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Liu J, Qu J, Chen H, Ge P, Jiang Y, Xu C, Chen H, Shang D, Zhang G. The pathogenesis of renal injury in obstructive jaundice: A review of underlying mechanisms, inducible agents and therapeutic strategies. Pharmacol Res 2020; 163:105311. [PMID: 33246170 DOI: 10.1016/j.phrs.2020.105311] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/30/2020] [Accepted: 11/15/2020] [Indexed: 12/14/2022]
Abstract
Kidney injury is one of the main complications of obstructive jaundice (OJ) and its pathogenesis has not been clarified. As an independent risk factor for OJ associated with significant morbidity and mortality, it can be mainly divided into two types of morphological injury and functional injury. We called these dysfunctions caused by OJ-induced kidney injury as OJKI. However, the etiology of OJKI is still not fully clear, and research studies on how OJKI becomes a facilitated factor of OJ are limited. This article reviews the underlying pathological mechanism from five aspects, including metabolisms of bile acids, hemodynamic disturbances, oxidative stress, inflammation and the organic transporter system. Some nephrotoxic drugs and measures that can enhance or reduce the renal function with potential intervention in perioperative periods to alleviate the incidence of OJKI were also described. Furthermore, a more in-depth study on the pathogenesis of OJKI from multiple aspects for exploring more targeted treatment measures were further put forward, which may provide new methods for the prevention and treatment of clinical OJKI and improve the prognosis.
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Affiliation(s)
- Jiayue Liu
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China
| | - Jialin Qu
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China; Institute (College) of Integrative Medicine, Dalian Medical University, No. 9, South Road of Lvshun, Dalian 116044, China
| | - Haiyang Chen
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China; Department of General Surgery, Pancreatic-Biliary Center, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China
| | - Peng Ge
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China; Department of General Surgery, Pancreatic-Biliary Center, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China
| | - Yuankuan Jiang
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China
| | - Caiming Xu
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China; Institute (College) of Integrative Medicine, Dalian Medical University, No. 9, South Road of Lvshun, Dalian 116044, China; Department of General Surgery, Pancreatic-Biliary Center, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China
| | - Hailong Chen
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China; Institute (College) of Integrative Medicine, Dalian Medical University, No. 9, South Road of Lvshun, Dalian 116044, China; Department of General Surgery, Pancreatic-Biliary Center, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China
| | - Dong Shang
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China; Institute (College) of Integrative Medicine, Dalian Medical University, No. 9, South Road of Lvshun, Dalian 116044, China; Department of General Surgery, Pancreatic-Biliary Center, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China
| | - Guixin Zhang
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China.
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Padillo F, Cruz A, Segura-Jiménez I, Ruiz-Rabelo J, Vázquez-Ezquerra M, Perea-álvarez M, Peña J, Briceño J, Muntané J. Anti-TNF-α Treatment and Bile Duct Drainage Restore Cellular Immunity and Prevent Tissue Injury in Experimental Obstructive Jaundice. Int J Immunopathol Pharmacol 2016; 20:855-60. [DOI: 10.1177/039463200702000425] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Several experimental studies of obstructive jaundice (OJ) have shown the presence of immunosuppressive state associated with the rise of tumor necrosis factor-α (TNF-α) concentration in plasma. The present study evaluates the impact of anti-TNF-α administration or bile duct drainage on the inflammatory response, liver injury and renal insufficiency in obstructed rats. OJ was induced by the ligation of bile duct in Wistar rats. The parameters were determined at 14 and 21 days after OJ. Two additional groups of animals were treated with anti-TNF-α antibodies or submitted to bile duct drainage at 14 days, and sacrificed 21 days after OJ. Cholestasis decreased glucose, and enhanced urea, Creatinin, bilirubin and transaminases. Cholestasis increased the number of different inflammatory cells (T and B lymphocytes, and monocytes-macrophages) but reduced the expression of the corresponding cellular activation markers. This low responsiveness of the inflammatory cells was related to a decreased free radical production and phagocytic activity of cells. Anti-TNF-α and bile duct drainage reduced tissue injury, and prevented the reduction of the number and activity of T lymphocytes and phagocytic cells observed at the advanced stages of cholestasis. In conclusion, anti-TNF-α and bile duct drainage improved cell immunodeficiency, and reduced liver injury, cholestasis and renal insufficiency in experimental OJ.
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Affiliation(s)
| | | | | | | | | | | | - J. Peña
- Immunology Department, Reina Sofia University Hospital, Ciberehd, Cordoba, Spain
| | - J. Briceño
- Immunology Department, Reina Sofia University Hospital, Ciberehd, Cordoba, Spain
| | - J. Muntané
- Research Unit, Reina Sofia University Hospital, Ciberehd, Cordoba, Spain
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Sauvanet A, Boher JM, Paye F, Bachellier P, Sa Cuhna A, Le Treut YP, Adham M, Mabrut JY, Chiche L, Delpero JR. Severe Jaundice Increases Early Severe Morbidity and Decreases Long-Term Survival after Pancreaticoduodenectomy for Pancreatic Adenocarcinoma. J Am Coll Surg 2015. [PMID: 26206638 DOI: 10.1016/j.jamcollsurg.2015.03.058] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The influence of jaundice on outcomes after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) is debated. This study aimed to determine, in a large multicentric series, the influence of severe jaundice (serum bilirubin level ≥250 μmol/L and 300 μmol/L) on early severe morbidity and survival after PD. STUDY DESIGN From 2004 to 2009, twelve hundred patients (median age 66 years, 57% male) with resectable PDAC underwent PD. Patients who received preoperative biliary drainage for neoadjuvant treatment or cholangitis were excluded. Pre- and intraoperative data were collected by a standardized form. Serum bilirubin level and creatinine clearance were analyzed as categorical variables. Predictive factors of severe complications and poor survival (Kaplan-Meier method) were identified by univariate and multivariate analysis. RESULTS Median follow-up was 21 months (95% CI, 19-23). Operative mortality was 3.9% (n = 47), with no predictive factors in multivariate analysis. Severe complications (Dindo-Clavien grade III to IV) occurred in 22% (n = 268), with male sex (p = 0.025), America Society of Anesthesiologists score 3 to 4 (p = 0.022), serum bilirubin level ≥300 μmol/L (p = 0.034), and creatinine clearance <60 mL/min/1.73 m(2) (p = 0.013) identified as predictive factors in multivariate analysis. Overall 3-year survival rate was 41% (95% CI, 37-45%). In multivariate analysis, serum bilirubin level ≥300 μmol/L (p = 0.048), low-volume center (p < 0.001), venous resection (p = 0.014), N1 status (p < 0.01), R1 status (p < 0.001), and absence of adjuvant treatment (p < 0.001) negatively impacted survival. There was a negative relationship between survival at 12 months or later and higher rates of bilirubin. Presence of a biliary stent did not influence early or long-term results. CONCLUSIONS In this multicentric study, serum bilirubin level ≥300 μmol/L increased severe morbidity and decreased long-term survival after PD for PDAC. These findings suggest that biliary stenting is appropriately indicated before PD in patients with PDAC and severe jaundice.
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Affiliation(s)
- Alain Sauvanet
- Department of Hepato-Biliary and Pancreatic Surgery, Hôpital Beaujon, Clichy, France.
| | - Jean-Marie Boher
- Department of Biostatistics and Methodology, Institut Paoli Calmettes, Marseille, France; Unité Mixte de Recherche Institut de Recherche pour le Développement, Aix-Marseille University, Marseille, France
| | - François Paye
- Department of Digestive Surgery, Hôpital Saint Antoine, Paris, France
| | | | - Antonio Sa Cuhna
- Centre Hépato-Biliaire, AP-HP, Hôpital Paul Brousse, Villejuif, France
| | | | - Mustapha Adham
- Department of Surgery, Hôpital Edouard-Herriot, Lyon, France
| | | | - Laurence Chiche
- Department of Surgery, Maison du Haut-Levêque, Pessac, France
| | - Jean-Robert Delpero
- Department of Surgical Oncology, Institut Paoli Calmettes, Marseille, France
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Álamo JM, Marín LM, Suarez G, Bernal C, Serrano J, Barrera L, Gómez MA, Muntané J, Padillo FJ. Improving outcomes in pancreatic cancer: Key points in perioperative management. World J Gastroenterol 2014; 20:14237-14245. [PMID: 25339810 PMCID: PMC4202352 DOI: 10.3748/wjg.v20.i39.14237] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 02/14/2014] [Accepted: 06/23/2014] [Indexed: 02/06/2023] Open
Abstract
This review focused in the perioperative management of patients with pancreatic cancer in order to improve the outcome of the disease. We consider that the most controversial points in pancreatic cancer management are jaundice management, vascular resection and neo-adjuvant therapy. Preoperative biliary drainage is recommended only in patients with severe jaundice, as it can lead to infectious cholangitis, pancreatitis and delay in resection, which can lead to tumor progression. The development of a phase III clinical trial is mandatory to clarify the role of neo-adjuvant radiochemotherapy in pancreatic adenocarcinoma. Venous resection does not adversely affect postoperative mortality and morbidity, therefore, the need for venous resection should not be a contraindication to surgical resection in selected patients. The data on arterial resection alone, or combined with vascular resection at the time of pancreatectomy are more heterogeneous, thus, patient age and comorbidity should be evaluated before a decision on operability is made. In patients undergoing R0 resection, arterial resection can also be performed.
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Wang C, Xu Y, Lu X. Should preoperative biliary drainage be routinely performed for obstructive jaundice with resectable tumor? Hepatobiliary Surg Nutr 2014; 2:266-71. [PMID: 24570957 DOI: 10.3978/j.issn.2304-3881.2013.09.01] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Accepted: 09/15/2013] [Indexed: 12/26/2022]
Abstract
Obstructive jaundice is a common clinical manifestation of malignant lesions adjacent to extrahepatic bile duct, ampulla or pancreatic head. Animal experiments and some clinical observations have demonstrated that preoperative biliary drainage could improve liver function as well as reduce endotoxemia, thereby reducing the incidence of perioperative complications. However, a number of randomized, controlled studies have found that preoperative biliary drainage failed to improve prognosis or reduce the incidence of perioperative complications; in contrast, it might increase the incidence of complications and cause extra financial burden on patients. Thus, whether preoperative biliary drainage should be performed or not is controversial. Since clinical randomized controlled studies are more relevant in clinical setting, we believe that preoperative biliary drainage should not be routinely performed for obstructive jaundice with resectable tumors. More randomized, controlled, prospective studies should be conducted for further exploration.
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Affiliation(s)
- Chu Wang
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, CAMS & PUMC, Beijing 100730, China
| | - Yiyao Xu
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, CAMS & PUMC, Beijing 100730, China
| | - Xin Lu
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, CAMS & PUMC, Beijing 100730, China
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Baghel K, Raj S, Awasthi I, Gupta V, Chandra A, Srivastava RN. A comparative analysis of nasogastric and intravenous fluid resuscitation in patients with malignant obstructive jaundice prior to endoscopic biliary drainage. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2013; 5:523-8. [PMID: 24251269 PMCID: PMC3818824 DOI: 10.4103/1947-2714.118932] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: An alternative to intravenous is nasogastric fluid administration through normal functioning gut. Though not common, this practice has significance in mass causalities and elective situations. Aim: The study was designed to compare nasogastric and intravenous fluid resuscitation in malignant obstructive jaundice (OJ) and their effect on endotoxemia. Materials and Methods: Sixty patients with malignant OJ undergoing endoscopic biliary drainage were randomized into two groups. A total of 4 l of fluid (Ringer's lactate) was administered to Group A through nasogastric tube and to Group B through intravenous route for 48 h. Vital parameters, serum bilirubin, serum creatinine, creatinine clearance rate, electrolytes, and endotoxemia were monitored. Results: Significant improvement in blood pressure (Group A, P = 0.014; Group B, P = 0.020) and significant decrease in serum bilirubin level (Group A, P = 0.001; Group B, P > 0.0001) was observed in both groups after resuscitation. Significantly decreased (P = 0.036) post hydration endotoxin level was observed in Group A as compared to Group B. Febrile events were significantly higher (P = 0.023) in Group B as compared to Group A (6 vs 0). Electrolyte abnormalities were found more in Group B, however statistically insignificant. Conclusion: In OJ patient undergoing biliary drainage, preoperative fluid resuscitation through nasogastric tube may be helpful in reducing postoperative septic complications and endotoxemia.
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Affiliation(s)
- Kavita Baghel
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, India
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Junejo MA, Siriwardena AK, Parker MJ. Peripheral oxygen extraction in patients with malignant obstructive jaundice. Anaesthesia 2013; 69:32-6. [DOI: 10.1111/anae.12478] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2013] [Indexed: 01/08/2023]
Affiliation(s)
- M. A. Junejo
- Hepatobiliary Surgery Unit; Manchester Royal Infirmary; Manchester UK
| | - A. K. Siriwardena
- Hepatobiliary Surgery Unit; Manchester Royal Infirmary; Manchester UK
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van der Gaag NA, Kloek JJ, de Castro SMM, Busch ORC, van Gulik TM, Gouma DJ. Preoperative biliary drainage in patients with obstructive jaundice: history and current status. J Gastrointest Surg 2009; 13:814-20. [PMID: 18726134 DOI: 10.1007/s11605-008-0618-4] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Accepted: 07/15/2008] [Indexed: 01/31/2023]
Abstract
RATIONALE Preoperative biliary drainage (PBD) has been introduced to improve outcome after surgery in patients suffering from obstructive jaundice due to a potentially resectable proximal or distal bile duct/pancreatic head lesion. In experimental models, PBD is almost exclusively associated with beneficial results: improved liver function and nutritional status; reduction of systemic endotoxemia; cytokine release; and, as a result, an improved immune response. Mortality was significantly reduced in these animal models. Human studies show conflicting results. FINDINGS For distal obstruction, currently the "best-evidence" available clearly shows that routine PBD does not yield the appreciated improvement in postoperative morbidity and mortality in patients undergoing resection. Moreover, PBD harbors its own complications. However, most of the available data are outdated or suffer from methodological deficits. CONCLUSION The highest level of evidence for PBD to be performed in proximal obstruction, as well as over the preferred mode, is lacking but, nevertheless, assimilated in the treatment algorithm for many centers. Logistics and waiting lists, although sometimes inevitable, could be factors that might influence the decision to opt for PBD, as well as an extended diagnostic workup with laparoscopy (on indication) or scheduled preoperative chemotherapy.
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Affiliation(s)
- N A van der Gaag
- Department of Surgery, Academic Medical Center at the University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
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Abstract
AIM Multiorgan dysfunction is often encountered in jaundiced patients and may compromise the postoperative outcome after liver resection for cholangiocarcinoma (CCA). The aim of the present study was to elucidate evidence-based medicine regarding the benefit of the available preoperative treatments currently used for the preparation of patients before surgery for hilar CCA. MATERIAL AND METHODS An electronic search using the Medline database was performed to identify relevant articles relating to renal dysfunction, bacterial translocation, hemostasis impairment, malnutrition, liver failure, and postoperative outcome in jaundiced patients undergoing liver resection for CCA. RESULTS There is grade B evidence to expand the extracellular water volume and to administer oral synbiotic supplements. Intravenous vitamin K administration is an effective treatment. Perioperative nutritional support should be administered preferably by the enteral route in severely malnourished patients with compromised liver function undergoing extended liver resection (grade A evidence). There is only grade C evidence to recommend a portal vein embolization in patients with CCA when the future remnant liver volume is <40%. CONCLUSIONS A simplified scheme that might be useful in the management of patients presenting with obstructive jaundice was presented. Despite surgical technique improvements, preparation of patients for surgery will continue to be one of the major determinants for the postoperative prognosis of jaundiced patients.
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Affiliation(s)
- E. Oussoultzoglou
- Centre de Chirurgie Viscérale et de Transplantation – Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Université Louis PasteurStrasbourgFrance
| | - D. Jaeck
- Centre de Chirurgie Viscérale et de Transplantation – Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Université Louis PasteurStrasbourgFrance
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Isla A, Gascón AR, Maynar J, Arzuaga A, Toral D, Pedraz JL. Cefepime and continuous renal replacement therapy (CRRT): In vitro permeability of two CRRT membranes and pharmacokinetics in four critically ill patients. Clin Ther 2005; 27:599-608. [PMID: 15978309 DOI: 10.1016/j.clinthera.2005.05.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2005] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cefepime is a fourth-generation cephalosporin with a broad spectrum of antimicrobial activity against gram-positive and gram-negative micro-organisms. It is a useful option for treating infections in critically ill patients in intensive care due to its high degree of activity and its tolerability. OBJECTIVE The aim of this study was to characterize in vitro the permeability to cefepime of 2 membranes frequently used in continuous renal replacement therapies (CRRTs). An in vivo study was also carried out to determine the pharmacokinetics of cefepime in critically ill patients undergoing CRRT. METHODS In vitro procedures were conducted in 3 different fluids using polyacrylonitrile (AN69) or polysulfone (PS) membranes. Continuous venovenous hemofiltration (CVVH) and continuous venovenous hemodialysis (CVVHD) were simulated. Four male patients undergoing CVVH or continuous venovenous hemodiafiltration, who received 2000 mg of cefepime intravenously every 8 hours, entered the in vivo study. Prefilter and ultrafiltrate samples were collected, and concentrations of cefepime were measured using high-performance liquid chromatography. The sieving coefficient (Sc), defined as the fraction of drug eliminated across the membrane, and the saturation coefficient (Sa), defined as the fraction of drug diffused through the membrane to the dialysate fluid, were analyzed. Pharmacokinetic parameters were determined according to a noncompartmental analysis. RESULTS The patients ranged in age from 18 to 75 years and weighed from 65 to 80 kg. By analyzing Sc and Sa values in the in vitro procedures, no differences were detected in the permeability of AN69 or PS membranes to cefepime in CVVH or CVVHD. Sc/Sa values were between 0.93 and 1.03 in Ringer's lactate and in bovine albumin-containing Ringer's lactate samples, but Sc/Sa values were lower in plasma samples (0.82-0.95). In the in vivo portion of the study, the patients' mean (SD) Sc/Sa value was 0.76 (0.21) and correlated well with the fraction unbound to proteins (0.79 [0.09]). Clearance by CRRT (mean [SD]) was 29.0 (16.8)% of the total clearance. Serum elimination t(1/2) was 4.6 (0.9) hours, and the volume of distribution at steady state was 0.6 (0.3) L/kg (mean [SD] values). CONCLUSIONS Cefepime was significantly removed by CRRT. No significant differences were found in the Sc or Sa of cefepime between AN69 and PS membranes used in the CVVH or CVVHD procedures. The clearance of cefepime by CRRT must be considered when dosing critically ill patients.
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Affiliation(s)
- Arantxazu Isla
- Laboratory of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of the Basque Country, Vitoria-Gasteiz, Spain
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