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Costantini S, Belliato M, Ferrari F, Gazzaniga G, Ravasi M, Manera M, De Piero ME, Curcelli A, Cardinale A, Lorusso R. A retrospective analysis of the hemolysis occurrence during extracorporeal membrane oxygenation in a single center. Perfusion 2023; 38:609-621. [PMID: 35225087 DOI: 10.1177/02676591211073768] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO)-associated hemolysis still represents a serious complication. The present study aimed to investigate those predictive factors, such as flow rates, the use of anticoagulants, and circuit connected dialysis, that might play a pivotal role in hemolysis in adult patients. METHODS This is a retrospective single-center case series of 35 consecutive adult patients undergoing veno-venous ECMO support at our center between April 2014 and February 2020. Daily plasma-free hemoglobin (pfHb) and haptoglobin (Hpt) levels were chosen as hemolysis markers and they were analyzed along with patients' characteristics, daily laboratory findings, and corresponding ECMO system variables, as well as continuous renal replacement therapy (CRRT) when administered, looking for factors influencing their trends over time. RESULTS Among the many settings related to the ECMO support, the presence of CRRT connected to the ECMO circuit has been found associated with both higher daily pfHb levels and lower Hpt levels. After correction for potential confounders, hemolysis was ascribable to circuit-related variables, in particular the membrane oxygenation dead space was associated with an Hpt reduction (B = -215.307, p = 0.004). Moreover, a reduction of ECMO blood flow by 1 L/min has been associated with a daily Hpt consumption of 93.371 mg/dL (p = 0.001). CONCLUSIONS Technical-induced hemolysis during ECMO should be monitored not only when suspected but also during quotidian management and check-ups. While considering the clinical complexity of patients on ECMO support, clinicians should not only be aware of and anticipate possible circuitry malfunctions or inadequate flow settings, but they should also take into account the effects of an ECMO circuit-connected CRRT, as an equally important key factor triggering hemolysis.
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Affiliation(s)
- Silvia Costantini
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, 19001University of Pavia, Pavia, Italy
| | - Mirko Belliato
- UOC Anestesia e Rianimazione II Cardiopolmonare, 18631Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Cardio-Thoracic Surgery Department, Heart & Vascular Centre, 199236Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Fiorenza Ferrari
- UOC Anestesia e Rianimazione I, 18631Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giulia Gazzaniga
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, 19001University of Pavia, Pavia, Italy
| | - Marta Ravasi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, 19001University of Pavia, Pavia, Italy
| | - Miriam Manera
- UOC Anestesia e Rianimazione II Cardiopolmonare, 18631Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Antonio Curcelli
- Cardiac Anesthesia and Intensive Care ICLAS Rapallo, 18591GVM Care & Res, Rapallo, Italy
| | - Alessandra Cardinale
- Department of Statistical Sciences, 9311Sapienza University of Rome, Rome, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, 199236Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,118066Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherland
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Cell-Free Hemoglobin Concentration in Blood Prime Solution Is a Major Determinant of Cell-Free Hemoglobin Exposure during Cardiopulmonary Bypass Circulation in the Newborn. J Clin Med 2022; 11:jcm11144071. [PMID: 35887835 PMCID: PMC9317140 DOI: 10.3390/jcm11144071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/04/2022] [Accepted: 07/06/2022] [Indexed: 11/17/2022] Open
Abstract
Exposure to circulating cell-free hemoglobin is a ubiquitous feature of open-heart surgery on cardiopulmonary bypass circulation. This study aims to determine the origins and dynamics of circulating cell-free hemoglobin and its major scavenger proteins haptoglobin and hemopexin during neonatal cardiopulmonary bypass. Forty neonates with an isolated critical congenital heart defect were included in a single-center prospective observational study. Blood samples were obtained preoperatively, hourly during bypass circulation, after bypass separation, at admission to the pediatric intensive care unit, and at postoperative days 1–3. Concentrations of cell-free hemoglobin, haptoglobin and hemopexin were determined using ELISA. Neonates were exposed to significantly elevated plasma concentrations of cell-free hemoglobin and a concomitant depletion of scavenger protein supplies during open-heart surgery. The main predictor of cell-free hemoglobin exposure was the concentration of cell-free hemoglobin in blood prime solution. Concentrations of haptoglobin and hemopexin in prime solution were important determinants for intra- and postoperative circulating scavenger protein resources.
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Solár P, Zamani A, Lakatosová K, Joukal M. The blood-brain barrier and the neurovascular unit in subarachnoid hemorrhage: molecular events and potential treatments. Fluids Barriers CNS 2022; 19:29. [PMID: 35410231 PMCID: PMC8996682 DOI: 10.1186/s12987-022-00312-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/24/2022] [Indexed: 12/12/2022] Open
Abstract
The response of the blood-brain barrier (BBB) following a stroke, including subarachnoid hemorrhage (SAH), has been studied extensively. The main components of this reaction are endothelial cells, pericytes, and astrocytes that affect microglia, neurons, and vascular smooth muscle cells. SAH induces alterations in individual BBB cells, leading to brain homeostasis disruption. Recent experiments have uncovered many pathophysiological cascades affecting the BBB following SAH. Targeting some of these pathways is important for restoring brain function following SAH. BBB injury occurs immediately after SAH and has long-lasting consequences, but most changes in the pathophysiological cascades occur in the first few days following SAH. These changes determine the development of early brain injury as well as delayed cerebral ischemia. SAH-induced neuroprotection also plays an important role and weakens the negative impact of SAH. Supporting some of these beneficial cascades while attenuating the major pathophysiological pathways might be decisive in inhibiting the negative impact of bleeding in the subarachnoid space. In this review, we attempt a comprehensive overview of the current knowledge on the molecular and cellular changes in the BBB following SAH and their possible modulation by various drugs and substances.
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Affiliation(s)
- Peter Solár
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
- Department of Neurosurgery, Faculty of Medicine, Masaryk University and St. Anne's University Hospital Brno, Pekařská 53, 656 91, Brno, Czech Republic
| | - Alemeh Zamani
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
| | - Klaudia Lakatosová
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
| | - Marek Joukal
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic.
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Sakhinia F, Ollerenshaw R, Wallace D. Mechanical stress-related haemolysis in a paediatric haemodialysis patient. BMJ Case Rep 2022; 15:e245248. [PMID: 35135788 PMCID: PMC8830101 DOI: 10.1136/bcr-2021-245248] [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] [Accepted: 11/18/2021] [Indexed: 11/04/2022] Open
Abstract
Haemodialysis (HD) is a common kidney replacement therapy (KRT) used in the management of children with end-stage kidney disease (ESKD). We describe the case of a 2-year-old child who developed mechanical intraluminal haemolytic anaemia secondary to the acute angulation of the HD line. In contrast to reports of arteriovenous fistula-associated haemolysis, onset was insidious in nature and detected through review of subtle serial biochemical and haematological changes. Development of hyperbilirubinaemia during HD was modest due to the partial clearance of bilirubin via HD-enabled diffusion. The only persistent and consistent marker was the post-HD rise in lactate dehydrogenase in association with decreasing haemoglobin. We propose that mechanical stress-induced haemolysis should be considered in children on HD who develop unexplained or persistent anaemia with resistance to increasing doses of iron and erythropoiesis-stimulating agent supplementation.
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Affiliation(s)
- Faezeh Sakhinia
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, Greater Manchester, UK
| | - Rebecca Ollerenshaw
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, Greater Manchester, UK
| | - Dean Wallace
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, Greater Manchester, UK
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Hemolysis and Plasma Free Hemoglobin During Extracorporeal Membrane Oxygenation Support: From Clinical Implications to Laboratory Details. ASAIO J 2020; 66:239-246. [PMID: 30985331 DOI: 10.1097/mat.0000000000000974] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) are lifesaving supports that are more and more frequently used in critically ill patients. Despite of major technological improvements observed during the last 20 years, ECMO-associated hemolysis is still a complication that may arise during such therapy. Hemolysis severity, directly appreciated by plasma free hemoglobin concentration, may be present with various intensity, from a nonalarming and tolerable hemolysis to a highly toxic one. Here, we propose a review dedicated to extracorporeal membrane oxygenation (ECMO)-associated hemolysis, with a particular emphasis on pathophysiology, prevalence, and clinical consequences of such complication. We also focus on laboratory assessment of hemolysis and on the limits that have to be known by clinicians to prevent and manage hemolytic events.
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Aili D, Kraglund MR, Tavacoli J, Chatzichristodoulou C, Jensen JO. Polysulfone-polyvinylpyrrolidone blend membranes as electrolytes in alkaline water electrolysis. J Memb Sci 2020. [DOI: 10.1016/j.memsci.2019.117674] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Cho NJ, Park S, Islam MI, Song HY, Lee EY, Gil HW. Long-term effect of medium cut-off dialyzer on middle uremic toxins and cell-free hemoglobin. PLoS One 2019; 14:e0220448. [PMID: 31348802 PMCID: PMC6660073 DOI: 10.1371/journal.pone.0220448] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 07/16/2019] [Indexed: 12/22/2022] Open
Abstract
The medium cut-off (MCO) dialyzer has shown good clearance of large middle molecules, but its long-term effects are unclear. We investigated whether MCO hemodialysis (HD) over one year could reduce middle molecule levels and cell-free hemoglobin (CFH), without albumin loss. A prospective cohort study in 57 hemodialysis patients was conducted. The patients were assigned to the MCO dialyzer group or the high-flux dialyzer group, according to the HD machine they used. The reduction ratio (RR) and one-year changes in small and middle molecules and CFH were analyzed. Over a 12-month follow-up, MCO HD did not reduce the serum levels of middle molecules (lambda free light chain [FLC], from 135.7 ± 39.9 to 132.0 ± 39.1 mg/L; kappa FLC, from 168.2 ± 58.5 to 167.7 ± 65.8 mg/L; β2-microglobulin, from 25.6 ± 9.6 to 28.4 ± 4.8 mg/L) or albumin (from 3.96 ± 0.31 to 3.94 ± 0.37 g/dL). MCO HD provided excellent RR of lambda FLC (49.3 ± 10.3%), kappa FLC (69.6 ± 10.4%) and β2-microglobulin (80.9 ± 7.3%), compared to high-flux HD. CFH was also removed well during an MCO HD session (RR of CPH, 85.5 [78.7–97.3] %), but long-term change was not significant (from 57.8 [46.2–79.1] to 62.0 [54.6–116.7] mg/L). The MCO dialyzer can be used effectively and safely in conventional HD settings, but long-term effects on large middle molecules and CFH were not significant. Further studies are needed to verify clinical benefits of the MCO dialyzer.
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Affiliation(s)
- Nam-Jun Cho
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Samel Park
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Md Imtiazul Islam
- Department of Microbiology and Immunology, School of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Ho-Yeon Song
- Department of Microbiology and Immunology, School of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Eun Young Lee
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Hyo-Wook Gil
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
- * E-mail:
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Cucchiari D, Reverter E, Blasco M, Molina-Andujar A, Carpio A, Sanz M, Escorsell A, Fernández J, Poch E. High cut-off membrane for in-vivo dialysis of free plasma hemoglobin in a patient with massive hemolysis. BMC Nephrol 2018; 19:250. [PMID: 30286730 PMCID: PMC6172805 DOI: 10.1186/s12882-018-1051-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 09/20/2018] [Indexed: 11/10/2022] Open
Abstract
Background The possibility of clearing Cell-free Plasma Hemoglobin (CPH) from human plasma may appear attractive, especially when considering the noxious effects that CPH has on the immune function and the renal damage caused by its filtration. The existence of the so-called High Cut-Off (HCO) filters, possessing pores as big as 60 kDa, could potentially allow the clearance of the αβ dimers (31.3 kDa), the form in which the α2β2 hemoglobin tetramers (62.6 kDa) physiologically dissociate in plasma. We present herein the first reported case in which such an attempt was made. Case presentation The patient was a 51-year-old man with hemolytic crisis due to glucose-6-phosphate dehydrogenase deficiency, further complicated by pigment-induced nephropathy. He underwent a 48-h CVVHD session, in which a HCO filter was used. The Sieving Coefficient (SC) for CPH was initially 0.08 and decreased to 0.02 after 24 h. This unexpected low SC was due to the initial high concentration of CPH (4.24 g/L). At such concentrations, the α2β2 tetramer poorly dissociates into the αβ dimer; but increases exponentially at concentrations lower than 1 g/L. Conclusions Clearance of CPH through a HCO filter is technically feasible but its performance markedly relies on the initial concentration of CPH. Critically ill patients with smoldering hemolysis, as it happens during septic shock or ECMO treatment, may benefit the most from the use of this membrane in order to clear CPH.
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Affiliation(s)
- David Cucchiari
- Nephrology and Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08036, Barcelona, Spain.
| | - Enric Reverter
- Liver Intensive Care Unit, Hepatology. Hospital Clínic, Barcelona, Spain
| | - Miquel Blasco
- Nephrology and Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08036, Barcelona, Spain
| | - Alicia Molina-Andujar
- Nephrology and Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08036, Barcelona, Spain
| | - Adriá Carpio
- Liver Intensive Care Unit, Hepatology. Hospital Clínic, Barcelona, Spain
| | - Miquel Sanz
- Liver Intensive Care Unit, Hepatology. Hospital Clínic, Barcelona, Spain
| | - Angels Escorsell
- Liver Intensive Care Unit, Hepatology. Hospital Clínic, Barcelona, Spain
| | - Javier Fernández
- Liver Intensive Care Unit, Hepatology. Hospital Clínic, Barcelona, Spain
| | - Esteban Poch
- Nephrology and Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08036, Barcelona, Spain
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