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Petitclerc T, Béné B. Can regional anticoagulation with calcium-free dialysate be extended to maintenance hemodialysis? Artif Organs 2024; 48:704-712. [PMID: 38716639 DOI: 10.1111/aor.14764] [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: 03/06/2024] [Revised: 04/09/2024] [Accepted: 04/15/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Regional anticoagulation in hemodialysis avoids the use of heparin, which is responsible for both hemorrhagic and non-hemorrhagic complications. Typically, blood is decalcified by injecting citrate into the arterial line of the extracorporeal circuit. Calcium-free dialysate improves anticoagulation efficacy but requires injection of a calcium-containing solution into the venous line and strict monitoring of blood calcium levels. Recent improvements have made regional anticoagulation with calcium-free dialysate safer and easier. OBSERVATIONS (1) Adjusting the calcium injection rate to ionic dialysance avoids the risk of dyscalcemia, thus making unnecessary the monitoring of blood calcium levels. This adjustment could be carried out automatically by the hemodialysis monitor. (2) As calcium-free dialysate reduces the amount of citrate required, this can be supplied by dialysate obtained from currently available concentrates containing citric acid. This avoids the need for citrate injection and the risk of citrate overload. (3) Calcium-free dialysate no longer needs the dialysate acidification required for avoiding calcium carbonate precipitation in bicarbonate-containing dialysate. CONCLUSIONS Regional anticoagulation with calcium-free dialysate enables an acid- and heparin-free procedure that is more biocompatible and environmentally friendly than conventional bicarbonate hemodialysis. The availability of specific acid-free concentrates and adapted hemodialysis monitors is required to extend this procedure to maintenance hemodialysis.
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Wu X, Xia Y, Dai H, Hong C, Zhao Y, Wei W, Zheng D. Metabolic Control During Macrophage Polarization by a Citrate-Functionalized Scaffold for Maintaining Bone Homeostasis. Adv Healthc Mater 2024:e2400770. [PMID: 38626942 DOI: 10.1002/adhm.202400770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Indexed: 05/14/2024]
Abstract
Metabolites, as markers of phenotype at the molecular level, can regulate the function of DNA, RNA, and proteins through chemical modifications or interactions with large molecules. Citrate is an important metabolite that affects macrophage polarization and osteoporotic bone function. Therefore, a better understanding of the precise effect of citrate on macrophage polarization may provide an effective alternative strategy to reverse osteoporotic bone metabolism. In this study, a citrate functional scaffold to control the metabolic pathway during macrophage polarization based on the metabolic differences between pro-inflammatory and anti-inflammatory phenotypes for maintaining bone homeostasis, is fabricated. Mechanistically, only outside M1 macrophages are accumulated high concentrations of citrate, in contrast, M2 macrophages consume massive citrate. Therefore, citrate-functionalized scaffolds exert more sensitive inhibitory effects on metabolic enzyme activity during M1 macrophage polarization than M2 macrophage polarization. Citrate can block glycolysis-related enzymes by occupying the binding-site and ensure sufficient metabolic flux in the TCA cycle, so as to turn the metabolism of macrophages to oxidative phosphorylation of M2 macrophage, largely maintaining bone homeostasis. These studies indicate that exogenous citrate can realize metabolic control of macrophage polarization for maintaining bone homeostasis in osteoporosis.
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Affiliation(s)
- Xiaopei Wu
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan, 430070, China
- Foshan Xianhu Laboratory of the Advanced Energy Science and Technology Guangdong Laboratory, Xianhu hydrogen Valley, Foshan, 528200, China
| | - Yuhao Xia
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan, 430070, China
| | - Honglian Dai
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan, 430070, China
- Foshan Xianhu Laboratory of the Advanced Energy Science and Technology Guangdong Laboratory, Xianhu hydrogen Valley, Foshan, 528200, China
| | - Chuhang Hong
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan, 430070, China
| | - Yanan Zhao
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan, 430070, China
| | - Wenying Wei
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan, 430070, China
| | - Dian Zheng
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan, 430070, China
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Natale P, Palmer SC, Ruospo M, Longmuir H, Dodds B, Prasad R, Batt TJ, Jose MD, Strippoli GF. Anticoagulation for people receiving long-term haemodialysis. Cochrane Database Syst Rev 2024; 1:CD011858. [PMID: 38189593 PMCID: PMC10772979 DOI: 10.1002/14651858.cd011858.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND Haemodialysis (HD) requires safe and effective anticoagulation to prevent clot formation within the extracorporeal circuit during dialysis treatments to enable adequate dialysis and minimise adverse events, including major bleeding. Low molecular weight heparin (LMWH) may provide a more predictable dose, reliable anticoagulant effects and be simpler to administer than unfractionated heparin (UFH) for HD anticoagulation, but may accumulate in the kidneys and lead to bleeding. OBJECTIVES To assess the efficacy and safety of anticoagulation strategies (including both heparin and non-heparin drugs) for long-term HD in people with kidney failure. Any intervention preventing clotting within the extracorporeal circuit without establishing anticoagulation within the patient, such as regional citrate, citrate enriched dialysate, heparin-coated dialysers, pre-dilution haemodiafiltration (HDF), and saline flushes were also included. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to November 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-randomised controlled studies (quasi-RCTs) evaluating anticoagulant agents administered during HD treatment in adults and children with kidney failure. DATA COLLECTION AND ANALYSIS Two authors independently assessed the risk of bias using the Cochrane tool and extracted data. Treatment effects were estimated using random effects meta-analysis and expressed as relative risk (RR) or mean difference (MD) with 95% confidence intervals (CI). Evidence certainty was assessed using the Grading of Recommendation, Assessment, Development and Evaluation approach (GRADE). MAIN RESULTS We included 113 studies randomising 4535 participants. The risk of bias in each study was adjudicated as high or unclear for most risk domains. Compared to UFH, LMWH had uncertain effects on extracorporeal circuit thrombosis (3 studies, 91 participants: RR 1.58, 95% CI 0.46 to 5.42; I2 = 8%; low certainty evidence), while major bleeding and minor bleeding were not adequately reported. Regional citrate anticoagulation may lower the risk of minor bleeding compared to UFH (2 studies, 82 participants: RR 0.34, 95% CI 0.14 to 0.85; I2 = 0%; low certainty evidence). No studies reported data comparing regional citrate to UFH on risks of extracorporeal circuit thrombosis and major bleeding. The effects of very LMWH, danaparoid, prostacyclin, direct thrombin inhibitors, factor XI inhibitors or heparin-grafted membranes were uncertain due to insufficient data. The effects of different LMWH, different doses of LMWH, and the administration of LMWH anticoagulants using inlet versus outlet bloodline or bolus versus infusion were uncertain. Evidence to compare citrate to another citrate or control was scant. The effects of UFH compared to no anticoagulant therapy or different doses of UFH were uncertain. Death, dialysis vascular access outcomes, blood transfusions, measures of anticoagulation effect, and costs of interventions were rarely reported. No studies evaluated the effects of treatment on non-fatal myocardial infarction, non-fatal stroke and hospital admissions. Adverse events were inconsistently and rarely reported. AUTHORS' CONCLUSIONS Anticoagulant strategies, including UFH and LMWH, have uncertain comparative risks on extracorporeal circuit thrombosis, while major bleeding and minor bleeding were not adequately reported. Regional citrate may decrease minor bleeding, but the effects on major bleeding and extracorporeal circuit thrombosis were not reported. Evidence supporting clinical decision-making for different forms of anticoagulant strategies for HD is of low and very low certainty, as available studies have not been designed to measure treatment effects on important clinical outcomes.
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Affiliation(s)
- Patrizia Natale
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, Universityof Foggia, Foggia, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Marinella Ruospo
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | | | - Benjamin Dodds
- School of Medicine, University of Tasmania, Hobart, Australia
| | - Ritam Prasad
- Department of Haematology/Pathology, Royal Hobart Hospital, Hobart, Australia
| | - Tracey J Batt
- Department of Haematology, Westmead Hospital, Westmead, Australia
| | - Matthew D Jose
- School of Medicine, University of Tasmania, Hobart, Australia
| | - Giovanni Fm Strippoli
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Demuynck T, Grooteman M, Ter Wee P, Cozzolino M, Meijers B. Regional Citrate Anticoagulation: A Tale of More Than Two Stories. Semin Nephrol 2023; 43:151481. [PMID: 38212212 DOI: 10.1016/j.semnephrol.2023.151481] [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] [Indexed: 01/13/2024]
Abstract
Calcium is a key clotting factor, and several inorganic molecules that bind to calcium have been found to reduce the clotting propensity of blood. Citrate, a calcium chelator, is used as inhibitor of the coagulation cascade in blood transfusion. Also, it is used as an anaticoagulant during dialysis to maintain patency of the extracorporeal circuit, known as regional citrate anticoagulation (RCA). The amount of citrate should be chosen such that ionized calcium concentrations in the extracorporeal circuit are reduced enough to minimize propagation of the coagulation cascade. The dialytic removal of the calcium-citrate complexes combined with reduced ionized calcium concentrations makes necessary calcium supplementation of the blood returning to the patient. This can be achieved in different ways. In classical RCA, citrate and calcium are infused in the afferent and efferent tubing, respectively, whereas the dialysate does not contain calcium. This setup has been shown to be highly efficacious with a very low clotting propensity. Strict monitoring of blood electrolytes is required. Alternatively, the use of a high-calcium dialysate leads to calcium loading, obviating the need for a separate calcium infusion pump. The main advantages are simplified delivery of RCA and less fluctuation of systemic calcium concentrations. Currently, citric acid is sometimes added to the acid concentrate as a replacement for acetic acid. Differences and similarities between RCA and citrate-containing dialysate are discussed. RCA is an excellent alternative to heparin for patients at high risk of bleeding.
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Affiliation(s)
- Thomas Demuynck
- Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Muriel Grooteman
- Department of Nephrology, Amsterdam UMC, Amsterdam, Netherlands; Diabetes and Metabolism, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Piet Ter Wee
- Department of Nephrology, Amsterdam UMC, Amsterdam, Netherlands; Diabetes and Metabolism, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Mario Cozzolino
- Renal Division, Department of Health Sciences, University of Milan, Milan, Italy
| | - Björn Meijers
- Department of Nephrology, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.
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Sethi S, Mangat G, Soundararajan A, Marakini AB, Pecoits-Filho R, Shah R, Davenport A, Raina R. Archetypal sustained low-efficiency daily diafiltration (SLEDD-f) for critically ill patients requiring kidney replacement therapy: towards an adequate therapy. J Nephrol 2023; 36:1789-1804. [PMID: 37341966 DOI: 10.1007/s40620-023-01665-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/29/2023] [Indexed: 06/22/2023]
Abstract
Sustained low-efficiency dialysis is a hybrid form of kidney replacement therapy that has gained increasing popularity as an alternative to continuous forms of kidney replacement therapy in intensive care unit settings. During the COVID-19 pandemic, the shortage of continuous kidney replacement therapy equipment led to increasing usage of sustained low-efficiency dialysis as an alternative treatment for acute kidney injury. Sustained low-efficiency dialysis is an efficient method for treating hemodynamically unstable patients and is quite widely available, making it especially useful in resource-limited settings. In this review, we aim to discuss the various attributes of sustained low-efficiency dialysis and how it is comparable to continuous kidney replacement therapy in efficacy, in terms of solute kinetics and urea clearance, and the various formulae used to compare intermittent and continuous forms of kidney replacement therapy, along with hemodynamic stability. During the COVID-19 pandemic, there was increased clotting of continuous kidney replacement therapy circuits, which led to increased use of sustained low-efficiency dialysis alone or together with extra corporeal membrane oxygenation circuits. Although sustained low-efficiency dialysis can be delivered with continuous kidney replacement therapy machines, most centers use standard hemodialysis machines or batch dialysis systems. Even though antibiotic dosing differs between continuous kidney replacement therapy and sustained low-efficiency dialysis, reports of patient survival and renal recovery are similar for continuous kidney replacement therapy and sustained low-efficiency dialysis. Health care studies indicate that sustained low-efficiency dialysis has emerged as a cost-effective alternative to continuous kidney replacement therapy. Although there is considerable data to support sustained low-efficiency dialysis treatments for critically ill adult patients with acute kidney injury, there are fewer pediatric data, even so, currently available studies support the use of sustained low-efficiency dialysis for pediatric patients, particularly in resource-limited settings.
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Affiliation(s)
- Sidharth Sethi
- Department of Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Guneive Mangat
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Anvitha Soundararajan
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Abhilash Bhat Marakini
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Catolica Do Parana, Curitiba, Brazil
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Raghav Shah
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK
| | - Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
- Department of Pediatric Nephrology, Akron Children's Hospital, Akron, OH, USA.
- Department of Internal Medicine, Northeast Ohio Medical University, Rootstown, OH, USA.
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Liu SY, Xu SY, Yin L, Yang T, Jin K, Zhang QB, Sun F, Tan DY, Xin TY, Chen YG, Zhao XD, Yu XZ, Xu J. Management of regional citrate anticoagulation for continuous renal replacement therapy: guideline recommendations from Chinese emergency medical doctor consensus. Mil Med Res 2023; 10:23. [PMID: 37248514 DOI: 10.1186/s40779-023-00457-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 04/28/2023] [Indexed: 05/31/2023] Open
Abstract
Continuous renal replacement therapy (CRRT) is widely used for treating critically-ill patients in the emergency department in China. Anticoagulant therapy is needed to prevent clotting in the extracorporeal circulation during CRRT. Regional citrate anticoagulation (RCA) has been shown to potentially be safer and more effective and is now recommended as the preferred anticoagulant method for CRRT. However, there is still a lack of unified standards for RCA management in the world, and there are many problems in using this method in clinical practice. The Emergency Medical Doctor Branch of the Chinese Medical Doctor Association (CMDA) organized a panel of domestic emergency medicine experts and international experts of CRRT to discuss RCA-related issues, including the advantages and disadvantages of RCA in CRRT anticoagulation, the principle of RCA, parameter settings for RCA, monitoring of RCA (mainly metabolic acid-base disorders), and special issues during RCA. Based on the latest available research evidence as well as the paneled experts' clinical experience, considering the generalizability, suitability, and potential resource utilization, while also balancing clinical advantages and disadvantages, a total of 16 guideline recommendations were formed from the experts' consensus.
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Affiliation(s)
- Shu-Yuan Liu
- Emergency Department, The Sixth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China
| | - Sheng-Yong Xu
- State Key Laboratory of Complex Severe and Rare Diseases, Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Lu Yin
- Emergency Department, Peking University Shenzhen Hospital, Shenzhen, 518000, China
| | - Ting Yang
- Emergency Department, The First Affiliated Hospital of Kunming Medical University, Kunming, 650000, China
| | - Kui Jin
- Emergency Department, The First Affiliated Hospital of University of Science and Technology of China, Hefei, 230001, China
| | - Qiu-Bin Zhang
- Emergency Department, The Second Affiliated Hospital of Hainan Medical College, Haikou, 570100, China
| | - Feng Sun
- Emergency Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Ding-Yu Tan
- Emergency Department, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, 225001, China
| | - Tian-Yu Xin
- Emergency Department, The Sixth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China
| | - Yu-Guo Chen
- Emergency Department and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, 100005, China.
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Jinan, 100005, China.
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, 100005, China.
| | - Xiao-Dong Zhao
- Emergency Department, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China.
| | - Xue-Zhong Yu
- State Key Laboratory of Complex Severe and Rare Diseases, Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
| | - Jun Xu
- State Key Laboratory of Complex Severe and Rare Diseases, Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
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Boer W, van Tornout M, Brusseleers M, Strauven M, de Vooght P, Vander Laenen M, Hoste E, Jorens PG. The effects of differing anticoagulant regimes on blood quality after cell salvage in coronary artery bypass grafting (CABG): a pilot study. J Cardiothorac Surg 2023; 18:116. [PMID: 37031168 PMCID: PMC10082980 DOI: 10.1186/s13019-023-02246-w] [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: 08/28/2022] [Accepted: 04/02/2023] [Indexed: 04/10/2023] Open
Abstract
BACKGROUND Cell salvage reduces allogenic blood transfusion requirements in surgery. We present a pilot study exploring the impact of anticoagulant choice, citrate or heparin, on the quality of cell salvaged blood in adults undergoing coronary artery bypass grafting (CABG). MATERIALS AND METHODS Elective on pump CABG patients were randomly allocated to citrate or heparin anticoagulation. We measured red blood cell characteristics and inflammation in both the blood collection reservoir and the washed red blood cell concentrate. Postoperatively, the level of biomarkers and the coagulation profile in the peripheral blood as well as the transfusion requirements of allogenic blood products were studied. RESULTS Thirty eight patients were included, 19 in the citrate group and 19 in the heparin group. Baseline characteristics were similar. In the washed red blood cell concentrate, Mean Hb (g/dl) and Ht (%) were lower in the citrate group [Hb: 18.1 g/dL (SD 1.3) vs. 21.1 (1.6), p < 0.001; Ht: 59.9% (54.7-60.9) vs. 63.7% (62.3-64.8); p < 0.001]; Mean corpuscular volume (MCV, μm 3) was higher [99.1fL (9.4) vs. 88 (4.2), p < 0.001] and mean corpuscular hemoglobin concentration (MCHC, g/dl) lower in the citrate group [31.9 g/dl (29.6-32.4) vs. 33.6 (33.1-34.0) p < 0.001]. Thrombocyte count (1000/μl) was higher in the citrate group [31.0 (26.0-77.0) vs. 13.0 (10.0-39.0); p = 0.006]. There were no differences in the requirement for allogenic blood products' transfusion (intraoperatively and postoperatively) or in the coagulation parameters after washed red blood cell concentrate infusion. Higher IL-10 was found in the citrate group in the blood collection reservoir, higher neutrophil-derived myeloperoxidase (MPO) in the heparin group after washed red blood cell concentrate infusion. CONCLUSION Though red blood cells in washed red blood cell concentrate were more swollen and diluted in the citrate group with more residual thrombocytes, published quality guidelines were met in both groups. Our pilot study suggests that differences in inflammatory markers in the blood collection reservoir and after infusion of washed red blood cell concentrate indicate a possible pro-inflammatory effect of heparin compared to citrate. A larger study is warranted to confirm these results and their possible clinical consequences. Trial registration ClinicalTrials.gov : NCT02674906. Registered 5 February 2016.
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Affiliation(s)
- Willem Boer
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium.
| | - Mathias van Tornout
- Department of Anesthesiology and Intensive Care Medicine, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium
| | - Maarten Brusseleers
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium
| | - Maarten Strauven
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium
| | - Pieter de Vooght
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium
| | - Margot Vander Laenen
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium
| | - Eric Hoste
- Intensive Care Unit, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium
- Research Foundation Flanders (FWO), Brussels, Belgium
| | - Philippe G Jorens
- Department of Critical Care Medicine, Antwerp University Hospital, University of Antwerp, LEMP, Edegem, Belgium
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8
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Gao F, Niu Y, Sun L, Li W, Xia H, Zhang Y, Geng S, Guo Z, Lin H, Du G. Integrating network pharmacology and transcriptomic validation to investigate the efficacy and mechanism of Mufangji decoction preventing lung cancer. JOURNAL OF ETHNOPHARMACOLOGY 2022; 298:115573. [PMID: 35917893 DOI: 10.1016/j.jep.2022.115573] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 07/08/2022] [Accepted: 07/18/2022] [Indexed: 06/02/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Mufangji decoction (MFJD), a famous traditional Chinese medicine formula in Synopsis of Golden Chamber (Jingui yaolue), has been utilized to treat cough and asthma and release chest pain over 2000 years in China. Chinese old herbalist doctor use MFJD to treat lung cancer and cancerous pleural fluid, but the preventive effect of MFJD on lung cancer and the underlying mechanism are indefinite. AIM OF THE STUDY The goal of this study is to explore the efficacy and mechanism of Mufangji decoction preventing lung cancer referring to the traditional use. MATERIALS AND METHODS Tumor allograft experiment and host versus tumor experiment were used to observe the direct anti-tumor effect and indirect anti-tumor immune effect, the mouse lung carcinogenic model was used to evaluate the dose-response and the preventive effect of MFJD on lung cancer. The active ingredients of MFJD were obtained by UPLC-MS/MS. The potential targets of MFJD were screened by network pharmacology and transcriptomics. The therapeutic targets and pathways of MFJD on lung cancer were obtained by protein-protein interaction, molecular docking and David database. The predicted results were verified in vitro and in vivo. RESULTS MFJD could significantly prevent tumor growth in host versus tumor experiment but could not in tumor allograft experiment, indicating an anti-tumor immune effect against lung cancer. MFJD could reduce lung nodules with a dose-response in mouse lung carcinogenic model. Myeloperoxidase (MPO) was selected as the core target due to the highest degree value in Protein-Protein interaction network and had potently binding activity to sinomenine and dehydrocostus lactone in molecular docking. In vivo, MPO-expressed neutrophils are negatively correlated with lung cancer progression and MFJD could promote the neutrophil-related immune surveillance. In vitro, sinomenine and dehydrocostus lactone could promote neutrophil phagocytosis, MPO and ROS production in a dose dependent manner. The major compounds from MFJD were identified to regulate 36 targets for lung cancer prevention by UPLC-MS/MS, network pharmacology and transcriptomics. David database exhibited that MFJD plays an important role in immunoregulation by modulating 4 immune-related biological processes and 3 immune-related pathways. CONCLUSIONS MFJD prevents lung cancer by mainly promoting MPO expression to maintain neutrophil immune surveillance, its key compounds are sinomenine and dehydrocostus lactone.
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Affiliation(s)
- Fan Gao
- Henan Province Engineering Research Center of High Value Utilization to Natural Medical Resource in Yellow River Basin, Pharmaceutical College of Henan University, Jinming District, Kaifeng, Henan Province, 475004, China.
| | - Yuju Niu
- Henan Province Engineering Research Center of High Value Utilization to Natural Medical Resource in Yellow River Basin, Pharmaceutical College of Henan University, Jinming District, Kaifeng, Henan Province, 475004, China.
| | - Luyao Sun
- Henan Province Engineering Research Center of High Value Utilization to Natural Medical Resource in Yellow River Basin, Pharmaceutical College of Henan University, Jinming District, Kaifeng, Henan Province, 475004, China.
| | - Wenwen Li
- Henan Province Engineering Research Center of High Value Utilization to Natural Medical Resource in Yellow River Basin, Pharmaceutical College of Henan University, Jinming District, Kaifeng, Henan Province, 475004, China.
| | - Haojie Xia
- Henan Province Engineering Research Center of High Value Utilization to Natural Medical Resource in Yellow River Basin, Pharmaceutical College of Henan University, Jinming District, Kaifeng, Henan Province, 475004, China.
| | - Yaru Zhang
- Henan Province Engineering Research Center of High Value Utilization to Natural Medical Resource in Yellow River Basin, Pharmaceutical College of Henan University, Jinming District, Kaifeng, Henan Province, 475004, China.
| | - Shengnan Geng
- School of Pharmacy and Chemical Engineering, Zhengzhou University of Industry Technology, Xinzheng, Henan Province, 451150, China.
| | - Zhenzhen Guo
- Henan Province Engineering Research Center of High Value Utilization to Natural Medical Resource in Yellow River Basin, Pharmaceutical College of Henan University, Jinming District, Kaifeng, Henan Province, 475004, China.
| | - Haihong Lin
- Henan Province Engineering Research Center of High Value Utilization to Natural Medical Resource in Yellow River Basin, Pharmaceutical College of Henan University, Jinming District, Kaifeng, Henan Province, 475004, China.
| | - Gangjun Du
- Henan Province Engineering Research Center of High Value Utilization to Natural Medical Resource in Yellow River Basin, Pharmaceutical College of Henan University, Jinming District, Kaifeng, Henan Province, 475004, China; School of Pharmacy and Chemical Engineering, Zhengzhou University of Industry Technology, Xinzheng, Henan Province, 451150, China.
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9
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Use of regional citrate anticoagulation with medium cut-off membrane: pilot report. BMC Nephrol 2022; 23:346. [PMID: 36303108 PMCID: PMC9615209 DOI: 10.1186/s12882-022-02960-y] [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] [Received: 06/06/2022] [Revised: 08/24/2022] [Accepted: 09/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Regional citrate anticoagulation during hemodialysis provides an immediate and complete anticoagulant effect, which is limited to the extracorporeal circuit. Citrate has become the standard anticoagulant in acute renal replacement therapy and is widely used in various intermittent hemodialysis modalities, especially for patients with contraindications for heparin. With the increased adoption of medium cut-off membranes, experience with regional citrate anticoagulation is needed. To our knowledge, this is the first report to assess the feasibility of regional citrate anticoagulation in expanded hemodialysis. Methods We prospectively analyzed 5 expanded hemodialysis procedures in 5 patients in which a medium cut-off membrane (Theranova®) was used. We followed our standard citrate protocol developed and tested for high-flux membrane. Anticoagulation was performed with a continuous infusion of 8% trisodium citrate into the arterial line and supplementation of 1 M calcium chloride into the venous line. We monitored ionized calcium and magnesium, sodium and blood gas analysis. Anticoagulation effectiveness was assessed by post-filter ionized calcium and by visual inspection of the anticoagulation in the circuit. Results There were no prematurely terminated procedures due to anticoagulation-related complications. With a blood flow of 250 mL/min and a dialysate flow of 500 mL/min, we were able to maintain serum ionized calcium in the range of 0.89–1.29 mmol/L and serum sodium in the range of 136–144 mmol/L. The mean pre- and post-dialysis arterial circuit pH was 7.42 (± 0.04) and 7.53 (± 0.23), respectively. The mean pre- and post-dialysis serum ionized magnesium was 0.54 (± 0.04) mmol/L and 0.43 (± 0.03) mmol/L, respectively (measurements were done on a point-of-care ionometer with a lower normal range for ionized magnesium). Conclusion We have shown that our standard citrate protocol for high-flux hemodialysis membrane could be successfully adopted for use in expanded hemodialysis with a medium cut-off membrane. Overall, electrolyte and acid-base balances were relatively well-controlled and anticoagulation effectiveness was excellent. Trial registration This is a pilot report with results taken from a larger ongoing trial (registered at ClinicalTrials.gov on October 25, 2019 under number NCT04139525) comparing citrate and heparin anticoagulation during expanded hemodialysis.
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10
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Medrano C, Cointault O, Lavayssiere L, Nogier MB, Colliou E, Setbon N, Kamar N, Faguer S. Heparin-free regional anticoagulation of haemodialysis filters with calcium-free dialysate: is citrate mandatory? Clin Kidney J 2021; 14:2534-2538. [PMID: 34950464 PMCID: PMC8690133 DOI: 10.1093/ckj/sfab087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/20/2021] [Indexed: 11/25/2022] Open
Abstract
Background There is an unmet need to develop safe and successful heparin-free regional anticoagulation modalities in haemodialysed patients at risk of bleeding. Whether the addition of citrate as a prefilter injection or in the dialysate itself is required to reach anticoagulation objectives when calcium-free dialysate is used as regional anticoagulation remains unclear. Methods In this monocentric retrospective study, we report our experience of 908 dialysis sessions performed with a calcium-free citrate-containing dialysate and calcium reinjection according to the ionic dialysance, without additional heparin. Results Premature termination for filter clotting occurred in 20 sessions (2.2%) and duration of session was >4.5 h in 135 (15%; maximum duration 6 h). In addition, we could investigate the citrate, calcium and acid–basis status during haemodialysis sessions performed with (citrate group, n = 20 sessions) or without (citrate-free group, n = 19 sessions) citrate in the dialysate. In 20 sessions performed in patients with underlying liver disorders and using calcium-free citrate-containing dialysate, patients’ ionized calcium (iCa) and serum citrate levels were stable and remained within the normal range, respectively. Post-filter iCa was below 0.4 mmol/L in 19/20 sessions and citrate was 0.304 mmol/L (range: 0.011; 0.548). In 19 sessions that used calcium and citrate-free dialysate, post-filter iCa was 0.41 mmol/L (0.34; 0.5) and all sessions extended to 4 h or beyond. Conclusions Regional anticoagulation of haemodialysis with a calcium-free dialysate and calcium reinjection according to the ionic dialysance is safe. Adding citrate to the dialysate is not mandatory to prevent dialysis circuit clotting in most patients.
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Affiliation(s)
- Chloé Medrano
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Olivier Cointault
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Laurence Lavayssiere
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Marie-Béatrice Nogier
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Eloïse Colliou
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Nicolas Setbon
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Nassim Kamar
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
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11
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Chen H, Ma Y, Hong N, Wang H, Su L, Liu C, He J, Jiang H, Long Y, Zhu W. Early warning of citric acid overdose and timely adjustment of regional citrate anticoagulation based on machine learning methods. BMC Med Inform Decis Mak 2021; 21:126. [PMID: 34330247 PMCID: PMC8323216 DOI: 10.1186/s12911-021-01489-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/07/2021] [Indexed: 12/29/2022] Open
Abstract
Background Regional citrate anticoagulation (RCA) is an important local anticoagulation method during bedside continuous renal replacement therapy. To improve patient safety and achieve computer assisted dose monitoring and control, we took intensive care units patients into cohort and aiming at developing a data-driven machine learning model to give early warning of citric acid overdose and provide adjustment suggestions on citrate pumping rate and 10% calcium gluconate input rate for RCA treatment. Methods Patient age, gender, pumped citric acid dose value, 5% NaHCO3 solvent, replacement fluid solvent, body temperature value, and replacement fluid PH value as clinical features, models attempted to classify patients who received regional citrate anticoagulation into correct outcome category. Four models, Adaboost, XGBoost, support vector machine (SVM) and shallow neural network, were compared on the performance of predicting outcomes. Prediction results were evaluated using accuracy, precision, recall and F1-score. Results For classifying patients at the early stages of citric acid treatment, the accuracy of neutral networks model is higher than Adaboost, XGBoost and SVM, the F1-score of shallow neutral networks (90.77%) is overall outperformed than other models (88.40%, 82.17% and 88.96% for Adaboost, XGBoost and SVM). Extended experiment and validation were further conducted using the MIMIC-III database, the F1-scores for shallow neutral networks, Adaboost, XGBoost and SVM are 80.00%, 80.46%, 80.37% and 78.90%, the AUCs are 0.8638, 0.8086, 0.8466 and 0.7919 respectively. Conclusion The results of this study demonstrated the feasibility and performance of machine learning methods for monitoring and adjusting local regional citrate anticoagulation, and further provide decision-making recommendations to clinicians point-of-care. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-021-01489-8.
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Affiliation(s)
- Huan Chen
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yingying Ma
- Digital Health China Technologies Co., Ltd., Beijing, 100080, China
| | - Na Hong
- Digital Health China Technologies Co., Ltd., Beijing, 100080, China
| | - Hao Wang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Longxiang Su
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Chun Liu
- Digital Health China Technologies Co., Ltd., Beijing, 100080, China
| | - Jie He
- Digital Health China Technologies Co., Ltd., Beijing, 100080, China
| | - Huizhen Jiang
- Department of General Internal Medicine, Department of Information Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Weiguo Zhu
- Department of Primary Care and Family Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China. .,Department of General Internal Medicine, Department of Information Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China.
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12
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Orsag A, Bozic-Mijovski M, Hudoklin S, Simcic S, Gubensek J. Biocompatibility Parameters with Standard and Increased Dose of Citrate in Hemodialysis-A Randomized Trial. J Clin Med 2021; 10:jcm10132987. [PMID: 34279471 PMCID: PMC8268353 DOI: 10.3390/jcm10132987] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 06/23/2021] [Accepted: 07/01/2021] [Indexed: 12/03/2022] Open
Abstract
Background: The dose of citrate needed in regional citrate anticoagulation (RCA) to achieve optimal biocompatibility is unknown. We performed a randomized trial comparing two doses (ACTRN12613001340729). Methods: In 30 patients a single hemodialysis with either standard (2.7 mmol/L) or increased dose of citrate (4 mmol/L) was performed. C5a-desArg, myeloperoxidase (MPO), thrombin-antithrombin complex (TAT), and platelet factor 4 (PF4) were measured and the inner surface of the dialyzer fibers was evaluated with scanning electron microscopy (SEM). Results: A good separation of anticoagulation effect was achieved (post-filter ionized calcium 0.20 vs. 0.31 mmol/L, p < 0.05). There was no effect of citrate dose on any of the biocompatibility parameters; transient and parallel increase in PF4 after 30 min and parallel increase in TAT after 4 h were observed. There were no visually detected clotting problems within the circuit and no significant hypocalcemia in either group. SEM clotting score was excellent and comparable in both groups (p = 0.59). Conclusions: Given the excellent results in both groups, absence of between group differences and inability of the increased dose of citrate to completely blunt the small residual increase in PF4 and TAT, we conclude that the standard dose of citrate seems sufficient in RCA for chronic hemodialysis.
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Affiliation(s)
- Alesa Orsag
- Department of Nephrology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia;
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Mojca Bozic-Mijovski
- Department of Vascular Diseases, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia;
| | - Samo Hudoklin
- Faculty of Medicine, Institute of Cell Biology, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Sasa Simcic
- Faculty of Medicine, Institute of Microbiology and Immunology, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Jakob Gubensek
- Department of Nephrology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia;
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Correspondence: ; Tel.: +386-1-522-3112; Fax: +386-1-522-2292
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13
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Roumeliotis S, Roumeliotis A, Gorny X, Mertens PR. Could Antioxidant Supplementation Delay Progression of Cardiovascular Disease in End-Stage Renal Disease Patients? Curr Vasc Pharmacol 2021; 19:41-54. [PMID: 32183680 DOI: 10.2174/1570161118666200317151553] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 12/27/2022]
Abstract
In end-stage renal disease patients, the leading causes of mortality are of cardiovascular (CV) origin. The underlying mechanisms are complex, given that sudden heart failure is more common than acute myocardial infarction. A contributing role of oxidative stress is postulated, which is increased even at early stages of chronic kidney disease, is gradually augmented in parallel to progression to endstage renal disease and is further accelerated by renal replacement therapy. Oxidative stress ensues when there is an imbalance between reactive pro-oxidants and physiologically occurring electron donating antioxidant defence systems. During the last decade, a close association of oxidative stress with accelerated atherosclerosis and increased risk for CV and all-cause mortality has been established. Lipid peroxidation has been identified as a trigger for endothelial dysfunction, the first step towards atherogenesis. In order to counteract the deleterious effects of free radicals and thereby ameliorate, or delay, CV disease, exogenous administration of antioxidants has been proposed. Here, we attempt to summarize existing data from studies that test antioxidants for CV protection, such as vitamins E and C, statins, omega-3 fatty acids and N-acetylcysteine.
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Affiliation(s)
- Stefanos Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athanasios Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Xenia Gorny
- Clinic of Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Leipziger Str. 40, 39120, Magdeburg, Germany
| | - Peter R Mertens
- Clinic of Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Leipziger Str. 40, 39120, Magdeburg, Germany
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14
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Scarfoglière V, Bobot M, Guilhem C, Bouchouareb D, Brunet P, Robert T. Regional anticoagulation with calcium-free dialysate containing citrate in chronic haemodialysis patients. Nephrol Dial Transplant 2021; 36:745-746. [PMID: 33326039 DOI: 10.1093/ndt/gfaa365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/04/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Violaine Scarfoglière
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France
| | - Mickaël Bobot
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France.,Aix-Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
| | - Cavaille Guilhem
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France
| | - Dammar Bouchouareb
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France
| | - Philippe Brunet
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France.,Aix-Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
| | - Thomas Robert
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France.,MMG, Bioinformatics & Genetics, UMR_S910, Aix-Marseille Université, Marseille, France
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15
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Marcelli D, Basile C. Has time come to replace the residual acetate with citrate in the dialysis fluid? J Nephrol 2021; 35:87-90. [PMID: 33661506 DOI: 10.1007/s40620-021-00991-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Affiliation(s)
| | - Carlo Basile
- Division of Nephrology, Clinical Research Branch, Miulli General Hospital, Acquaviva delle Fonti, Italy. .,Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy.
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16
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Pizzarelli F, Cantaluppi V, Panichi V, Toccafondi A, Ferro G, Farruggio S, Grossini E, Dattolo PC, Miniello V, Migliori M, Grimaldi C, Casani A, Borzumati M, Cusinato S, Capitanini A, Quercia A, Filiberti O, Dani L. Citrate high volume on-line hemodiafiltration modulates serum Interleukin-6 and Klotho levels: the multicenter randomized controlled study "Hephaestus". J Nephrol 2021; 34:1701-1710. [PMID: 33559851 DOI: 10.1007/s40620-020-00943-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 11/30/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Studies addressing the anti-inflammatory properties of citrate dialysate enrolled patients in both hemodialysis (HD) and hemodiafiltration (HDF), the latter not adjusted for adequate convective exchange. This is a potential source of confounding in that HDF itself has anti-inflammatory effects regardless of the buffer, and optimal clinical outcomes are related to the amount of convection. METHODS To distinguish the merits of the buffer from those of convection, we performed a 6-month, prospective, randomized, crossover AB-BA study. Comparisons were made during the 3-month study period of on-line HDF with standard dialysate containing three mmol of acetic acid (OL-HDFst) and the 3-month of OL-HDF with dialysate containing one mmol of citric acid (OL-HDFcit). Primary outcome measure of the study was interleukin-6 (IL-6). Klotho, high sensitivity C-reactive protein (hsCRP), fetuin and routine biochemical parameters were also analyzed. RESULTS We analyzed 47 patients (mean age 64 years, range 27-84 years) enrolled in 10 participating Nephrology Units. Convective volumes were around 25 L/session with 90 percent of sessions > 20 L and ß2-microglobulin reduction rate 76% in both HDFs. Baseline median IL-6 values in OL-HDFst were 5.6 pg/ml (25:75 interquartile range IQR 2.9:10.6) and in OL-HDFcit 6.6 pg/ml (IQR 3.4:11.4 pg/ml). The difference was not statistically significant (p 0.88). IL-6 values were lower during OL-HDFcit than during OL-HDFst, both when analyzed as the median difference of overall IL-6 values (p 0.02) and as the median of pairwise differences between the baseline and the 3-month time points (p 0.03). The overall hsCRP values too, were lower during OL-HDFcit than during OL-HDFst (p 0.01). Klotho levels showed a time effect (p 0.02) and the increase was significant only during OL-HDFcit (p 0.01). CONCLUSIONS Citrate buffer modulated IL-6, hsCRP and Klotho levels during high volume OL-HDF. These results are not attributable to differences in the dialysis technology that was applied and may suggest a potential biological effect of citrate on CKD-associated inflammatory state. ClinicalTrials.gov identifier NCT02863016.
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Affiliation(s)
- Francesco Pizzarelli
- Nephrology and Dialysis Unit, SM Annunziata Hospital, ASL Toscana Centro, via dell'Antella, 50012, Firenze, Italy.
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale (UPO), Novara, Italy
| | - Vincenzo Panichi
- Nephrology and Dialysis Unit, Versilia Hospital, ASL Nord-Ovest, Lido Di Camaiore, Italy
| | - Alessandro Toccafondi
- Nephrology and Dialysis Unit, SM Annunziata Hospital, ASL Toscana Centro, via dell'Antella, 50012, Firenze, Italy
| | - Giuseppe Ferro
- Nephrology and Dialysis Unit, SM Annunziata Hospital, ASL Toscana Centro, via dell'Antella, 50012, Firenze, Italy
| | - Serena Farruggio
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale (UPO), Novara, Italy
| | - Elena Grossini
- Lab Physiology, Department Translational Medicine, University of Piemonte Orientale (UPO), Novara, Italy
| | - Pietro Claudio Dattolo
- Nephrology and Dialysis Unit, SM Annunziata Hospital, ASL Toscana Centro, via dell'Antella, 50012, Firenze, Italy
| | | | - Massimiliano Migliori
- Nephrology and Dialysis Unit, Versilia Hospital, ASL Nord-Ovest, Lido Di Camaiore, Italy
| | - Cristina Grimaldi
- Nephrology and Dialysis Unit, NSGD Hospital, ASL Toscana Centro, Firenze, Italy
| | - Aldo Casani
- Nephrology and Dialysis Unit, ASL Nord-Ovest, Massa Carrara, Italy
| | - Maurizio Borzumati
- Nephrology and Dialysis Unit, ASL VCO, Verbania, Verbano Cusio Ossola, Italy
| | - Stefano Cusinato
- Nephrology and Dialysis Unit, Borgomanero Hospital, ASL NO Novara, Borgomanero, Italy
| | | | | | | | - Lucia Dani
- Nephrology and Dialysis Unit, ASL Toscana Centro, Empoli, Italy
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17
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Leroy C, Pereira B, Soum E, Bachelier C, Coupez E, Calvet L, Bachoumas K, Dupuis C, Souweine B, Lautrette A. Comparison between regional citrate anticoagulation and heparin for intermittent hemodialysis in ICU patients: a propensity score-matched cohort study. Ann Intensive Care 2021; 11:13. [PMID: 33481169 PMCID: PMC7822996 DOI: 10.1186/s13613-021-00803-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/07/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) is the gold standard of anticoagulation for continuous renal replacement therapy but is rarely used for intermittent hemodialysis (IHD) in ICU. Few studies assessed the safety and efficacy of RCA during IHD in ICU; however, no data are available comparing RCA to heparin anticoagulation, which are commonly used for IHD. The aim of this study was to assess the efficacy and safety of RCA compared to heparin anticoagulation during IHD. METHODS This retrospective single-center cohort study included consecutive ICU patients treated with either heparin anticoagulation (unfractionated or low-molecular-weight heparin) or RCA for IHD from July to September in 2015 and 2017. RCA was performed with citrate infusion according to blood flow and calcium infusion by diffusive influx from dialysate. Using a propensity score analysis, as the primary endpoint we assessed whether RCA improved efficacy, quantified with Kt/V from the ionic dialysance, compared to heparin anticoagulation. The secondary endpoint was safety. Exploratory analyses were performed on the changes in efficacy and safety between the implementation period (2015) and at long term (2017). RESULTS In total, 208 IHD sessions were performed in 56 patients and were compared (124 RCA and 84 heparin coagulation). There was no difference in Kt/V between RCA and heparin (0.95 ± 0.38 vs. 0.89 ± 0.32; p = 0.98). A higher number of circuit clotting (12.9% vs. 2.4%; p = 0.02) and premature interruption resulting from acute high transmembrane pressure (21% vs. 7%; p = 0.02) occurred in the RCA sessions compared to the heparin sessions. In the propensity score-matching analysis, RCA was associated with an increased risk of circuit clotting (absolute differences = 0.10, 95% CI [0.03-0.18]; p = 0.008). There was no difference in efficacy and safety between the two time periods (2015 and 2017). CONCLUSION RCA with calcium infusion by diffusive influx from dialysate for IHD was easy to implement with stable long-term efficacy and safety but did not improve efficacy and could be associated with an increased risk of circuit clotting compared to heparin anticoagulation in non-selected ICU patients. Randomized trials to determine the best anticoagulation for IHD in ICU patients should be conducted in a variety of settings.
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Affiliation(s)
- Christophe Leroy
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
- Intensive Care Unit, Regional Hospital Center, Puy en Velay, France
| | - Bruno Pereira
- Biostatistics Unit (DRCI), Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Edouard Soum
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Claire Bachelier
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Elisabeth Coupez
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Laure Calvet
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Konstantinos Bachoumas
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Claire Dupuis
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Bertrand Souweine
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
- LMGE (Laboratoire Micro-Organismes: Génome et Environnement), UMR CNRS 6023, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Alexandre Lautrette
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France.
- LMGE (Laboratoire Micro-Organismes: Génome et Environnement), UMR CNRS 6023, Université Clermont Auvergne, Clermont-Ferrand, France.
- Intensive Care Medicine, Gabriel Montpied Teaching Hospital, Intensive Care Unit, Centre Jean Perrin, 54 rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France.
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18
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Overmyer KA, Shishkova E, Miller IJ, Balnis J, Bernstein MN, Peters-Clarke TM, Meyer JG, Quan Q, Muehlbauer LK, Trujillo EA, He Y, Chopra A, Chieng HC, Tiwari A, Judson MA, Paulson B, Brademan DR, Zhu Y, Serrano LR, Linke V, Drake LA, Adam AP, Schwartz BS, Singer HA, Swanson S, Mosher DF, Stewart R, Coon JJ, Jaitovich A. Large-Scale Multi-omic Analysis of COVID-19 Severity. Cell Syst 2021; 12:23-40.e7. [PMID: 33096026 PMCID: PMC7543711 DOI: 10.1016/j.cels.2020.10.003] [Citation(s) in RCA: 353] [Impact Index Per Article: 117.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/24/2020] [Accepted: 10/05/2020] [Indexed: 01/08/2023]
Abstract
We performed RNA-seq and high-resolution mass spectrometry on 128 blood samples from COVID-19-positive and COVID-19-negative patients with diverse disease severities and outcomes. Quantified transcripts, proteins, metabolites, and lipids were associated with clinical outcomes in a curated relational database, uniquely enabling systems analysis and cross-ome correlations to molecules and patient prognoses. We mapped 219 molecular features with high significance to COVID-19 status and severity, many of which were involved in complement activation, dysregulated lipid transport, and neutrophil activation. We identified sets of covarying molecules, e.g., protein gelsolin and metabolite citrate or plasmalogens and apolipoproteins, offering pathophysiological insights and therapeutic suggestions. The observed dysregulation of platelet function, blood coagulation, acute phase response, and endotheliopathy further illuminated the unique COVID-19 phenotype. We present a web-based tool (covid-omics.app) enabling interactive exploration of our compendium and illustrate its utility through a machine learning approach for prediction of COVID-19 severity.
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Affiliation(s)
- Katherine A Overmyer
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA; Morgridge Institute for Research, Madison, WI 53562, USA
| | - Evgenia Shishkova
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA; Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Ian J Miller
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA; Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Joseph Balnis
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY 12208, USA; Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY 12208, USA
| | | | - Trenton M Peters-Clarke
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA; Department of Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Jesse G Meyer
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA; Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Qiuwen Quan
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA; Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Laura K Muehlbauer
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA; Department of Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Edna A Trujillo
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA; Department of Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Yuchen He
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA; Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Amit Chopra
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY 12208, USA
| | - Hau C Chieng
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY 12208, USA
| | - Anupama Tiwari
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY 12208, USA; Division of Sleep Medicine, Albany Medical Center, Albany, NY 12208, USA
| | - Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY 12208, USA
| | - Brett Paulson
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA; Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Dain R Brademan
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA; Department of Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Yunyun Zhu
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA; Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Lia R Serrano
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA; Department of Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Vanessa Linke
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA; Department of Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Lisa A Drake
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY 12208, USA; Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY 12208, USA
| | - Alejandro P Adam
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY 12208, USA; Department of Ophthalmology, Albany Medical College, Albany, NY 12208, USA
| | | | - Harold A Singer
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY 12208, USA
| | - Scott Swanson
- Morgridge Institute for Research, Madison, WI 53562, USA
| | - Deane F Mosher
- Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Ron Stewart
- Morgridge Institute for Research, Madison, WI 53562, USA
| | - Joshua J Coon
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA; Morgridge Institute for Research, Madison, WI 53562, USA; Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA; Department of Chemistry, University of Wisconsin, Madison, WI 53562, USA.
| | - Ariel Jaitovich
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY 12208, USA; Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY 12208, USA.
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19
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Giani M, Scaravilli V, Stefanini F, Valsecchi G, Rona R, Grasselli G, Bellani G, Pesenti AM, Foti G. Continuous Renal Replacement Therapy in Venovenous Extracorporeal Membrane Oxygenation: A Retrospective Study on Regional Citrate Anticoagulation. ASAIO J 2020; 66:332-338. [PMID: 31045918 DOI: 10.1097/mat.0000000000001003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Systemic infusion of unfractionated heparin (UFH) is the standard anticoagulation technique for continuous renal replacement therapy (CRRT) during extracorporeal membrane oxygenation (ECMO), but often fails to avoid CRRT circuit clotting. The aim of this study was to assess, in patients undergoing CRRT during venovenous ECMO (vv-ECMO), the efficacy and safety of adding regional citrate anticoagulation (RCA) for CRRT circuit anticoagulation (RCA + UFH group) compared with the sole systemic heparin anticoagulation (UFH group). We performed a retrospective chart review (2009-2018) of patients treated with CRRT during ECMO. We evaluated filter life span, rate of CRRT circuit clotting, and coagulation parameters. The incidence of citrate anticoagulation-related complications was recorded. Forty-eight consecutive adult patients underwent CRRT during vv-ECMO in the study period. The incidence of CRRT circuit clotting was lower in the RCA + UFH group (11% vs. 38% in the UFH group, p < 0.001). Log-rank survival analysis demonstrated longer circuit lifetime for RCA + UFH group. No complication ascribable to citrate anticoagulation was recorded. Regional citrate anticoagulation resulted a feasible, safe, and effective technique as additional anticoagulation for CRRT circuits during ECMO. Compared with systemic heparinization only, this technique allowed to reduce the rate of CRRT circuit clotting.
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Affiliation(s)
- Marco Giani
- From the Dipartimento di Emergenza-Urgenza, Ospedale San Gerardo, ASST Monza, Monza, Italy
| | - Vittorio Scaravilli
- Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Flavia Stefanini
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Gabriele Valsecchi
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Roberto Rona
- From the Dipartimento di Emergenza-Urgenza, Ospedale San Gerardo, ASST Monza, Monza, Italy
| | - Giacomo Grasselli
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy.,Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
| | - Giacomo Bellani
- From the Dipartimento di Emergenza-Urgenza, Ospedale San Gerardo, ASST Monza, Monza, Italy.,Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Antonio M Pesenti
- Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.,Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
| | - Giuseppe Foti
- From the Dipartimento di Emergenza-Urgenza, Ospedale San Gerardo, ASST Monza, Monza, Italy.,Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy
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20
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Zarbock A, Küllmar M, Kindgen-Milles D, Wempe C, Gerss J, Brandenburger T, Dimski T, Tyczynski B, Jahn M, Mülling N, Mehrländer M, Rosenberger P, Marx G, Simon TP, Jaschinski U, Deetjen P, Putensen C, Schewe JC, Kluge S, Jarczak D, Slowinski T, Bodenstein M, Meybohm P, Wirtz S, Moerer O, Kortgen A, Simon P, Bagshaw SM, Kellum JA, Meersch M. Effect of Regional Citrate Anticoagulation vs Systemic Heparin Anticoagulation During Continuous Kidney Replacement Therapy on Dialysis Filter Life Span and Mortality Among Critically Ill Patients With Acute Kidney Injury: A Randomized Clinical Trial. JAMA 2020; 324:1629-1639. [PMID: 33095849 PMCID: PMC7585036 DOI: 10.1001/jama.2020.18618] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
IMPORTANCE Although current guidelines suggest the use of regional citrate anticoagulation (which involves the addition of a citrate solution to the blood before the filter of the extracorporeal dialysis circuit) as first-line treatment for continuous kidney replacement therapy in critically ill patients, the evidence for this recommendation is based on few clinical trials and meta-analyses. OBJECTIVE To determine the effect of regional citrate anticoagulation, compared with systemic heparin anticoagulation, on filter life span and mortality. DESIGN, SETTING, AND PARTICIPANTS A parallel-group, randomized multicenter clinical trial in 26 centers across Germany was conducted between March 2016 and December 2018 (final date of follow-up, January 21, 2020). The trial was terminated early after 596 critically ill patients with severe acute kidney injury or clinical indications for initiation of kidney replacement therapy had been enrolled. INTERVENTIONS Patients were randomized to receive either regional citrate anticoagulation (n = 300), which consisted of a target ionized calcium level of 1.0 to 1.40 mg/dL, or systemic heparin anticoagulation (n = 296), which consisted of a target activated partial thromboplastin time of 45 to 60 seconds, for continuous kidney replacement therapy. MAIN OUTCOMES AND MEASURES Coprimary outcomes were filter life span and 90-day mortality. Secondary end points included bleeding complications and new infections. RESULTS Among 638 patients randomized, 596 (93.4%) (mean age, 67.5 years; 183 [30.7%] women) completed the trial. In the regional citrate group vs systemic heparin group, median filter life span was 47 hours (interquartile range [IQR], 19-70 hours) vs 26 hours (IQR, 12-51 hours) (difference, 15 hours [95% CI, 11 to 20 hours]; P < .001). Ninety-day all-cause mortality occurred in 150 of 300 patients vs 156 of 296 patients (Kaplan-Meier estimator percentages, 51.2% vs 53.6%; unadjusted difference, -2.4% [95% CI, -10.5% to 5.8%]; unadjusted hazard ratio, 0.91 [95% CI, 0.72 to 1.13]; unadjusted P = .38; adjusted difference, -6.1% [95% CI, -12.6% to 0.4%]; primary adjusted hazard ratio, 0.79 [95% CI, 0.63 to 1.004]; primary adjusted P = .054). Of 38 prespecified secondary end points, 34 showed no significant difference. Compared with the systemic heparin group, the regional citrate group had significantly fewer bleeding complications (15/300 [5.1%] vs 49/296 [16.9%]; difference, -11.8% [95% CI, -16.8% to -6.8%]; P < .001) and significantly more new infections (204/300 [68.0%] vs 164/296 [55.4%]; difference, 12.6% [95% CI, 4.9% to 20.3%]; P = .002). CONCLUSIONS AND RELEVANCE Among critically ill patients with acute kidney injury receiving continuous kidney replacement therapy, anticoagulation with regional citrate, compared with systemic heparin anticoagulation, resulted in significantly longer filter life span. The trial was terminated early and was therefore underpowered to reach conclusions about the effect of anticoagulation strategy on mortality. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02669589.
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Affiliation(s)
- Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany
| | - Mira Küllmar
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany
| | - Detlef Kindgen-Milles
- Department of Anesthesiology and Critical Care Medicine, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany
| | - Carola Wempe
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Timo Brandenburger
- Department of Anesthesiology and Critical Care Medicine, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany
| | - Thomas Dimski
- Department of Anesthesiology and Critical Care Medicine, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany
| | | | - Michael Jahn
- Department of Nephrology, University Hospital Essen, Essen, Germany
| | - Nils Mülling
- Department of Nephrology, University Hospital Essen, Essen, Germany
| | - Martin Mehrländer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Peter Rosenberger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Gernot Marx
- Department of Intensive Care Medicine, University of Aachen, Aachen, Germany
| | - Tim Philipp Simon
- Department of Intensive Care Medicine, University of Aachen, Aachen, Germany
| | - Ulrich Jaschinski
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Augsburg, Augsburg, Germany
| | - Philipp Deetjen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Augsburg, Augsburg, Germany
| | - Christian Putensen
- University Hospital Bonn, Department of Anesthesiology and Intensive Care Medicine, Bonn, Germany
| | - Jens-Christian Schewe
- University Hospital Bonn, Department of Anesthesiology and Intensive Care Medicine, Bonn, Germany
| | - Stefan Kluge
- University Medical Center Hamburg-Eppendorf, Department of Intensive Care, Hamburg, Germany
| | - Dominik Jarczak
- University Medical Center Hamburg-Eppendorf, Department of Intensive Care, Hamburg, Germany
| | - Torsten Slowinski
- Department of Nephrology and Medical Intensive Care, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Marc Bodenstein
- Universitätsmedizin Mainz, Department of Anesthesiology, Mainz, Germany
| | - Patrick Meybohm
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Frankfurt, Frankfurt, Germany
- Department of Anesthesiology, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Wirtz
- Department of Anesthesiology, Intensive Care and Pain Medicine, Helios Klinikum Bad Saarow, Bad Saarow, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Andreas Kortgen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, Jena, Germany
| | - Philipp Simon
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
| | - John A. Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany
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21
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Effect of uremic serum on Th17/Treg cell balance and endoplasmic reticulum stress in rats. Biomed Pharmacother 2020; 131:110705. [PMID: 32919190 DOI: 10.1016/j.biopha.2020.110705] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/26/2020] [Accepted: 08/28/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND/AIMS The imbalance of T helper 17 (Th17) and regulatory T (Treg) cells exists in the occurrence and development of various diseases. Endoplasmic reticulum stress (ERS) is an important self-protective cellular response to harmful stimuli, such as uremic environment. The objective of this study was to investigate the Th17/Treg cell balance and ERS in a uremic environment and analyze the relationship between them. METHODS (1) The rat spleen lymphocytes were extracted and treated with thapsigargin (inducer of ERS) and sodium citrate. The proportion of Th17 and Treg cells were then detected. (2) The uremic serum-cultured lymphocytes were used and divided into three groups: non-uremic serum group, uremic serum group, and uremic serum + sodium citrate group. Afterward, the proportion of Th17/Treg cells and the expression of ERS-related proteins (GRP78 and CHOP) were detected. RESULTS Thapsigargin had no significant effect on the proportion of Th17 cells within a limited concentration range, but it could reduce the proportion of Treg cells, sodium citrate had a negative influence on the deviation of Th17/Treg cells treated with thapsigargin. Uremic serum treatment reduced the proportion of Treg cells, resulting in an increase of the Th17/Treg ratio. However, sodium citrate had no influence on the deviation of Th17/Treg cells treated by uremic serum. Sodium citrate reduced the elevation of ERS-related proteins induced by uremic serum. CONCLUSIONS Uremic serum can lead to the imbalance of Th17/Treg cells as well as ERS, suggesting that ERS is one of the mechanisms of the imbalance of Th17/Treg cells induced by uremic serum. Sodium citrate can inhibit ERS induced by uremic serum.
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22
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Strobl K, Harm S, Fichtinger U, Schildböck C, Hartmann J. Impact of anion exchange adsorbents on regional citrate anticoagulation. Int J Artif Organs 2020; 44:149-155. [PMID: 32787606 PMCID: PMC7944420 DOI: 10.1177/0391398820947733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Heparin and citrate are commonly used anticoagulants in membrane/adsorption based extracorporeal liver support systems. However, anion exchange resins employed for the removal of negatively charged target molecules including bilirubin may also deplete these anticoagulants due to their negative charge. The aim of this study was to evaluate the adsorption of citrate by anion exchange resins and the impact on extracorporeal Ca2+ concentrations. METHODS Liver support treatments were simulated in vitro. Citrate and Ca2+ concentrations were measured pre and post albumin filter as well as pre and post adsorbents. In addition, batch experiments were performed to quantify citrate adsorption. RESULTS Pre albumin filter target Ca2+ concentrations were reached well with only minor deviations. Citrate was adsorbed by anion exchange resins, resulting in a higher Ca2+ concentration downstream of the adsorbent cartridges during the first hour of treatment. CONCLUSIONS The anion exchange resin depletes citrate, leading to an increased Ca2+ concentration in the extracorporeal circuit, which may cause an increased risk of clotting during the first hour of treatment. An increase of citrate infusion during the first hour of treatment should therefore be considered to compensate for the adsorption of citrate.
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Affiliation(s)
- Karin Strobl
- Center for Biomedical Technology, Department for Biomedical Research, Danube University Krems, Krems, Austria
| | - Stephan Harm
- Center for Biomedical Technology, Department for Biomedical Research, Danube University Krems, Krems, Austria
| | - Ute Fichtinger
- Center for Biomedical Technology, Department for Biomedical Research, Danube University Krems, Krems, Austria
| | - Claudia Schildböck
- Center for Biomedical Technology, Department for Biomedical Research, Danube University Krems, Krems, Austria
| | - Jens Hartmann
- Center for Biomedical Technology, Department for Biomedical Research, Danube University Krems, Krems, Austria
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23
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Overmyer KA, Shishkova E, Miller IJ, Balnis J, Bernstein MN, Peters-Clarke TM, Meyer JG, Quan Q, Muehlbauer LK, Trujillo EA, He Y, Chopra A, Chieng HC, Tiwari A, Judson MA, Paulson B, Brademan DR, Zhu Y, Serrano LR, Linke V, Drake LA, Adam AP, Schwartz BS, Singer HA, Swanson S, Mosher DF, Stewart R, Coon JJ, Jaitovich A. Large-scale Multi-omic Analysis of COVID-19 Severity. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020:2020.07.17.20156513. [PMID: 32743614 PMCID: PMC7388490 DOI: 10.1101/2020.07.17.20156513] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
We performed RNA-Seq and high-resolution mass spectrometry on 128 blood samples from COVID-19 positive and negative patients with diverse disease severities. Over 17,000 transcripts, proteins, metabolites, and lipids were quantified and associated with clinical outcomes in a curated relational database, uniquely enabling systems analysis and cross-ome correlations to molecules and patient prognoses. We mapped 219 molecular features with high significance to COVID-19 status and severity, many involved in complement activation, dysregulated lipid transport, and neutrophil activation. We identified sets of covarying molecules, e.g., protein gelsolin and metabolite citrate or plasmalogens and apolipoproteins, offering pathophysiological insights and therapeutic suggestions. The observed dysregulation of platelet function, blood coagulation, acute phase response, and endotheliopathy further illuminated the unique COVID-19 phenotype. We present a web-based tool (covid-omics.app) enabling interactive exploration of our compendium and illustrate its utility through a comparative analysis with published data and a machine learning approach for prediction of COVID-19 severity.
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Affiliation(s)
- Katherine A. Overmyer
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA
- Morgridge Institute for Research, Madison, WI 53562, USA
| | - Evgenia Shishkova
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA
- Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Ian J. Miller
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA
- Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Joseph Balnis
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY, USA
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY, USA
| | | | - Trenton M. Peters-Clarke
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA
- Department of Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Jesse G. Meyer
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA
- Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Qiuwen Quan
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA
- Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Laura K. Muehlbauer
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA
- Department of Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Edna A. Trujillo
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA
- Department of Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Yuchen He
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA
- Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Amit Chopra
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY, USA
| | - Hau C. Chieng
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY, USA
| | - Anupama Tiwari
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY, USA
- Division of Sleep Medicine, Albany Medical Center, Albany, NY, USA
| | - Marc A. Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY, USA
| | - Brett Paulson
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA
- Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Dain R. Brademan
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA
- Department of Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Yunyun Zhu
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA
- Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Lia R. Serrano
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA
- Department of Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Vanessa Linke
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA
- Department of Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Lisa A. Drake
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY, USA
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY, USA
| | - Alejandro P. Adam
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY, USA
- Department of Ophthalmology, Albany Medical College, Albany, NY, USA
| | | | - Harold A. Singer
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY, USA
| | - Scott Swanson
- Morgridge Institute for Research, Madison, WI 53562, USA
| | - Deane F. Mosher
- Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Ron Stewart
- Morgridge Institute for Research, Madison, WI 53562, USA
| | - Joshua J. Coon
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA
- Morgridge Institute for Research, Madison, WI 53562, USA
- Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53562, USA
- Department of Chemistry, University of Wisconsin, Madison, WI 53562, USA
| | - Ariel Jaitovich
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY, USA
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY, USA
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24
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Neri L, Bellocchio F, Kircelli F, Jirka T, Levannier M, Guillaume J, Attaf D, Barbieri C, Garbelli M, Stuard S, Canaud B, Chazot C. Long-term mortality risk associated with citric acid- and acetic acid-based bicarbonate haemodialysis: a historical cohort propensity score-matched study in a large, multicentre, population-based study. Nephrol Dial Transplant 2020; 35:1237-1244. [DOI: 10.1093/ndt/gfaa089] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 03/27/2020] [Indexed: 01/02/2023] Open
Abstract
Abstract
Background
Citric acid-based bicarbonate dialysate (CiD) is increasingly used in haemodialysis (HD) to improve haemodynamic tolerance and haemocompatibility associated with acetic acid-based bicarbonate dialysate. Safety concerns over CiD have been raised recently after a French ecological study reported higher mortality hazard in HD clinics with high CiD consumption. Therefore, we evaluated the mortality risk associated with various acidifiers (AcD, CiD) of bicarbonate dialysate.
Methods
In this multicentre, historical cohort study, we included adult incident HD patients (European, Middle-East and Africa Fresenius Medical Care network; 1 January 2014 to 31 October 2018). We recorded acidifiers of bicarbonate dialysis and dialysate composition for each dialysis session. In the primary intention-to-treat analysis, patients were assigned to the exposed group if they received CiD in >70% of sessions during the first 3 months (CiD70%), whereas the non-exposed group received no CiD at all. In the secondary analysis, exposure was assessed on a monthly basis for the whole duration of the follow-up.
Results
We enrolled 10 121 incident patients during the study period. Of them, 371 met the criteria for inclusion in CiD70%. After propensity score matching, mortality was 11.43 [95% confidence interval (CI) 8.86–14.75] and 12.04 (95% CI 9.44–15.35) deaths/100 person-years in the CiD0% and CiD70% groups, respectively (P = 0.80). A similar association trend was observed in the secondary analysis.
Conclusions
We did not observe evidence of increased mortality among patients exposed to CiD in a large European cohort of dialysis patients despite the fact that physicians were more inclined to prescribe CiD to subjects with worse medical conditions.
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Affiliation(s)
- Luca Neri
- Clinical & Data Intelligence Systems, Fresenius Medical Care Deutschland GmbH, Vaiano Cremasco (CR), Italy
| | - Francesco Bellocchio
- Clinical & Data Intelligence Systems, Fresenius Medical Care Deutschland GmbH, Vaiano Cremasco (CR), Italy
| | - Fatih Kircelli
- Clinical & Data Intelligence Systems, Fresenius Medical Care Deutschland GmbH, Vaiano Cremasco (CR), Italy
| | - Tomas Jirka
- Clinical & Data Intelligence Systems, Fresenius Medical Care Deutschland GmbH, Vaiano Cremasco (CR), Italy
| | | | - Jean Guillaume
- Dialysis Unit of Tassin-Charcot, Nephrocare, Tassin-Charcot, France
| | - David Attaf
- Clinical & Data Intelligence Systems, Fresenius Medical Care Deutschland GmbH, Vaiano Cremasco (CR), Italy
| | - Carlo Barbieri
- Clinical & Data Intelligence Systems, Fresenius Medical Care Deutschland GmbH, Vaiano Cremasco (CR), Italy
| | - Mario Garbelli
- Clinical & Data Intelligence Systems, Fresenius Medical Care Deutschland GmbH, Vaiano Cremasco (CR), Italy
| | - Stefano Stuard
- Dialysis Unit of Tassin-Charcot, Nephrocare, Tassin-Charcot, France
| | | | - Charles Chazot
- Country Medical Director, NephroCare France, Fresnes, France
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25
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Pizzarelli F, Basile C. The Gordian knot of the long-term safety of dialysate citrate: is there really a concern about patient hard outcomes? Nephrol Dial Transplant 2020; 35:1090-1094. [DOI: 10.1093/ndt/gfaa033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 01/27/2020] [Indexed: 01/03/2023] Open
Affiliation(s)
| | - Carlo Basile
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
- Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
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Increasing the Magnesium Concentration in Various Dialysate Solutions Differentially Modulates Oxidative Stress in a Human Monocyte Cell Line. Antioxidants (Basel) 2020; 9:antiox9040319. [PMID: 32326605 PMCID: PMC7222382 DOI: 10.3390/antiox9040319] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/01/2020] [Accepted: 04/14/2020] [Indexed: 12/14/2022] Open
Abstract
Oxidative stress is exacerbated in hemodialysis patients by several factors, including the uremic environment and the use of dialysis fluids (DFs). Since magnesium (Mg) plays a key role in modulating immune function and in reducing oxidative stress, we aimed to evaluate whether increasing the Mg concentration in different DFs could protect against oxidative stress in immunocompetent cells in vitro. Effect of ADF (acetate 3 mM), CDF (citrate 1 mM), and ACDF (citrate 0.8 mM + acetate 0.3 mM) dialysates with Mg at standard (0.5 mM) or higher (1, 1.25, and 2 mM) concentrations were assessed in THP-1 monocyte cultures. Reactive oxygen species (ROS) and malondialdehyde (MDA) levels were quantified under basal and uremic conditions (indoxyl sulfate (IS) treatment). Under uremic conditions, the three DFs with 0.5 mM Mg promoted higher ROS production and lipid damage than the control solution. However, CDF and ACDF induced lower levels of ROS and MDA, compared to that induced by ADF. High Mg concentration (1.25 and/or 2 mM) in CDF and ACDF protected against oxidative stress, indicated by reduced ROS and MDA levels compared to respective DFs with standard concentration of Mg. Increasing Mg concentrations in ADF promoted high ROS production and MDA content. Thus, an increase in Mg content in DFs has differential effects on the oxidative stress in IS-treated THP-1 cells depending on the dialysate used.
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Joint Toxicity of a Multi-Heavy Metal Mixture and Chemoprevention in Sprague Dawley Rats. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17041451. [PMID: 32102388 PMCID: PMC7068392 DOI: 10.3390/ijerph17041451] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 02/20/2020] [Accepted: 02/20/2020] [Indexed: 11/16/2022]
Abstract
To explore the joint toxicity and bio-accumulation of multi-heavy metals and potential chemoprevention strategies, Male Sprague Dawley (SD) rats (n = 30) were treated orally once a week for six months with 500mg/kg•bw of eight heavy metals which were commonly identified in aquatic products in the Ningbo area including chromium, manganese, nickel, copper, zinc, cadmium, mercury, and lead. At the same time, 200mg/kg•bw of epigallocatechin-3-gallate (EGCG), trisodium citrate dihydrate (TCD) or glutathione (GSH) were administered to evaluate their antagonistic effects against adverse effects of multi-heavy metal mixture. The Morris water maze test was used to evaluate spatial learning and memory in the treated rats. Then the rats were anesthetized by pentobarbital sodium (40 mg/kg•bw) to obtain blood samples for biochemical analysis and organs (heart, liver, spleen, lungs, kidneys, brain, testis) to be conducted for biopsy and organ coefficients. Inductively coupled plasma mass spectrometer (ICP-MS) was used to analyze the concentrations of heavy metals. Results indicated that six months of exposure to a multi-heavy metal mixture under this experimental dosage resulted in accumulation in organs and adverse effects on the blood, reproductive system, and liver function. EGCG, TCD or GSH all showed certain chemoprevention effects against the joint toxicity induced by the multi-heavy metal mixture and indicated alleviation and the potential mechanism that also included the promotion of excretion of metals to which animals were exposed.
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Zhang H, Gao Y, Jiao Y, Lu W, Shuang S, Dong C. Highly sensitive fluorescent carbon dots probe with ratiometric emission for the determination of ClO−. Analyst 2020; 145:2212-2218. [DOI: 10.1039/c9an02570g] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A ratiometric fluorescent N,S co-doped carbon dots (N,S-CD) probe for ClO− has been facilely obtained via a one-step hydrothermal method.
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Affiliation(s)
- Huilin Zhang
- College of Chemistry and Chemical Engineering
- Shanxi University
- Taiyuan 030006
- P. R. China
| | - Yifang Gao
- Institute of Environmental Science
- Shanxi University
- Taiyuan 030006
- P. R. China
| | - Yuan Jiao
- Institute of Environmental Science
- Shanxi University
- Taiyuan 030006
- P. R. China
| | - Wenjing Lu
- College of Chemistry and Chemical Engineering
- Shanxi University
- Taiyuan 030006
- P. R. China
| | - Shaomin Shuang
- College of Chemistry and Chemical Engineering
- Shanxi University
- Taiyuan 030006
- P. R. China
| | - Chuan Dong
- Institute of Environmental Science
- Shanxi University
- Taiyuan 030006
- P. R. China
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Zhang J, Yan J. Protective Effect of Ginkgolic Acid in Attenuating LDL Induced Inflammation Human Peripheral Blood Mononuclear Cells via Altering the NF-κB Signaling Pathway. Front Pharmacol 2019; 10:1241. [PMID: 31780924 PMCID: PMC6856219 DOI: 10.3389/fphar.2019.01241] [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: 04/27/2019] [Accepted: 09/27/2019] [Indexed: 12/12/2022] Open
Abstract
Oxidized low-density lipoprotein (ox-LDL) is considered as the significant maker of inflammatory reaction. ox-LDL was reported to play a crucial role in the pathogenesis of atherosclerosis (AS). In the current study, we scrutinize the suppressive effect of ginkgolic acid against ox-LDL induced an oxidative and inflammatory response in human microvascular endothelial cells (HMEC-1) and human peripheral blood mononuclear cells (nPBMCs) and explore the mechanism of action. HMEC-1 cells are treated with ox-LDL in the presence of different concentration of ginkgolic acid. MTT 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay was performed for the estimation of cell viability effect. Reactive oxygen species (ROS), inflammatory cytokines, and NF-κB activity are also estimated. For the hPBMCs assay, the cells were isolated from the healthy volunteers and cultured. The cells were further divided into different group and received the ginkgolic acid. Additionally, ROS, inflammatory marker such as prostaglandin E2 (PGE2), lipoxygenase (LOX), nitric oxide (NO), cyclooxygenase (COX) protein expression, and mRNA expression of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and vascular cell adhesion protein 1 (VCAM-1) were estimated in the ox-LDL treated group. The result exhibited that ginkgolic acid treatment induced the cell viability boosting in ox-LDL treatment and intracellular ROS significantly decreased by ginkgolic acid. Pro-inflammatory cytokines also downregulated via ginkgolic acid. Moreover, ginkgolic acid reduced the ox-LDL-induced NF-κB. The mRNA and protein expression of TNF-α, IL-6, and VCAM-1 considerably increased in the ox-LDL treated group and ginkgolic acid significantly reduced the mRNA and protein expression. An inflammatory marker such as PGE2, LOX, and NO were increased in the ox-LDL treated group and ginkgolic acid treated group exhibited the reduction of an inflammatory marker. Based on the result, we can conclude that ginkgolic acid significantly reduced and reversed the ox-LDL-induced modulation, suggesting its anti-inflammatory effect via the NF-κB pathway.
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Affiliation(s)
- Juan Zhang
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jifeng Yan
- Heart Center of Henan Provincial People’s Hospital, Central China Fuwai Hospital, Zhengzhou, China
- Central China Fuwai Hospital of ZhengZhou University, ZhengZhou, China
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30
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Samuelsson L, Tydén J, Herwald H, Hultin M, Walldén J, Steinvall I, Sjöberg F, Johansson J. Renal clearance of heparin-binding protein and elimination during renal replacement therapy: Studies in ICU patients and healthy volunteers. PLoS One 2019; 14:e0221813. [PMID: 31465432 PMCID: PMC6715206 DOI: 10.1371/journal.pone.0221813] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/15/2019] [Indexed: 11/20/2022] Open
Abstract
Background Heparin-binding protein (HBP) is released by neutrophils upon activation, and elevated plasma levels are seen in inflammatory states like sepsis, shock, cardiac arrest, and burns. However, little is known about the elimination of HBP. We wanted to study renal clearance of HBP in healthy individuals and in burn patients in intensive care units (ICUs). We also wished to examine the levels of HBP in the effluent of renal replacement circuits in ICU patients undergoing continuous renal replacement therapy (CRRT). Methods We measured plasma and urine levels of HBP and urine flow rate in 8 healthy individuals and 20 patients in a burn ICU. In 32 patients on CRRT, we measured levels of HBP in plasma and in the effluent of the CRRT circuit. Results Renal clearance of HBP (median (IQR) ml/min) was 0.19 (0.08–0.33) in healthy individuals and 0.30 (0.01–1.04) in burn ICU patients. In ICU patients with cystatin C levels exceeding 1.44 mg/l, clearance was 0.45 (0.15–2.81), and in patients with cystatin C below 1.44 mg/l clearance was lower 0.28 (0.14–0.55) (p = 0.04). Starting CRRT did not significantly alter plasma levels of HBP (p = 0.14), and the median HBP level in the effluent on CRRT was 9.1 ng/ml (IQR 7.8–14.4 ng/ml). Conclusion In healthy individuals and critically ill burn patients, renal clearance of HBP is low. It is increased when renal function is impaired. Starting CRRT in critically ill patients does not alter plasma levels of HBP significantly, but HBP can be found in the effluent. It seems unlikely that impaired kidney function needs to be considered when interpreting concentrations of HBP in previous studies. Starting CRRT does not appear to be an effective way of reducing HBP concentrations.
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Affiliation(s)
- Line Samuelsson
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine (Östersund), Umeå University, Umeå, Sweden
| | - Jonas Tydén
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine (Östersund), Umeå University, Umeå, Sweden
- * E-mail:
| | - Heiko Herwald
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Magnus Hultin
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Jakob Walldén
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine (Sundsvall) Umeå University, Umeå, Sweden
| | - Ingrid Steinvall
- Department of Hand Surgery, Plastic Surgery and Burns and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Folke Sjöberg
- Department of Hand Surgery, Plastic Surgery and Burns and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- Department of Anesthesiology and Intensive Care, Linköping University, Linköping, Sweden
| | - Joakim Johansson
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine (Östersund), Umeå University, Umeå, Sweden
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Citrate anion improves chronic dialysis efficacy, reduces systemic inflammation and prevents Chemerin-mediated microvascular injury. Sci Rep 2019; 9:10622. [PMID: 31337804 PMCID: PMC6650610 DOI: 10.1038/s41598-019-47040-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 06/25/2019] [Indexed: 12/04/2022] Open
Abstract
Systemic inflammation and uremic toxins (UT) determine the increased cardiovascular mortality observed in chronic hemodialysis (HD) patients. Among UT, the adipokine Chemerin induces vascular dysfunction by targeting both endothelial and vascular smooth muscular cells (EC and VSMC). As Citrate anion modulates oxidative metabolism, systemic inflammation and vascular function, we evaluated whether citrate-buffered dialysis improves HD efficiency, inflammatory parameters and chemerin-mediated microvascular injury. 45 patients were treated in sequence with acetate, citrate and, again, acetate-buffered dialysis solution (3 months per interval). At study admission and after each treatment switch, we evaluated dialysis efficacy and circulating levels of chemerin and different inflammatory biomarkers. In vitro, we stimulated EC and VSMC with patients’ plasma and we investigated the role of chemerin as UT. Citrate dialysis increased HD efficacy and reduced plasma levels of CRP, fibrinogen, IL6 and chemerin. In vitro, patients’ plasma induced EC and VSMC dysfunction. These effects were reduced by citrate-buffered solutions and paralleled by the decrease of chemerin levels. Consistently, chemerin receptor knockdown reduced EC and VSMC dysfunction. In conclusion, Switching from acetate to citrate improved dialysis efficacy and inflammatory parameters; in vitro, chemerin-induced EC and VSMC injury were decreased by using citrate as dialysis buffer.
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32
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Wu X, Dai H, Xu C, Liu L, Li S. Citric acid modification of a polymer exhibits antioxidant and anti‐inflammatory properties in stem cells and tissues. J Biomed Mater Res A 2019; 107:2414-2424. [DOI: 10.1002/jbm.a.36748] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 05/19/2019] [Accepted: 05/27/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Xiaopei Wu
- State Key Laboratory of Advanced Technology for Materials Synthesis and ProcessingWuhan University of Technology Wuhan China
| | - Honglian Dai
- State Key Laboratory of Advanced Technology for Materials Synthesis and ProcessingWuhan University of Technology Wuhan China
- Biomedical Materials and Engineering Research Center of Hubei Province Wuhan China
| | - Chao Xu
- State Key Laboratory of Advanced Technology for Materials Synthesis and ProcessingWuhan University of Technology Wuhan China
| | - Langlang Liu
- State Key Laboratory of Advanced Technology for Materials Synthesis and ProcessingWuhan University of Technology Wuhan China
| | - Shipu Li
- State Key Laboratory of Advanced Technology for Materials Synthesis and ProcessingWuhan University of Technology Wuhan China
- Biomedical Materials and Engineering Research Center of Hubei Province Wuhan China
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Mares J, Tuma Z, Moravec J, Pavlina R, Matejovic M. Proteins adsorbed to a polysulfone hemodialysis membrane under heparin and citrate anticoagulation regimens. Artif Organs 2019; 43:1092-1103. [PMID: 31162876 DOI: 10.1111/aor.13506] [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: 02/12/2019] [Revised: 04/29/2019] [Accepted: 05/30/2019] [Indexed: 01/13/2023]
Abstract
The study aim was to compare molecular-level effects (blood-dialyzer interactions) of heparin and citrate anticoagulation using proteome-wide analysis of biofilm adsorbed to dialysis membrane. Ten patients receiving maintenance hemodialysis were examined in a crossover design under three different anticoagulation regimens, namely citrate, heparin, and anticoagulation-free (control). Following a regular hemodialysis session (4 hours, polysulfone membrane), dialyzers were flushed and the surface biofilm eluted by acetic acid. Protein composition of the eluates was determined by 2-dimensional gel electrophoresis and resulting patterns compared between regimens. Proteins responsible for the difference were identified by mass spectrometry. Citrate anticoagulation was associated with significantly less protein adsorption to the membrane than heparin (2.2 [1.1-2.9] mg vs. 6.5 [2.9-11.6] mg, P = 0.009). Among the proteins identified as major discriminators between citrate and the other regimens, fibrin α-chain fragments of molecular weight below 40 kDa prevailed. In these fragments, an analysis of the amino acid sequence has been performed by comparison with the UniProt database. It showed missing α-chain cross-links. On the contrary, heparin prevented adsorption and cleavage of several heparin-binding proteins; especially complement factor H-related protein 3, insulin-like growth factor binding proteins (2, 4, and 5), and chemerin. Compared to heparin, citrate is associated with less protein adsorption and imperfectly crosslinked fibrin clot formation. Membrane adsorptive properties are significantly modified by the anticoagulation regimen.
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Affiliation(s)
- Jan Mares
- Department of Internal Medicine I, Charles University Medical School and Teaching Hospital, Plzen, Czech Republic
| | - Zdenek Tuma
- Proteomic Laboratory, Charles University Medical School, Plzen, Czech Republic
| | - Jiri Moravec
- Proteomic Laboratory, Charles University Medical School, Plzen, Czech Republic
| | - Richtrova Pavlina
- Department of Internal Medicine I, Charles University Medical School and Teaching Hospital, Plzen, Czech Republic
| | - Martin Matejovic
- Department of Internal Medicine I, Charles University Medical School and Teaching Hospital, Plzen, Czech Republic
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Gomółka M, Niemczyk L, Szamotulska K, Mossakowska M, Smoszna J, Rymarz A, Pączek L, Niemczyk S. Biocompatibility of Hemodialysis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1251:91-97. [PMID: 31832901 DOI: 10.1007/5584_2019_461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
This study was designed to investigate the biocompatibility of hemodialysis procedures, largely depending on the contact of patient's blood with the dialysis membranes. We addressed the issue by comparing the content of the proteolytic enzymes collagenase and cathepsin B and that of neutrophil myeloperoxidase (MPO) and C-reactive protein (CRP) in the blood before and after a single session treatment and a full course of successive 8-week-long therapies with three types of hemodialysis: low-flux (lfHD), high-flux (hfHD), and post-dilution hemodiafiltration (HDF). The study included 19 patients with chronic nephropathy. We found that collagenase significantly increased after a single session of each type of hemodialysis. Cathepsin B tended to decrease after single sessions; the decrease reached significance only after hfHD. CRP increased significantly after single hfHD and HDF treatments. These changes were meager, with no differences depending on the dialysis type, and their significance was lost after 8-week-long therapy, except the persisting increase in CRP after HDF. Neutrophil MPO apparently was not activated during any type of dialysis, as its content was below the detection threshold. We conclude that all three types of hemodialysis are compatible with the biological system, so that they would rather unlikely lead to clinically harmful effects in chronically hemodialyzed patients. Nonetheless, proteolytic enzymes and myeloperoxidase seem hardly appropriable estimators of hemodialysis biocompatibility due to meager and variable changes. Upregulation of C-reactive protein, on the other hand, expresses a general pro-inflammatory propensity of hemodialysis and is not a suitable estimator of biocompatibility either.
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Affiliation(s)
- Małgorzata Gomółka
- Department of Internal Medicine, Nephrology and Dialysis, Military Institute of Medicine, Warsaw, Poland
| | - Longin Niemczyk
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland.
| | - Katarzyna Szamotulska
- Department of Epidemiology and Biostatistics, Institute of Mother and Child in Warsaw, Warsaw, Poland
| | - Magdalena Mossakowska
- Department of Internal Medicine, Nephrology and Dialysis, Military Institute of Medicine, Warsaw, Poland
| | - Jerzy Smoszna
- Department of Internal Medicine, Nephrology and Dialysis, Military Institute of Medicine, Warsaw, Poland
| | - Aleksandra Rymarz
- Department of Internal Medicine, Nephrology and Dialysis, Military Institute of Medicine, Warsaw, Poland
| | - Leszek Pączek
- Department of Immunology, Transplantology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Stanisław Niemczyk
- Department of Internal Medicine, Nephrology and Dialysis, Military Institute of Medicine, Warsaw, Poland
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Citrate reduced oxidative damage in stem cells by regulating cellular redox signaling pathways and represent a potential treatment for oxidative stress-induced diseases. Redox Biol 2018; 21:101057. [PMID: 30576924 PMCID: PMC6302140 DOI: 10.1016/j.redox.2018.11.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 11/14/2018] [Accepted: 11/21/2018] [Indexed: 02/07/2023] Open
Abstract
Chemical substances containing citrate such as calcium citrate, citrate esters and citric acid exhibit anti-oxidant and anti-inflammatory properties in different cells and tissues. However, data on the anti-oxidant and anti-inflammatory properties and mechanisms of action of citrate are insufficient. In this study, we systematically evaluated the anti-oxidant capacity of citrate using chemical, cellular and animal assays. Citrate showed a stable molecular structure and did not directly react with oxides. Citrate exerted protective and anti-apoptotic effects on BMSCs and also showed significant inhibitory effects on the oxidative stress and inflammatory reactions in the rat air pouch model. By using proteomics, we found that PPARγ contributed to the upregulation of various free radical scavenging proteins and the downregulation of diverse components of the inflammatory responses. Citrate-regulated global PPARγ expression was evidenced by the significant increase expression of PPARγ in PC12 cell line. Our results provide novel insights into the role of citrate in regulating cellular redox signaling and the function of PPARγ signaling in this process and also provide basic molecular cell biology information to improve the applications of biomaterials or stem cells as treatments for oxidative stress-induced degenerative diseases and inflammatory diseases. Citrate exerts anti-oxidant and anti-inflammatory properties in BMSCs and tissues. Citrate can upregulate and downregulate anti-oxidant and anti-inflammatory proteins in BMSCs. Citrate can regulate anti-oxidant and anti-inflammatory proteins via PPARγ dependent and independent pathways.
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Liakopoulos V, Roumeliotis S, Zarogiannis S, Eleftheriadis T, Mertens PR. Oxidative stress in hemodialysis: Causative mechanisms, clinical implications, and possible therapeutic interventions. Semin Dial 2018; 32:58-71. [PMID: 30288786 DOI: 10.1111/sdi.12745] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Oxidative stress (OS) is the result of prooxidant molecules overwhelming the antioxidant defense mechanisms. Hemodialysis (HD) constitutes a state of elevated inflammation and OS, due to loss of antioxidants during dialysis and activation of white blood cells triggering production of reactive oxygen species. Dialysis vintage, dialysis methods, and type and condition of vascular access, biocompatibility of dialyzer membrane and dialysate, iron administration, and anemia all can play a role in aggravating OS, which in turn has been associated with increased morbidity and mortality. Oral or intravenous administration of antioxidants may detoxify the oxidative molecules and at least in part repair OS-mediated tissue damage. Lifestyle interventions and optimization of a highly biocompatible HD procedure might ameliorate OS development in dialysis.
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Affiliation(s)
- Vassilios Liakopoulos
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.,Clinic of Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
| | - Stefanos Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sotirios Zarogiannis
- Department of Physiology, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Theodoros Eleftheriadis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Peter R Mertens
- Clinic of Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
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Pérez-García R, Ramírez Chamond R, de Sequera Ortiz P, Albalate M, Puerta Carretero M, Ortega M, Ruiz Caro MC, Alcazar Arroyo R. Citrate dialysate does not induce oxidative stress or inflammation in vitro as compared to acetate dialysate. Nefrologia 2018; 37:630-637. [PMID: 29122211 DOI: 10.1016/j.nefro.2017.03.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 02/20/2017] [Accepted: 03/16/2017] [Indexed: 11/17/2022] Open
Abstract
Increased acetataemia during haemodialysis sessions has been associated with a number of abnormalities, including increased oxidative stress, pro-inflammatory cytokines and nitric oxide synthesis. However, citric acid may play an alternative role to acetate as a dialysate stabiliser given that the effect of citrate on complement and leukocyte activation is different to that of acetate. The purpose of this study was to compare the inflammatory effect in immunocompetent blood cells of acetate dialysate and citrate dialysate. MATERIAL AND METHODS The effect of acetate and/or citrate was investigated in the whole blood of uraemic patients and in healthy in vitro samples. Four types of dialysate were tested: dialysate 1, acetate-free with 1mmol/L of citrate; dialysate 2, with 0.8mmol/L of citrate and 0.3mmol/L of acetate; dialysate 3, citrate-free with 3mmol/L of acetate; and dialysate 4, citrate-free with 4mmol/L of acetate. The cell types used were: human monocyte culture (THP-1); and peripheral blood mononuclear cells (PBMCs) from healthy subjects and uraemic patients on haemodialysis. ICAM-1 was determined and levels of reactive oxygen species and total microvesicles were quantified. RESULTS Unlike the citrate dialysates, the dialysates with acetate (dialysate 3 and dialysate 4) induced increased ICAM-1 expression density in THP-1 cells; an increase in ICAM-1 expression was observed in the immunocompetent cells of healthy subjects with acetate dialysate (dialysate 3 and dialysate 4) but not with citrate dialysate (dialysate 1 and dialysate 2). No significant ICAM-1 differences were found between the different dialysates in the cells of haemodialysed patients. Reactive oxygen species expression and the number of microvesicles increased significantly with acetate dialysate but not with citrate dialysate in the cells of both healthy subjects and haemodialysed patients. CONCLUSIONS At the concentrations in which it is generally used in clinical practice, acetate-based dialysate increases oxidative stress and the total number of microvesicles and may induce other pro-inflammatory stimuli typical of uraemic patients on haemodialysis. Citrate dialysates do not induce this activation, which could make them a suitable alternative in clinical practice.
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Affiliation(s)
- Rafael Pérez-García
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España.
| | - Rafael Ramírez Chamond
- Departamento de Biología de Sistemas, Facultad de Medicina y Ciencias de la Salud Universidad de Alcalá, Alcalá de Henares (Madrid), España
| | | | - Marta Albalate
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
| | | | - Mayra Ortega
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
| | - M Caridad Ruiz Caro
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
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Gubensek J, Strobl K, Harm S, Weiss R, Eichhorn T, Buturovic-Ponikvar J, Weber V, Hartmann J. Influence of citrate concentration on the activation of blood cells in an in vitro dialysis setup. PLoS One 2018; 13:e0199204. [PMID: 29898003 PMCID: PMC5999235 DOI: 10.1371/journal.pone.0199204] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 06/04/2018] [Indexed: 02/02/2023] Open
Abstract
Background Regional citrate anticoagulation has been associated with enhanced biocompatibility in hemodialysis, but the optimal dose of citrate remains to be established. Here, we compared parameters related to cellular activation during in vitro dialysis, using two doses of citrate. Methods Human whole blood, anticoagulated with either 3 mM or 4 mM of citrate, was recirculated in an in vitro miniaturized dialysis setup. Complement (C3a-desArg), soluble platelet factor 4 (PF4), thromboxane B2 (TXB2), myeloperoxidase (MPO), as well as platelet- and red blood cell-derived extracellular vesicles (EV) were quantified during recirculation. Dialyzer fibers were examined by scanning electron microscopy after recirculation to assess the activation of clotting and the deposition of blood cells. Results Increases in markers of platelet and leukocyte activation, PF4, TXB2, and MPO were comparable between both citrate groups. Complement activation tended to be lower at higher citrate concentration, but the difference between the two citrate groups did not reach significance. A strong increase in EVs, particularly platelet-derived EVs, was observed during in vitro dialysis for both citrate groups, which was significantly less pronounced in the high citrate group at the end of the experiment. Assessment of dialyzer clotting scores after analysis of individual fibers by scanning electron microscopy revealed significantly lower scores in the high citrate group. Conclusions Our data indicate that an increase in the citrate concentration from 3 mM to 4 mM further dampens cellular activation, thereby improving biocompatibility. A concentration of 4 mM citrate might therefore be optimal for use in clinical practice.
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Affiliation(s)
- Jakob Gubensek
- Department of Nephrology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- * E-mail:
| | - Karin Strobl
- Center for Biomedical Technology, Department for Health Sciences and Biomedicine, Danube University Krems, Krems, Austria
| | - Stephan Harm
- Center for Biomedical Technology, Department for Health Sciences and Biomedicine, Danube University Krems, Krems, Austria
| | - Rene Weiss
- Center for Biomedical Technology, Department for Health Sciences and Biomedicine, Danube University Krems, Krems, Austria
- Christian Doppler Laboratory for Innovative Therapy Approaches in Sepsis, Danube University Krems, Krems, Austria
| | - Tanja Eichhorn
- Center for Biomedical Technology, Department for Health Sciences and Biomedicine, Danube University Krems, Krems, Austria
- Christian Doppler Laboratory for Innovative Therapy Approaches in Sepsis, Danube University Krems, Krems, Austria
| | - Jadranka Buturovic-Ponikvar
- Department of Nephrology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Viktoria Weber
- Center for Biomedical Technology, Department for Health Sciences and Biomedicine, Danube University Krems, Krems, Austria
- Christian Doppler Laboratory for Innovative Therapy Approaches in Sepsis, Danube University Krems, Krems, Austria
| | - Jens Hartmann
- Center for Biomedical Technology, Department for Health Sciences and Biomedicine, Danube University Krems, Krems, Austria
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Schmitz M, Joannidis M, Czock D, John S, Jörres A, Klein SJ, Oppert M, Schwenger V, Kielstein J, Zarbock A, Kindgen-Milles D, Willam C. [Regional citrate anticoagulation in renal replacement therapy in the intensive care station : Recommendations from the renal section of the DGIIN, ÖGIAIN and DIVI]. Med Klin Intensivmed Notfmed 2018; 113:377-383. [PMID: 29737362 DOI: 10.1007/s00063-018-0445-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/03/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) in continuous renal replacement therapy can effectively anticoagulate dialysis circuits without having adverse effects on systemic heparin application. In particular, in continuous renal replacement therapy RCA is well established and represents a safe procedure with longer filter lifetimes and fewer bleeding complications. OBJECTIVES To provide guidance on the indications, advantages and disadvantages, and use of RCA, current recommendations from the renal section of the DGIIN (Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin), ÖGIAIN (Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin) and DIVI (Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin) are stated. MATERIALS AND METHODS The recommendations in this paper are based on the current KDIGO (Kidney Disease: Improving Global Outcomes) guidelines, other published guidelines and protocols as well as the expert knowledge and clinical experience of the authors. RESULTS The use of commercially available machines with coupled pumps and integrated safety features, effective personal training and standardized protocols for clinical usage (SOP) is particularly important for the safe clinical use of RCA in renal replacement therapy. Contrary to previous recommendations, even liver failure or shock with lactic acidosis may no longer be an absolute contra-indication for RCA. However, these particular patients have to be carefully monitored for signs of citrate accumulation.
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Affiliation(s)
- M Schmitz
- Klinik für Nephrologie und Allgemeine Innere Medizin, Städtisches Klinikum Solingen, Gotenstraße 1, 42653, Solingen, Deutschland.
| | - M Joannidis
- Gemeinsame Einrichtung internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - D Czock
- Medizinische Klinik, Abteilung Klinische Pharmakologie und Pharmakoepidemiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Deutschland
| | - S John
- Abteilung Internistische Intensivmedizin, Medizinische Klinik 8, Paracelsus Medizinische Privatuniversität (PMU) Nürnberg, Universität Erlangen-Nürnberg, Klinikum Nürnberg-Süd, Nürnberg, Deutschland
| | - A Jörres
- Medizinische Klinik I für Nephrologie, Transplantationsmedizin und internistische Intensivmedizin, Klinikum der Universität Witten/Herdecke, Köln-Merheim, Deutschland
| | - S J Klein
- Gemeinsame Einrichtung internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - M Oppert
- Klinik für Notfall- und internistische Intensivmedizin, Klinikum Ernst von Bergmann, Potsdam, Deutschland
| | - V Schwenger
- Klinik für Nieren‑, Hochdruck- und Autoimmunerkrankungen, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Deutschland
| | - J Kielstein
- Medizinische Klinik V, Nephrologie, Rheumatologie, Blutreinigungsverfahren, Städtisches Klinikum Braunschweig, Braunschweig, Deutschland
| | - A Zarbock
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - D Kindgen-Milles
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Moorenstr. 5, 40225, Düsseldorf, Deutschland
| | - C Willam
- Medizinische Klinik 4, Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland
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Buturovic-Ponikvar J, Cerne S, Gubensek J, Ponikvar R. Regional Citrate Anticoagulation for Hemodialysis: Calcium-Free Vs. Calcium Containing Dialysate - A Randomized Trial. Int J Artif Organs 2018; 31:418-24. [DOI: 10.1177/039139880803100507] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The majority of citrate protocols for hemodialysis (HD) use calcium (Ca)-free dialysate, a limited number use dialysate with Ca, aiming to simplify the procedure. This randomized clinical study sought to compare the anticoagulant effect of citrate using Ca-free dialysate and dialysate with Ca 1.25 mmol/L. Methods Fifty HD procedures (in 5 chronic HD patients treated by chronic citrate anticoagulation) were randomly assigned to Ca-free dialysate (25 procedures) or Ca-1.25 dialysate (25 procedures), both with Mg 0.5 mmol/L, Na 138 mmol/L, and bicarbonate 28 mmol/L. Ca-free HD: 15% Na3 citrate 80 ml/hour was infused into the arterial line, and 1 M CaCl2, 14 ml/hour into the venous line. Ca-1.25 group: 15% Na3 citrate 100 ml/hour, 1 M CaCl2 2–4 ml/hour. Polyflux H dialyzers were used. Antithrombotic effect was assessed visually after HD at 3 points: dialyzer, arterial, and venous bubble traps, using a score of 5 (no clotting) to 1 (total clotting). Results Ca-free group: arterial bubble trap score 4.7 ± 0.5, dialyzer 4.5 ± 0.6, venous bubble trap 4.8 ± 0.6. Ionized calcium (iCa) at dialyzer inlet 0.34 ± 0.17, outlet 0.21 ± 0.06 mmol/L. All HDs were completed successfully. Ca-1.25 group: arterial bubble trap score 4.7 ± 0.5 (NS), dialyzer 2.6 ± 1.04 (p<0.01), venous bubble trap 2.4 ± 0.9 (p<0.01). Volume of clot in venous bubble trap was 1.9 ± 1.8 mL (range 0.5–6 mL). iCa at dialyzer inlet 0.24 ± 0.05 mmol/L (p<0.05), outlet 0.63 ± 0.11 mmol/L (p<0.01). Four of 25 HD procedures (16%) were prematurely terminated due to threatening dialyzer clotting, in 6/25 HD procedures (24%), the venous line was changed (p<0.01). Conclusion Citrate anticoagulation with Ca-1.25 dialysate resulted in significantly worse anticoagulation of dialyzer and venous bubble trap compared with Ca-free dialysate, despite higher citrate dose.
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Affiliation(s)
- J. Buturovic-Ponikvar
- Center for Dialysis, Department of Nephrology, University Medical Center Ljubljana, Ljubljana - Slovenia
| | - S. Cerne
- Center for Dialysis, Department of Nephrology, University Medical Center Ljubljana, Ljubljana - Slovenia
| | - J. Gubensek
- Center for Dialysis, Department of Nephrology, University Medical Center Ljubljana, Ljubljana - Slovenia
| | - R. Ponikvar
- Center for Dialysis, Department of Nephrology, University Medical Center Ljubljana, Ljubljana - Slovenia
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Heparin-Free Prolonged Intermittent Hemodialysis Using Calcium-Free Citrate Dialysate in Critically Ill Patients. Crit Care Med 2017; 45:1887-1892. [PMID: 28857854 DOI: 10.1097/ccm.0000000000002694] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Critically ill patients who have a high risk of bleeding but require prolonged intermittent dialysis need a heparin-free easy-to-use alternative type of anticoagulation within the dialysis circuit. We assessed the safety and efficiency of heparin-free regional citrate anticoagulation of the dialysis circuit using a calcium-free citrate-containing dialysate, with calcium reinjected according to ionic dialysance. DESIGN Prospective cohort study. SETTING Critical care units. PATIENTS Critically ill patients who required renal replacement therapy. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 101 dialysis sessions were performed in 35 patients (mechanical ventilation n = 78; norepinephrine n = 13). Median duration of dialysis was 294 minutes (interquartile range, 240-300), and median ultrafiltration volume was 2.3 L (1-2.8). Urea and β2-microglobulin reduction rates were 64.5% ± 0.4% and 48% ± 0.13%, respectively. Postfilter ionized calcium was 0.35 ± 0.17 and 0.38 ± 0.14 mmol/L at 1 and 3 hours, respectively, within the extracorporeal circuit. A major clotting event that led to premature termination of the session occurred in only three of 101 sessions. In these three cases, major catheter dysfunction occurred before clotting within the circuit. Prefilter ionized calcium remained within narrow ranges (before/after change +0.07 ± 0.006 mmol/L), and total-to-ionized calcium ratio, a surrogate marker for citratemia, was unchanged. CONCLUSIONS Dialysis anticoagulation with calcium-free citrate-containing dialysate and calcium reinjection according to ionic dialysance is an easy-to-use, efficient, and inexpensive form of heparin-free regional anticoagulation. It allows prolonged hemodialysis sessions in critically ill patients without the need to systemically monitor ionized calcium. Furthermore, sessions can be safely extended according to the hemodynamic tolerance to ensure an adequate dose of dialysis and a negative water balance, a major point in patients with severe acute kidney disease.
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Wisgrill L, Lamm C, Hartmann J, Preißing F, Dragosits K, Bee A, Hell L, Thaler J, Ay C, Pabinger I, Berger A, Spittler A. Peripheral blood microvesicles secretion is influenced by storage time, temperature, and anticoagulants. Cytometry A 2017; 89:663-72. [PMID: 27442840 DOI: 10.1002/cyto.a.22892] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 04/20/2016] [Accepted: 05/19/2016] [Indexed: 12/13/2022]
Abstract
Microvesicles (MVs) are small membrane bound vesicles released from various cell types after activation or apoptosis. In the last decades, MVs received an increased interest as biomarkers in inflammation, coagulation and cancer. However, standardized pre-analytical steps are crucial for the minimization of artifacts in the MV analysis. Thus, this study evaluated the MV release in whole blood samples under the influence of different anticoagulants, storage time and various temperature conditions. Samples were collected from healthy probands and processed immediately, after 4, 8, 24 and 48 hours at room temperature (RT) or 4°C. To identify MV subpopulations, platelet free plasma (PFP) was stained with Annexin V, calcein AM, CD15, CD41 and CD235a. Analysis was performend on a CytoFLEX flow cytometer. Procoagulatory function of MVs was measured using a phospholipid dependent activity and a tissue factor MVactivity assay. Without prior storage, sodium citrate showed the lowest MV count compared to heparin and EDTA. Interestingly, EDTA showed a significant release of myeloid-derived MVs (MMVs) compared to sodium citrate. Sodium citrate showed a stable MV count at RT in the first 8 hours after blood collection. Total MV counts increased after 24 hours in sodium citrated or heparinzed blood which was related to all subpopulations. Interestingly, EDTA showed stable platelet-derived MV (PMV) and erythrocyte-derived MV (EryMV) count at RT over a 48 h period. In addition, the procoagulatory potential increased significantly after 8-hour storage. Based on both, this work and literature data, the used anticoagulant, storage time and storage temperature differently influence the analysis of MVs within 8 hours. To date, sodium citrated tubes are recommended for MV enumeration and functional analysis. EDTA tubes might be an option for the clinical routine due to stable PMV and EryMV counts. These new approaches need to be validated in a clinical laboratory setting before being applied to patient studies. © 2016 International Society for Advancement of Cytometry.
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Affiliation(s)
- Lukas Wisgrill
- Department of Paediatrics and Adolescent Medicine, Division of Neonatology, Paediatric Intensive Care & Neuropaediatrics, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria
| | - Christian Lamm
- Department of Surgery, Research Labs, Medical University of Vienna, Lazarettgasse 14, Vienna, 1090, Austria
| | - Julia Hartmann
- Department of Surgery, Research Labs, Medical University of Vienna, Lazarettgasse 14, Vienna, 1090, Austria
| | - Falk Preißing
- Department of Surgery, Research Labs, Medical University of Vienna, Lazarettgasse 14, Vienna, 1090, Austria
| | - Klaus Dragosits
- Department of Surgery, Research Labs, Medical University of Vienna, Lazarettgasse 14, Vienna, 1090, Austria
| | - Annica Bee
- Department of Surgery, Research Labs, Medical University of Vienna, Lazarettgasse 14, Vienna, 1090, Austria
| | - Lena Hell
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Währinger Gürtel 18-20, Austria
| | - Johannes Thaler
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Währinger Gürtel 18-20, Austria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Währinger Gürtel 18-20, Austria
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Währinger Gürtel 18-20, Austria
| | - Angelika Berger
- Department of Paediatrics and Adolescent Medicine, Division of Neonatology, Paediatric Intensive Care & Neuropaediatrics, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria
| | - Andreas Spittler
- Department of Surgery, Research Labs, Medical University of Vienna, Lazarettgasse 14, Vienna, 1090, Austria
- Core Facility Flow Cytometry, Medical University of Vienna, Lazarettgasse 14, Vienna, 1090, Austria
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Buturovic-Ponikvar J. Is Regional Citrate Anticoagulation the Future of Hemodialysis? Ther Apher Dial 2017; 20:234-9. [PMID: 27312907 DOI: 10.1111/1744-9987.12429] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 03/23/2016] [Indexed: 11/29/2022]
Abstract
Citrate has many characteristics of the ideal anticoagulant for hemodialysis. In addition to immediate and complete anticoagulation in the dialysis circuit, citrate has important effects beyond anticoagulation, mainly in reducing inflammatory response induced by hemodialysis. Citrate has already become the standard anticoagulant in acute kidney injury requiring continuous renal replacement therapy (CRRT), both for adults and children, with the citrate module being a part of modern CRRT monitors. Although the citrate module is not yet available for intermittent hemodialysis, precise infusion pumps, point-of-care ionometers and high citrate clearance from high flux dialyzers increase safety while reducing the risk of metabolic complications, both in adult and pediatric patients. Slovenia has a long tradition, high volume and expansion of citrate use in hemodialysis, including long-term citrate anticoagulation in selected patients. At the Department of Nephrology, University Medical Centre Ljubljana, more than 10 000 citrate procedures were performed in 2015. We believe that regional citrate anticoagulation may replace heparin as the main anticoagulant for intermittent hemodialysis in the not so distant future.
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Affiliation(s)
- Jadranka Buturovic-Ponikvar
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Slovenia
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Oxidative Stress in Hemodialysis Patients: A Review of the Literature. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2017; 2017:3081856. [PMID: 29138677 PMCID: PMC5613374 DOI: 10.1155/2017/3081856] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 08/14/2017] [Indexed: 02/07/2023]
Abstract
Hemodialysis (HD) patients are at high risk for all-cause mortality and cardiovascular events. In addition to traditional risk factors, excessive oxidative stress (OS) and chronic inflammation emerge as novel and major contributors to accelerated atherosclerosis and elevated mortality. OS is defined as the imbalance between antioxidant defense mechanisms and oxidant products, the latter overwhelming the former. OS appears in early stages of chronic kidney disease (CKD), advances along with worsening of renal failure, and is further exacerbated by the HD process per se. HD patients manifest excessive OS status due to retention of a plethora of toxins, subsidized under uremia, nutrition lacking antioxidants and turn-over of antioxidants, loss of antioxidants during renal replacement therapy, and leukocyte activation that leads to accumulation of oxidative products. Duration of dialysis therapy, iron infusion, anemia, presence of central venous catheter, and bioincompatible dialyzers are several factors triggering the development of OS. Antioxidant supplementation may take an overall protective role, even at early stages of CKD, to halt the deterioration of kidney function and antagonize systemic inflammation. Unfortunately, clinical studies have not yielded unequivocal positive outcomes when antioxidants have been administered to hemodialysis patients, likely due to their heterogeneous clinical conditions and underlying risk profile.
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Lehner GF, Harler U, Feistritzer C, Haller VM, Hasslacher J, Bellmann R, Joannidis M. Hemofiltration induces generation of leukocyte-derived CD31+/CD41- microvesicles in sepsis. Ann Intensive Care 2017; 7:89. [PMID: 28871391 PMCID: PMC5583134 DOI: 10.1186/s13613-017-0312-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/18/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Microvesicles (MV) are extracellular vesicles known to be associated with cellular activation and inflammation. Hemofiltration is an effective blood purification technique for patients with renal failure and possibly also eliminates inflammatory mediators in the setting of sepsis. On the other hand, proinflammatory stimuli are induced by blood contacting the artificial membrane during extracorporeal blood purification. In chronic dialysis patients a systemic increase in MV has been described. The aim of the study was to investigate whether hemofilter passage of blood in continuous veno-venous hemofiltration (CVVH) alters MV composition and levels in critically ill patients with sepsis. METHODS Pre- and postfilter bloods as well as ultrafiltrate samples from intensive care unit patients with severe sepsis were obtained during CVVH with regional citrate anticoagulation. MV subtypes in blood were analyzed by high-sensitivity flow cytometry. Additionally, tissue factor (TF) levels and MV-associated TF activities as well as MV activities were quantified. All parameters were corrected for hemoconcentration applied during CVVH. RESULTS Twelve patients were analyzed. A significant increase in presumably mostly leukocyte-derived CD31+/CD41- MV (1.32 (1.09-1.93)-fold [median (25th-75th quartiles)], p = 0.021) was observed post- to prefilter, whereas platelet-derived MV as well as AnnexinV-binding MV were unaltered. Increments of AnnexinV+, CD42b+ and CD31+/CD41- MV post- to prefilter correlated with filtration fraction (FF) (all p < 0.05). Significant reductions in MV activity [0.72 (0.62-0.84)-fold, p = 0.002] and TF level [0.95 (0.87-0.99)-fold, p = 0.0093] were detected postfilter compared to prefilter. No MV activity was measurable in ultrafiltrate samples. CONCLUSIONS Despite clearing a fraction of small PS-exposing MV CVVH does not eliminate larger MV. Concurrently, CVVH induces the release of CD31+/CD4- MV that indicate leukocyte activation during hemofilter passage in septic patients. Increments of several MV subtypes within the hemofilter correlate with FF, which supports common recommendations to keep FF low. A fraction of TF is being cleared by CVVH via ultrafiltration.
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Affiliation(s)
- Georg Franz Lehner
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Ulrich Harler
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Clemens Feistritzer
- Department of Internal Medicine V - Haematology and Oncology, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Viktoria Maria Haller
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Julia Hasslacher
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Romuald Bellmann
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Cardiac Surgery-Associated Acute Kidney Injury. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0224-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Dyla A, Mielnicki W, Bartczak J, Zawada T, Garba P. Effectiveness and Safety Assessment of Citrate Anticoagulation During Albumin Dialysis in Comparison to Other Methods of Anticoagulation. Artif Organs 2017; 41:818-826. [PMID: 28337775 DOI: 10.1111/aor.12876] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/26/2016] [Accepted: 08/31/2016] [Indexed: 12/14/2022]
Abstract
Liver failure is a serious and often deadly disease often requiring MARS (Molecular Adsorbent Recirculating System) therapy. Choosing the safe and effective method of anticoagulation during artificial liver support systems seems to be very difficult and extremely important. The aim of this study was to assess effectiveness and safety of regional anticoagulation with citrate in liver failure patients during MARS. We used a single center observational study. We analyzed 158 MARS sessions performed in 65 patients: 105 (66.5%) sessions in 41 patients with heparin anticoagulation, 40 (25.3%) sessions in 19 patients with citrate, and 13 (8%) sessions in only five patients without anticoagulation, that were excluded from part of the analysis. To determine the effectiveness of regional anticoagulation with citrate, probability of filter survival and changes in laboratory parameters were analyzed according to the applied method of anticoagulation. The safety of citrate was determined by Ca/Ca2+ ratio, acid-base balance, bleeding complications, and the need for blood product transfusions. The probability of filter survival in the citrate group was 94% and in the heparin group 82% (P = 0.204). There was no relationship between the method of anticoagulation and effectiveness of MARS therapy in lowering the levels of the analyzed parameters. Only one patient had a Ca/Ca2+ ratio higher than he safety margin. There were no statistically significant changes in pH and lactate level irrespective of anticoagulation; bicarbonate dropped significantly only in the heparin group (P = 0.03). The frequency of bleeding complications and the need for transfusions did not differ significantly between groups. Regional anticoagulation with citrate can be an effective and safe method of anticoagulation during MARS therapy, but requires attentive monitoring and further studies in liver failure patients.
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Affiliation(s)
- Agnieszka Dyla
- Anesthesiology 4th Military Clinical Hospital, Wroclaw, Poland
| | | | - Joanna Bartczak
- Anesthesiology 4th Military Clinical Hospital, Wroclaw, Poland
| | - Tomasz Zawada
- Anesthesiology 4th Military Clinical Hospital, Wroclaw, Poland
| | - Piotr Garba
- Anesthesiology 4th Military Clinical Hospital, Wroclaw, Poland
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Nseir V, Rachas A, Elias M, Francois H, Nnang Obada E, Lorenzo HK, Charpentier B, Durrbach A, Beaudreuil S. Comparison of the AN69ST Membrane versus Citrate-Enriched Dialysate on Clotting Events during Hemodialysis without Systemic Anticoagulation. Blood Purif 2017; 44:60-65. [PMID: 28253497 DOI: 10.1159/000456532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 01/12/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND The optimal management of anticoagulation in hemodialyzed patients with a high risk of bleeding is controversial. METHODS We compared premature termination of dialysis caused by clotting events between AN69ST membranes (G1) and 0.8 mmol/L citrate-enriched dialysate (G2). The number of sessions that had increased venous pressure (VP) and variations in urea-reduction ratio (URR) were analyzed. RESULTS Six hundred and two sessions were analyzed in 259 patients: 22.4% had sessions that ended prematurely (25% in G1 and 19.1% in G2, p = ns, OR 0.60 [0.34-1.08], p = 0.08). The increase in VP was lower in G2 (23 vs. 70, p < 0.001). URR was higher in G2 (0.56 vs. 0.60, p < 0.001). CONCLUSION Clotting events that led to the termination of dialysis were comparable in the 2 groups. However, UUR was better in G2, and the number of patients with increased VP in the sessions was lower in G2. SHORT SUMMARY Our study compared the effects of the AN69ST membrane and citrate-enriched dialysate on clotting events during the dialysis of 259 patients with a high risk of bleeding. URR was significantly better and fewer cases of increased VP occurred in the citrate group compared to the AN69 ST group. No significant difference was observed regarding the need to prematurely terminate a dialysis session.
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Affiliation(s)
- Vanessa Nseir
- IFRNT, Department of Nephrology, Bicêtre Hospital, University of Paris-Sud, Le Kremlin-Bicêtre, France
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Kissling S, Legallais C, Pruijm M, Teta D, Vogt B, Burnier M, Rondeau E, Ridel C. A new prescription model for regional citrate anticoagulation in therapeutic plasma exchanges. BMC Nephrol 2017; 18:81. [PMID: 28249613 PMCID: PMC5333425 DOI: 10.1186/s12882-017-0494-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 02/21/2017] [Indexed: 12/02/2022] Open
Abstract
Background Regional citrate anticoagulation (RCA) is proposed for various extracorporeal purification techniques to overcome the risk of bleeding that might result from systemic anticoagulation. Yet, no individualized treatment protocol has been proposed for therapeutic plasma exchange (TPE) so far. The objective of this study was to assess the determinants of blood citrate concentration needed and to develop an individualized RCA protocol useful for clinical practice. Methods The study population included 14 patients who underwent a total of 47 TPE sessions. Citrate was infused pre-plasmafilter. Post-plasmafilter and systemic plasma ionized calcium concentrations were measured at standardized time intervals. An algorithm was proposed for the supplementation of calcium. During the discovery phase, citrate was infused at a fixed starting rate, and adapted accordingly to obtained post-plasmafilter ionized calcium levels. Using a mathematical approach, an algorithm was thereafter developed for individualized prescriptions of citrate. Results Pre-treatment values of hematocrit and plasma ionized calcium were the main determinants of the required rate of citrate infusion. These can be integrated into a final equation enabling to individualize the prescription. A prefilter ionized calcium concentration between 0.24 and 0.33 mmol/l prevented coagulation of the extracorporeal circuit. Significant hypocalcemia occurred in 8.5% of treatments. There were no significant acid–base disturbances. Conclusion We propose a new protocol, which enables for the first time to individualize the prescription of regional citrate anticoagulation during TPE, in an efficient manner. The immediately obtained regional anticoagulation protects against both the risk of coagulation of the membrane and the exposure to an excess of citrate. Electronic supplementary material The online version of this article (doi:10.1186/s12882-017-0494-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sébastien Kissling
- Service d'Urgences néphrologiques et Transplantation rénale (UNTR), Hôpital Tenon, Paris, 75020, France. .,Biomécanique et Bioingénierie, Université de Technologie de Compiègne (UTC), UMR CNRS 7338, Compiègne, 60203, France. .,Service de Néphrologie et Hypertension, Centre Hospitalier Universitaire Vaudois (CHUV), Rte du Bugnon 17, 1011, Lausanne, CH, Switzerland.
| | - Cécile Legallais
- Biomécanique et Bioingénierie, Université de Technologie de Compiègne (UTC), UMR CNRS 7338, Compiègne, 60203, France
| | - Menno Pruijm
- Service de Néphrologie et Hypertension, Centre Hospitalier Universitaire Vaudois (CHUV), Rte du Bugnon 17, 1011, Lausanne, CH, Switzerland
| | - Daniel Teta
- Service de Néphrologie et Hypertension, Centre Hospitalier Universitaire Vaudois (CHUV), Rte du Bugnon 17, 1011, Lausanne, CH, Switzerland
| | - Bruno Vogt
- Service de Néphrologie et Hypertension, Centre Hospitalier Universitaire Vaudois (CHUV), Rte du Bugnon 17, 1011, Lausanne, CH, Switzerland
| | - Michel Burnier
- Service de Néphrologie et Hypertension, Centre Hospitalier Universitaire Vaudois (CHUV), Rte du Bugnon 17, 1011, Lausanne, CH, Switzerland
| | - Eric Rondeau
- Service d'Urgences néphrologiques et Transplantation rénale (UNTR), Hôpital Tenon, Paris, 75020, France
| | - Christophe Ridel
- Service d'Urgences néphrologiques et Transplantation rénale (UNTR), Hôpital Tenon, Paris, 75020, France
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The role of ionized calcium and magnesium in regional citrate anticoagulation and its impact on inflammatory parameters. Int J Artif Organs 2017; 40:15-21. [PMID: 28218351 DOI: 10.5301/ijao.5000558] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2017] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Regional anticoagulation with citrate has been found to be superior to heparin in terms of biocompatibility, and numerous protocols for regional citrate anticoagulation have been published, while a consensus on the target concentration of ionized calcium (Ca2+) in the extracorporeal circuit has not been reached so far. METHODS The aim of this in vitro study was to assess the impact of different citrate concentrations on coagulation as well as on complement activation and cytokine secretion and to investigate the impact of ionized magnesium (Mg2+) on these parameters. RESULTS We found that citrate effectively reduced coagulation, complement activation, and cytokine secretion in a dose-dependent manner and that a target Ca2+ concentration of 0.2-0.25 mM was required for efficient anticoagulation. Mg2+ triggered complement activation as well as interleukin (IL)-1β secretion in lipopolysaccharide (LPS)-stimulated whole blood in a dose-dependent manner and independently of Ca2+. Additionally, it was found to reduce activated clotting time (ACT) in samples with low Ca2+ levels, but not at physiological Ca2+. CONCLUSIONS Taken together, our data support the notion that regional citrate anticoagulation results in decreased release of inflammatory mediators in the extracorporeal circuit, requiring the depletion of both, Ca2+ and Mg2+.
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