrafiltration and effective strategies for RRT weaning and discontinuation.
Collapse
Affiliation(s)
- Ron Wald
- Division of Nephrology, St. Michael's Hospital and the University of Toronto, 61 Queen Street East, 9-140, Toronto, ON, M5C 2T2, Canada. .,Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
| | | | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Javier A Neyra
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marlies Ostermann
- Department of Critical Care Medicine, Guys and St. Thomas Hospital, London, UK
| | - Samuel A Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen's University, Kingston, ON, Canada
| | - Suvi Vaara
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, Muenster, Germany
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| |
Collapse
|
|
21
|
Santana-Padilla Y, Berrocal-Tomé F, Santana-López B. Las terapias adsortivas como coadyuvante al soporte vital en el paciente crítico. ENFERMERIA INTENSIVA 2022. [DOI: 10.1016/j.enfi.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
|
22
|
Piotte J, Louis F, Buyansky D, Mereniuk E, Lévesque R, Wald R, Cailhier JF, Côté JM, Beaubien-Souligny W. Online hemodiafiltration compared to conventional hemodialysis in critically ill patients. Kidney Int Rep 2022; 7:2376-2387. [DOI: 10.1016/j.ekir.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/15/2022] [Accepted: 08/15/2022] [Indexed: 10/15/2022] Open
|
|
23
|
Clark EG, Vijayan A. Intensive RRT for AKI: Dial Down Your Enthusiasm! KIDNEY360 2022; 3:1439-1441. [PMID: 36176669 PMCID: PMC9416838 DOI: 10.34067/kid.0000972022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/01/2022] [Indexed: 01/11/2023]
Affiliation(s)
- Edward G. Clark
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Anitha Vijayan
- Division of Nephrology, Washington University in St. Louis, St. Louis, Missouri
| |
Collapse
|
|
24
|
Affiliation(s)
- Stéphane Gaudry
- From INSERM, UMR_S1155, Common and Rare Kidney Diseases, Hôpital Tenon, Sorbonne Université (S.G., D.D.), and Université de Paris (D.D.), Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, and the Health Care Simulation Center, UFR SMBH, Université Paris 13, Sorbonne Paris Cité, Bobigny (S.G.), and Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Hôpital Louis Mourier, Colombes (D.D.) - all in France; and the Kidney Medicine Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, and the Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh - both in Pittsburgh (P.M.P.)
| | - Paul M Palevsky
- From INSERM, UMR_S1155, Common and Rare Kidney Diseases, Hôpital Tenon, Sorbonne Université (S.G., D.D.), and Université de Paris (D.D.), Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, and the Health Care Simulation Center, UFR SMBH, Université Paris 13, Sorbonne Paris Cité, Bobigny (S.G.), and Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Hôpital Louis Mourier, Colombes (D.D.) - all in France; and the Kidney Medicine Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, and the Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh - both in Pittsburgh (P.M.P.)
| | - Didier Dreyfuss
- From INSERM, UMR_S1155, Common and Rare Kidney Diseases, Hôpital Tenon, Sorbonne Université (S.G., D.D.), and Université de Paris (D.D.), Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, and the Health Care Simulation Center, UFR SMBH, Université Paris 13, Sorbonne Paris Cité, Bobigny (S.G.), and Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Hôpital Louis Mourier, Colombes (D.D.) - all in France; and the Kidney Medicine Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, and the Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh - both in Pittsburgh (P.M.P.)
| |
Collapse
|
|
25
|
Stahl K, Bode C, David S. Extrakorporale Behandlungsstrategien der Sepsis. TRANSFUSIONSMEDIZIN 2022. [DOI: 10.1055/a-1557-3201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Zusammenfassung
Hintergrund Die Mortalität der Sepsis bleibt auch im 21. Jahrhundert sehr hoch. Verschiedene adjuvante Strategien zur extrakorporalen Zytokinelimination wurden als zusätzliche
therapeutische Maßnahmen bei Sepsis und septischem Schock untersucht.
Ziele Zusammenfassung einer Auswahl extrakorporaler Blutreinigungstechniken und der aktuellen Erkenntnisse in der klinischen Anwendung mit besonderem Schwerpunkt auf dem
therapeutischen Plasmaaustausch.
Methoden Nicht systematische Literaturrecherche.
Ergebnisse Verschiedene extrakorporale Blutreinigungstechniken mit unterschiedlichen Evidenzniveaus hinsichtlich Zytokinelimination, Verbesserung der Hämodynamik und Verringerung der
Mortalität werden derzeit klinisch eingesetzt. Die am ausführlichsten untersuchten Modalitäten umfassen die hochvolumige Hämofiltration/Dialyse mit und ohne High-Cut-off-Filter sowie
Hämoadsorptionstechniken (einschließlich CytoSorb- und Polymyxin-B-Filter). Trotz teilweise ermutigender Beobachtungen bezüglich der Entfernung proinflammatorischer Zytokine und verbesserten
Hämodynamik zeigten randomisierte Outcome-Studien bislang keinen positiven Einfluss auf das Überleben. Aufgrund der Verwendung von Spenderplasma als Substitutionsflüssigkeit stellt der
therapeutische Plasmaaustausch das einzige Verfahren dar, das neben einer reinen Elimination zusätzlich verbrauchte protektive Faktoren ersetzen kann.
Schlussfolgerungen Die Anwendung extrakorporaler Blutreinigungsmethoden kann für Sepsispatienten außerhalb klinischer Studien bisher nicht empfohlen werden, da derzeit keine Beweise
für ihre Wirksamkeit vorliegen. Zukünftige Untersuchungen sollten darauf abzielen, das Patientenkollektiv hinsichtlich des klinischen Schweregrads, des Zeitpunkts der Intervention und
verschiedener inflammatorischer (Sub-)Phänotypen zu homogenisieren.
Collapse
Affiliation(s)
- Klaus Stahl
- Abteilung für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Deutschland
| | - Christian Bode
- Klinik für Anästhesie und operative Intensivmedizin, Universitätsklinikum Bonn, Deutschland
| | - Sascha David
- Abteilung für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover & Institut für Intensivmedizin, Universitätsspital Zürich, Schweiz
| |
Collapse
|
|
26
|
AN69 Filter Membranes with High Ultrafiltration Rates during Continuous Venovenous Hemofiltration Reduce Mortality in Patients with Sepsis-Induced Multiorgan Dysfunction Syndrome. MEMBRANES 2021; 11:membranes11110837. [PMID: 34832066 PMCID: PMC8618352 DOI: 10.3390/membranes11110837] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 12/29/2022]
Abstract
Polyacrylonitrile (AN69) filter membranes adsorb cytokines during continuous venovenous hemofiltration (CVVH). Although high-volume hemofiltration has shown limited benefits, the dose-effect relationship in CVVH with AN69 membranes on severe sepsis remains undetermined. This multi-centered study enrolled 266 patients with sepsis-induced multiorgan dysfunction syndrome (MODS) who underwent CVVH with AN69 membranes between 2014 and 2015. We investigated the effects of ultrafiltration rates (UFR) on mortality. We categorized patients that were treated with UFR of 20-25 mL/kg/h as the standard UFR group (n = 124) and those that were treated with a UFR >25 mL/kg/h as the high UFR group (n = 142). Among the patient characteristics, the baseline estimated glomerular filtration rates (eGFR) <60 mL/min/1.73 m2, hemoglobin levels <10 g/dL, and a sequential organ failure assessment (SOFA) score ≥15 at CVVH initiation were independently associated with in-hospital mortality. In the subgroup analysis, for patients with SOFA scores that were ≥15, the 90-day survival rate was higher in the high UFR group than in the standard UFR group (HR 0.54, CI: 0.36-0.79, p = 0.005). We concluded that in patients with sepsis-induced MODS, SOFA scores ≥15 predicted a poor rate of survival. High UFR setting >25 mL/kg/h in CVVH with AN69 membranes may reduce the mortality risk in these high-risk patients.
Collapse
|
|
27
|
Neyra JA, Tolwani A. CRRT prescription and delivery of dose. Semin Dial 2021; 34:432-439. [PMID: 33909931 DOI: 10.1111/sdi.12974] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/22/2021] [Accepted: 03/30/2021] [Indexed: 12/31/2022]
Abstract
Continuous renal replacement therapy (CRRT) is the preferred modality of extracorporeal renal support for critically ill patients with acute kidney injury (AKI). The dose of CRRT is reported as effluent flow in ml/kg body weight per hour (ml/kg/h). Solid evidence supports that the delivered CRRT effluent dose for critically ill patients with AKI should be 20-25 ml/kg/h on average. To account for treatment interruptions and the natural decline in filter efficiency over time, it is recommended to prescribe 25-30 ml/kg/h of effluent dose. However, transient higher doses of CRRT in specific clinical scenarios may be needed to accommodate specific solute control needs of a particular patient at a given time. Consequently, there should be consideration of the potential adverse consequences of non-selective clearance such as undesired antimicrobials and nutrients removal. In this manuscript, we provide a summary of evidence related to CRRT dose, practical aspects for its calculation at the time of prescribing CRRT, and considerations for addressing the expected gap between prescribed and delivered CRRT dose. We also provide a framework for monitoring and implementation of CRRT dose as a quality indicator of CRRT delivery.
Collapse
Affiliation(s)
- Javier A Neyra
- Department of Internal Medicine, Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - Ashita Tolwani
- Department of Internal Medicine, Division of Nephrology, University of Alabama, Birmingham, AL, USA
| |
Collapse
|
|
28
|
Zhang L, Feng Y, Fu P. Blood purification for sepsis: an overview. PRECISION CLINICAL MEDICINE 2021; 4:45-55. [PMID: 35693122 PMCID: PMC8982546 DOI: 10.1093/pcmedi/pbab005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/09/2021] [Accepted: 02/17/2021] [Indexed: 02/05/2023] Open
Abstract
Sepsis is a life-threatening organ failure exacerbated by a maladaptive infection response from the host, and is one of the major causes of mortality in the intensive care unit. In recent decades, several extracorporeal blood purification techniques have been developed to manage sepsis by acting on both the infectious agents themselves and the host immune response. This research aims to summarize recent progress on extracorporeal blood purification technologies applied for sepsis, discuss unanswered questions on renal replacement therapy for septic patients, and present a decision-making strategy for practitioners.
Collapse
Affiliation(s)
- Ling Zhang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Yuying Feng
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Ping Fu
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China
| |
Collapse
|
|
29
|
Alabbas A, Kirpalani A, Morgan C, Mammen C, Licht C, Phan V, Wade A, Harvey E, Zappitelli M, Clark EG, Hiremath S, Soroka SD, Wald R, Weir MA, Chanchlani R, Lemaire M. Canadian Association of Paediatric Nephrologists COVID-19 Rapid Response: Guidelines for Management of Acute Kidney Injury in Children. Can J Kidney Health Dis 2021; 8:2054358121990135. [PMID: 33614056 PMCID: PMC7868478 DOI: 10.1177/2054358121990135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/04/2021] [Indexed: 01/08/2023] Open
Abstract
PURPOSE This article provides guidance on managing acute kidney injury (AKI) and kidney replacement therapy (KRT) in pediatrics during the COVID-19 pandemic in the Canadian context. It is adapted from recently published rapid guidelines on the management of AKI and KRT in adults, from the Canadian Society of Nephrology (CSN). The goal is to provide the best possible care for pediatric patients with kidney disease during the pandemic and ensure the health care team's safety. INFORMATION SOURCES The Canadian Association of Paediatric Nephrologists (CAPN) COVID-19 Rapid Response team derived these rapid guidelines from the CSN consensus recommendations for adult patients with AKI. We have also consulted specific documents from other national and international agencies focused on pediatric kidney health. We identified additional information by reviewing the published academic literature relevant to pediatric AKI and KRT, including recent journal articles and preprints related to COVID-19 in children. Finally, our group also sought expert opinions from pediatric nephrologists across Canada. METHODS The leadership of the CAPN, which is affiliated with the CSN, solicited a team of clinicians and researchers with expertise in pediatric AKI and acute KRT. The goal was to adapt the guidelines recently adopted for Canadian adult patients for pediatric-specific settings. These included specific COVID-19-related themes relevant to AKI and KRT in a Canadian setting, as determined by a group of kidney disease experts and leaders. An expert group of clinicians in pediatric AKI and acute KRT reviewed the revised pediatric guidelines. KEY FINDINGS (1) Current Canadian data do not suggest an imminent threat of an increase in acute KRT needs in children because of COVID-19; however, close coordination between nephrology programs and critical care programs is crucial as the pandemic continues to evolve. (2) Pediatric centers should prepare to reallocate resources to adult centers as needed based on broader health care needs during the COVID-19 pandemic. (3) Specific suggestions pertinent to the optimal management of AKI and KRT in COVID-19 patients are provided. These suggestions include but are not limited to aspects of fluid management, KRT vascular access, and KRT modality choice. (4) Considerations to ensure adequate provision of KRT if resources become scarce during the COVID-19 pandemic. LIMITATIONS We did not conduct a formal systematic review or meta-analysis. We did not evaluate our specific suggestions in the clinical environment. The local context, including how the provision of care for AKI and acute KRT is organized, may impede the implementation of many suggestions. As knowledge is advancing rapidly in the area of COVID-19, suggestions may become outdated quickly. Finally, most of the literature for AKI and KRT in COVID-19 comes from adult data, and there are few pediatric-specific studies. IMPLICATIONS Given that most acute KRT related to COVID-19 is likely to be required in the pediatric intensive care unit initial setting, close collaboration and planning between critical care and pediatric nephrology programs are needed. Our group will update these suggestions with a supplement if necessary as newer evidence becomes available that may change or add to the recommendations provided.
Collapse
Affiliation(s)
- Abdullah Alabbas
- Department of Paediatrics, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Amrit Kirpalani
- Department of Paediatrics, Division of Nephrology, Western University, London, ON, Canada
| | - Catherine Morgan
- Department of Paediatrics, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Cherry Mammen
- Department of Paediatrics, Division of Nephrology, The University of British Columbia, Vancouver, Canada
| | - Christoph Licht
- Department of Paediatrics, Division of Nephrology, University of Toronto, ON, Canada
| | - Veronique Phan
- Department of Paediatrics, Division of Nephrology, Université de Montréal, Québec, Canada
| | - Andrew Wade
- Department of Paediatrics, Division of Nephrology, University of Calgary, AB, Canada
| | - Elizabeth Harvey
- Department of Paediatrics, Division of Nephrology, University of Toronto, ON, Canada
| | - Michael Zappitelli
- Department of Paediatrics, Division of Nephrology, University of Toronto, ON, Canada
| | - Edward G. Clark
- Division of Nephrology, Department of Medicine, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Steven D. Soroka
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital and Department of Medicine, University of Toronto, ON, Canada
| | - Matthew A. Weir
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, ON, Canada
| | - Mathieu Lemaire
- Department of Paediatrics, Division of Nephrology, University of Toronto, ON, Canada
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
| |
Collapse
|
|
30
|
Vásquez Jiménez E, Anumudu SJ, Neyra JA. Dose of Continuous Renal Replacement Therapy in Critically Ill Patients: A Bona Fide Quality Indicator. Nephron Clin Pract 2021; 145:91-98. [PMID: 33540417 PMCID: PMC7965247 DOI: 10.1159/000512846] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 10/24/2020] [Indexed: 11/19/2022] Open
Abstract
Acute kidney injury (AKI) is common in critically ill patients, and renal replacement therapy (RRT) constitutes an important aspect of acute management during critical illness. Continuous RRT (CRRT) is frequently utilized in intensive care unit settings, particularly in patients with severe AKI, fluid overload, and hemodynamic instability. The main goal of CRRT is to timely optimize solute control, acid-base, and volume status. Total effluent dose of CRRT is a deliverable that depends on multiple factors and therefore should be systematically monitored (prescribed vs. delivered) and iteratively adjusted in a sustainable mode. In this manuscript, we review current evidence of CRRT dosing and provide recommendations for its implementation as a quality indicator of CRRT delivery.
Collapse
Affiliation(s)
- Enzo Vásquez Jiménez
- Department of Nephrology, National Institute of Cardiology Mexico, Mexico City, Mexico
| | - Samaya J Anumudu
- Division of Nephrology, Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Internal Medicine, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA,
| |
Collapse
|
|
31
|
Ghandour M, Bhat ZY, Rossi NF, Ciccotelli G, Osman-Malik Y. Wayne State University Nephrology service experience in the constraint of COVID-19. Ther Apher Dial 2021; 25:1012-1013. [PMID: 33528080 PMCID: PMC8014492 DOI: 10.1111/1744-9987.13632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/18/2021] [Accepted: 02/01/2021] [Indexed: 11/25/2022]
Affiliation(s)
| | - Zeenat Y Bhat
- Wayne State University, Nephrology Division, Detroit, Michigan, USA
| | - Noreen F Rossi
- Wayne State University, Nephrology Division, Detroit, Michigan, USA
| | | | | |
Collapse
|
|
32
|
White-Dzuro G, Gibson LE, Zazzeron L, White-Dzuro C, Sullivan Z, Diiorio DA, Low SA, Chang MG, Bittner EA. Multisystem effects of COVID-19: a concise review for practitioners. Postgrad Med 2021; 133:20-27. [PMID: 32921198 PMCID: PMC7651182 DOI: 10.1080/00325481.2020.1823094] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/07/2020] [Indexed: 01/08/2023]
Abstract
While COVID-19 has primarily been characterized by the respiratory impact of viral pneumonia, it affects every organ system and carries a high consequent risk of death in critically ill patients. Higher sequential organ failure assessment (SOFA) scores have been associated with increased mortality in patients critically ill patients with COVID-19. It is important that clinicians managing critically ill COVID-19 patients be aware of the multisystem impact of the disease so that care can be focused on the prevention of end-organ injuries to potentially improve clinical outcomes. We review the multisystem complications of COVID-19 and associated treatment strategies to improve the care of critically ill COVID-19 patients.
Collapse
Affiliation(s)
- Gabrielle White-Dzuro
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lauren E. Gibson
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Luca Zazzeron
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Colin White-Dzuro
- School of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Zachary Sullivan
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Daren A. Diiorio
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sarah A. Low
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marvin G. Chang
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Edward A. Bittner
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
|
33
|
Zhu CY, Pan AJ, Mei Q, Chen T. Successful cure of a patient with urosepsis using a combination of extracorporeal membrane oxygenation and continuous renal replacement therapy: A case report and literature review. Chin J Traumatol 2020; 23:372-375. [PMID: 33039249 PMCID: PMC7718516 DOI: 10.1016/j.cjtee.2020.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 08/10/2020] [Accepted: 09/09/2020] [Indexed: 02/04/2023] Open
Abstract
Holmium laser lithotripsy (HLL) is one of the common surgical methods for urolithiasis. It causes minor surgical trauma, but complications are not rare. Extracorporeal membrane oxygenation (ECMO) treatment of sepsis is common, but venoarterial (VA)-ECMO treatment of urosepsis has not been reported yet. In this article, we reported a 67-year-old female patient with refractory septic shock caused by HLL under percutaneous nephroscope, involving breathing, heart, kidney and other organs, and organs support treatment was ineffective for the patient. Finally, we successfully treated the patient under VA-ECMO with continuous renal replacement therapy (CRRT). Combined ECMO and CRRT may provide a solution for addressing refractory sepsis. Here we present the case and review relevant literature, so as to provide a treatment strategy for patients with refractory urogenic sepsis and to reduce the mortality rate.
Collapse
Affiliation(s)
- Chun-Yan Zhu
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Hefei 230032, China
| | - Ai-Jun Pan
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Hefei 230032, China.
| | - Qing Mei
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Hefei 230032, China
| | - Ting Chen
- Department of Critical Care Medicine, The Second People's Hospital of Hefei, Hefei 230009, China
| |
Collapse
|
|
34
|
Clark EG, Hiremath S, Soroka SD, Wald R, Weir MA. CSN COVID-19 Rapid Review Program: Management of Acute Kidney Injury. Can J Kidney Health Dis 2020; 7:2054358120941679. [PMID: 32728473 PMCID: PMC7364799 DOI: 10.1177/2054358120941679] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 01/08/2023] Open
Abstract
PURPOSE Severe acute kidney injury (AKI) is a potential complication of COVID-19-associated critical illness. This has implications for the management of COVID-19-associated AKI and the resulting increased need for kidney replacement therapy (KRT) in the intensive care unit (ICU) and elsewhere in the hospital. The Canadian Society of Nephrology COVID-19 Rapid Review Team has sought to collate and synthesize currently available resources to inform ethically justifiable decisions. The goal is the provision of the best possible care for the largest number of patients with kidney disease while considering how best to ensure the safety of the health care team. INFORMATION SOURCES Local, provincial, national, and international guidance and planning documents related to the COVID-19 pandemic; guidance documents available from nephrology and critical care-related professional organizations; recent journal articles and preprints related to the COVID-19 pandemic; expert opinion from nephrologists from across Canada. METHODS A working group of kidney specialist physicians was established with representation from across Canada. Kidney physician specialists met via teleconference and exchanged e-mails to refine and agree on the proposed suggestions in this document. KEY FINDINGS (1) Nephrology programs should work with ICU programs to plan for the possibility that up to 30% or more of critically ill patients with COVID-19 admitted to ICU will require kidney replacement therapy (KRT). (2) Specific suggestions pertinent to the optimal management of AKI and KRT in patients with COVID-19. These suggestions include, but are not limited to, aspects of fluid management, KRT vascular access, and KRT modality choice. (3) We describe considerations related to ensuring adequate provision of KRT, should resources become scarce during the COVID-19 pandemic. LIMITATIONS A systematic review or meta-analysis was not conducted. Our suggestions have not been specifically evaluated in the clinical environment. The local context, including how the provision of acute KRT is organized, may impede the implementation of many suggestions. Knowledge is advancing rapidly in the area of COVID-19 and suggestions may become outdated quickly. IMPLICATIONS Given that most acute KRT related to COVID-19 is likely to be required initially in the ICU setting, close collaboration and planning between critical care and nephrology programs is required. Suggestions may be updated as newer evidence becomes available.
Collapse
Affiliation(s)
- Edward G. Clark
- Division of Nephrology, Department of Medicine, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Steven D. Soroka
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital and Department of Medicine, University of Toronto, ON, Canada
| | - Matthew A. Weir
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| |
Collapse
|
|
35
|
Abstract
Sepsis is the primary cause of acute kidney injury in critically ill patients. During the past decades, several extracorporeal blood purification techniques have been developed for sepsis and sepsis-induced acute kidney injury management. These therapies could act on both the infectious agent itself and the host immune response. In this article, we review the available literature discussing the different extracorporeal blood purification techniques, including high-volume hemofiltration, cascade hemofiltration, hemoperfusion, coupled plasma filtration adsorption, plasma exchange, and specific optimized renal replacement therapy membranes.
Collapse
Affiliation(s)
- Thibaut Girardot
- Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France; EA 7426 PI3 (Pathophysiology of Injury‑Induced Immunosuppression), Claude Bernard University Lyon 1, Biomérieux, Hospices Civils de Lyon, Lyon, France.
| | - Antoine Schneider
- Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Thomas Rimmelé
- Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France; EA 7426 PI3 (Pathophysiology of Injury‑Induced Immunosuppression), Claude Bernard University Lyon 1, Biomérieux, Hospices Civils de Lyon, Lyon, France
| |
Collapse
|
|
36
|
Ying P, Yang C, Wu X, Cai Q, Xin W. Effect of hydrocortisone on the 28-day mortality of patients with septic acute kidney injury. Ren Fail 2020; 41:794-799. [PMID: 31880211 PMCID: PMC6735306 DOI: 10.1080/0886022x.2019.1658605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Objectives: To evaluate the efficacy of hydrocortisone in patients with septic acute kidney injury (SAKI). Methods: This retrospective cohort study consisted of all consecutive patients with SAKI who were admitted to the Taizhou First People's Hospital from March 2016 to February 2018. The patients who were treated with usual care including antibiotics, fluid resuscitation, and blood glucose control were regarded as the control group, and those received add-on hydrocortisone by the clinicians' discretion was considered in the intervention group. Hydrocortisone was administered as a 50 mg intravenous bolus every six hours for seven days. To adjust the potential baseline differences between the hydrocortisone and control groups, a 1:1 propensity score matching (PSM) was performed to identify a matched control subject for each patient in the hydrocortisone group. Results: In the propensity-matched cohort, the 28-day mortality was significantly lower for patients in the hydrocortisone group (p = .04). Both Acute Physiology and Chronic Health Evaluation (APACHE) II and the Sequential Organ Failure Assessment (SOFA) scores were significantly lower at day 7 in the hydrocortisone group (both p < .01). Serum IL-1β, IL-6, and TNF-α concentrations significantly decreased for hydrocortisone group at day 7 (all p < .01). The levels of serum creatinine (SCr), Cystatin C (CysC), and procalcitonin (PCT) were significantly lower, while the levels of glomerular filtration rate (GFR) and urine volume were significantly higher for hydrocortisone group at day 7 (all p < .01). Conclusions: Glucocorticoid supplementation may improve renal function and reduce the 28-day mortality of patients with SAKI.
Collapse
Affiliation(s)
- Pan Ying
- Taizhou First People's Hospital, Taizhou, China
| | - Chenguang Yang
- Health Care Center for Women and Children of Huangyan District, Taizhou, China
| | - Xianlong Wu
- Taizhou First People's Hospital, Taizhou, China
| | - Qiqi Cai
- Taizhou First People's Hospital, Taizhou, China
| | - Wenwei Xin
- Taizhou First People's Hospital, Taizhou, China
| |
Collapse
|
|
37
|
Thongprayoon C, Hansrivijit P, Kovvuru K, Kanduri SR, Torres-Ortiz A, Acharya P, Gonzalez-Suarez ML, Kaewput W, Bathini T, Cheungpasitporn W. Diagnostics, Risk Factors, Treatment and Outcomes of Acute Kidney Injury in a New Paradigm. J Clin Med 2020; 9:1104. [PMID: 32294894 PMCID: PMC7230860 DOI: 10.3390/jcm9041104] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 12/13/2022] Open
Abstract
Acute kidney injury (AKI) is a common clinical condition among patients admitted in the hospitals. The condition is associated with both increased short-term and long-term mortality. With the development of a standardized definition for AKI and the acknowledgment of the impact of AKI on patient outcomes, there has been increased recognition of AKI. Two advances from past decades, the usage of computer decision support and the discovery of AKI biomarkers, have the ability to advance the diagnostic method to and further management of AKI. The increasingly widespread use of electronic health records across hospitals has substantially increased the amount of data available to investigators and has shown promise in advancing AKI research. In addition, progress in the finding and validation of different forms of biomarkers of AKI within diversified clinical environments and has provided information and insight on testing, etiology and further prognosis of AKI, leading to future of precision and personalized approach to AKI management. In this this article, we discussed the changing paradigms in AKI: from mechanisms to diagnostics, risk factors, and management of AKI.
Collapse
Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Panupong Hansrivijit
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA 17105, USA;
| | - Karthik Kovvuru
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.); (M.L.G.-S.)
| | - Swetha R. Kanduri
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.); (M.L.G.-S.)
| | - Aldo Torres-Ortiz
- Department of Medicine, Ochsner Medical Center, New Orleans, LA 70121, USA;
| | - Prakrati Acharya
- Division of Nephrology, Department of Medicine, Texas Tech University Health Sciences Center, El Paso, TX 79905, USA;
| | - Maria L. Gonzalez-Suarez
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.); (M.L.G.-S.)
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand;
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85724, USA;
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.); (M.L.G.-S.)
| |
Collapse
|
|
38
|
Karkar A, Ronco C. Prescription of CRRT: a pathway to optimize therapy. Ann Intensive Care 2020; 10:32. [PMID: 32144519 PMCID: PMC7060300 DOI: 10.1186/s13613-020-0648-y] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/26/2020] [Indexed: 12/21/2022] Open
Abstract
Severe acute kidney injury (AKI), especially when caused or accompanied by sepsis, is associated with prolonged hospitalization, progression to chronic kidney disease (CKD), financial burden, and high mortality rate. Continuous renal replacement therapy (CRRT) is a predominant form of renal replacement therapy (RRT) in the intensive care unit (ICU) due to its accurate volume control, steady acid-base and electrolyte correction, and achievement of hemodynamic stability. This manuscript reviews the different aspects of CRRT prescription in critically ill patients with severe AKI, sepsis, and multiorgan failure in ICU. These include the choice of CRRT versus Intermittent and extended hemodialysis (HD), life of the filter/dialyzer including assessment of filtration fraction, anticoagulation including regional citrate anticoagulation (RCA), prescribed versus delivered CRRT dose, vascular access management, timing of initiation and termination of CRRT, and prescription in AKI/sepsis including adsorptive methods of removing endotoxins and cytokines.
Collapse
Affiliation(s)
- Ayman Karkar
- Medical Affairs-Renal Care, Scientific Office, Baxter A.G., Burj Al Salam, PO Box 64332, Dubai, United Arab Emirates.
- Department of Nephrology Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy.
| | - Claudio Ronco
- Medical Affairs-Renal Care, Scientific Office, Baxter A.G., Burj Al Salam, PO Box 64332, Dubai, United Arab Emirates
| |
Collapse
|
|
39
|
Peerapornratana S, Manrique-Caballero CL, Gómez H, Kellum JA. Acute kidney injury from sepsis: current concepts, epidemiology, pathophysiology, prevention and treatment. Kidney Int 2019; 96:1083-1099. [PMID: 31443997 DOI: 10.1016/j.kint.2019.05.026] [Citation(s) in RCA: 875] [Impact Index Per Article: 145.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/19/2019] [Accepted: 05/08/2019] [Indexed: 12/16/2022]
Abstract
Sepsis-associated acute kidney injury (S-AKI) is a frequent complication of the critically ill patient and is associated with unacceptable morbidity and mortality. Prevention of S-AKI is difficult because by the time patients seek medical attention, most have already developed acute kidney injury. Thus, early recognition is crucial to provide supportive treatment and limit further insults. Current diagnostic criteria for acute kidney injury has limited early detection; however, novel biomarkers of kidney stress and damage have been recently validated for risk prediction and early diagnosis of acute kidney injury in the setting of sepsis. Recent evidence shows that microvascular dysfunction, inflammation, and metabolic reprogramming are 3 fundamental mechanisms that may play a role in the development of S-AKI. However, more mechanistic studies are needed to better understand the convoluted pathophysiology of S-AKI and to translate these findings into potential treatment strategies and add to the promising pharmacologic approaches being developed and tested in clinical trials.
Collapse
Affiliation(s)
- Sadudee Peerapornratana
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The Clinical Research, Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Excellence Center for Critical Care Nephrology, Division of Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Department of Laboratory Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Carlos L Manrique-Caballero
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The Clinical Research, Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Hernando Gómez
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The Clinical Research, Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The Clinical Research, Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
| |
Collapse
|
|
40
|
Junhai Z, Beibei C, Jing Y, Li L. Effect of High-Volume Hemofiltration in Critically Ill Patients: A Systematic Review and Meta-Analysis. Med Sci Monit 2019; 25:3964-3975. [PMID: 31134957 PMCID: PMC6582686 DOI: 10.12659/msm.916767] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Studies have been carried out to assess the efficacy of high-volume hemofiltration (HVHF) among critically ill patients. However, it is currently unclear whether HVHF is really valuable in critically ill patients. Material/Methods Randomized controlled trials evaluating HVHF for critically ill adult patients were included in this analysis. Three databases were searched up to July 27, 2018. The relative risk (RR), mean difference (MD), and 95% confidence intervals (CI) were determined. Results Twenty-one randomized controlled trials were included in this analysis. Overall, HVHF was associated with lower mortality compared with control measures (RR=0.88, 95% CI=0.81 to 0.96, P=0.004) in critically ill patients. Sub-analysis revealed HVHF reduced mortality in sepsis and acute respiratory distress syndrome patients, but no similar effect in other diseases. HVHF decreased levels of plasma tumor necrosis factor and interleukin 6. The heart rate of the HVHF group after treatment was slower than the control group, while we found higher mean arterial pressure in the HVHF group, but oxygenation index was not significantly different between the two groups. HVHF had no remarkable influence on acute physiological and chronic health evaluation score (APACHE II score) compared with the control group. Conclusions HVHF might be superior to conventional therapy in critically ill patients.
Collapse
Affiliation(s)
- Zhen Junhai
- Department of Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China (mainland)
| | - Cao Beibei
- Department of Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China (mainland)
| | - Yan Jing
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, Zhejiang, China (mainland)
| | - Li Li
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, Zhejiang, China (mainland)
| |
Collapse
|
|
41
|
Honore PM, Hoste E, Molnár Z, Jacobs R, Joannes-Boyau O, Malbrain MLNG, Forni LG. Cytokine removal in human septic shock: Where are we and where are we going? Ann Intensive Care 2019; 9:56. [PMID: 31089920 PMCID: PMC6517449 DOI: 10.1186/s13613-019-0530-y] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/07/2019] [Indexed: 02/07/2023] Open
Abstract
Although improving, the mortality from septic shock still remains high despite increased international awareness. As a consequence, much effort has focused on alternative treatment strategies in an effort to improve outcomes. The application of blood purification therapies to improve immune homeostasis has been suggested as one such method, but these approaches, such as high-volume continuous haemofiltration or cytokine and/or endotoxin removal, have enjoyed little success to date. More recently, the use of sorbent technologies has attracted much attention. These adsorbers are highly effective at removing inflammatory mediators, in particular, cytokines, from the bloodstream. This narrative review is the executive summary of meetings held throughout the 6th International Fluid Academy Days in Antwerp, Belgium (Nov 23-25, 2017), focusing on the current understanding regarding the use of such adsorbers in humans with septic shock. We followed a modified Delphi approach involving a combination of evidence appraisal together with expert opinion in order to achieve recommendations for practice and, importantly, future research.
Collapse
Affiliation(s)
- Patrick M. Honore
- Intensive Care Department, CHU Brugmann University Hospital, 4, Place Arthur Van Gehuchtenplein, 1020 Brussels, Belgium
| | - Eric Hoste
- Intensive Care Department, Ghent University Hospital, Ghent, Belgium
| | - Zsolt Molnár
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Rita Jacobs
- Intensive Care Department, University Hospital Brussels (UZB), Jette, Belgium
| | | | - Manu L. N. G. Malbrain
- Intensive Care Department, University Hospital Brussels (UZB), Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Lui G. Forni
- Department of Critical Care, Royal Surrey County Hospital, NHS Foundation Trust, Guildford, UK
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, Guildford, UK
| |
Collapse
|
|
42
|
Zha J, Li C, Cheng G, Huang L, Bai Z, Fang C. The efficacy of renal replacement therapy strategies for septic-acute kidney injury: A PRISMA-compliant network meta-analysis. Medicine (Baltimore) 2019; 98:e15257. [PMID: 31008965 PMCID: PMC6494389 DOI: 10.1097/md.0000000000015257] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Renal replacement therapy (RRT) is the main treatment for patients with sepsis-induced acute kidney injury (SAKI). However, the choice of RRT strategy remains controversial. OBJECTIVE This study assessed the effectiveness of RRT variants in SAKI patients by a network meta-analysis. METHODS This study searched the literature in the PubMed, EmBase, and Cochrane Library databases up to August 18, 2018. The outcomes of the analysis were the survival rate, renal recovery rate, intensive care unit (ICU) duration, and hospital duration. RESULTS Twenty-two articles were included in the analysis. The results showed that only the negative control was inferior to the regimens of RRT with polymyxin B-immobilized fiber (PMXF), PMXF alone, continuous venovenous hemofiltration (CVVH), CVVH plus alkaline phosphatase (AP), continuous venovenous hemodialysis (CVVHD), high-volume CVVH, and extra high-volume CVVH in terms of the survival rate. According to the surface under the cumulative ranking , RRT with PMXF (84.4%) and PMXF (84.3%) were the treatments most likely to improve the survival rate among SAKI patients, followed by CVVH plus AP (69%). Continuous venovenous hemodiafiltration (CVVHDF), extra high-volume CVVHDF, intermittent venovenous hemodiafiltration (IVVHDF), and low-volume CVVHDF resulted in very similar survival rates. CVVH plus AP conferred relative advantages in the renal recovery rate and ICU duration. CONCLUSION CVVH, CVVHD, and their derived RRT strategies can improve survival rates in SAKI patients, but there is no significant difference among the RRT strategies. There was also no significant difference in the survival rate among CVVHDF, IVVHDF, and their derived strategies. More high-quality randomized controlled trials with large sample sizes are needed for further research.
Collapse
|
|
43
|
Abstract
Vasodilatory shock is a critical manifestation of cardiovascular failure. There is uncontrolled vasodilation and vascular hyporesponsiveness to endogenous vasoconstrictors, causing the failure of physiologic vasoregulatory mechanisms. Unfortunately, only few randomized studies exist to guide clinical management and hemodynamic stabilization in patients who do not respond to the standard approach of managing vasodilatory shock. The present review offers the latest updates in management of this important clinical entity and a guidance framework for future research.
Collapse
Affiliation(s)
- Sandeep Lahiry
- Department of Pharmacology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Sayanta Thakur
- Department of Pharmacology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Dwaipayan S Chakraborty
- Department of Pharmacology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| |
Collapse
|
|
44
|
Honore PM, De Bels D, Preseau T, Redant S, Attou R, Gallerani A, Spapen HD. Clinical benefit of high-volume hemofiltration in severe burn injury: is it removing bad humors or actually avoiding hypervolemia? Crit Care 2018; 22:290. [PMID: 30382905 PMCID: PMC6211596 DOI: 10.1186/s13054-018-2230-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 10/12/2018] [Indexed: 11/27/2022] Open
Affiliation(s)
- Patrick M. Honore
- ICU Department, Centre Hospitalier Universitaire Brugmann—Brugmann University Hospital, Place Van Gehuchtenplein,4, 1020 Brussels, Belgium
| | - David De Bels
- ICU Department, Centre Hospitalier Universitaire Brugmann—Brugmann University Hospital, Place Van Gehuchtenplein,4, 1020 Brussels, Belgium
| | - Thierry Preseau
- Emergency Department, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium
| | - Sebastien Redant
- ICU Department, Centre Hospitalier Universitaire Brugmann—Brugmann University Hospital, Place Van Gehuchtenplein,4, 1020 Brussels, Belgium
| | - Rachid Attou
- ICU Department, Centre Hospitalier Universitaire Brugmann—Brugmann University Hospital, Place Van Gehuchtenplein,4, 1020 Brussels, Belgium
| | - Andrea Gallerani
- ICU Department, Centre Hospitalier Universitaire Brugmann—Brugmann University Hospital, Place Van Gehuchtenplein,4, 1020 Brussels, Belgium
| | | |
Collapse
|
|
45
|
Ankawi G, Neri M, Zhang J, Breglia A, Ricci Z, Ronco C. Extracorporeal techniques for the treatment of critically ill patients with sepsis beyond conventional blood purification therapy: the promises and the pitfalls. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:262. [PMID: 30360755 PMCID: PMC6202855 DOI: 10.1186/s13054-018-2181-z] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 09/10/2018] [Indexed: 02/07/2023]
Abstract
Sepsis is one of the leading causes of morbidity and mortality worldwide. It is characterized by a dysregulated immune response to infections that results in life-threatening organ dysfunction and even death. Bacterial cell wall components (endotoxin or lipopolysaccharide), known as pathogen-associated molecular patterns (PAMPs), as well as damage-associated molecular patterns (DAMPs) released by host injured cells, are well-recognized triggers resulting in the elevation of both pro-inflammatory and anti-inflammatory cytokines. Understanding this complex pathophysiology has led to the development of therapeutic strategies aimed at restoring a balanced immune response by eliminating/deactivating these inflammatory mediators. Different extracorporeal techniques have been studied in recent years in the hope of maximizing the effect of renal replacement therapy in modulating the exaggerated host inflammatory response, including the use of high volume hemofiltration (HVHF), high cut-off (HCO) membranes, adsorption alone, and coupled plasma filtration adsorption (CPFA). These strategies are not widely utilized in practice, depending on resources and local expertise. The literature examining their use in septic patients is growing, but the evidence to support their use at this stage is considered of low level. Our aim is to provide a comprehensive overview of the technical aspects, clinical applications, and associated side effects of these techniques.
Collapse
Affiliation(s)
- Ghada Ankawi
- Department of Internal Medicine and Nephrology, King Abdulaziz University, Jeddah, Saudi Arabia. .,International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy.
| | - Mauro Neri
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Jingxiao Zhang
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy.,Department of Emergency and Critical Care Medicine, The Second Hospital of Jilin University, Changchun, China
| | - Andrea Breglia
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy.,Department of Internal Medicine, University of Trieste, Trieste, Italy
| | - Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Paediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| |
Collapse
|
|
46
|
Gao N, Yan C, Zhang G. Changes of Serum Procalcitonin (PCT), C-Reactive Protein (CRP), Interleukin-17 (IL-17), Interleukin-6 (IL-6), High Mobility Group Protein-B1 (HMGB1) and D-Dimer in Patients with Severe Acute Pancreatitis Treated with Continuous Renal Replacement Therapy (CRRT) and Its Clinical Significance. Med Sci Monit 2018; 24:5881-5886. [PMID: 30136704 PMCID: PMC6118162 DOI: 10.12659/msm.910099] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 04/24/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the changes in serum levels of procalcitonin (PCT), C-reactive protein (CRP), interleukin-17 (IL-17), interleukin-6 (IL-6), high mobility group protein-B1 (HMGB1), and D-dimer in severe acute pancreatitis (SAP) patients during treatment with continuous renal replacement therapy (CRRT) and the clinical significance. MATERIAL AND METHODS A total of 92 SAP patients admitted to our hospital from January 2017 to December 2017 were selected and randomly divided into the observation group and the control group using a random number table method, with 46 cases in each group. The control group was given conventional therapy, and the observation group was given CRRT in addition to conventional therapy. RESULTS After 1 week, the total effective rate of treatment in the observation group was significantly higher than that in the control group (P<0.05). In the observation group, each index showed a continuous downward trend at 6, 12, and 24 hours after treatment, and at different time points after treatment, the indexes were significantly lower than those in the control group (P<0.05). CONCLUSIONS CRRT is more effective in the treatment of SAP, and its effects are more obvious in removing a variety of inflammatory factors and reducing the serum levels of PCT, HMGB1, and D-dimer, which is of great clinical significance.
Collapse
Affiliation(s)
- Ning Gao
- Department of Intensive Care Unit, Jining No. 1 People’s Hospital, Jining, Shandong, P.R. China
| | - Chengjun Yan
- Department of Emergency, Jining No. 1 People’s Hospital, Jining, Shandong, P.R. China
| | - Guochang Zhang
- Department of Intensive Care Unit, Jining No. 1 People’s Hospital, Jining, Shandong, P.R. China
| |
Collapse
|
|
47
|
Łysenko L, Leśnik P, Nelke K, Gerber H. Immune disorders in sepsis and their treatment as a significant problem of modern intensive care. POSTEP HIG MED DOSW 2017; 71:703-712. [PMID: 28894043 DOI: 10.5604/01.3001.0010.3849] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Despite the great advances in the treatment of sepsis over the past 20 years, sepsis remains the main cause of death in intensive care units. In the context of new possibilities of treating sepsis, a comprehensive response of the immune system to the infection, immunosuppression, in particular, has in recent years gained considerable interest. There is vast evidence pointing to the correlation between comorbid immunosuppression and an increased risk of recurrent infections and death. Immune disorders may impact the clinical course of sepsis. This applies in particular to patients with deteriorated clinical response to infections. They usually suffer from comorbidities and conditions accompanied by immunosuppression. Sepsis disrupts innate and adaptive immunity. The key to diagnose the immune disorders in sepsis and undertake targeted immunomodulatory therapy is to define the right biomarkers and laboratory methods, which permit prompt "bedside" diagnosis. Flow cytometry is a laboratory tool that meets these criteria. Two therapeutic methods are currently being suggested to restore the immune homeostasis of sepsis patients. Excessive inflammatory response may be controlled through extracorporeal blood purification techniques, in large part derived from renal replacement therapy. These are such techniques as high-volume haemofiltration, cascade haemofiltration, plasma exchange, coupled plasma filtration and adsorption, high-absorption membranes, high cut-off membranes. The main task of theses techniques is the selective elimination of middle molecular weight molecules, such as cytokines. Pharmacotherapy with the use of such immunostimulants as interleukin 7, granulocyte-macrophage colony-stimulating factor, interferon gamma, PD-1, PD-L1 and CTLA-4 antagonists, intravenous immunoglobulins may help fight immunosuppressive immune disorders.
Collapse
Affiliation(s)
- Lidia Łysenko
- Department of Anaesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Patrycja Leśnik
- Department of Anaesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Kamil Nelke
- Department of Maxillofacial Surgery, Wroclaw Medical University, Wrocław, Poland
| | - Hanna Gerber
- Department of Maxillofacial Surgery, Wroclaw Medical University, Wrocław, Poland
| |
Collapse
|
|
48
|
Ricci Z, Romagnoli S, Ronco C. The 10 false beliefs in adult critical care nephrology. Intensive Care Med 2017; 44:1302-1305. [PMID: 29196792 DOI: 10.1007/s00134-017-5011-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 11/28/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, 00165, Rome, Italy.
| | - Stefano Romagnoli
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla, 3, 50139, Florence, Italy
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Via Rodolfi, 37, 36100, Vicenza, Italy.,International Renal Research Institute of Vicenza (IRRIV), Via Rodolfi, 37, 36100, Vicenza, Italy
| |
Collapse
|
|
49
|
Chung KK, Coates EC, Smith DJ, Karlnoski RA, Hickerson WL, Arnold-Ross AL, Mosier MJ, Halerz M, Sprague AM, Mullins RF, Caruso DM, Albrecht M, Arnoldo BD, Burris AM, Taylor SL, Wolf SE. High-volume hemofiltration in adult burn patients with septic shock and acute kidney injury: a multicenter randomized controlled trial. Crit Care 2017; 21:289. [PMID: 29178943 PMCID: PMC5702112 DOI: 10.1186/s13054-017-1878-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 10/30/2017] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Sepsis and septic shock occur commonly in severe burns. Acute kidney injury (AKI) is also common and often results as a consequence of sepsis. Mortality is unacceptably high in burn patients who develop AKI requiring renal replacement therapy and is presumed to be even higher when combined with septic shock. We hypothesized that high-volume hemofiltration (HVHF) as a blood purification technique would be beneficial in this population. METHODS We conducted a multicenter, prospective, randomized, controlled clinical trial to evaluate the impact of HVHF on the hemodynamic profile of burn patients with septic shock and AKI involving seven burn centers in the United States. Subjects randomized to the HVHF were prescribed a dose of 70 ml/kg/hour for 48 hours while control subjects were managed in standard fashion in accordance with local practices. RESULTS During a 4-year period, a total of nine subjects were enrolled for the intervention during the ramp-in phase and 28 subjects were randomized, 14 each into the control and HVHF arms respectively. The study was terminated due to slow enrollment. Ramp-in subjects were included along with those randomized in the final analysis. Our primary endpoint, the vasopressor dependency index, decreased significantly at 48 hours compared to baseline in the HVHF group (p = 0.007) while it remained no different in the control arm. At 14 days, the multiple organ dysfunction syndrome score decreased significantly in the HVHF group when compared to the day of treatment initiation (p = 0.02). No changes in inflammatory markers were detected during the 48-hour intervention period. No significant difference in survival was detected. No differences in adverse events were noted between the groups. CONCLUSIONS HVHF was effective in reversing shock and improving organ function in burn patients with septic shock and AKI, and appears safe. Whether reversal of shock in these patients can improve survival is yet to be determined. TRIAL REGISTRATION Clinicaltrials.gov NCT01213914 . Registered 30 September 2010.
Collapse
Affiliation(s)
- Kevin K. Chung
- Brooke Army Medical Center, Fort Sam Houston, TX USA
- Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Elsa C. Coates
- United States Army Institute of Surgical Research, Fort Sam Houston, TX USA
| | - David J. Smith
- University of South Florida Tampa General Hospital, Tampa, FL USA
| | | | | | | | | | | | - Amy M. Sprague
- Doctors Hospital Joseph M. Still Burn Center, Augusta, GA USA
| | | | - Daniel M. Caruso
- Arizona Burn Center Maricopa Integrated Health Systems, Phoenix, AZ USA
| | - Marlene Albrecht
- Arizona Burn Center Maricopa Integrated Health Systems, Phoenix, AZ USA
| | | | - Agnes M. Burris
- University of Texas Southwestern Medical Center, Dallas, TX USA
| | | | - Steven E. Wolf
- University of Texas Southwestern Medical Center, Dallas, TX USA
| |
Collapse
|
|
50
|
Miao H, Wang F, Xiong X, Wang C, Zhang Y. Clinical Benefits of High-Volume Hemofiltration in Critically Ill Pediatric Patients with Severe Sepsis: A Retrospective Cohort Study. Blood Purif 2017; 45:18-27. [PMID: 29161713 DOI: 10.1159/000481249] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 09/04/2017] [Indexed: 12/22/2022]
Abstract
AIMS The study aimed to assess the clinical benefits of high-volume hemofiltration (HVHF) in pediatric patients with severe sepsis compared with standard-volume continuous veno-venous hemofiltration (CVVH). METHODS We retrospectively analyzed the medical records of 155 pediatric patients with severe sepsis admitted to the pediatric intensive care unit of Shanghai Children's Hospital from January 2010 to June 2016. A total of 93 patients were treated with HVHF and 62 patients were treated with CVVH. RESULTS HVHF treatment did not significantly reduce 28-day mortality. Moreover, there was no significant difference in reducing the plasma level of inflammatory mediators and improving hemodynamic variables between HVHF and CVVH group. However, the incidence of hyperglycemia was significantly higher in HVHF group than in CVVH group. CONCLUSIONS There is no evidence to indicate that HVHF is superior to CVVH in reducing 28-day mortality as an adjunct to the treatment of severe sepsis in pediatric patients.
Collapse
Affiliation(s)
- Huijie Miao
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Putuo District, Shanghai, China
| | | | | | | | | |
Collapse
|