101
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Lumlertgul N, Srisawat N. The haemodynamic effects of oXiris haemofilter in septic shock patients requiring renal support: A single-centre experience. Int J Artif Organs 2020; 44:17-24. [PMID: 32393096 DOI: 10.1177/0391398820917150] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Excessive pro-inflammatory and anti-inflammatory cytokines are mediators for haemodynamic alterations, metabolic acidosis, and multi-organ failure in sepsis. Recently, oXiris® haemofilter (Baxter, IL, USA) has been introduced as a novel haemofilter to mitigate inflammatory response during sepsis-associated acute kidney injury requiring renal replacement therapy. In the present case series, the researchers retrospectively reviewed critically ill patients with septic shock with the use of at least one oXiris haemofilter during continuous renal replacement therapy between June 2015 and December 2017. The timing for oXiris initiation was at the nephrologists' discretion. The impact of oXiris haemofilter was evaluated on mean arterial pressure, vasopressor dosage, Sequential Organ Failure Assessment score, lactate and base excess during 72 h after treatment. Thirty-five patients were enrolled in the study. An improvement of haemodynamic status was found, shown by increased mean arterial pressure by 6.1% (p = 0.35), decreased norepinephrine dose by 45.9% (p = 0.02), inotropic score by 26.4% (p = 0.02) and vasopressor dependency index by 40.5% (p = 0.01). Cardiovascular Sequential Organ Failure Assessment scores significantly decreased over 72 h (p = 0.02). Blood lactate levels and base excess also showed statistically significant improvements. The median filter lifetime was 23 (interquartile range = 14-36) hours. The intensive care unit mortality was 82.9%. Treatment with oXiris was safe and well-tolerated with no device-related adverse events. In conclusion, continuous renal replacement therapy with oXiris haemofilter is safe and may improve haemodynamic parameters in septic patients with severe renal dysfunction. Nonetheless, these findings were drawn from a retrospective analysis without a control group, and therefore cannot be generalised. Randomised controlled trials are warranted to confirm these findings.
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Affiliation(s)
- Nuttha Lumlertgul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center for Critical Care Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center for Critical Care Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Academy of Science, Royal Society of Thailand, Bangkok, Thailand.,Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand
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102
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Suzuki Y, Kawakami S, Yamada M, Sohmiya M, Shibuya K, Maeda N. Clinical effects of polymyxin B-immobilized fiber column direct hemoperfusion for severe bacterial meningitis: A series of 10 cases. Clin Case Rep 2020; 8:823-832. [PMID: 32477526 PMCID: PMC7250985 DOI: 10.1002/ccr3.2756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 01/31/2020] [Accepted: 02/04/2020] [Indexed: 12/26/2022] Open
Abstract
Our results suggest a possible role for Polymyxin B-immobilized fiber column direct hemoperfusion in combination with standard therapy in the rapid improvement of impaired consciousness in patients with severe bacterial meningitis.
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Affiliation(s)
- Yoko Suzuki
- Department of NeurologyOmori Red Cross HospitalTokyoJapan
| | | | - Minako Yamada
- Department of NeurologyOmori Red Cross HospitalTokyoJapan
| | - Makoto Sohmiya
- Graduate School of Health SciencesGunma Paz UniversityTakasakiJapan
| | - Ken Shibuya
- Department of NephrologyOmori Red Cross HospitalTokyoJapan
| | - Nobuya Maeda
- Department of NeurologyOmori Red Cross HospitalTokyoJapan
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103
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Identifying Septic Shock Populations Benefitting From Polymyxin B Hemoperfusion: A Prospective Cohort Study Incorporating a Restricted Cubic Spline Regression Model. Shock 2020; 54:667-674. [PMID: 32195922 DOI: 10.1097/shk.0000000000001533] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Polymyxin B hemoperfusion (PMX-HP) is an adjuvant therapy for sepsis or septic shock that removes circulating endotoxin. However, PMX-HP has seldom achieved expectations in randomized trials targeting nonspecific overall sepsis patients. If used in an optimal population, PMX-HP may be beneficial. This study aimed to identify the optimal population for PMX-HP in patients with septic shock. METHODS We used a prospective nationwide cohort targeting consecutive adult patients with severe sepsis (Sepsis-2) in 59 intensive care units in Japan. Associations between PMX-HP therapy and in-hospital mortality were assessed using multivariable Cox proportional hazard regression models. To identify best targets for PMX-HP, we developed a non-linear restricted cubic spline model including two-way interaction term (treatment × Acute Physiology and Chronic Health Evaluation [APACHE] II score/Sequential Organ Failure Assessment [SOFA] score) and three-way interaction term (treatment × age × each score). RESULTS The final study cohort comprised 741 sepsis patients (92 received PMX-HP, 625 did not). Cox proportional hazards regression model adjusted for the covariates suggested no association between PMX-HP therapy and improved mortality overall. Effect modification of PMX-HP by APACHE II score was statistically significant (P for interaction = 0.189) but non-significant for SOFA score (P for interaction = 0.413). Three-way interaction analysis revealed suppressed risk hazard in the PMX-HP group versus control group only in septic shock patients with high age and in the most severe subset of both scores, whereas increased risk hazard was observed in those with high age but in the lower severity subset of both scores. CONCLUSIONS Our results suggested that although PMX-HP did not reduce in-hospital mortality among overall septic shock patients, it may benefit a limited population with high age and higher disease severity.
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104
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Kang JH. Multiscale Biofluidic and Nanobiotechnology Approaches for Treating Sepsis in Extracorporeal Circuits. BIOCHIP JOURNAL 2020; 14:63-71. [PMID: 32218896 PMCID: PMC7095347 DOI: 10.1007/s13206-020-4106-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 03/01/2020] [Indexed: 12/29/2022]
Abstract
Infectious diseases and their pandemics periodically attract public interests due to difficulty in treating the patients and the consequent high mortality. Sepsis caused by an imbalanced systemic inflammatory response to infection often leads to organ failure and death. The current therapeutic intervention mainly includes “the sepsis bundles,” antibiotics (antibacterial, antiviral, and antifungal), intravenous fluids for resuscitation, and surgery, which have significantly improved the clinical outcomes in past decades; however, the patients with fulminant sepsis are still in desperate need of alternative therapeutic approaches. One of the potential supportive therapies, extracorporeal blood treatment, has emerged and been developed for improving the current therapeutic efficacy. Here, I overview how the treatment of infectious diseases has been assisted with the extracorporeal adjuvant therapy and the potential utility of various nanobiotechnology and microfluidic approaches for developing new auxiliary therapeutic methods.
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Affiliation(s)
- Joo H Kang
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology (UNIST), 50, UNIST-gil, Ulsan, 44919 Republic of Korea
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105
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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: 72] [Impact Index Per Article: 18.0] [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.
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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
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106
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Importance of Endotoxin Clearance in Endotoxemic Septic Shock: An Analysis From the Evaluating Use of PolymyxinB Hemoperfusion in a Randomized Controlled Trial of Adults Treated for Endotoxemic Septic Shock (EUPHRATES) Trial. Crit Care Explor 2020; 2:e0083. [PMID: 32211615 PMCID: PMC7069594 DOI: 10.1097/cce.0000000000000083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
To investigate the relationship between survival and treatment-related reduction in endotoxin activity for patients in the Evaluating Use of PolymyxinB Hemoperfusion in a Randomized controlled trial of Adults Treated for Endotoxemia and Septic shock trial with baseline endotoxin activity assay greater than or equal to 0.60 to less than 0.90 units. Design Post hoc analysis of a multicenter randomized controlled clinical trial. Setting Fifty-five tertiary hospitals in North America. Patients Patients with septic shock and endotoxin activity assay level greater than or equal to 0.60 to less than 0.90 and multiple organ dysfunction syndrome greater than 9. Interventions Two polymyxin B hemoperfusion treatments or Sham. Measurements and Main Results One-hundred ninety-four patients were included (88 polymyxin B and 106 Sham). We evaluated the impact of changes in endotoxin activity assay based on comparison to the median reduction from baseline to day 3 and a second method where a target post-treatment endotoxin activity assay level (day 3) was established. The population median reduction in endotoxin activity assay level was 10.4%. In patients with a greater than median reduction, there was trend toward lower mortality with polymyxin B (17.1% vs 33.3%; p = 0.07) and a significant increase in mechanical ventilation-free days (20 vs 13.5; p = 0.04). The pressure adjusted heart rate showed a significant improvement in the polymyxin B group (p = 0.02). For patients who achieved an endotoxin activity assay of less than 0.65 at day 3, the polymyxin B treated group had a trend toward a mortality reduction compared to Sham (16% vs 33%;p = 0.06) and a significant increase in ventilation-free day (20 vs 16; p = 0.05). Kaplan-Meier analysis showed a 17% reduction in mortality with polymyxin B (p = 0.04). Conclusions These findings suggest that reducing endotoxin activity assay levels with polymyxin B as measured by comparison to a median reduction or when a treatment target is established, may result in improvements in mortality and organ function outcomes. This article is the first to report endotoxin activity assay measurements in response to polymyxin B use versus Sham in patients with septic shock and elevated endotoxin activity assay. These findings are considered to be hypothesis generating and will need to be prospectively validated.
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107
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Could There Be a Biologically Plausible Niche for Polymyxin B-Immobilized Fiber Column Direct Hemoperfusion Treatment in Early Onset Neonatal Septic Shock? Pediatr Crit Care Med 2020; 21:202-203. [PMID: 32032268 DOI: 10.1097/pcc.0000000000002164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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108
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Abstract
Sepsis is a heterogeneous disease state that is both common and consequential in critically ill patients. Unfortunately, the heterogeneity of sepsis at the individual patient level has hindered advances in the field beyond the current therapeutic standards, which consist of supportive care and antibiotics. This complexity has prompted attempts to develop a precision medicine approach, with research aimed towards stratifying patients into more homogeneous cohorts with shared biological features, potentially facilitating the identification of new therapies. Several investigators have successfully utilized leukocyte-derived mRNA and discovery-based approaches to subgroup patients on the basis of biological similarities defined by transcriptomic signatures. A critical next step is to develop a consensus sepsis subclassification system, which includes transcriptomic signatures as well as other biological and clinical data. This goal will require collaboration among various investigative groups, and validation in both existing data sets and prospective studies. Such studies are required to bring precision medicine to the bedside of critically ill patients with sepsis.
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109
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Endotoxin removal by polymyxin B: is it a question of dose or duration or both? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:297. [PMID: 31484574 PMCID: PMC6724261 DOI: 10.1186/s13054-019-2584-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 08/27/2019] [Indexed: 01/03/2023]
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110
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De Rosa S, Villa G, Ronco C. The golden hour of polymyxin B hemoperfusion in endotoxic shock: The basis for sequential extracorporeal therapy in sepsis. Artif Organs 2019; 44:184-186. [PMID: 31386769 PMCID: PMC7003912 DOI: 10.1111/aor.13550] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/23/2019] [Accepted: 07/29/2019] [Indexed: 12/26/2022]
Abstract
Endotoxin is recognized as a major trigger of the immune response leading to pro- and anti-inflammatory cytokine release, activation of the coagulation cascade, vasoplegic shock, and multiple organ dysfunction syndrome. A beneficial effect could be achieved through extracorporeal adsorption of circulating endotoxins in the blood as adjunctive treatment for unresponsive endotoxic shock. However, the precise clinical indication for its initiation is widely debated in the literature. Similar to the source control, microbiological cultures and antibiotics administration, endotoxin activity assay evaluation at regular intervals, and the targeted use of PMX-B hemoperfusion could be lifesaving and adequate within the golden hour for the diagnosis and treatment of endotoxic shock.
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Affiliation(s)
- Silvia De Rosa
- International Renal Research Institute of Vicenza, Vicenza, Italy.,Department of Anesthesiology and Intensive Care, San Bortolo Hospital, Vicenza, Italy
| | - Gianluca Villa
- International Renal Research Institute of Vicenza, Vicenza, Italy.,Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Florence, Italy
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation and International, Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy.,Department of Medicine, University of Padova, Padova, Italy
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111
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Tanaka T, Tabata T, Fujino K, Tsujita Y, Eguchi Y. "Impact of timing of polymyxin B-immobilized fiber column direct hemoperfusion on outcome in patients with septic shock: a single-center observational study". Acute Med Surg 2019; 7:e446. [PMID: 31988760 PMCID: PMC6971457 DOI: 10.1002/ams2.446] [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] [Received: 02/03/2019] [Accepted: 07/02/2019] [Indexed: 12/29/2022] Open
Abstract
Aim The effect of polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) is controversial. The present study investigates whether outcome in septic shock patients is affected by the time until PMX-DHP initiation and the location of the infection site (intra- or extra-abdominal infection (IAI/EAI)]. Methods This retrospective observational study included patients receiving PMX-DHP for septic shock but excluded those treated after cardiac surgery or cardiac arrest. Based on the median and/or quartile time from catecholamine treatment to PMX-DHP initiation, the patient cohort was divided into four groups and the IAI and EAI groups into two subgroups. Results Among the 49 eligible patients, overall 90-day mortality in group 1 (PMX-DHP within 6 h) at 8.3% was significantly lower than in groups 2 (6-9 h; 46.1%), 3 (9-29 h; 58.3%) and 4 (>29 h; 75.0%) (P = 0.021). Multivariate logistic regression analysis showed that the duration from catecholamine treatment to PMX-DHP initiation correlated with 90-day mortality (odds ratio 1.060; 95% confidence interval, 1.004-1.117; P = 0.028). Among the 29 IAI patients, 90-day mortality was significantly lower in the early (within 9 h) than the late group (>9 h) (13.3% versus 64.2%; P = 0.003), but no significant intergroup difference was noted among the 20 EAI patients. Conclusion Our results suggest that early PMX-DHP initiation (within 9 h after catecholamine treatment) reduces mortality from septic shock, especially in IAI patients.
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Affiliation(s)
- Tomoki Tanaka
- Shiga University of Medical Science Emergency and Intensive Care Unit Otsu Japan
| | - Takahisa Tabata
- Department of Critical and Intensive Care Medicine Shiga University of Medical Science Otsu Japan
| | - Kazunori Fujino
- Department of Critical and Intensive Care Medicine Shiga University of Medical Science Otsu Japan
| | - Yasuyuki Tsujita
- Shiga University of Medical Science Emergency and Intensive Care Unit Otsu Japan
| | - Yutaka Eguchi
- Department of Critical and Intensive Care Medicine Shiga University of Medical Science Otsu Japan
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112
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Møller MH, Alhazzani W, Shankar-Hari M. Focus on sepsis. Intensive Care Med 2019; 45:1459-1461. [PMID: 31267195 DOI: 10.1007/s00134-019-05680-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 06/24/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark. .,Centre for Research in Intensive Care, Copenhagen, Denmark.
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada
| | - Manu Shankar-Hari
- School of Immunology and Microbial Science, Kings College London, London, SE1 9RT, UK.,Guy's and St Thomas' NHS Foundation Trust, ICU Support Offices, St Thomas' Hospital, 1st Floor, East Wing, London, SE1 7EH, UK
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113
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Comparative Evaluation of Endotoxin Activity Level and Various Biomarkers for Infection and Outcome of ICU-Admitted Patients. Biomedicines 2019; 7:biomedicines7030047. [PMID: 31261907 PMCID: PMC6784048 DOI: 10.3390/biomedicines7030047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 06/27/2019] [Accepted: 06/27/2019] [Indexed: 11/24/2022] Open
Abstract
Here, we concurrently measured the endotoxin activity (EA) level and levels of multiple biomarkers in patient blood obtained within 24 h after being admitted into the intensive care unit (ICU) and analyzed whether there were links between these markers and their associations with patient conditions and outcomes. The EA levels highly correlated with disease severity and patient survival, and showed a significant positive association with levels of lactate, procalcitonin, presepsin, and interleukin-6. Notably, the EA level was the marker that most highly correlated with the results of blood culture, and the presepsin level was the marker most highly correlated with the survival outcome at 28 days. Thus, the optimal biomarker should be selected based on whether it will be used to discriminate the presence of an infection or to predict survival.
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114
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Mallat J, Leone S, Cascella M, Fiore M. Should endotoxin be a research priority in Gram-negative sepsis and septic shock? Expert Rev Clin Pharmacol 2019; 12:697-699. [PMID: 31194595 DOI: 10.1080/17512433.2019.1627871] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Jihad Mallat
- a Department of Critical Care Medicine, Cleveland Clinic Abu Dhabi , Abu Dhabi , UAE
| | - Sebastiano Leone
- b Division of Infectious Diseases, "San Giuseppe Moscati" Hospital , Avellino , Italy
| | - Marco Cascella
- c Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale , Naples , Italy
| | - Marco Fiore
- d Department of Women, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli" , Naples , Italy
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115
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Palma P, Rello J. Precision medicine for the treatment of sepsis: recent advances and future prospects. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2019. [DOI: 10.1080/23808993.2019.1626714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Pedro Palma
- Infectious Diseases Department, São João University Hospital Center, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Jordi Rello
- Clinical Research/epidemiology in Pneumonia & Sepsis (CRIPS), Vall d’Hebron Institute of Research (VHIR), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermidades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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116
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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: 733] [Impact Index Per Article: 146.6] [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.
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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.
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117
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Iba T, Klein DJ. The wind changed direction and the big river still flows: from EUPHRATES to TIGRIS. J Intensive Care 2019; 7:31. [PMID: 31131109 PMCID: PMC6521478 DOI: 10.1186/s40560-019-0386-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 04/30/2019] [Indexed: 11/17/2022] Open
Abstract
The overall result of the randomized controlled double-blinded trial for polymyxin B-immobilized fiber column on septic shock (EUPHRATES trial) was disappointing. However, post hoc analysis showed benefits for patients with certain Endotoxin Activity Assay (EAA) levels. Thus, the study will be repeated, and the data will be added to the former trial. Using a precision medicine approach, eligibility criteria have been modified in TIGRIS to include patients with MODS score > 9 and EAA levels between 0.60 and 0.89. We are currently feeling the change in the wind as the rivers continue to flow towards PMX therapy for endotoxemic septic shock.
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Affiliation(s)
- Toshiaki Iba
- 1Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421 Japan
| | - David J Klein
- 2Department of Critical Care, St. Michael's Hospital, University of Toronto, Toronto, Canada
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118
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The effect of direct hemoperfusion with polymyxin B immobilized cartridge on meropenem in critically ill patients requiring renal support. J Crit Care 2019; 51:71-76. [PMID: 30769293 DOI: 10.1016/j.jcrc.2019.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 02/02/2019] [Accepted: 02/02/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE To evaluate the effect of direct hemoperfusion with polymyxin B immobilized cartridge (DHP-PMX) on meropenem pharmacokinetics in critically ill patients with sepsis requiring continuous venovenous hemofiltration (CVVH). MATERIAL AND METHODS After intravenous infusion of 1 g meropenem over 3 h repeated every 8 h for at least 3 doses, 2 serial blood and ultrafiltration fluid samples were collected: one over a dose interval of meropenem with DHP-PMX therapy; and the other on the following day over a dose interval of meropenem with no DHP-PMX therapy. Meropenem concentrations were measured by high performance liquid chromatography. Pharmacokinetic parameters of meropenem and extraction ratio of DHP-PMX were calculated. RESULTS Mean AUC0-8 of meropenem on DHP-PMX day was comparable to that of the DHP-PMX free day (285.2 ± 138.2 vs 297.8 ± 130.2 mg ∗ h/L; paired t-test, p = .618). No statistical significance of peak and trough concentrations, volume of distribution, sieving coefficient, or half-life were found. Extraction ratio of DHP-PMX on meropenem was 0 [0-0.03] and clearance by DHP-PMX was 0.04 [0-0.2] L/h which was not considered clinically significant. CONCLUSIONS No significant effect of DHP-PMX on meropenem pharmacokinetics was observed among severe sepsis/septic shock patients during CVVH treatment. TRIAL REGISTRATION Clinical Trial Registry detail: NCT registry: 02413541 (First registered March 3, 2015, last update October 16, 2017).
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Affiliation(s)
- Didier Payen
- UMR Inserm 1160, Université Paris 7 Denis-Diderot, Paris Cité Sorbone, France.
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120
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Pickkers P, Russell JA. Treatment with a polymyxin B filter to capture endotoxin in sepsis patients: is there a signal for therapeutic efficacy? Intensive Care Med 2018; 45:282-283. [PMID: 30511248 DOI: 10.1007/s00134-018-5481-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 11/21/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Peter Pickkers
- Department of Intensive Care Medicine (710), Radboud University Medical Centre, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
- Radboud Center for Infectious diseases, Nijmegen, The Netherlands.
| | - James A Russell
- Centre for Heart Lung Innovation, and Division of Critical Care Medicine, St. Paul's Hospital and University of British Columbia, 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
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