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Park SJ, Park I, Kim S, Kim MK, Kim S, Jeong H, Kim D, Cho SW, Park TE, Ni A, Lim H, Joo J, Lee JH, Kang JH. Extracorporeal Blood Treatment Using Functional Magnetic Nanoclusters Mitigates Organ Dysfunction of Sepsis in Swine. SMALL METHODS 2024; 8:e2301428. [PMID: 38161256 DOI: 10.1002/smtd.202301428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/18/2023] [Indexed: 01/03/2024]
Abstract
Mitigating sepsis-induced severe organ dysfunction with magnetic nanoparticles has shown remarkable advances in extracorporeal blood treatment. Nevertheless, treating large septic animals remains challenging due to insufficient magnetic separation at rapid blood flow rates (>6 L h-1) and limited incubation time in an extracorporeal circuit. Herein, superparamagnetic nanoclusters (SPNCs) coated with red blood cell (RBC) membranes are developed, which promptly capture and magnetically separate a wide range of pathogens at high blood flow rates in a swine sepsis model. The SPNCs exhibited an ultranarrow size distribution of clustered iron oxide nanocrystals and exceptionally high saturation magnetization (≈ 90 emu g-1) close to that of bulk magnetite. It is also revealed that CD47 on the RBCs allows the RBC-SPNCs to remain at a consistent concentration in the blood by evading innate immunity. The uniform size distribution of the RBC-SPNCs greatly enhances their effectiveness in eradicating various pathogenic materials in extracorporeal blood. The use of RBC-SPNCs for extracorporeal treatment of swine infected with multidrug-resistant E. coli is validated and found that severe bacteremic sepsis-induced organ dysfunction is significantly mitigated after 12 h. The findings highlight the potential application of RBC-SPNCs for extracorporeal therapy of severe sepsis in large animal models and potentially humans.
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Affiliation(s)
- Sung Jin Park
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
| | - Inwon Park
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 44919, Republic of Korea
| | - Suhyun Kim
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
| | - Min Kyu Kim
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
| | - Seonghye Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 44919, Republic of Korea
| | - Hwain Jeong
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 44919, Republic of Korea
| | - Dongsung Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 44919, Republic of Korea
| | - Seung Woo Cho
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
| | - Tae-Eun Park
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
| | - Aleksey Ni
- School of Energy and Chemical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
| | - Hankwon Lim
- School of Energy and Chemical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
| | - Jinmyoung Joo
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
- Center for Genomic Integrity, Institute for Basic Science, Ulsan, 44919, Republic of Korea
| | - Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 44919, Republic of Korea
| | - Joo H Kang
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology (UNIST), Ulsan, 44919, Republic of Korea
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García-Villegas R, Arni S. Hemoadsorption in Organ Preservation and Transplantation: A Narrative Review. Life (Basel) 2023; 14:65. [PMID: 38255680 PMCID: PMC10817660 DOI: 10.3390/life14010065] [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: 10/31/2023] [Revised: 12/19/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024] Open
Abstract
Cytokine adsorption can resolve different complications characteristic of transplantation medicine, such as cytokine storm activation and blood ABO and immune incompatibilities. Cytokine adsorption is also performed for the treatment of various life-threatening conditions, such as endotoxic septic shock, acute respiratory distress syndrome, and cardiogenic shock, all potentially leading to adverse clinical outcomes during transplantation. After surgery, dysmetabolism and stress response limit successful graft survival and can lead to primary or secondary graft dysfunction. In this clinical context, and given that a major problem in transplant medicine is that the demand for organs far exceeds the supply, a technological innovation such as a hemoadsorption system could greatly contribute to increasing the number of usable organ donors. The objectives of this review are to describe the specific advantages and disadvantages of the application of cytokine adsorption in the context of transplantation and examine, before and/or after organ transplantation, the benefits of the addition of a cytokine adsorption therapy protocol.
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Affiliation(s)
- Refugio García-Villegas
- Departamento de Fisiología, Biofísica y Neurociencias, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, D.F., Mexico City 07360, Mexico;
| | - Stephan Arni
- Department of Thoracic Surgery, University Hospital Zürich, 8091 Zürich, Switzerland
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Wendel-Garcia PD, Eberle B, Kleinert EM, Hilty MP, Blumenthal S, Spanaus K, Fodor P, Maggiorini M. Effects of enhanced adsorption haemofiltration versus haemoadsorption in severe, refractory septic shock with high levels of endotoxemia: the ENDoX bicentric, randomized, controlled trial. Ann Intensive Care 2023; 13:127. [PMID: 38095800 PMCID: PMC10721780 DOI: 10.1186/s13613-023-01224-8] [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: 09/29/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Endotoxin adsorption is a promising but controversial therapy in severe, refractory septic shock and conflicting results exist on the effective capacity of available devices to reduce circulating endotoxin and inflammatory cytokine levels. METHODS Multiarm, randomized, controlled trial in two Swiss intensive care units, with a 1:1:1 randomization of patients suffering severe, refractory septic shock with high levels of endotoxemia, defined as an endotoxin activity ≥ 0.6, a vasopressor dependency index ≥ 3, volume resuscitation of at least 30 ml/kg/24 h and at least single organ failure, to a haemoadsorption (Toraymyxin), an enhanced adsorption haemofiltration (oXiris) or a control intervention. Primary endpoint was the difference in endotoxin activity at 72-h post-intervention to baseline. In addition, inflammatory cytokine, vasopressor dependency index and SOFA-Score dynamics over the initial 72 h were assessed inter alia. RESULTS In the 30, out of 437 screened, randomized patients (10 Standard of care, 10 oXiris, 10 Toraymyxin), endotoxin reduction at 72-h post-intervention-start did not differ among interventions (Standard of Care: 12 [1-42]%, oXiris: 21 [10-51]%, Toraymyxin: 23 [10-36]%, p = 0.82). Furthermore, no difference between groups could be observed neither for reduction of inflammatory cytokine levels (p = 0.58), nor for vasopressor weaning (p = 0.95) or reversal of organ injury (p = 0.22). CONCLUSIONS In a highly endotoxemic, severe, refractory septic shock population neither the Toraymyxin adsorber nor the oXiris membrane could show a reduction in circulating endotoxin or cytokine levels over standard of care. Trial registration ClinicalTrials.gov. NCT01948778. Registered August 30, 2013. https://clinicaltrials.gov/study/NCT01948778.
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Affiliation(s)
- Pedro David Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Barbara Eberle
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Eva-Maria Kleinert
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Matthias Peter Hilty
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | | | - Katharina Spanaus
- Institute of Clinical Chemistry, University Hospital Zurich, Zurich, Switzerland
| | - Patricia Fodor
- Institute of Intensive Care Medicine, Triemli Hospital, Zurich, Switzerland
| | - Marco Maggiorini
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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Teixeira JP, Zeidman A, Beaubien-Souligny W, Cerdá J, Connor MJ, Eggleston K, Juncos LA, da Silva JR, Wells C, Yessayan L, Barker AB, McConville W, Speer R, Wille KM, Neyra JA, Tolwani A. Proceedings of the 2022 UAB CRRT Academy: Non-Invasive Hemodynamic Monitoring to Guide Fluid Removal with CRRT and Proliferation of Extracorporeal Blood Purification Devices. Blood Purif 2023; 52:857-879. [PMID: 37742622 DOI: 10.1159/000533573] [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: 03/22/2023] [Accepted: 06/29/2023] [Indexed: 09/26/2023]
Abstract
In 2022, we celebrated the 15th anniversary of the University of Alabama at Birmingham (UAB) Continuous Renal Replacement Therapy (CRRT) Academy, a 2-day conference attended yearly by an international audience of over 100 nephrology, critical care, and multidisciplinary trainees and practitioners. This year, we introduce the proceedings of the UAB CRRT Academy, a yearly review of select emerging topics in the field of critical care nephrology that feature prominently in the conference. First, we review the rapidly evolving field of non-invasive hemodynamic monitoring and its potential to guide fluid removal by renal replacement therapy (RRT). We begin by summarizing the accumulating data associating fluid overload with harm in critical illness and the potential for harm from end-organ hypoperfusion caused by excessive fluid removal with RRT, underscoring the importance of accurate, dynamic assessment of volume status. We describe four applications of point-of-care ultrasound used to identify patients in need of urgent fluid removal or likely to tolerate fluid removal: lung ultrasound, inferior vena cava ultrasound, venous excess ultrasonography, and Doppler of the left ventricular outflow track to estimate stroke volume. We briefly introduce other minimally invasive hemodynamic monitoring technologies before concluding that additional prospective data are urgently needed to adapt these technologies to the specific task of fluid removal by RRT and to learn how best to integrate them into practical fluid-management strategies. Second, we focus on the growth of novel extracorporeal blood purification devices, starting with brief reviews of the inflammatory underpinnings of multiorgan dysfunction and the specific applications of pathogen, endotoxin, and/or cytokine removal and immunomodulation. Finally, we review a series of specific adsorptive technologies, several of which have seen substantial clinical use during the COVID-19 pandemic, describing their mechanisms of target removal, the limited existing data supporting their efficacy, ongoing and future studies, and the need for additional prospective trials.
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Affiliation(s)
- J Pedro Teixeira
- Division of Nephrology and Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Amanda Zeidman
- Division of Nephrology, Department of Medicine, Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Jorge Cerdá
- Department of Medicine, Nephrology, Albany Medical College, Albany, New York, USA
| | - Michael J Connor
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine and Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - Luis A Juncos
- Division of Nephrology, Department of Internal Medicine, Central Arkansas Veterans' Healthcare System, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | | | - Catherine Wells
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew B Barker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Wendy McConville
- School of Nursing, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Rajesh Speer
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Keith M Wille
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Ashita Tolwani
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
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Li Y, Sun P, Chang K, Yang M, Deng N, Chen S, Su B. Effect of Continuous Renal Replacement Therapy with the oXiris Hemofilter on Critically Ill Patients: A Narrative Review. J Clin Med 2022; 11:jcm11226719. [PMID: 36431196 PMCID: PMC9695587 DOI: 10.3390/jcm11226719] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022] Open
Abstract
Critically ill patients with sepsis and severe COVID-19 are commonly characterized by a dysregulated immune response and an acute kidney injury. Continuous renal replacement therapy (CRRT) is now proposed as a promising adjuvant therapy to treat these critically ill patients by removing cytokines, pathogen-associated molecular patterns, and damage-associated molecular patterns from the blood. Although multiple hemofilters, including high-cutoff membranes, the oXiris hemofilter, the CytoSorb hemoadsorption device, and the Toraymyxin hemoperfusion cartridge, have been used in current clinical practice, the use of the oXiris hemofilter in critically ill patients is of particular interest because it is the only kind of hemofilter that can provide renal replacement therapy, remove endotoxins, and adsorb cytokines simultaneously. During the past five years, a growing body of literature has shown that CRRT with the oXiris hemofilter can improve hemodynamics and organ function and can decrease cytokines and endotoxins in both septic and COVID-19 patients. Here, we performed a narrative review to describe the development history of the oXiris hemofilter and to discuss the therapeutic effect of oXiris-CRRT on critically ill patients by searching the PubMed, Web of Science, and clinicaltrials.gov databases for articles published from inception to 8 September 2022 (updated on 1 November) with an English language restriction. We also summarized the current knowledge on anticoagulation techniques and safety concerns when delivering oXiris-CRRT sessions.
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Affiliation(s)
- Yupei Li
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Peiyan Sun
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Kaixi Chang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Mei Yang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu 610041, China
- Department of Nephrology, The First People’s Hospital of Shuangliu District, Chengdu 610200, China
| | - Ningyue Deng
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Shanshan Chen
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Baihai Su
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu 610041, China
- West China School of Medicine, Sichuan University, Chengdu 610041, China
- Med-X Center for Materials, Sichuan University, Chengdu 610041, China
- Med+ Biomaterial Institute of West China Hospital, Sichuan University, Chengdu 610041, China
- Correspondence: ; Tel.: +86-028-85423341
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6
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Li Y, Yang Z, Hu J, Lin Z. Preliminary study on the safety and efficacy of a new polymyxin B‐immoblized resin column in treatment of LPS‐induced sepsis beagles. Animal Model Exp Med 2022; 5:161-171. [PMID: 35234365 PMCID: PMC9043726 DOI: 10.1002/ame2.12199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/05/2021] [Accepted: 12/20/2021] [Indexed: 11/07/2022] Open
Abstract
Background This study aims to assess the safety and efficacy of direct hemoperfusion using a new polymyxin B‐immobilized resin column (disposable endotoxin adsorber, KCEA) in an endotoxin/ lipopolysaccharide (LPS)‐induced sepsis model. Methods Eighteen beagles were randomized into 1 intervention group (KCEA group, n = 6) and 2 control groups (sham group and model group, n = 6 each). Sepsis was induced by continuous intravenous application of 0.5 mg/kg body weight of endotoxin for 60 min. An extracorporeal hemoperfusion device made with KCEA for endotoxin adsorption was used. Model group beagles received standard treatment with fluids and vasoactive drugs, KCEA group beagles received standard treatment and direct hemoperfusion of KCEA for 2 h, and sham group beagles were treated with standard treatment and direct hemoperfusion of a sham column for 2 h. Results Good blood compatibility of KCEA was confirmed by assessing clinical parameters. Blood endotoxin peak levels in the KCEA group were significantly lower, resulting in a significant suppression of IL‐6, TNF‐α and procalcitonin, which improved mean arterial pressure and significantly lowered vasopressor demand, thereby protecting organ function and improving survival time and rate. In the KCEA group, MAP was significantly higher over 6 h than those recorded both in the sham group and model group. The 7‐day survival rates of the KCEA, sham and model groups were 50%, 0% and 0%, respectively. Conclusion KCEA hemoadsorption was effective at detoxifying circulatory endotoxin and inflammatory mediators and contributed to the decreased mortality rate in the sepsis beagles.
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Affiliation(s)
- Yonggui Li
- Research and Development Center Guangzhou Koncen Bioscience Co., Ltd. Guangzhou PR China
- Guangdong Provincial Key Laboratory of Hemoadsorption Technology Guangzhou PR China
| | - Zhenggen Yang
- Research and Development Center Guangzhou Koncen Bioscience Co., Ltd. Guangzhou PR China
- Guangdong Provincial Key Laboratory of Hemoadsorption Technology Guangzhou PR China
| | - Jialiang Hu
- Research and Development Center Guangzhou Koncen Bioscience Co., Ltd. Guangzhou PR China
- Guangdong Provincial Key Laboratory of Hemoadsorption Technology Guangzhou PR China
| | - Zhennan Lin
- Research and Development Center Guangzhou Koncen Bioscience Co., Ltd. Guangzhou PR China
- Guangdong Provincial Key Laboratory of Hemoadsorption Technology Guangzhou PR China
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Yao G, Huang C, Ji F, Ren J, Zang B, Jia L. Nanobody-loaded immunosorbent for highly-specific removal of interleukin-17A from blood. J Chromatogr A 2021; 1654:462478. [PMID: 34450522 DOI: 10.1016/j.chroma.2021.462478] [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: 05/21/2021] [Revised: 08/13/2021] [Accepted: 08/14/2021] [Indexed: 10/20/2022]
Abstract
Elimination of overproduced cytokines from blood can relieve immune system disorders caused by hypercytokinemia. Due to the central roles of interleukin-17A (IL-17A) plays in regulating the immunity and inflammatory responses in humans, here, a novel immunosorbent containing anti-IL-17A nanobodies (Nbs) was constructed for IL-17A removal from blood. The theoretical maximum adsorption capacity estimated from the Langmuir isotherm is up to 11.55 mg/g gel, which is almost consistent with the saturated adsorption capacity determined in dynamic adsorption. The in vitro plasma perfusion test demonstrated a remarkable adsorptive performance of the Nb-coupled sorbent since more than 75% IL-17A could be eliminated under the plasma/sorbent ratio of 1000:1. These results indicated the Nb-loaded immunosorbent can provide a simple and economic platform technology for immunoaffinity depletion of single or even multiple cytokines from plasma.
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Affiliation(s)
- Guangshuai Yao
- Liaoning Key Laboratory of Molecular Recognition and imaging, School of Bioengineering, Dalian University of Technology, No.2 Linggong Road, Dalian, Liaoning 116023, PR China
| | - Chundong Huang
- Liaoning Key Laboratory of Molecular Recognition and imaging, School of Bioengineering, Dalian University of Technology, No.2 Linggong Road, Dalian, Liaoning 116023, PR China
| | - Fangling Ji
- Liaoning Key Laboratory of Molecular Recognition and imaging, School of Bioengineering, Dalian University of Technology, No.2 Linggong Road, Dalian, Liaoning 116023, PR China
| | - Jun Ren
- Liaoning Key Laboratory of Molecular Recognition and imaging, School of Bioengineering, Dalian University of Technology, No.2 Linggong Road, Dalian, Liaoning 116023, PR China
| | - Berlin Zang
- Liaoning Key Laboratory of Molecular Recognition and imaging, School of Bioengineering, Dalian University of Technology, No.2 Linggong Road, Dalian, Liaoning 116023, PR China
| | - Lingyun Jia
- Liaoning Key Laboratory of Molecular Recognition and imaging, School of Bioengineering, Dalian University of Technology, No.2 Linggong Road, Dalian, Liaoning 116023, PR China.
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Li Y, Ji XJ, Jing DY, Huang ZH, Duan ML. Successful treatment of gastrointestinal infection-induced septic shock using the oXiris ® hemofilter: A case report. World J Clin Cases 2021; 9:8157-8163. [PMID: 34621875 PMCID: PMC8462223 DOI: 10.12998/wjcc.v9.i27.8157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 07/26/2021] [Accepted: 08/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Septic shock leads to multiple organ failure, and bacterial endotoxins and endogenous cytokines play essential roles in the pathogenesis. The oXiris® hemofilter can efficiently adsorb endotoxins and cytokines.
CASE SUMMARY We admitted a critically ill 59 year-old male patient with gastrointestinal septic shock due to infection by a Gram-negative bacterium and septic acute kidney injury (AKI). Prior to intensive care unit admission, the patient reported intermittent diarrhea and decreased urine output. His blood pressure was 70/40 mmHg, necessitating fluid resuscitation and large doses of noradrenaline. Based on the results of a blood culture and the presence of hypotension, oliguria, and hypoxemia, we diagnosed septic shock, AKI, and multiple organ dysfunction. We administered continuous renal replacement therapy (CRRT) with an oXiris® hemofilter for 72 h with intermittent continuous veno-venous hemodiafiltration (CVVHDF), and changed the filter every 12 h. After his hemodynamic parameters were stable, we used a traditional filter (AN69 hemofilter) with intermittent CVVHDF. The 72 h CRRT with the oXiris® hemofilter led to stabilization of his vital signs, marked reductions in disease severity scores, and decreased levels of procalcitonin, endotoxin, and inflammatory factors. After 8 d of CRRT, his kidney function had completely recovered.
CONCLUSION We conclude that the oXiris® hemofilter combined with appropriate antibacterial therapy was an effective treatment for this patient with gastrointestinal septic shock.
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Affiliation(s)
- Yu Li
- Department of Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Xiao-Jun Ji
- Department of Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Dan-Yang Jing
- Department of Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zheng-Hui Huang
- Department of Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Mei-Li Duan
- Department of Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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Abstract
Objectives: Our understanding of the immunopathogenesis of coronavirus disease 2019 is evolving; however, a “cytokine storm” has been implicated. Ongoing clinical trials are evaluating the value of anticytokine therapies to treat patients with coronavirus disease 2019. This review summarizes the existing literature evaluating the efficacy and safety of anticytokine therapy to tackle the dysregulated immune response to infectious pathogens, discusses potential reasons for failure, applicability to coronavirus disease 2019, and future direction. Data Sources: Medline, PubMed, ClinicalTrials.gov, and media reports. Study Selection: The studies were included by author consensus. Data Extraction: Data were selected for inclusion after reviewing each study by author consensus. Data Synthesis: “Cytokine storm” is a nonspecific term, encompassing systemic inflammatory response to infectious pathogens, autoimmune conditions, cancers, trauma, and various chemotherapies. Like bacterial sepsis, viral pathogens may fuel immunopathogenesis by inducing a dysregulated autoamplifying cytokine cascade, ultimately leading to organ injury. This narrative review discusses what we know of the immune milieu of coronavirus disease 2019 versus noncoronavirus disease 2019 sepsis and/or acute respiratory distress syndrome, summarizes the existing literature on cytokine inhibitors in patients with sepsis and/or acute respiratory distress syndrome, and discusses possible reasons for recurrent failure. In doing so, it aims to assist decisions regarding the use of anticytokine therapy in patients with coronavirus disease 2019, as many regions of the world confront the second wave of the pandemic. Conclusions: As ongoing clinical trials determine the efficacy and safety of anticytokine therapy in patients with coronavirus disease 2019, clinicians should uphold caution when incorporating it into treatment protocols, while maintaining focus on established evidence-based practices and the mantra of “less is more.”
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Continuous Renal Replacement Therapy (CRRT) for Nonrenal Indications among Critically Ill Children with Malignancy. Case Rep Pediatr 2021; 2021:6660466. [PMID: 33791137 PMCID: PMC7984898 DOI: 10.1155/2021/6660466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/08/2021] [Accepted: 02/22/2021] [Indexed: 11/22/2022] Open
Abstract
The role of continuous renal replacement therapy (CRRT) has been expanding beyond support for acute kidney injury (AKI) in recent years. Children with malignancy are particularly at risk of developing conditions that may require CRRT. We reported three children with malignancy who received CRRT for non-AKI indications. Patient 1 was a 17-year-old teenage girl who developed refractory type B lactic acidosis due to relapse of acute lymphoblastic leukemia (ALL). Her peak lactate level was 18 mmol/L, and the lowest pH and bicarbonate level was 7.13 and 6.0 mmol/L, respectively. She received three sessions of high-volume hemodiafiltration to bring down the lactate level. Patient 2 was a 15-year-old male with T-cell ALL who developed cytokine storm requiring mechanical ventilatory and high-dose inotropic support due to necrotizing enterocolitis complicated by pneumoperitoneum and Klebsiella pneumoniae septicemia. He received two sessions of hemoperfusion using a specific filter capable of endotoxin absorption and cytokine removal and was successfully weaned off all inotropes after the treatment. Patient 3 was an 8-year-old boy who received bone marrow transplantation and developed worsening hyperbilirubinemia and deteriorating liver function. He received a session of single-pass albumin dialysis for bilirubin removal prior to liver biopsy. Except for mild electrolyte disturbances, no major CRRT complication was encountered. Our report demonstrated that CRRT is an effective and safe procedure for a wide spectrum of nonrenal conditions among children with oncological diagnoses in the pediatric intensive care unit. However, the optimal dose, regime, timing of initiation, and monitoring target for these indications remain to be determined.
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11
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Abstract
Acute kidney injury (AKI) is one of the most frequent complications of sepsis. Because sepsis and AKI synergistically worsen the outcomes of critically ill patients, better therapeutics against septic AKI urgently are required. In addition to the complexity of disease mechanisms of both sepsis and AKI, there is substantial regional variation in clinical practice, which further hampers the development of new treatments for septic AKI. To overcome this problem, evidence accumulation is necessary for building the foundation for developing novel septic AKI treatments. This review provides a summary of updated evidence regarding septic AKI from Asian regions.
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Affiliation(s)
- Kohei Yoshimoto
- Department of Acute Medicine, University of Tokyo, Tokyo, Japan
| | - Yohei Komaru
- Department of Nephrology and Endocrinology, University of Tokyo, Tokyo, Japan
| | - Masao Iwagami
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Kent Doi
- Department of Acute Medicine, University of Tokyo, Tokyo, Japan.
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Wei T, Chen Z, Li P, Tang X, Marshall MR, Zhang L, Fu P. Early use of endotoxin absorption by oXiris in abdominal septic shock: A case report. Medicine (Baltimore) 2020; 99:e19632. [PMID: 32664051 PMCID: PMC7360291 DOI: 10.1097/md.0000000000019632] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Septic shock leads to multiple organ failure and increases mortality rate. We reported a critical patient with abdominal septic shock, which was the first case successfully treated with continuous renal replacement therapy (CRRT) and a newly designed endotoxin removal device oXiris in mainland China. PATIENT CONCERNS A 51-year-old man developed gastric ulcer perforation after resection of a benign peritoneal tumor and had a second abdominal surgery. His blood pressure decreased to 70/40 mm Hg with oliguria, requiring large doses of noradrenaline and intravenous fluid for resuscitation. The abdominal cavity was not sutured after the second open surgery due to severe abdominal infection and distention. His leukocyte count was over 30109/L, while the blood lactic acid was 12.5 mmol/L and procalcitonin (PCT) was >100 ng/mL. DIAGNOSIS Since the bacterial culture of peritoneal exudate showed positive with Enterobacter aerogenes and Pseudomonas aeruginosa after the second surgery, and the patient had severe low blood pressure, hyoxemia and oliguria, combined with the laboratory tests results, he was diagnosed with Gram-negative related septic shock, acute kidney injury, and multiple organ dysfunction. INTERVENTIONS CRRT with oXiris membrane was performed for 80hours and followed by AN69 ST membranes during the subsequent 27 days. Antibiotics together with other medical treatment were applied to the patient in the meantime. OUTCOMES At the end of 80 hours treatment with oXiris, PCT of the patient had decreased to 14.52 ng/mL and lactic acid decreased to 4.2 mmol/L. The total sequential organ failure assessment (SOFA) score decreased from 15 to 11. Urine output steadily increased to 250 mL/h, and vital signs and blood pressure were stable without noradrenaline. At the end of the 27 days of conventional CRRT, his kidney function had completely recovered with a total sequential organ failure assessment score (SOFA score) of 6. LESSONS oXiris, with its enhanced endotoxin adsorption, appeared to accelerate improvement in organ dysfunction and ultimate survival in our patient. In critical patients with abdominal septic shock, oXiris is an important adjunctive consideration to supplement definitive source control and antimicrobial therapy.
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Affiliation(s)
- Tiantian Wei
- Department of Nephrology, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Zhiwen Chen
- Department of Nephrology, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Peiyun Li
- Department of Nephrology, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Xin Tang
- Department of Nephrology, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Mark R. Marshall
- Department of Renal Medicine, Middlemore Hospital, Auckland 93311, New Zealand
- Medical Affairs, Baxter Healthcare (Asia) Pte Ltd., 189720, Singapore
| | - Ling Zhang
- Department of Nephrology, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Ping Fu
- Department of Nephrology, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China
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Li Y, Zhou L, Yang L, Yuan F. Septic shock after liver transplantation successfully treated with endotoxin and cytokine adsorption continuous renal replacement therapy: a case report and literature review. J Int Med Res 2020; 48:300060520940439. [PMID: 32686965 PMCID: PMC7372632 DOI: 10.1177/0300060520940439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/17/2020] [Indexed: 02/05/2023] Open
Abstract
Endotoxins and cytokines play an important role in multiple organ failure pathogenesis in patients with severe Gram-negative bacterial infection. We present a clinical case where an oXiris hemofilter was used for continuous renal replacement therapy (CRRT) treatment in a patient with septic shock after liver transplantation. A 35-year-old man with a 20-year history of hepatitis B presented with jaundice, loss of appetite, and decreased urine output. He was diagnosed with decompensated cirrhosis with acute-on-chronic liver failure, and liver transplantation was indicated. The day after surgery, he developed hyperthermia, hypotension, anuria, and a progressive increase in blood inflammatory markers and creatinine. Combined with the donor source and blood culture results, septic shock after transplantation was considered. The patient was immediately treated with endotoxin and cytokine adsorption CRRT (oXiris hemofilter) with tigecycline, caspofungin, and ganciclovir as anti-infectives. After 48 hours on CRRT, his blood pressure gradually stabilized, the CLIF Consortium Acute-on-Chronic Liver Failure score decreased from 63 to 43. Procalcitonin, endotoxin, and the inflammatory factors interleukin (IL)-6 and IL-10 also decreased gradually. The patient's liver and kidney functions were completely restored. Our experience suggests that oXiris CRRT combined with antibacterial therapy is an effective treatment for septic shock after liver transplantation.
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Affiliation(s)
- Yining Li
- Department of Organ Transplantation, The Second Xiangya Hospital of
Central South University, Changsha, China
| | - Linshan Zhou
- Department of Nephrology, ESRD Center of the Second Xiangya Hospital,
Central South University, Changsha, China
| | - Lingzhi Yang
- Department of Nephrology, ESRD Center of the Second Xiangya Hospital,
Central South University, Changsha, China
| | - Fang Yuan
- Department of Nephrology, ESRD Center of the Second Xiangya Hospital,
Central South University, Changsha, China
- Fang Yuan, Department of Nephrology, The Second
Xiangya Hospital of Central South University, No. 139 Renmin Road, Changsha 410011, China.
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14
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Abstract
Sepsis is the primary cause of acute kidney injury in critically ill patients. During the past decades, several extracorporeal blood purification techniques have been developed for sepsis and sepsis-induced acute kidney injury management. These therapies could act on both the infectious agent itself and the host immune response. In this article, we review the available literature discussing the different extracorporeal blood purification techniques, including high-volume hemofiltration, cascade hemofiltration, hemoperfusion, coupled plasma filtration adsorption, plasma exchange, and specific optimized renal replacement therapy membranes.
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Affiliation(s)
- Thibaut Girardot
- Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France; EA 7426 PI3 (Pathophysiology of Injury‑Induced Immunosuppression), Claude Bernard University Lyon 1, Biomérieux, Hospices Civils de Lyon, Lyon, France.
| | - Antoine Schneider
- Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Thomas Rimmelé
- Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France; EA 7426 PI3 (Pathophysiology of Injury‑Induced Immunosuppression), Claude Bernard University Lyon 1, Biomérieux, Hospices Civils de Lyon, Lyon, France
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15
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Lumlertgul N, Srisawat N. The haemodynamic effects of oXiris haemofilter in septic shock patients requiring renal support: A single-centre experience. Int J Artif Organs 2020; 44:17-24. [PMID: 32393096 DOI: 10.1177/0391398820917150] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Excessive pro-inflammatory and anti-inflammatory cytokines are mediators for haemodynamic alterations, metabolic acidosis, and multi-organ failure in sepsis. Recently, oXiris® haemofilter (Baxter, IL, USA) has been introduced as a novel haemofilter to mitigate inflammatory response during sepsis-associated acute kidney injury requiring renal replacement therapy. In the present case series, the researchers retrospectively reviewed critically ill patients with septic shock with the use of at least one oXiris haemofilter during continuous renal replacement therapy between June 2015 and December 2017. The timing for oXiris initiation was at the nephrologists' discretion. The impact of oXiris haemofilter was evaluated on mean arterial pressure, vasopressor dosage, Sequential Organ Failure Assessment score, lactate and base excess during 72 h after treatment. Thirty-five patients were enrolled in the study. An improvement of haemodynamic status was found, shown by increased mean arterial pressure by 6.1% (p = 0.35), decreased norepinephrine dose by 45.9% (p = 0.02), inotropic score by 26.4% (p = 0.02) and vasopressor dependency index by 40.5% (p = 0.01). Cardiovascular Sequential Organ Failure Assessment scores significantly decreased over 72 h (p = 0.02). Blood lactate levels and base excess also showed statistically significant improvements. The median filter lifetime was 23 (interquartile range = 14-36) hours. The intensive care unit mortality was 82.9%. Treatment with oXiris was safe and well-tolerated with no device-related adverse events. In conclusion, continuous renal replacement therapy with oXiris haemofilter is safe and may improve haemodynamic parameters in septic patients with severe renal dysfunction. Nonetheless, these findings were drawn from a retrospective analysis without a control group, and therefore cannot be generalised. Randomised controlled trials are warranted to confirm these findings.
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Affiliation(s)
- Nuttha Lumlertgul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center for Critical Care Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center for Critical Care Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Academy of Science, Royal Society of Thailand, Bangkok, Thailand.,Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand
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16
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An update on membranes and cartridges for extracorporeal blood purification in sepsis and septic shock. Curr Opin Crit Care 2019; 24:463-468. [PMID: 30247215 DOI: 10.1097/mcc.0000000000000542] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review aims to summarize the most recent advances on different membranes and cartridges used for extracorporeal blood purification in critically ill patients with sepsis or septic shock. RECENT FINDINGS Despite positive signals from experimental, cases and small clinical studies, blood purification showed no distinct morbidity and mortality benefit in large clinical trials. SUMMARY None of the discussed specific membranes or cartridges can currently be recommended as sole adjunctive treatment in sepsis and septic shock. Any available technique should be timely initiated and adapted to the patient's status. Sickest patients seem to benefit more from blood purification. Patient selection is thus of crucial importance and may be optimized by focusing on disease severity and degree of organ failure. Measurement of endotoxin activity and plasma procalcitonin levels can support the selection process but ideal cutoff values need to be defined. Well-designed prospective randomized clinical trials assessing or comparing the various available membranes and cartridges are eagerly awaited.
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17
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Napp LC, Ziegeler S, Kindgen-Milles D. Rationale of Hemoadsorption during Extracorporeal Membrane Oxygenation Support. Blood Purif 2019; 48:203-214. [PMID: 31096211 PMCID: PMC6878728 DOI: 10.1159/000500015] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/29/2019] [Indexed: 12/14/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) and extracorporeal life support are increasingly used for treating various forms of shock, lung failure, protected interventions and life support including resuscitation. Most patients on ECMO are affected by a systemic inflammatory response caused by the underlying disease as well as the ECMO support itself, which contributes to vasoplegia, multi-organ failure, deterioration and death. Unfortunately, effective strategies for control of inflammation and related organ failure and shock on ECMO are lacking. Recently, a new polystyrene-based device for hemoadsorption, which aims to reduce excessive levels of inflammatory molecules such as interleukins, cytokines as well as damage- and pathogen-associated molecular patterns, has become available. Here we summarize the rationale, available data and technical aspects of polystyrene-based hemoadsorption during ECMO support, and give recommendations based on existing experience.
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Affiliation(s)
- L Christian Napp
- Department of Cardiology and Angiology, Cardiac Arrest Center, Advanced Heart Failure Unit, Hannover Medical School, Hannover, Germany,
| | - Stephan Ziegeler
- Department of Anesthesiology, Operative Intensive Care Medicine, Pain Management and Emergency Medicine, Hospital Ibbenbüren, Ibbenbüren, Germany
| | - Detlef Kindgen-Milles
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
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18
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Bottari G, Di Nardo M, Gleeson J, Minoia F, Moscatelli A, Cecchetti C, Verrina EE. Extracorporeal blood purification techniques in children with hyper-inflammatory syndromes: a clinical overview. Minerva Anestesiol 2019; 85:531-542. [DOI: 10.23736/s0375-9393.19.13189-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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19
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Chaïbi K, Barbar S, Quenot JP, Dreyfuss D, Gaudry S. Retarder une épuration extrarénale dans l’insuffisance rénale aiguë : la nuit nous appartient. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2018-0081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Les indications de l’épuration extrarénale (EER) dans le contexte d’insuffisance rénale aiguë en réanimation sont débattues avec une certaine passion. Il est évident que les situations qui peuvent menacer immédiatement le pronostic vital (hyperkaliémie ou acidose métabolique réfractaire et sévère ou oedème pulmonaire de surcharge chez le patient anurique) nécessitent un recours urgent à l’EER. Hormis ces situations extrêmes, des études de haut niveau de preuve ont récemment montré que retarder l’indication de l’EER n’affecte pas la survie des patients et pourrait même favoriser la récupération de la fonction rénale par comparaison à une EER trop précoce. Cette mise au point se propose de discuter les risques théoriques liés au fait de différer l’EER et s’attache à montrer qu’ils constituent plus des craintes que des réalités.
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20
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Kobashi S, Maruhashi T, Nakamura T, Hatabayashi E, Kon A. The 28-day survival rates of two cytokine-adsorbing hemofilters for continuous renal replacement therapy: a single-center retrospective comparative study. Acute Med Surg 2018; 6:60-67. [PMID: 30651999 PMCID: PMC6328921 DOI: 10.1002/ams2.382] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 11/02/2018] [Indexed: 12/29/2022] Open
Abstract
Aim Continuous renal replacement therapy (CRRT) with a cytokine‐adsorbing hemofilter (CAH) is effective in the treatment of sepsis. Two filter types, namely polymethyl methacrylate (PMMA) and surface‐treated AN69 (AN69ST) hemofilters, have been successfully used for CRRT, but no direct comparisons have been published to date. This study compared the efficacy, as measured by 28‐day survival rates, of PMMA and AN69ST hemofilters in patients receiving CAH‐CRRT. Methods This retrospective observational study reviewed the medical records of 142 patients who received CAH‐CRRT between November 2013 and February 2015. Results The 28‐day survival rates were higher in the AN69ST group than in the PMMA group for patients with or without sepsis (all patients, 79.4% versus 54.1%; patients with sepsis, 77.3% versus 50.0%; patients without sepsis, 83.3% versus 57.5%; P < 0.05). No significant differences were observed regarding 28‐day survival rates of patients with or without sepsis (AN69ST, 77.3% versus 83.3%; P = 0.51; PMMA, 50.0% versus 57.5%; P = 0.61) using the same hemofilter. Conclusion The AN69ST hemofilter could be more effective than PMMA hemofilters for improving the survival outcomes of patients with or without sepsis.
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Affiliation(s)
- Shuichi Kobashi
- Faculty of Clinical Engineering Hachinohe City Hospital Aomori Japan
| | - Takaaki Maruhashi
- Department of Emergency and Critical Care Medicine Kitasato University School of Medicine Sagamihara Kanagawa Japan.,Emergency and Critical Care Center Hachinohe City Hospital Aomori Japan
| | - Tomoya Nakamura
- Faculty of Clinical Engineering Hachinohe City Hospital Aomori Japan
| | - Erika Hatabayashi
- Faculty of Clinical Engineering Hachinohe City Hospital Aomori Japan
| | - Akihide Kon
- Emergency and Critical Care Center Hachinohe City Hospital Aomori Japan
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21
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22
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Abstract
It is now well established that profound immunosuppression develops within a few days after sepsis onset in patients. This should be considered additional organ failure because it is associated with increased rate of nosocomial infections, mortality, and long-term complications, thus constituting the rationale for immunomodulation in patients. Nevertheless, the demonstration of the efficacy of such therapeutic strategy in improving deleterious outcomes in sepsis remains to be made. Results from clinical trials based on interleukin 7 and granulocyte macrophage colony-stimulating factor immunoadjuvant therapies in septic shock patients are expected for 2018.
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Affiliation(s)
- Fabienne Venet
- Laboratoire d'Immunologie, Cellular Immunology Laboratory, Hospices Civils de Lyon, Hôpital Edouard Herriot, Pavillon E - 5 place d'Arsonval, Lyon Cedex 03 69437, France; EA 7426 PI3 "Pathophysiology of Injury-induced Immunosuppression", Université Claude Bernard Lyon I, Hospices Civils de Lyon, bioMérieux, Hôpital Edouard Herriot, Place d'Arsonval, Lyon Cedex 03 69437, France
| | - Thomas Rimmelé
- EA 7426 PI3 "Pathophysiology of Injury-induced Immunosuppression", Université Claude Bernard Lyon I, Hospices Civils de Lyon, bioMérieux, Hôpital Edouard Herriot, Place d'Arsonval, Lyon Cedex 03 69437, France; Departement of Anesthesiology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Pavillon E - 5 place d'Arsonval, Lyon Cedex 03 69437, France
| | - Guillaume Monneret
- Laboratoire d'Immunologie, Cellular Immunology Laboratory, Hospices Civils de Lyon, Hôpital Edouard Herriot, Pavillon E - 5 place d'Arsonval, Lyon Cedex 03 69437, France; EA 7426 PI3 "Pathophysiology of Injury-induced Immunosuppression", Université Claude Bernard Lyon I, Hospices Civils de Lyon, bioMérieux, Hôpital Edouard Herriot, Place d'Arsonval, Lyon Cedex 03 69437, France; TRIGGERSEP (TRIal Group for Global Evaluation and Research in SEPsis), F-CRIN Network, France.
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23
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Doi K, Iwagami M, Yoshida E, Marshall MR. Associations of Polyethylenimine-Coated AN69ST Membrane in Continuous Renal Replacement Therapy with the Intensive Care Outcomes: Observations from a Claims Database from Japan. Blood Purif 2017; 44:184-192. [PMID: 28609776 PMCID: PMC5804855 DOI: 10.1159/000476052] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/24/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND/AIMS Polyethylenimine-coated polyacrylonitrile (AN69ST) membrane is expected to improve the outcomes of critically ill patients treated by continuous renal replacement therapy (CRRT). METHODS Using a Japanese health insurance claim database, we identified adult patients receiving CRRT in intensive care units (ICUs) from April 2014 to October 2015. We used a multivariable logistic regression model to assess in-hospital mortality and Fine and Gray's proportional subhazards model to assess the ICU length of stay (ICU-LOS) accounting for the competing risks. RESULTS Of 2,469 ICU patients, 156 were treated by AN69ST membrane. Crude in-hospital mortality was 50.0% in the AN69ST group and 54.0% in the non-AN69ST group. Adjusted odds ratio (OR) of AN69ST membrane use for in-hospital mortality was 0.65 (95% CI 0.45-0.93). The use of AN69ST membrane was also independently associated with shorter ICU-LOS. CONCLUSION This retrospective observational study suggested that CRRT with AN69ST membrane might be associated with better in-hospital outcomes.
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Affiliation(s)
- Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo, Japan
| | - Masao Iwagami
- London School of Hygiene and Tropical Medicine, London, England
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24
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Ma S, Xu Q, Deng B, Zheng Y, Tian H, Wang L, Ding F. Granulocyte and monocyte adsorptive apheresis ameliorates sepsis in rats. Intensive Care Med Exp 2017; 5:18. [PMID: 28342161 PMCID: PMC5366986 DOI: 10.1186/s40635-017-0129-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 03/08/2017] [Indexed: 01/07/2023] Open
Abstract
Background Overwhelming activation of granulocytes and monocytes is central to inflammatory responses during sepsis. Granulocyte and monocyte adsorptive apheresis (GMA) is an extracorporeal leukocyte apheresis device filled with cellulose acetate beads and selectively adsorbs granulocytes and monocytes from the peripheral blood. Methods In this study, septic rats received the GMA treatment for 2 h at 18 h after cecal ligation and puncture. Results GMA selectively adsorbed activated neutrophils and monocytes from the peripheral blood, reduced serum inflammatory cytokine expression, and seemed to improve organ injuries and animal survival. GMA potentially reduced lung injury by alleviating the infiltration of inflammatory cells and the secretion of cytokines. Conclusions This study showed that selective granulocyte and monocyte adsorption with cellulose acetate beads might ameliorate cecal ligation and puncture (CLP)-induced sepsis and improve survival and organ function.
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Affiliation(s)
- Shuai Ma
- Division of Nephrology & Unit of Critical Nephrology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiaotong University, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Qingqing Xu
- Division of Nephrology & Unit of Critical Nephrology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiaotong University, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Bo Deng
- Division of Nephrology & Unit of Critical Nephrology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiaotong University, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Yin Zheng
- Division of Nephrology, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, China
| | - Hongyan Tian
- Division of Nephrology & Unit of Critical Nephrology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiaotong University, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Li Wang
- Division of Nephrology & Unit of Critical Nephrology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiaotong University, 639 Zhizaoju Road, Shanghai, 200011, China.
| | - Feng Ding
- Division of Nephrology & Unit of Critical Nephrology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiaotong University, 639 Zhizaoju Road, Shanghai, 200011, China.
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25
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Hattori N, Oda S. Cytokine-adsorbing hemofilter: old but new modality for septic acute kidney injury. RENAL REPLACEMENT THERAPY 2016. [DOI: 10.1186/s41100-016-0051-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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26
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Li Bassi G, Marti JD, Xiol EA, Comaru T, De Rosa F, Rigol M, Terraneo S, Rinaudo M, Fernandez L, Ferrer M, Torres A. The effects of direct hemoperfusion using a polymyxin B-immobilized column in a pig model of severe Pseudomonas aeruginosa pneumonia. Ann Intensive Care 2016; 6:58. [PMID: 27378201 PMCID: PMC4932027 DOI: 10.1186/s13613-016-0155-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 06/02/2016] [Indexed: 02/06/2023] Open
Abstract
Background Hemoperfusion through a column containing polymyxin B-immobilized fiber (PMX-HP) is beneficial in abdominal sepsis. We assessed the effects of PMX-HP in a model of severe Pseudomonas aeruginosa pneumonia. Methods Eighteen pigs with severe P. aeruginosa pneumonia were mechanically ventilated for 76 h. Pigs were randomized to receive standard treatment with fluids and vasoactive drugs, or standard treatment with two 3-h PMX-HP sessions. Antibiotics against P. aeruginosa were never administered. We assessed endotoxemia through the endotoxin activity assay (EA). We measured the static lung elastance, ratio of arterial partial pressure per inspiratory fraction of oxygen (PaO2/FIO2), mean arterial pressure, cardiac output, systemic vascular resistance and inotropic score. Finally, every 24 h, we assessed complete blood count. Results In comparison with the control group, PMX-HP decreased percentage of circulating neutrophils from 47.4 ± 13.8 to 40.8 ± 11.5 % (p = 0.009). In a subgroup of animals with the worst hemodynamic impairment, EA in the control and PMX-HP groups was 0.50 ± 0.29 and 0.29 ± 0.14, respectively (p = 0.018). Additionally, in the control and PMX-HP groups, static lung elastance was 26.9 ± 8.7 and 25.3 ± 7.5 cm H2O/L (p = 0.558), PaO2/FIO2 was 347.3 ± 61.9 and 356.4 ± 84.0 mmHg (p = 0.118), mean arterial pressure was 81.2 ± 10.3 and 81.6 ± 13.1 mmHg (p = 0.960), cardiac output was 3.30 ± 1.11 and 3.28 ± 1.19 L/min (p = 0.535), systemic vascular resistance was 1982.6 ± 608.4 and 2011.8 ± 750.0 dyne/s/cm–5 (p = 0.939), and inotropic score was 0.25 ± 0.10 and 0.26 ± 0.18 (p = 0.864). Conclusions In mechanically ventilated pigs with severe P. aeruginosa pneumonia, PMX-HP does not have any valuable clinical benefit, and studies are warranted to fully evaluate a potential role of PMX-HP in septic shock associated with severe pulmonary infections. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0155-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gianluigi Li Bassi
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Majorca, Spain.,University of Barcelona, Barcelona, Spain
| | - Joan Daniel Marti
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Majorca, Spain
| | - Eli Aguilera Xiol
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, Barcelona, Spain.,Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Majorca, Spain
| | - Talitha Comaru
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, Barcelona, Spain
| | - Francesca De Rosa
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, Barcelona, Spain.,University of Milan, Milan, Italy
| | - Montserrat Rigol
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Majorca, Spain
| | - Silvia Terraneo
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, Barcelona, Spain.,University of Milan, Milan, Italy
| | - Mariano Rinaudo
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, Barcelona, Spain
| | - Laia Fernandez
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Majorca, Spain.,University of Barcelona, Barcelona, Spain.,Research Laboratory, Department of Pulmonary and Critical Care Medicine, Hospital Clinic, Barcelona, Spain
| | - Miguel Ferrer
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Majorca, Spain.,University of Barcelona, Barcelona, Spain
| | - Antoni Torres
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, Barcelona, Spain. .,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. .,Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Majorca, Spain. .,University of Barcelona, Barcelona, Spain.
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Girardot T, Venet F, Rimmelé T. Immunomodulation: The Future for Sepsis? ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2016. [DOI: 10.1007/978-3-319-27349-5_5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Extracorporeal liver assist device to exchange albumin and remove endotoxin in acute liver failure: Results of a pivotal pre-clinical study. J Hepatol 2015; 63:634-42. [PMID: 25937432 PMCID: PMC4541472 DOI: 10.1016/j.jhep.2015.04.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Revised: 04/04/2015] [Accepted: 04/22/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS In acute liver failure, severity of liver injury and clinical progression of disease are in part consequent upon activation of the innate immune system. Endotoxaemia contributes to innate immune system activation and the detoxifying function of albumin, critical to recovery from liver injury, is irreversibly destroyed in acute liver failure. University College London-Liver Dialysis Device is a novel artificial extracorporeal liver assist device, which is used with albumin infusion, to achieve removal and replacement of dysfunctional albumin and reduction in endotoxaemia. We aimed to test the effect of this device on survival in a pig model of acetaminophen-induced acute liver failure. METHODS Pigs were randomised to three groups: Acetaminophen plus University College London-Liver Dialysis Device (n=9); Acetaminophen plus Control Device (n=7); and Control plus Control Device (n=4). Device treatment was initiated two h after onset of irreversible acute liver failure. RESULTS The Liver Dialysis Device resulted in 67% reduced risk of death in acetaminophen-induced acute liver failure compared to Control Device (hazard ratio=0.33, p=0.0439). This was associated with 27% decrease in circulating irreversibly oxidised human non-mercaptalbumin-2 throughout treatment (p=0.046); 54% reduction in overall severity of endotoxaemia (p=0.024); delay in development of vasoplegia and acute lung injury; and delay in systemic activation of the TLR4 signalling pathway. Liver Dialysis Device-associated adverse clinical effects were not seen. CONCLUSIONS The survival benefit and lack of adverse effects would support clinical trials of University College London-Liver Dialysis Device in acute liver failure patients.
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Jacquet-Lagrèze M, Allaouchiche B, Restagno D, Paquet C, Ayoub JY, Etienne J, Vandenesch F, Dauwalder O, Bonnet JM, Junot S. Gut and sublingual microvascular effect of esmolol during septic shock in a porcine model. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:241. [PMID: 26041462 PMCID: PMC4490718 DOI: 10.1186/s13054-015-0960-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 05/21/2015] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Esmolol may efficiently reduce heart rate (HR) and decrease mortality during septic shock. An improvement of microcirculation dissociated from its macrocirculatory effect may a role. The present study investigated the effect of esmolol on gut and sublingual microcirculation in a resuscitated piglet model of septic shock. METHODS Fourteen piglets, anesthetized and mechanically ventilated, received a suspension of live Pseudomonas aeruginosa. They were randomly assigned to two groups: the esmolol (E) group received an infusion of esmolol, started at 7.5 μg⋅kg(-1)⋅min(-1), and progressively increased to achieve a HR below 90 beats⋅min(-1). The control (C) group received an infusion of Ringer's lactate solution. HR, mean arterial pressure (MAP), cardiac index (CI), stroke index (SI), systemic vascular resistance (SVR), arterio-venous blood gas and lactate were recorded. Oxygen consumption (VO2), delivery (DO2) and peripheral extraction (O2ER) were computed. Following an ileostomy, a laser Doppler probe was applied on ileal mucosa to monitor gut microcirculatory laser Doppler flow (GMLDF). Videomicroscopy was also used on ileal mucosa and sublingual areas to evaluate mean flow index (MFI), heterogeneity, ratio of perfused villi and proportion of perfused vessels. Resuscitation maneuvers were performed following a defined algorithm. RESULTS Bacterial infusion induced a significant alteration of the gut microcirculation with an increase in HR. Esmolol produced a significant time/group effect with a decrease in HR (P <0.004) and an increase in SVR (P <0.004). Time/group effect was not significant for CI and MAP, but there was a clear trend toward a decrease in CI and MAP in the E group. Time/group effect was not significant for SI, O2ER, DO2, VO2, GMLDF and lactate. A significant time/group effect of ileal microcirculation was found with a lower ileal villi perfusion (P <0.025) in the C group, and a trend toward a better MFI in the E group. No difference between both groups was found regarding microcirculatory parameters in the sublingual area. CONCLUSIONS Esmolol provided a maintenance of microcirculation during sepsis despite its negative effects on macrocirculation. Some parameters even showed a trend toward an improvement of the microcirculation in the gut area in the esmolol group.
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Affiliation(s)
- Matthias Jacquet-Lagrèze
- Service d'anesthésie-réanimation, Hospices Civils de Lyon, Hôpital Edouard-Herriot, 5 place d'Arsonval, 69437, Lyon, Cedex 03, France.
| | - Bernard Allaouchiche
- Service d'anesthésie-réanimation, Hospices Civils de Lyon, Hôpital Edouard-Herriot, 5 place d'Arsonval, 69437, Lyon, Cedex 03, France. .,Université Claude-Bernard, Lyon 1. Campus Lyon Santé Est, 8 avenue Rockefeller, 69008, Lyon, France.
| | - Damien Restagno
- EA 4174 Sepsis Inflammation Hémostase, Université de Lyon, VetAgro Sup - Campus Vétérinaire de Lyon, 1 Avenue Bourgelat, 69280, Marcy-l'Étoile, France.
| | - Christian Paquet
- EA 4174 Sepsis Inflammation Hémostase, Université de Lyon, VetAgro Sup - Campus Vétérinaire de Lyon, 1 Avenue Bourgelat, 69280, Marcy-l'Étoile, France.
| | - Jean-Yves Ayoub
- EA 4174 Sepsis Inflammation Hémostase, Université de Lyon, VetAgro Sup - Campus Vétérinaire de Lyon, 1 Avenue Bourgelat, 69280, Marcy-l'Étoile, France.
| | - Jêrome Etienne
- Université Claude-Bernard, Lyon 1. Campus Lyon Santé Est, 8 avenue Rockefeller, 69008, Lyon, France. .,Laboratory of Microbiology, Groupement Hospitalier Est, 59 Boulevard Pinel, 69500, Bron, France.
| | - François Vandenesch
- Université Claude-Bernard, Lyon 1. Campus Lyon Santé Est, 8 avenue Rockefeller, 69008, Lyon, France. .,Laboratory of Microbiology, Groupement Hospitalier Est, 59 Boulevard Pinel, 69500, Bron, France.
| | - Olivier Dauwalder
- Laboratory of Microbiology, Groupement Hospitalier Est, 59 Boulevard Pinel, 69500, Bron, France.
| | - Jeanne-Marie Bonnet
- EA 4174 Sepsis Inflammation Hémostase, Université de Lyon, VetAgro Sup - Campus Vétérinaire de Lyon, 1 Avenue Bourgelat, 69280, Marcy-l'Étoile, France.
| | - Stéphane Junot
- EA 4174 Sepsis Inflammation Hémostase, Université de Lyon, VetAgro Sup - Campus Vétérinaire de Lyon, 1 Avenue Bourgelat, 69280, Marcy-l'Étoile, France.
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Hasper D, Schefold JC, Jörres A. [Adsorption therapy in sepsis]. Med Klin Intensivmed Notfmed 2014; 110:272-7. [PMID: 25248547 DOI: 10.1007/s00063-014-0415-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 07/31/2014] [Accepted: 08/09/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The activation of multiple pro- and anti-inflammatory mediators is a key feature in the pathophysiology of sepsis. Many of these mediators may directly contribute to organ dysfunction and determine disease severity. So far our ability to modulate these upregulated mediator pathways is very limited. Therefore the adsorption of such mediators via an extracorporeal circuit may be a beneficial intervention during sepsis. OBJECTIVES Recent technical innovations have made this intervention feasible. Both systems for exclusive mediator adsorption and for adsorption beside a conventional renal replacement therapy are now available. Some of the membranes can adsorb a broad range of mediators by rather unspecific binding, whereas others specifically adsorb endotoxin or mediators. DISCUSSION Whilst biochemical efficacy could be demonstrated by some of the systems, controlled and randomized studies demonstrating improved clinical endpoints are still lacking. Therefore the use of such therapies outside clinical studies cannot yet be recommended.
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Affiliation(s)
- D Hasper
- Klinik für Nephrologie und Internistische Intensivmedizin, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland,
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In vivo antibiotic removal during coupled plasma filtration adsorption: a retrospective study. ASAIO J 2014; 60:70-5. [PMID: 24270228 DOI: 10.1097/mat.0000000000000009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Coupled plasma filtration adsorption (CPFA) is a blood purification therapy aimed at modulating the host inflammatory response involved in sepsis pathogenesis. One potential drawback of this technique is the unexpected elimination of antibiotics. The aim of this study was to assess the elimination of several antibiotics with CPFA. We performed a retrospective analysis of the serum and ultrafiltrate concentrations of different antibiotics routinely measured during CPFA sessions in five patients experiencing septic shock. The adsorbent extraction ratio (AER) for piperacillin and vancomycin 2 h into the CPFA session were high: 95.4 ± 6.9% and 99.6 ± 0.9%, respectively. These AER decreased significantly by 8 h (at 8 h: 6.3 ± 51.8% and -30.2 ± 25.6%, respectively), suggesting saturation of the resin cartridge. Conversely, the tazobactam AER was low (7.2 ± 15% after 2 h of CPFA). No significant changes in the mean serum concentrations of piperacillin, tazobactam, and vancomycin were observed. Thus, as opposed to tazobactam, we report high adsorption of piperacillin and vancomycin on the CPFA resin but with no reduction in serum concentrations.
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Jacquet-Lagrèze M, Bonnet-Garin JM, Allaouchiche B, Vassal O, Restagno D, Paquet C, Ayoub JY, Etienne J, Vandenesch F, Daulwader O, Junot S. A new device for continuous assessment of gut perfusion: proof of concept on a porcine model of septic shock. Crit Care 2014; 18:R153. [PMID: 25030376 PMCID: PMC4223372 DOI: 10.1186/cc13992] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 06/24/2014] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION We evaluate an innovative device consisting of an enteral feeding tube equipped with a photoplethysmography (PPG) sensor in contact with the duodenal mucosa. This study aims to determine if the PPG signal, composed of a continuous (PDC) and a pulsatile part (PAC), is a reliable method to assess gut perfusion in a porcine model of septic shock. METHOD Fourteen piglets were anesthetized and mechanically ventilated. They were randomly assigned to two groups: the nonseptic (NS) group received an infusion of Ringer's lactate solution (RL) alone, the septic (S) group received in addition a suspension of live Pseudomonas aeruginosa. Heart rate (HR), pulse oximetry (SpO2), mean arterial pressure (MAP), cardiac index (CI) and serum lactates were recorded and gut microcirculation (GM) was monitored with a laser Doppler probe applied on the duodenal serosa. PDC and PAC were given by the PPG probe inserted in the duodenum. Data was collected every 15 minutes (t0, t15…) during 150 minutes (t150). After administration of the bacteria suspension (t0), resuscitation maneuvers were performed following a defined algorithm. GM PAC, and PDC were expressed as variation from baseline (GMvar, PACvar, PDCvar). Analysis of variance (ANOVA) with repeated measures was performed to compare hemodynamic variables, with Bonferroni correction as post hoc analysis on t0, t60 and t150. RESULTS One piglet was withdrawn from analysis due to a defective probe. S group (six piglets) received resuscitation therapy while NS group (seven piglets) did not. A significant group effect was found for the all parameters except HR. Post hoc analysis found a significant decrease for GM and PAC at t60. The correlation between PAC, PDC and microcirculatory parameters were as follows: rPACvar-GMvar = 0.496, P <0.001, rPDCvar-GMvar = 0.244; P = 0.002. In the septic group, correlations were as follows: rPAC-lactate = -0.772, P <0.001; rPDC-lactate = -0.681, P <0.01). At the onset of shock, a decrease of PAC, PDC and GM occurred before the alteration of MAP. CONCLUSIONS PAC and PDC decreased at the onset of shock and were correlated with GM and lactate. These results confirm that PPG signal reliably reflects the early perfusion alteration of the gut. Further studies should assess the clinical use of this device.
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Affiliation(s)
- Matthias Jacquet-Lagrèze
- Service d’Anesthésie-Réanimation, Hospices Civils de Lyon, hôpital Edouard-Herriot, 5 place d’Arsonval, 69437 Lyon, Cedex 03, France
| | - Jeanne-Marie Bonnet-Garin
- Université de Lyon, EA 4174 Hémostase, Inflammation et Sepsis, VetAgro Sup - Campus Vétérinaire de Lyon, 1 Avenue Bourgelat, 69280 Marcy l'Étoile, France
| | - Bernard Allaouchiche
- Service d’Anesthésie-Réanimation, Hospices Civils de Lyon, hôpital Edouard-Herriot, 5 place d’Arsonval, 69437 Lyon, Cedex 03, France
- Université Claude Bernard, 43 Boulevard du 11 Novembre 1918, 69100 Villeurbanne, Lyon, France
| | - Olivia Vassal
- Service d’Anesthésie-Réanimation, Hospices Civils de Lyon, hôpital Edouard-Herriot, 5 place d’Arsonval, 69437 Lyon, Cedex 03, France
| | - Damien Restagno
- Université de Lyon, EA 4174 Hémostase, Inflammation et Sepsis, VetAgro Sup - Campus Vétérinaire de Lyon, 1 Avenue Bourgelat, 69280 Marcy l'Étoile, France
| | - Christian Paquet
- Université de Lyon, EA 4174 Hémostase, Inflammation et Sepsis, VetAgro Sup - Campus Vétérinaire de Lyon, 1 Avenue Bourgelat, 69280 Marcy l'Étoile, France
| | - Jean-Yves Ayoub
- Université de Lyon, EA 4174 Hémostase, Inflammation et Sepsis, VetAgro Sup - Campus Vétérinaire de Lyon, 1 Avenue Bourgelat, 69280 Marcy l'Étoile, France
| | - Jérôme Etienne
- Université Claude Bernard, 43 Boulevard du 11 Novembre 1918, 69100 Villeurbanne, Lyon, France
- Laboratoire de Microbiologie, Groupement Hospitalier Est, Lyon, France
| | - François Vandenesch
- Université Claude Bernard, 43 Boulevard du 11 Novembre 1918, 69100 Villeurbanne, Lyon, France
- Laboratoire de Microbiologie, Groupement Hospitalier Est, Lyon, France
| | - Olivier Daulwader
- Laboratoire de Microbiologie, Groupement Hospitalier Est, Lyon, France
| | - Stéphane Junot
- Université de Lyon, EA 4174 Hémostase, Inflammation et Sepsis, VetAgro Sup - Campus Vétérinaire de Lyon, 1 Avenue Bourgelat, 69280 Marcy l'Étoile, France
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Extracorporeal organ support following trauma: the dawn of a new era in combat casualty critical care. J Trauma Acute Care Surg 2013; 75:S120-8; discussion S128-9. [PMID: 23883896 DOI: 10.1097/ta.0b013e318299d0cb] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Immunomodulation in sepsis: the role of endotoxin removal by polymyxin B-immobilized cartridge. Mediators Inflamm 2013; 2013:507539. [PMID: 24249974 PMCID: PMC3819752 DOI: 10.1155/2013/507539] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 09/16/2013] [Indexed: 12/14/2022] Open
Abstract
Severe sepsis results in high morbidity and mortality. Immunomodulation strategies could be an adjunctive therapy to treat sepsis. Endotoxin is a component of gram-negative bacteria and plays an important role in the pathogenesis of septic shock when it is recognized by immune cells. Removal of endotoxin could be an effective adjunctive approach to the management of sepsis. Devices to adsorb endotoxin or inflammatory cytokines have been designed as a strategy to treat severe sepsis, especially sepsis caused by gram-negative bacteria. Polymyxin B-immobilized cartridge has been successfully used to treat patients with sepsis of abdominal origin. Although this cartridge was conceived to adsorb endotoxin, several other immunological mechanisms have been elucidated, and this device has also yielded promising results in patients with nonseptic respiratory failure. In this paper, we summarize the immune modulation actions of Polymyxin B-immobilized cartridge to explore its potential usefulness beyond endotoxin elimination.
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Newly designed CRRT membranes for sepsis and SIRS--a pragmatic approach for bedside intensivists summarizing the more recent advances: a systematic structured review. ASAIO J 2013; 59:99-106. [PMID: 23438770 DOI: 10.1097/mat.0b013e3182816a75] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
In recent years, after all the attention has been focused on the dose for continuous renal replacement therapy (CRRT) in sepsis and systemic inflammation response syndrome (SIRS), the relatively negative results of all those studies did urge our expectations on new approaches regarding CRRT in sepsis and SIRS. So far, after the failure of the major randomized studies on dose, attention is now drawn to new membranes that could better eliminate massive amounts of unbound mediators in wider spectrum and also in greater magnitude Nevertheless, for septic acute kidney injury, the recommended dose will remain 35 ml/kg/h until the IVOIRE (hIgh VOlume in Intensive Care) study will be published. In this new armamentarium, we have distinguished the first tools that can still be called membranes ranging from AN69 Surface Treated (ST), SEPTEX, polymethylmetacrylate, to Oxiris that can still run with a CRRT device. Polymyxin B is still a kind of membrane although it has a larger surface, but it can run in a hemoperfusion system and is also much more selective. Adsorptive columns and sorbents are not anymore membranes but are seen as cartridges as the surface is extremely huge when compared with that of membranes (more than 500 m). They can still run in a hemoperfusion device. At the very end, we do have apheresis or selective plasma exchange (also very close to sorbents and columns) but we have very few data up to now regarding sepsis. Regarding spectrum, CytoSorb seems to be very promising although it is not able to capture endotoxin and IL-10. Oxiris is also promising as it can capture endotoxin and cytokines. AN69 ST is very powerful to capture numerous cytokines and especially high-mobility group box 1 protein (a very upstream cytokine). Polymethylmetacrylate has also the power to capture endotoxin and numerous other cytokines probably with a larger magnitude than Oxiris although this is not proven. Lastly, high-porosity membranes (Septex) may play a role especially when used in continuous venovenous hemodialysis mode. At the end, if we look for a more enlarged spectrum and a higher magnitude, CytoSorb might be seen as the most promising although not having the ability to fix endotoxin. Future studies will tell us which membrane or sorbent will be most useful in the adjunctive treatment for sepsis.
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Peng ZY, Zhang J, Rimmelé T, Zhou F, Chuasuwan A, Kaynar AM, Kellum JA. Development of venovenous extracorporeal blood purification circuits in rodents for sepsis. J Surg Res 2013; 185:790-6. [PMID: 23953896 DOI: 10.1016/j.jss.2013.07.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 06/28/2013] [Accepted: 07/10/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Unlike pharmacologic interventions in sepsis, extracorporeal blood purification, which is widely used in septic patients, is not typically studied in experimental rodents. Most of the previous studies have performed extracorporeal blood purification in larger animals and typically use arteriovenous (AV) vascular access. We developed a venovenous (VV) purification model in the rat as an adjunct for the treatment of sepsis. METHODS Using adult male Sprague-Dawley rats, we cannulated the femoral artery or vein and the jugular vein with P50 tubing and created an AV or VV circuit. Blood flow was maintained by arterial pressure in the AV circuit, whereas in the VV circuit the blood flow was regulated using a rotary pump. The safety of this circuit was evaluated using the changes of blood interleukin 6, rectal temperature, and 7-d survival with sham extracorporeal circulation (circuit connection without treatment) compared with the control (without circuit). The main side complications of this VV circuit were compared with those of the AV circuit. RESULTS The differences in interleukin 6, body temperature, and cumulative survival were not statistically significant after extracorporeal circulation. The main complications of extracorporeal circulation occurred less often with VV compared with AV therapy: massive bleeding (2.5% versus 15%, P = 0.04); clot formation (2.5% versus 15%, P = 0.04). This VV circuit has been successfully used in different septic rodent models with different techniques (hemoadsorption and hemofiltration). CONCLUSIONS VV blood purification in a rodent model appears to be effective and is safer than AV circuit.
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Affiliation(s)
- Zhi-Yong Peng
- The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
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Cytokine removal on extracorporeal life support for treatment of acute endotoxemia: a randomized controlled animal study. Int J Cardiol 2013; 168:4699-704. [PMID: 23954008 DOI: 10.1016/j.ijcard.2013.07.175] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 06/18/2013] [Accepted: 07/20/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND We prospectively evaluated the effectiveness of resin adsorption incorporated in an extracorporeal life support (ELS) circuit in an animal model of sepsis for removal of cytokines and prevention of hemodynamic deterioration during the treatment of septic shock. METHODS Twelve female landrace pigs were randomly assigned to two groups, a study group(n=6), treated with high-flow resin adsorption (300 mL/min) and ELS, and a control group (n=6), treated only with ELS. Septic shock was induced by intravenous 0.02 μg/kg/min infusion was of Escherichia coli lipopolysaccharide (LPS). Measurements were carried out in the study group at baseline, at the end of LPS injection(t0) at 30(t1), 60(t2), 90(t3) and 120 min (t4) and 60 min after stopping resin-adsorption (t5). In the control group measurements were performed at baseline (t0), t1 and only t2, as no control animal survived beyond this latter experimental timepoint. RESULTS The final population consisted of 9 animals, five in the study group and 4 in the control group. Plasma values of both tumor necrosis factor α (TNF-α) and interleukin-6 (IL-6) were reduced during resin-adsorption (t1-t4) while these mediators increased in controls undergoing ELS only. With a clearance of TNF-α of 15,233 pg/min and IL-6 of 10,233 pg/min, 79.2% of TNF-α and 95.3% of IL-6 produced were adsorbed. Systemic vascular resistance decreased significantly in both groups at t0. While it further was reduced during the control experiments at t1 and t2, it returned to normal in the study animals. Cardiac output increased at t0, t1 and t2 in the control experiments. In contrast, in study animals after a peak at t0, it returned to the baseline value and did not vary thereafter. CONCLUSIONS Combined resin-adsorption and ELS improved hemodynamics resulting from effective removal of inflammatory mediators in a pig model of septic shock.
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Joannes-Boyau O, Honoré PM, Perez P, Bagshaw SM, Grand H, Canivet JL, Dewitte A, Flamens C, Pujol W, Grandoulier AS, Fleureau C, Jacobs R, Broux C, Floch H, Branchard O, Franck S, Rozé H, Collin V, Boer W, Calderon J, Gauche B, Spapen HD, Janvier G, Ouattara A. High-volume versus standard-volume haemofiltration for septic shock patients with acute kidney injury (IVOIRE study): a multicentre randomized controlled trial. Intensive Care Med 2013; 39:1535-46. [PMID: 23740278 DOI: 10.1007/s00134-013-2967-z] [Citation(s) in RCA: 223] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 05/14/2013] [Indexed: 12/11/2022]
Abstract
PURPOSE Septic shock is a leading cause of death among critically ill patients, in particular when complicated by acute kidney injury (AKI). Small experimental and human clinical studies have suggested that high-volume haemofiltration (HVHF) may improve haemodynamic profile and mortality. We sought to determine the impact of HVHF on 28-day mortality in critically ill patients with septic shock and AKI. METHODS This was a prospective, randomized, open, multicentre clinical trial conducted at 18 intensive care units in France, Belgium and the Netherlands. A total of 140 critically ill patients with septic shock and AKI for less than 24 h were enrolled from October 2005 through March 2010. Patients were randomized to either HVHF at 70 mL/kg/h or standard-volume haemofiltration (SVHF) at 35 mL/kg/h, for a 96-h period. RESULTS Primary endpoint was 28-day mortality. The trial was stopped prematurely after enrolment of 140 patients because of slow patient accrual and resources no longer being available. A total of 137 patients were analysed (two withdrew consent, one was excluded); 66 patients in the HVHF group and 71 in the SVHF group. Mortality at 28 days was lower than expected but not different between groups (HVHF 37.9 % vs. SVHF 40.8 %, log-rank test p = 0.94). There were no statistically significant differences in any of the secondary endpoints between treatment groups. CONCLUSIONS In the IVOIRE trial, there was no evidence that HVHF at 70 mL/kg/h, when compared with contemporary SVHF at 35 mL/kg/h, leads to a reduction of 28-day mortality or contributes to early improvements in haemodynamic profile or organ function. HVHF, as applied in this trial, cannot be recommended for treatment of septic shock complicated by AKI.
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Affiliation(s)
- Olivier Joannes-Boyau
- Service d'Anesthésie-Réanimation 2, Centre Hospitalier Universitaire (CHU) de Bordeaux, 33000, Bordeaux, France.
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Pestaña D, Ojeda N, Padrón OM, Higuera E, Rey T, Aldecoa C. [Usefulness of haemoperfusion in the treatment of the severe septic patient: an update]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 60:336-343. [PMID: 23044210 DOI: 10.1016/j.redar.2012.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 08/30/2012] [Indexed: 06/01/2023]
Abstract
Haemoperfusion is an extracorporeal technique that removes endotoxin and/or inflammatory mediators by means of an adsorptive mechanism during the passage of the blood through a porous filter. Most of the studies in the literature use polymyxin B as the adsorptive agent. This treatment is based on the assumption that the removal of endotoxin and inflammatory mediators from the circulation attenuates the inflammatory response in sepsis. This review summarizes the theoretical basis, and the experimental and clinical results published to date with the use of haemoperfusion. Although most of the studies show positive results, some doubts have arisen about the suitability of the methods described (small number of cases, low quality of the experimental design, and excessive mortality in the control groups). There are also some inconsistencies regarding the theoretical basis of its use (lack of positive effects after the removal of endotoxin from the circulation using alternative mechanisms, discrepancies regarding the best moment to initiate the therapy, unexplained beneficial effects in the absence of increased endotoxin levels). It is the opinion of the authors that haemoperfusion represents a promising therapy for the treatment of sepsis, but consider that its usefulness requires confirmation in well designed studies before being included in protocols.
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Affiliation(s)
- D Pestaña
- Servicio de Anestesiología y Reanimación, Hospital Universitario Ramón y Cajal, Madrid, España.
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Rimmelé T, Kaynar AM, McLaughlin JN, Bishop JV, Fedorchak MV, Chuasuwan A, Peng Z, Singbartl K, Frederick DR, Zhu L, Carter M, Federspiel WJ, Zeevi A, Kellum JA. Leukocyte capture and modulation of cell-mediated immunity during human sepsis: an ex vivo study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R59. [PMID: 23531333 PMCID: PMC3672497 DOI: 10.1186/cc12587] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 03/18/2013] [Indexed: 01/06/2023]
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Turani F, Candidi F, Barchetta R, Grilli E, Belli A, Papi E, di Marzio A, Falco M. Continuous renal replacement therapy with the adsorbent membrane oXiris in septic patients: a clinical experience. Crit Care 2013. [PMCID: PMC3642903 DOI: 10.1186/cc12001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Koremoto M, Takahara N, Takahashi M, Okada Y, Satoh K, Kimura T, Hirai T, Ebihara I, Nagasaku D, Miyata S, Maniwa S, Kouzuma T, Arimura T, Kamei J. Improvement of intradialytic hypotension in diabetic hemodialysis patients using vitamin E-bonded polysulfone membrane dialyzers. Artif Organs 2012; 36:901-10. [PMID: 22845774 PMCID: PMC3500504 DOI: 10.1111/j.1525-1594.2012.01483.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Currently, there are no detailed reports on the effects of vitamin E-bonded polysulfone (PS) membrane dialyzers on intradialytic hypotension (IDH) in diabetic hemodialysis (HD) patients. This study was designed to evaluate changes in intradialytic systolic blood pressure (SBP) using "VPS-HA" vitamin E-bonded super high-flux PS membrane dialyzers. The subjects were 62 diabetic HD patients whose intradialytic SBP fell by more than 20%. Group A comprised patients who required vasopressors to be able to continue treatment or who had to discontinue therapy due to their lowest intradialytic SBP being observed at 210 min (28 patients). Group B comprised patients who showed no symptoms and required no vasopressors but showed a gradual reduction in blood pressure, with the lowest intradialytic SBP seen at the end of dialysis (34 patients). The primary outcome was defined as the lowest intradialytic SBP after 3 months using VPS-HA. Secondary outcomes included changes in the following: lowest intradialytic diastolic blood pressure, pulse pressure, pulse rate, plasma nitric oxide and peroxynitrite, serum albumin, and hemoglobin A1c. Group A's lowest intradialytic SBP had significantly improved at 3 months (128.0 ± 25.1 mm Hg vs. 117.1 ± 29.2 mm Hg; P = 0.017). Group B's lowest intradialytic SBP had significantly improved at 1 month (134.4 ± 13.2 mm Hg vs. 121.5 ± 25.8 mm Hg; P = 0.047) and 3 months (139.1 ± 20.9 mm Hg vs. 121.5 ± 25.8 mm Hg; P = 0.011). We conclude that VPS-HA may improve IDH in diabetic HD patients.
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A comparison of the effect of convection against diffusion in hemodynamics and cytokines clearance in an experimental model of septic shock. J Trauma Acute Care Surg 2012; 73:855-60. [DOI: 10.1097/ta.0b013e31825eea8a] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Christaki E, Anyfanti P, Opal SM. Immunomodulatory therapy for sepsis: an update. Expert Rev Anti Infect Ther 2012; 9:1013-33. [PMID: 22029521 DOI: 10.1586/eri.11.122] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Currently the treatment mainstay of sepsis is early and appropriate antibiotic therapy, accompanied by aggressive fluid administration, the use of vasopressors when needed and the prompt initiation of measures to support each failing organ. Activated protein C and hydrocortisone, when used accordingly can affect mortality. As the pathophysiologic events that take place during sepsis are being elucidated, new molecules that target each step of those pathways are being tested. However, a lot of those molecules affect various mediators of the sepsis cascade including inflammatory cytokines, cellular receptors, nuclear transcription factors, coagulation activators and apoptosis regulators. Over the last decade, a multitude of clinical trials and animal studies have investigated strategies that aimed to restore immune homeostasis either by reducing inflammation or by stimulating the innate and adaptive immune responses. Antibiotics, statins and other molecules with multipotent immunomodulatory actions have also been studied in the treatment of sepsis.
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Affiliation(s)
- Eirini Christaki
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece.
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Honoré PM, Jacobs R, Boer W, Joannes-Boyau O, De Regt J, De Waele E, Van Gorp V, Collin V, Spapen HD. New insights regarding rationale, therapeutic target and dose of hemofiltration and hybrid therapies in septic acute kidney injury. Blood Purif 2011; 33:44-51. [PMID: 22179226 DOI: 10.1159/000333837] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Mediator removal from tissue (capillary blood compartment, CABC) and transport to the central circulation (central blood compartment, CEBC) must be effective. Effectiveness through a passive mechanism seems unlikely as the surface of CEBC (30 m(2)) is smaller than CABC (300 m(2)) whereby the former will be a limiting factor in passive transport. According to studies, a high exchange volume can induce an 80-fold increase in lymphatic flow. This results in displacement (active transport) of mediators to CEBC. Recent studies have shown that the delivered dose constitutes the mainstay of continuous renal replacement therapy. However, these results are not likely to change the recommendation: 35 ml/kg/h, adjusted for predilution, in septic acute kidney injury (AKI). Recently, studies were focusing on global intensive care unit AKI. In non-septic AKI, those studies show that 20-25 ml/kg/h was optimal. The DO-RE-MI trial underscored the importance of delivery which could be obtained by targeting doses between 5 and 10 ml/kg/h higher than prescribed. Until the IVOIRE trial becomes available, septic AKI should be treated by continuous veno-venous hemofiltration at 35 ml/kg/h. In non-septic AKI, 25 ml/kg/h remains optimal.
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Affiliation(s)
- P M Honoré
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium. Patrick.Honore @ uzbrussel.be
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Altrichter J, Sauer M, Kaftan K, Birken T, Gloger D, Gloger M, Henschel J, Hickstein H, Klar E, Koball S, Pertschy A, Nöldge-Schomburg G, Vagts DA, Mitzner SR. Extracorporeal cell therapy of septic shock patients with donor granulocytes: a pilot study. Crit Care 2011; 15:R82. [PMID: 21371308 PMCID: PMC3219336 DOI: 10.1186/cc10076] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2010] [Revised: 01/14/2011] [Accepted: 03/03/2011] [Indexed: 11/24/2022] Open
Abstract
Introduction Neutrophil granulocytes are the first defense line in bacterial infections. However, granulocytes are also responsible for severe local tissue impairment. In order to use donor granulocytes, but at the same time to avoid local side effects, we developed an extracorporeal immune support system. This first-in-man study investigated whether an extracorporeal plasma treatment with a granulocyte bioreactor is tolerable in patients with septic shock. A further intention was to find suitable efficacy end-points for subsequent controlled trials. Methods The trial was conducted as a prospective uncontrolled clinical phase I/II study with 28-day follow-up at three university hospital intensive care units. Ten consecutive patients (five men, five women, mean age 60.3 ± 13.9 standard deviation (SD) years) with septic shock with mean ICU entrance scores of Acute Physiology and Chronic Health Evaluation (APACHE) II of 29.9 ± 7.2 and of Simplified Acute Physiology Score (SAPS) II of 66.2 ± 19.5 were treated twice within 72 hours for a mean of 342 ± 64 minutes/treatment with an extracorporeal bioreactor containing 1.41 ± 0.43 × 10E10 granulocytes from healthy donors. On average, 9.8 ± 2.3 liters separated plasma were treated by the therapeutic donor cells. Patients were followed up for 28 days. Results Tolerance and technical safety during treatment, single organ functions pre/post treatment, and hospital survival were monitored. The extracorporeal treatments were well tolerated. During the treatments, the bacterial endotoxin concentration showed significant reduction. Furthermore, noradrenaline dosage could be significantly reduced while mean arterial pressure was stable. Also, C-reactive protein, procalcitonin, and human leukocyte antigen DR (HLA-DR) showed significant improvement. Four patients died in the hospital on days 6, 9, 18 and 40. Six patients could be discharged. Conclusions The extracorporeal treatment with donor granulocytes appeared to be well tolerated and showed promising efficacy results, encouraging further studies. Trial registration ClinicalTrials.gov Identifier: NCT00818597
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Affiliation(s)
- Jens Altrichter
- Department of Medicine, Division of Nephrology, Medical Faculty of University of Rostock, Ernst-Heydemann-Str. 6, Rostock, D-18057, Germany
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Herrera-Gutiérrez M, Seller-Pérez G, García GQ, Granados M, Domínguez J, Gómez-Villamandos R. Desarrollo de un modelo experimental de shock séptico orientado a la formación. Aplicación en el entrenamiento de técnicas de depuración en el manejo de la sepsis grave. Med Intensiva 2011; 35:84-91. [DOI: 10.1016/j.medin.2010.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Revised: 12/14/2010] [Accepted: 12/18/2010] [Indexed: 12/22/2022]
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Rimmelé T, Kellum JA. Clinical review: blood purification for sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:205. [PMID: 21371356 PMCID: PMC3222040 DOI: 10.1186/cc9411] [Citation(s) in RCA: 162] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Sepsis is the primary cause of death in the intensive care unit. Extracorporeal blood purification therapies have been proposed for patients with sepsis in order to improve outcomes since these therapies can alter the host inflammatory response by non-selective removal of inflammatory mediators or bacterial products or both. Recent technological progress has increased the number of techniques available for blood purification and their performance. In this overview, we report on the latest advances in blood purification for sepsis and how they relate to current concepts of disease, and we review the current evidence for high-volume hemofiltration, cascade hemofiltration, hemoadsorption, coupled plasma filtration adsorption, high-adsorption hemofiltration, and high-cutoff hemofiltration/hemodialysis. Promising results have been reported with all of these blood purification therapies, showing that they are well tolerated, effective in clearing inflammatory mediators or bacterial toxins (or both) from the plasma, and efficacious for improvement of various physiologic outcomes (for example, hemodynamics and oxygenation). However, numerous questions, including the timing, duration, and frequency of these therapies in the clinical setting, remain unanswered. Large multicenter trials evaluating the ability of these therapies to improve clinical outcomes (that is, mortality or organ failure), rather than surrogate markers such as plasma mediator clearance or transient improvement in physiologic variables, are required to define the precise role of blood purification in the management of sepsis.
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Affiliation(s)
- Thomas Rimmelé
- The CRISMA Laboratory, Department of Critical Care Medicine, University of Pittsburgh Medical Center, 3550 Terrace Street, Pittsburgh, PA 15261, USA
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Bagshaw SM, Bellomo R, Devarajan P, Johnson C, Karvellas CJ, Kutsiogiannis DJ, Mehta R, Pannu N, Romanovsky A, Sheinfeld G, Taylor S, Zappitelli M, Gibney RTN. Review article: Renal support in critical illness. Can J Anaesth 2010; 57:999-1013. [PMID: 20931311 DOI: 10.1007/s12630-010-9376-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Accepted: 08/12/2010] [Indexed: 01/20/2023] Open
Abstract
PURPOSE This review provides a focused and comprehensive update on established and emerging evidence in acute renal replacement therapy (RRT) for critically ill patients with acute kidney injury (AKI). PRINCIPAL FINDINGS There have been considerable technological innovations in the methods and techniques for provision of extracorporeal RRT in critical illness. These have greatly expanded our capability to provide both renal and non-renal life-sustaining organ support for critically ill patients. Recent data suggest earlier initiation of RRT in AKI may confer an advantage for survival and renal recovery. Two large trials have recently shown no added benefit to augmented RRT dose delivery in AKI. Observational data have also suggested that fluid accumulation in critically ill patients with AKI is associated with worse clinical outcome. However, several fundamental clinical questions remain to be answered, including issues regarding the time to ideally initiate/discontinue RRT, the role of high-volume hemofiltration or other blood purification techniques in sepsis, and extracorporeal support for combined liver-kidney failure. Extracorporeal support with RRT in sepsis, rhabdomyolysis, and liver failure are discussed, along with strategies for drug dosing and management of RRT in sodium disorders. CONCLUSIONS We anticipate that this field will continue to expand to promote research and innovation, hopefully for the benefit of sick critically ill patients.
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Affiliation(s)
- Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2B7, Canada.
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[Membrane roughness: A relevant concept in haemodialysis]. Nephrol Ther 2010; 6:158-61. [PMID: 20359975 DOI: 10.1016/j.nephro.2009.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Revised: 10/26/2009] [Accepted: 10/26/2009] [Indexed: 11/21/2022]
Abstract
The molecular process that occurs at the interface between blood and a haemodialysis membrane determines the host response. The resulting reactions define the degree of membrane biocompatibility. These reactions are triggered by plasma protein adsorption onto the membrane and blood cell stress. Over the past decade, atomic force microscopy (AFM) has provided mechanistic insights into the molecular level of interactions that occur at the biomaterial surface. AFM provides tridimentional images produced by both changes in applied shear nanoforces and dynamic imaging through the molecular analysis of attraction and repulsion forces. The aim of the present brief review is to shortly present the technique of AFM and its emerging applications in haemodialysis, comparing hydrophilic and hydrophobic structures. Dialysis membrane roughness and protein adsorption mapping can be quantitatively estimated, since AFM resolution power is in the range of a nanometer. It is suggested that estimation of roughness and force mapping determining structure/function relationship should be proposed for the best understanding of membrane biocompatibility.
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