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Waalders N, van Lier D, Gerretsen J, Moran L, Stegmann KA, Twigger W, Blanco-Andujar C, Frodsham G, Kox M, Pickkers P. Preclinical and first-in-human safety studies on a novel magnetism-based haemofiltration method. Sci Rep 2024; 14:14077. [PMID: 38890397 PMCID: PMC11189386 DOI: 10.1038/s41598-024-64379-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 06/07/2024] [Indexed: 06/20/2024] Open
Abstract
Extracorporeal haemofiltration devices that selectively remove cytokines could represent an adjunctive treatment in inflammatory diseases. One such device is the "IL-6-Sieve", wherein magnetic Anti-IL-6 Beads are introduced into an extracorporeal circuit via a Bead Adapter and then removed along with any surface-bound interleukin (IL)-6 by a Filter deployed in a Magnet, before the blood is returned to the patient. We report here on a series of animal studies, and a first-in-human study, on the safety of the IL-6-Sieve. Evaluations focused on the: (a) safety of Filter and Magnet placed in an extracorporeal circuit in sheep; (b) safety of Anti-IL-6 Beads-directly infused intravenously as worst case scenario of misuse; or injected into an extracorporeal circuit using the Bead Adapter, Filter, and Magnet as intended-in sheep; (c) biodistribution of Anti-IL-6 Beads intravenously infused in mice; and (d) safety of Filter and Magnet placed in an extracorporeal circuit in healthy volunteers. No serious adverse events or significant changes in vital signs or routine laboratory parameters occurred in any of the animals or humans. Although safety of the IL-6-Sieve requires further study, these initial evaluations represent a promising start for the translation of this new blood purification modality into clinical use.
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Affiliation(s)
- Nicole Waalders
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud University Medical Center, Radboud Center for Infectious Diseases (RCI), Nijmegen, The Netherlands
| | - Dirk van Lier
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud University Medical Center, Radboud Center for Infectious Diseases (RCI), Nijmegen, The Netherlands
| | - Jelle Gerretsen
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud University Medical Center, Radboud Center for Infectious Diseases (RCI), Nijmegen, The Netherlands
| | | | | | | | | | | | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud University Medical Center, Radboud Center for Infectious Diseases (RCI), Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
- Radboud University Medical Center, Radboud Center for Infectious Diseases (RCI), Nijmegen, The Netherlands.
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Guo C, Jiang X, Guo X, Ou L. An Evolutionary Review of Hemoperfusion Adsorbents: Materials, Preparation, Functionalization, and Outlook. ACS Biomater Sci Eng 2024; 10:3599-3611. [PMID: 38776416 DOI: 10.1021/acsbiomaterials.4c00259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Accumulation of pathogenic factors in the blood may cause irreversible damage and may even be life-threatening. Hemoperfusion is an effective technique for eliminating pathogenic factors, which is widely used in the treatment of various diseases including liver failure, renal failure, sepsis, and others. Hemoperfusion adsorbents are crucial in this process as they specifically bind and remove the target pathogenic factors. This review describes the development of hemoperfusion adsorbents, detailing the different properties exhibited by inorganic materials, organic polymers, and new materials. Advances in natural and synthetic polymers and novel materials manufacturing techniques have driven the expansion of hemoperfusion adsorbents in clinical applications. Stimuli-responsive (smart responsive) adsorbents with controllable molecular binding properties have many promising and environmentally friendly biomedical applications. Knowledge gaps, future research directions, and prospects for hemoperfusion adsorbents are discussed.
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Affiliation(s)
- Chen Guo
- Key Laboratory of Bioactive Materials, Ministry of Education, College of Life Science, Nankai University, Tianjin 300071, China
| | - Xinbang Jiang
- Key Laboratory of Bioactive Materials, Ministry of Education, College of Life Science, Nankai University, Tianjin 300071, China
| | - Xiaofang Guo
- Key Laboratory of Bioactive Materials, Ministry of Education, College of Life Science, Nankai University, Tianjin 300071, China
| | - Lailiang Ou
- Key Laboratory of Bioactive Materials, Ministry of Education, College of Life Science, Nankai University, Tianjin 300071, China
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Hernandez GN, Francis AJ, Hamid P. Enhancing Survival in Septic Shock: A Systematic Review and Meta-Analysis of the Efficacy of Plasma Exchange Therapy. Cureus 2024; 16:e60947. [PMID: 38910774 PMCID: PMC11193551 DOI: 10.7759/cureus.60947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2024] [Indexed: 06/25/2024] Open
Abstract
Sepsis is a life-threatening condition that occurs when the body's immune response to infection becomes unregulated, causing organ dysfunction and a heightened risk of mortality. Despite increased awareness campaigns, its prevalence escalates, annually afflicting over 1.7 million adults in the United States. This research explores the potential of therapeutic plasma exchange (TPE) in septic shock management, aiming to highlight its capacity to improve patient outcomes and reduce mortality. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, our comprehensive search across 51,534 studies, using keywords such as plasmapheresis, plasma exchange therapy, therapeutic plasma exchange, septic shock, and reduction in mortality integrated with medical subject headings terms, led to the meticulous selection of six pivotal studies. Through rigorous evaluation with tools such as the revised Cochrane Risk-of-Bias tool, Newcastle-Ottawa Scale, and Assessment of Methodological Quality of Systematic Reviews, we extracted strong evidence supporting TPE's significant impact on decreasing mortality in septic shock patients compared to standard care, as demonstrated in three randomized controlled trials and one cohort study, with an odds ratio (OR) of 0.43 (95% confidence interval (CI) = 0.26-0.72). Additionally, two meta-analyses further validate TPE's effectiveness, showing a mortality reduction with an OR of 0.30 (95% CI = 0.20-0.46). This advantage also extends to critically ill COVID-19 patients, underscoring TPE's crucial role in modulating the coagulation cascade, decreasing sepsis-related complications, and reducing the risk of bleeding and organ failure. Nevertheless, the benefits of TPE must be carefully balanced against potential risks such as hypocalcemia, hypotension, and citrate toxicity, especially in patients with underlying renal or liver issues, emphasizing the importance of shared decision-making. While TPE emerges as a promising therapy, its formal integration into standard care protocols awaits further confirmation, highlighting the critical need for more in-depth research to conclusively determine its efficacy and safety in septic shock management.
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Affiliation(s)
- Grethel N Hernandez
- Infectious Diseases, Louisiana State University Health Sciences Center, Shreveport, USA
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Aida J Francis
- Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Pousette Hamid
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Kuklin V, Sovershaev M, Bjerner J, Keith P, Scott LK, Thomas OMT, Szpirt W, Rock G, Stegmayr B. Influence of therapeutic plasma exchange treatment on short-term mortality of critically ill adult patients with sepsis-induced organ dysfunction: a systematic review and meta-analysis. Crit Care 2024; 28:12. [PMID: 38178170 PMCID: PMC10768220 DOI: 10.1186/s13054-023-04795-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 12/29/2023] [Indexed: 01/06/2024] Open
Abstract
INTRODUCTION The impact of therapeutic plasma exchange (TPE) on short-term mortality in adult patients with sepsis-induced organ dysfunction remains uncertain. The objective of the study is to assess the effect of adjunct TPE in this setting through a comprehensive literature review. METHODS The National Library of Medicine's Medline, Ovid (Embase), the Cochrane Library database and clinicaltrial.gov from January 01, 1966, until October 01, 2022, were searched for terms: therapeutic plasma exchange, plasmapheresis, sepsis, and septic shock. We reviewed, selected and extracted data from relevant randomized clinical trials (RCTs) and matched cohort studies (MCSs) comparing short-term mortality in critically ill adult septic patients treated with standard therapy versus those receiving adjunct TPE. Risk of bias was assessed in the RCTs using Cochrane Collaboration tool and in MCSs using ROBINS-I tool. Summary statistics, risk ratios (RRs), and confidence intervals (CIs) were calculated using random effects model. RESULTS This systematic review included 937 adult critically ill septic patients from five RCTs (n = 367) and fifteen MCSs (n = 570). Of these total, 543 received treatment with TPE in addition to standard care. The meta-analysis includes all five RCTs and only six MCSs (n = 627). The adjunct TPE treatment (n = 300) showed a significant reduction in short-term mortality (RR 0.59, 95% CI 0.47-0.74, I2 3%) compared to standard therapy alone (n = 327). The systematic review of all 20 trials revealed that adding TPE to the standard therapy of critically ill septic patients resulted in faster clinical and/or laboratory recovery. CONCLUSIONS Our comprehensive and up-to-date review demonstrates that adjunct TPE may provide potential survival benefits when compared to standard care for critically ill adult patients with sepsis-induced organ dysfunction. While results of this meta-analysis are encouraging, large well-designed randomized trials are required to identify the optimal patient population and TPE procedure characteristics prior to widespread adoption into practice.
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Affiliation(s)
- Vladimir Kuklin
- Department of Anaesthesiology and Intensive Care Medicine, Ahus University Hospital, Sykehusveien, 25, 1478, Lorenskog, Norway.
| | | | | | - Philip Keith
- Critical Care Medicine, Lexington Medical Center, West Columbia, SC, USA
| | - L Keith Scott
- Division of Trauma and Surgical Critical Care, Louisiana State University Health Sciences Center, Shreveport, USA
| | | | - Wladimir Szpirt
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Gail Rock
- University of Ottawa, Ottawa, ON, Canada
| | - Bernd Stegmayr
- Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden
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Willam C. [Adsorbers and their evidence]. DIE ANAESTHESIOLOGIE 2023; 72:841-842. [PMID: 37789079 DOI: 10.1007/s00101-023-01347-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 10/05/2023]
Affiliation(s)
- Carsten Willam
- Medizinische Klinik 4, Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland.
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Heymann M, Schorer R, Putzu A. The Effect of CytoSorb on Inflammatory Markers in Critically Ill Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2023; 51:1659-1673. [PMID: 37607074 PMCID: PMC10645103 DOI: 10.1097/ccm.0000000000006007] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
OBJECTIVES The effectiveness of CytoSorb at removing inflammatory mediators in critically ill patients is controversial. DATA SOURCES Electronic databases were searched from inception to May 2023. STUDY SELECTION Randomized controlled trials reporting the effects of CytoSorb therapy on inflammatory parameters in critically ill patients with hyperinflammatory conditions were included. DATA EXTRACTION Two authors screened articles for eligibility, extracted data, and assessed the risk of bias, conflicts of interest, and certainty of evidence (CoE). The primary outcome was interleukin (IL)-6 at 1 day after initiation of the therapy. Secondary outcomes included various inflammatory markers at 1, 2, 3, and 5 days and mortality. Data were pooled if at least three trials reported the outcome of interest. We conducted meta-analyses of the data using a random-effects model. DATA SYNTHESIS Seventeen trials ( n = 855) were included. Fourteen trials were judged to have notable concern about conflicts of interest. Seven trials were performed in medical ICU patients with hyperinflammatory conditions and 10 in complex cardiovascular surgery under cardiopulmonary bypass. Hemoadsorption with CytoSorb was not associated with lower IL-6 at 1 day (mean difference -5.98 [95% CI, -30.44 to 18.48] pg/mL), 2 days, 3 days, or 5 days after initiation of the treatment, as well as the concentration of procalcitionin. The levels of C-reactive protein were not lower with CytoSorb at 1, 2, and 3 days. The use of CytoSorb was associated with higher mortality at latest follow-up (relative risk = 1.22 [95% CI, 1.02-1.45]) and at 30 days. CoE ranged from low to very low. CONCLUSIONS The use of CytoSorb hemoadsorption in a mixed population of critically ill patients with hyperinflammatory conditions does not exhibit a consistent decrease in IL-6 and other inflammatory parameters within the first 5 days of treatment. The significant uncertainty surrounding these findings highlights the need for further investigations.
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Affiliation(s)
- Marc Heymann
- Division of Anesthesiology, Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
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Chen JJ, Lai PC, Lee TH, Huang YT. Blood Purification for Adult Patients With Severe Infection or Sepsis/Septic Shock: A Network Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2023; 51:1777-1789. [PMID: 37470680 PMCID: PMC10645104 DOI: 10.1097/ccm.0000000000005991] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
OBJECTIVES This study aimed to conduct a comprehensive and updated systematic review with network meta-analysis (NMA) to assess the outcome benefits of various blood purification modalities for adult patients with severe infection or sepsis. DATA SOURCES We conducted a search of PubMed, MEDLINE, clinical trial registries, Cochrane Library, and Embase databases with no language restrictions. STUDY SELECTION Only randomized controlled trials (RCTs) were selected. DATA EXTRACTION The primary outcome was overall mortality. The secondary outcomes were the length of mechanical ventilation (MV) days and ICU stay, incidence of acute kidney injury (AKI), and kidney replacement therapy requirement. DATA SYNTHESIS We included a total of 60 RCTs with 4,595 participants, comparing 16 blood purification modalities with 17 interventions. Polymyxin-B hemoperfusion (relative risk [RR]: 0.70; 95% CI, 0.57-0.86) and plasma exchange (RR: 0.61; 95% CI, 0.42-0.91) were associated with low mortality (very low and low certainty of evidence, respectively). Because of the presence of high clinical heterogeneity and intransitivity, the potential benefit of polymyxin-B hemoperfusion remained inconclusive. The analysis of secondary outcomes was limited by the scarcity of available studies. HA330 with high-volume continuous venovenous hemofiltration (CVVH), HA330, and standard-volume CVVH were associated with shorter ICU stay. HA330 with high-volume CVVH, HA330, and standard-volume CVVH were beneficial in reducing MV days. None of the interventions showed a significant reduction in the incidence of AKI or the need for kidney replacement therapy. CONCLUSIONS Our NMA suggests that plasma exchange and polymyxin-B hemoperfusion may provide potential benefits for adult patients with severe infection or sepsis/septic shock when compared with standard care alone, but most comparisons were based on low or very low certainty evidence. The therapeutic effect of polymyxin-B hemoperfusion remains uncertain. Further RCTs are required to identify the specific patient population that may benefit from extracorporeal blood purification.
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Affiliation(s)
- Jia-Jin Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Linkou Main Branch, Taoyuan City, Taiwan
| | - Pei-Chun Lai
- Education Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | | | - Yen-Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Tomlinson G, Al-Khafaji A, Conrad SA, Factora FNF, Foster DM, Galphin C, Gunnerson KJ, Khan S, Kohli-Seth R, McCarthy P, Meena NK, Pearl RG, Rachoin JS, Rains R, Seneff M, Tidswell M, Walker PM, Kellum JA. Bayesian methods: a potential path forward for sepsis trials. Crit Care 2023; 27:432. [PMID: 37940985 PMCID: PMC10634134 DOI: 10.1186/s13054-023-04717-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/31/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Given the success of recent platform trials for COVID-19, Bayesian statistical methods have become an option for complex, heterogenous syndromes like sepsis. However, study design will require careful consideration of how statistical power varies using Bayesian methods across different choices for how historical data are incorporated through a prior distribution and how the analysis is ultimately conducted. Our objective with the current analysis is to assess how different uses of historical data through a prior distribution, and type of analysis influence results of a proposed trial that will be analyzed using Bayesian statistical methods. METHODS We conducted a simulation study incorporating historical data from a published multicenter, randomized clinical trial in the US and Canada of polymyxin B hemadsorption for treatment of endotoxemic septic shock. Historical data come from a 179-patient subgroup of the previous trial of adult critically ill patients with septic shock, multiple organ failure and an endotoxin activity of 0.60-0.89. The trial intervention consisted of two polymyxin B hemoadsorption treatments (2 h each) completed within 24 h of enrollment. RESULTS In our simulations for a new trial of 150 patients, a range of hypothetical results were observed. Across a range of baseline risks and treatment effects and four ways of including historical data, we demonstrate an increase in power with the use of clinically defensible incorporation of historical data. In one possible trial result, for example, with an observed reduction in risk of mortality from 44 to 37%, the probability of benefit is 96% with a fixed weight of 75% on prior data and 90% with a commensurate (adaptive-weighting) prior; the same data give an 80% probability of benefit if historical data are ignored. CONCLUSIONS Using Bayesian methods and a biologically justifiable use of historical data in a prior distribution yields a study design with higher power than a conventional design that ignores relevant historical data. Bayesian methods may be a viable option for trials in critical care medicine where beneficial treatments have been elusive.
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Affiliation(s)
- George Tomlinson
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Ali Al-Khafaji
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, 600 Scaife Hall, Pittsburgh, PA, 15261, USA
| | - Steven A Conrad
- Departments of Medicine, Emergency Medicine, Pediatrics and Surgery, Louisiana State University Health, Shreveport, LA, USA
| | - Faith N F Factora
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH, USA
| | | | - Claude Galphin
- Southeast Renal Research Institute, CHI Memorial Hospital, Chattanooga, TN, USA
| | - Kyle J Gunnerson
- Departments of Emergency Medicine, Anesthesiology, and Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Sobia Khan
- Department of Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Roopa Kohli-Seth
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul McCarthy
- West Virginia University, Heart & Vascular Institute, Morgantown, WV, USA
| | - Nikhil K Meena
- Division of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ronald G Pearl
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Jean-Sebastien Rachoin
- Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Ronald Rains
- Pulmonary Associates, Univ of Colorado Health-Memorial Hospital, Colorado Springs, CO, USA
| | - Michael Seneff
- Department of Anesthesia and Critical Care, George Washington University Hospital, Washington, DC, USA
| | - Mark Tidswell
- Pulmonary and Critical Care Division, Baystate Medical Center, Springfield, MA, USA
| | | | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, 600 Scaife Hall, Pittsburgh, PA, 15261, USA.
- Spectral Medical Inc, Toronto, ON, Canada.
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Zhang L, Zhao X, Guo S, Jiang J, Wang G, Weng Y. An inquiry into the treatment of sepsis using plasma exchange therapy: A systematic review and meta-analysis. Int Wound J 2023; 20:1979-1986. [PMID: 36717980 PMCID: PMC10332988 DOI: 10.1111/iwj.14059] [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: 09/15/2022] [Accepted: 12/06/2022] [Indexed: 02/01/2023] Open
Abstract
Sepsis is a potentially lethal condition that occurs when the body's response to infection damages tissue and organs. The production of inflammatory mediators typically assists in defending the body against infection; however, an overreaction to inflammation can cause coagulation problems, vascular endothelial damage, and organ hypoperfusion. Blood purification methods, such as plasmapheresis, can effectively remove inflammatory mediators from plasma. The purpose of this meta-analysis was to explore the efficacy of plasma exchange for sepsis treatment as noted in recent studies. The authors searched the Pubmed (Medline), Cochrane Central Register of Controlled Trials (The Cochrane Library), Embase (Ovid), and Scopus databases and included controlled clinical studies that compared plasmapheresis or plasma filtration with conventional treatment in patients with severe sepsis. The Newcastle-Ottawa Scale literature quality assessment tool was used to assess the risk of bias. The primary study outcome was all-cause mortality. The random effects model was adopted for conducting the meta-analysis. Among the 1013 records found, the study included 5 trials, all of which carried a low risk of bias. The use of plasmapheresis was associated with a longer stay in the intensive care unit (odds ratio [OR], 0.85, 95% confidence interval [CI], 0.39-1.32, heterogeneity [I2 ] = 0%), a significant reduction in all-cause mortality (OR, 0.54, 95% CI, 0.33-0.89, I2 = 70%), and reduced mortality (OR, 0.29, 95% CI, 0.13-0.67, I2 = 0%) in adults; the results for children differed from this (OR, 0.79, 95% CI, 0.36-1.72, I2 = 89%). Four trials reported no adverse events; one trial reported an adverse event related to plasma exchange, including an instance of hypotension in one patient. Plasmapheresis appeared to be an effective treatment for patients suffering from sepsis. A large number of additional randomised controlled trials are needed to confirm this finding.
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Affiliation(s)
- Lei Zhang
- Department of Critical Care, Beijing Lu He hospitalCapital Medical UniversityBeijingPeople's Republic of China
| | - Xin‐Yu Zhao
- Department of Critical Care, Beijing Lu He hospitalCapital Medical UniversityBeijingPeople's Republic of China
| | - Shu‐Yan Guo
- Department of Critical Care, Beijing Lu He hospitalCapital Medical UniversityBeijingPeople's Republic of China
| | - Jian Jiang
- Department of Critical Care, Beijing Lu He hospitalCapital Medical UniversityBeijingPeople's Republic of China
| | - Guan Wang
- Department of Critical Care, Beijing Lu He hospitalCapital Medical UniversityBeijingPeople's Republic of China
| | - Yi‐Bing Weng
- Department of Critical Care, Beijing Lu He hospitalCapital Medical UniversityBeijingPeople's Republic of China
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10
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Rey S, Kulabukhov VM, Popov A, Nikitina O, Berdnikov G, Magomedov M, Kim T, Masolitin S, Ignatenko O, Krotenko N, Marysheva A, Chaus N, Ohinko L, Mendibaev M, Chumachenko A, Pisarev V. HEMOPERFUSION USING THE LPS-SELECTIVE MESOPOROUS POLYMERIC ADSORBENT IN SEPTIC SHOCK: A MULTICENTER RANDOMIZED CLINICAL TRIAL. Shock 2023; 59:846-854. [PMID: 37018802 PMCID: PMC10227945 DOI: 10.1097/shk.0000000000002121] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/20/2023] [Indexed: 04/07/2023]
Abstract
ABSTRACT Extracorporeal hemoperfusion (EHP) may improve the course and outcomes of patients with septic shock by targeting cytokines or bacterial endotoxins (lipopolysaccharide [LPS]). Here, we present the results of a multicenter randomized controlled trial ( clinicaltrials.gov/ct2/show/NCT04827407 ) to assess the efficiency and safety of Efferon LPS hemoperfusion cartridges engineered for multimodal targeting LPS, host-derived cytokine, and damage-associated molecule pattern molecules. Patients with intra-abdominal sepsis (IAS) and septic shock (Sepsis-3) were subjected to EHP procedures (n = 38). Control patients with IAS and septic shock (n = 20) were treated using conventional protocols without EHP. The primary end point was resolution of septic shock. Secondary end points included MAP, vasopressor drug dose, partial pressure of arterial oxygen/fraction of inspired oxygen ratio, Sequential Organ Failure Assessment score, length of stay in the intensive care unit, and satisfaction with device use by a 5-point Likert scale. Clinical laboratory tests for a blood cells count, lactate and creatinine concentration, nephelometry test for C-reactive protein, immunochemiluminescent test for procalcitonin, and immunoenzyme analysis for IL-6 concentration were used to monitor the EHP effect versus the control group. Data were analyzed followed the intention-to-treat approach. Wilcoxon STATA 16.0 (StataCorp, College Station, TX) and Excel 2019 with XLStat 2019 add-in (Addinsoft, Paris, France) were used for statistical analysis of the results. The Fine and Gray method of competing risks was used to analyze the primary end point and other data representing the time to event. EHP resulted in a significant and rapid increase in MAP and partial pressure arterial oxygen/fraction of inspired oxygen ratio, progressive decline in norepinephrine doses, and multiorgan deficiency, as evaluated by Sequential Organ Failure Assessment scores. Importantly, EHP led to significantly rapid cumulative mechanical ventilation weaning compared with the control group (subdistribution hazard ratio, 2.5; P = 0.037). Early 3-day mortality was significantly reduced in the Efferon LPS versus control group; however, no significant improvements in survival in 14 and 28 days were revealed. Laboratory tests showed rapidly decreased levels of LPS, procalcitonin, C-reactive protein, IL-6, creatinine, leukocytes, and neutrophils only in the Efferon LPS group. Results demonstrate that EHP with Efferon LPS is a safe procedure to abrogate septic shock and normalize clinical and pathogenically relevant biomarkers in patients with IAS.
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Affiliation(s)
- Sergei Rey
- N.V. Sklifosovsky Research Institute for Emergency Medicine
| | | | - Alexander Popov
- A.N. Nesmeyanov Institute of Organoelement Compounds, Russian Academy of Sciences
| | - Olga Nikitina
- N.V. Sklifosovsky Research Institute for Emergency Medicine
| | | | - Marat Magomedov
- N.I. Pirogov City Clinical Hospital N1
- Pirogov Russian National Research Medical University
| | - Timur Kim
- N.I. Pirogov City Clinical Hospital N1
| | | | | | | | | | | | | | | | - Anastasia Chumachenko
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Vladimir Pisarev
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
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11
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Berlot G, Tomasini A, Zanchi S, Moro E. The Techniques of Blood Purification in the Treatment of Sepsis and Other Hyperinflammatory Conditions. J Clin Med 2023; 12:jcm12051723. [PMID: 36902510 PMCID: PMC10002609 DOI: 10.3390/jcm12051723] [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: 01/10/2023] [Revised: 02/16/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023] Open
Abstract
Even in the absence of strong indications deriving from clinical studies, the removal of mediators is increasingly used in septic shock and in other clinical conditions characterized by a hyperinflammatory response. Despite the different underlying mechanisms of action, they are collectively indicated as blood purification techniques. Their main categories include blood- and plasma processing procedures, which can run in a stand-alone mode or, more commonly, in association with a renal replacement treatment. The different techniques and principles of function, the clinical evidence derived from multiple clinical investigations, and the possible side effects are reviewed and discussed along with the persisting uncertainties about their precise role in the therapeutic armamentarium of these syndromes.
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Affiliation(s)
- Giorgio Berlot
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy
- UCO Anestesia Rianimazione e Terapia Antalgica, Azienda Sanitaria Universitaria Giuliano Isontina, Strada di Fiume 447, 34149 Trieste, Italy
- Correspondence: ; Tel.: +039-04039904540; Fax: +039-040912278
| | - Ariella Tomasini
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy
| | - Silvia Zanchi
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy
| | - Edoardo Moro
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy
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Shoji H, Ferrer R. Potential survival benefit and early recovery from organ dysfunction with polymyxin B hemoperfusion: perspectives from a real-world big data analysis and the supporting mechanisms of action. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2022. [PMCID: PMC9207853 DOI: 10.1186/s44158-022-00056-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Endotoxin (ET) removal therapy with polymyxin B-immobilized fiber column hemoperfusion (PMX-HP) has been used for the treatment of septic shock. Some observational studies reported clinical benefits, particularly in specific subgroups of patients. However, larger randomized controlled trial results have been disappointing.
Main body
The four studies that revealed the survival benefit of PMX-HP were based on the Japanese Diagnosis Procedure Combination (DPC) national inpatient database (J-DPC study). Nevertheless, one J-DPC study and a randomized controlled trial (RCT) conducted in France evaluated PMX-HP in patients with abdominal septic shock and did not report a significant survival benefit. In both studies, the severity of illness was too low to find substantial significant differences in mortality. The results of the J-DPC studies further suggest that some subpopulations of patients could benefit from PMX-HP. Based on these results, this review revisited prior RCTs and other large-scale studies on PMX-HP. In addition, four J-DPC studies and one large-scale study reported a survival benefit with PMX-HP. A secondary analysis of the EUPHRATES trial, the most recent double-blinded RCT of PMX-HP conducted in North America, suggested a survival benefit in patients with high levels of endotoxemia. In the J-DPC studies and the EUPHRATES trial, ventilator-free days, vasoactive drug-free days, and renal replacement-free days were significantly improved in the PMX-HP groups. These findings suggest that PMX-HP can contribute to early recovery from organ dysfunction. The reduction of supportive care likely provides important health and economic benefits for managing patients with septic shock. Finally, the blood levels of mediators or biomarkers related to respiratory, cardiovascular, and renal dysfunction have been reported to be normalized with PMX-HP.
Conclusions
These results support the biological rationale for the improvement in organ dysfunction observed in the J-DPC studies and other large-scale studies, including the EUPHRATES trial. Real-world evidence from large data sets suggests an appropriate patient population that are likely to benefit from the utility of PMX-HP for septic shock.
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Leligdowicz A, Harhay MO, Calfee CS. Immune Modulation in Sepsis, ARDS, and Covid-19 - The Road Traveled and the Road Ahead. NEJM EVIDENCE 2022; 1:EVIDra2200118. [PMID: 38319856 DOI: 10.1056/evidra2200118] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Immune Modulation in Sepsis, ARDS, and Covid-19Leligdowicz et al. consider the history and future of immunomodulating therapies in sepsis and ARDS, including ARDS due to Covid-19, and remark on the larger challenge of clinical research on therapies for syndromes with profound clinical and biologic heterogeneity.
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Affiliation(s)
- Aleksandra Leligdowicz
- Department of Medicine, Division of Critical Care Medicine, Western University, London, ON, Canada
- Robarts Research Institute, Western University, London, ON, Canada
| | - Michael O Harhay
- Clinical Trials Methods and Outcomes Lab, Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Carolyn S Calfee
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco
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Wald R, Beaubien-Souligny W, Chanchlani R, Clark EG, Neyra JA, Ostermann M, Silver SA, Vaara S, Zarbock A, Bagshaw SM. Delivering optimal renal replacement therapy to critically ill patients with acute kidney injury. Intensive Care Med 2022; 48:1368-1381. [PMID: 36066597 DOI: 10.1007/s00134-022-06851-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
Critical illness is often complicated by acute kidney injury (AKI). In patients with severe AKI, renal replacement therapy (RRT) is deployed to address metabolic dysfunction and volume excess until kidney function recovers. This review is intended to provide a comprehensive update on key aspects of RRT prescription and delivery to critically ill patients. Recently completed trials have enhanced the evidence base regarding several RRT practices, most notably the timing of RRT initiation and anticoagulation for continuous therapies. Better evidence is still needed to clarify several aspects of care including optimal targets for ultrafiltration and effective strategies for RRT weaning and discontinuation.
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Affiliation(s)
- Ron Wald
- Division of Nephrology, St. Michael's Hospital and the University of Toronto, 61 Queen Street East, 9-140, Toronto, ON, M5C 2T2, Canada. .,Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
| | | | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Javier A Neyra
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marlies Ostermann
- Department of Critical Care Medicine, Guys and St. Thomas Hospital, London, UK
| | - Samuel A Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen's University, Kingston, ON, Canada
| | - Suvi Vaara
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, Muenster, Germany
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
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15
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Heymann M, Schorer R, Putzu A. Mortality and adverse events of hemoadsorption with CytoSorb® in critically ill patients: a systematic review and meta-analysis of randomized controlled trials. Acta Anaesthesiol Scand 2022; 66:1037-1050. [PMID: 35788557 PMCID: PMC9541789 DOI: 10.1111/aas.14115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/08/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022]
Abstract
Background The effects and safety of extracorporeal hemoadsorption with CytoSorb® in critically ill patients with inflammatory conditions are controversial. Methods We performed a systematic review with meta‐analysis and trial sequential analysis (TSA) of randomized‐controlled trials to assess the mortality and safety of CytoSorb® therapy in critically ill patients with inflammatory conditions. Electronic databases were searched up to April 2022. The primary outcome was mortality at longest follow‐up and secondary outcomes included various adverse event (AE) outcomes. Conflict of interest and funding of each trial were assessed. We calculated relative risk (RR) and 95% confidence interval (CI). Results Fourteen published (n = 764) and 4 unpublished (n = 111) trials were included. Eight trials were performed in medical ICU patients and 10 in complex cardiac surgery. Ten trials had significant industrial funding or an author conflict of interest. Hemoadsorption with CytoSorb® was associated with higher mortality at latest follow‐up (16 trials, n = 807, 120 of 402 [29.85%] patients in the CytoSorb® group vs. 98 of 405 [24.20%] patients in the control group, RR = 1.24 [95% CI, 1.04–1.49], p = .02, [TSA‐adjusted CI, 0.92–1.68]) and at 30‐days or in‐hospital (11 trials, n = 727; RR = 1.41 [95% CI, 1.06–1.88], p = .02, [TSA‐adjusted CI, 0.44–4.62]). Only one trial reported the definition of adverse event, while detailed results were reported in 3 trials; the risk of adverse events was not higher with CytoSorb®. Certainty of evidence ranged from low to very low. Conclusion Low certainty of evidence showed that the use of CytoSorb® might increase mortality in critically ill patients with inflammatory conditions. Adverse events were frequent but underreported and not systematically evaluated. Industrial funding and conflict of interest were common. Considerable uncertainty about the findings does not allow firm conclusions and suggests a need for high‐quality randomized trials to clarify mortality and adverse events related to CytoSorb®. Editorial Comment Hemoadsorption with CytoSorb® have been used in critically ill patients despite lack of high quality data from RCTs suggesting any patient‐important benefits. The findings from this systematic review and meta‐analysis suggests an increased risk of adverse events including mortality. With no apparent benefits and at the same time risk of harm, use of hemoadsorption with CytoSorb® in daily clinical practice cannot be recommended at this time.
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Affiliation(s)
- Marc Heymann
- Division of Anesthesiology, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Raoul Schorer
- Division of Anesthesiology, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Alessandro Putzu
- Division of Anesthesiology, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
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16
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Forni LG. Blood Purification Studies in the ICU: What Endpoints Should We Use? Blood Purif 2022; 51:990-996. [DOI: 10.1159/000523761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/21/2022] [Indexed: 11/19/2022]
Abstract
The potential for treatment of the critically ill using blood purification techniques has been discussed for several decades. However, since the first attempts at applying extracorporeal techniques to patients with sepsis were described, there has been considerable hesitancy towards the widespread adoption of such methods, given the lack of mortality benefit observed and indeed the paucity of randomized controlled studies. However, this is not unique so far as studies on the critically ill are concerned where there is a dearth of studies providing a positive finding to influence clinical practice. Consequently, as well as targeted patient selection, it is perhaps time to consider endpoints other than mortality in studies on the critically ill, particularly in blood purification studies where, to-date, such heterogeneous groups of patients have been studied.
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Berlot G, Di Bella S, Tomasini A, Roman-Pognuz E. The Effects of Hemoadsorption on the Kinetics of Antibacterial and Antifungal Agents. Antibiotics (Basel) 2022; 11:antibiotics11020180. [PMID: 35203783 PMCID: PMC8868360 DOI: 10.3390/antibiotics11020180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/28/2022] [Accepted: 01/29/2022] [Indexed: 11/16/2022] Open
Abstract
The extracorporeal elimination of a pathogen or damage-associated molecular pattern via blood purification techniques is increasingly being used in patients with septic shock and other clinical conditions characterized by a life-threatening inflammatory response. The removal of these substances can be accomoplished by means of ultrafiltration or hemoadsorption. Independently from the blood putification technique used, they could also affect the clearance of antibacterial and antifungal agents with a potentially significant clinical impact. In our review, we describe the basic principles of ultrafiltration and hemoadsorption, the available devices for this latter and the existing experimental and clinical studies; the final paragraph is dedicated to practical considerations that can help clinicians to consider the clearance of antibiotics and antifungals attributable to these techniques to minimize the risk of a iatrogenic underdosage.
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Affiliation(s)
- Giorgio Berlot
- Azienda Sanitaria Universitaria Giuliano-Isontina, Department of Anesthesia and Intensive Care Medicine, Cattinara University Hospital, 34100 Trieste, Italy; (A.T.); (E.R.-P.)
- Correspondence:
| | - Stefano Di Bella
- Clinical Department of Medical, Surgical and Health Sciences, Infectious Diseases Unit, Trieste University Hospital, 34100 Trieste, Italy;
| | - Ariella Tomasini
- Azienda Sanitaria Universitaria Giuliano-Isontina, Department of Anesthesia and Intensive Care Medicine, Cattinara University Hospital, 34100 Trieste, Italy; (A.T.); (E.R.-P.)
| | - Erik Roman-Pognuz
- Azienda Sanitaria Universitaria Giuliano-Isontina, Department of Anesthesia and Intensive Care Medicine, Cattinara University Hospital, 34100 Trieste, Italy; (A.T.); (E.R.-P.)
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18
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The Rationale and Current Status of Endotoxin Adsorption in the Treatment of Septic Shock. J Clin Med 2022; 11:jcm11030619. [PMID: 35160068 PMCID: PMC8836955 DOI: 10.3390/jcm11030619] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 02/05/2023] Open
Abstract
Lipopolysaccharide, the main component of the outer membrane of Gram-negative bacteria is a highly potent endotoxin responsible for organ dysfunction in sepsis. It is present in the blood stream not only in Gram-negative infections, but also in Gram-positive and fungal infections, presumably due to sepsis-related disruption of the intestinal barrier. Various pathways, both extra- and intracellular, are involved in sensing endotoxin and non-canonical activation of caspase-mediated pyroptosis is considered to have a major role in sepsis pathophysiology. Endotoxin induces specific pathological alterations in several organs, which contributes to poor outcomes. The adverse consequences of endotoxin in the circulation support the use of anti-endotoxin therapies, yet more than 30 years of experience with endotoxin adsorption therapies have not provided clear evidence in favor of this treatment modality. The results of small studies support timely endotoxin removal guided by measuring the levels of endotoxin; unfortunately, this has not been proven in large, randomized studies. The presence of endotoxemia can be demonstrated in the majority of patients with COVID-19, yet only case reports and case series describing the effects of endotoxin removal in these patients have been published to date. The place of blood purification therapies in the treatment of septic shock has not yet been determined.
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Berlot G, Samola V, Barbaresco I, Tomasini A, di Maso V, Bianco F, Gerini U. Effects of the timing and intensity of treatment on septic shock patients treated with CytoSorb ®: Clinical experience. Int J Artif Organs 2022; 45:249-253. [PMID: 35075942 DOI: 10.1177/03913988211073812] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION A group of adult septic shock patients treated with hemoperfusion (HA) with the Cytosorb® associated with CVVHD were studied to determine (a) the effects of this technique on different clinical variables; and (b) the impact of the pre CytoSorb® interval and its intensity on the outcome. METHODS The catecholamine index (CI) and the pressure-catecholamine Index (PCAI) were used to assess the amount of catecholamine administered at baseline and during the procedure, respectively. The pre-treatment time was calculated since the onset of the septic-shock related hypotension and the initiation of the first session and the intensity was assessed considering either the total volume of blood processed and the duration of the HA. RESULTS Overall, 51 patients with septic shock (30 m, 21 f), age 68 years (IQR 59-76) were retrospectively enrolled in the study; 26 were discharged alive form the ICU (S) and 25 died in ICU (NS); in the S group either CI and PCAI decreased significantly but in NS the CI increased and the PCAI remained stable in NS. In S, the time elapsing from the onset of symptoms and the start of Cytosorb® was shorter than in NS; the duration of the treatment and the volume of blood processed were significantly higher in S than in NS. CONCLUSIONS In this group of septic shock patients, the earlier initiation of Cytosorb®, its longer duration and the higher volume of blood processed were associated with a better survival.
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Affiliation(s)
- Giorgio Berlot
- Department of Anesthesia and Intensive Care Medicine, Cattinara University Hospital, Azienda Sanitaria Universitaria Giuliano-Isontina, Trieste, Friuli-Venezia Giulia, Italy
| | - Valentina Samola
- Department of Anesthesia and Intensive Care Medicine, Cattinara University Hospital, Azienda Sanitaria Universitaria Giuliano-Isontina, Trieste, Friuli-Venezia Giulia, Italy
| | - Ilaria Barbaresco
- Department of Anesthesia and Intensive Care Medicine, Cattinara University Hospital, Azienda Sanitaria Universitaria Giuliano-Isontina, Trieste, Friuli-Venezia Giulia, Italy
| | - Ariella Tomasini
- Department of Anesthesia and Intensive Care Medicine, Cattinara University Hospital, Azienda Sanitaria Universitaria Giuliano-Isontina, Trieste, Friuli-Venezia Giulia, Italy
| | - Vittorio di Maso
- Department of Nephrology, Cattinara University Hospital, Azienda Sanitaria Universitaria Giuliano-Isontina, Trieste, Friuli-Venezia Giulia, Italy
| | - Francesco Bianco
- Department of Nephrology, Cattinara University Hospital, Azienda Sanitaria Universitaria Giuliano-Isontina, Trieste, Friuli-Venezia Giulia, Italy
| | - Ugo Gerini
- Department of Nephrology, Cattinara University Hospital, Azienda Sanitaria Universitaria Giuliano-Isontina, Trieste, Friuli-Venezia Giulia, Italy
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Hellman T, Uusalo P, Järvisalo MJ. Renal Replacement Techniques in Septic Shock. Int J Mol Sci 2021; 22:10238. [PMID: 34638575 PMCID: PMC8508758 DOI: 10.3390/ijms221910238] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/16/2021] [Accepted: 09/21/2021] [Indexed: 12/15/2022] Open
Abstract
Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to an infection; it carries a risk for mortality, considerably exceeding that of a mere infection. Sepsis is the leading cause for acute kidney injury (AKI) and the requirement for renal replacement therapy (RRT) in intensive care unit (ICU) patients. Almost every second critically ill patient with sepsis will develop AKI. In septic shock, the dysregulated host response to infectious pathogens leads to a cytokine storm with uncontrolled production and release of humoral proinflammatory mediators that evoke cellular toxicity and promote the development of organ dysfunction and increased mortality. In addition to treating AKI, RRT techniques can be employed for extracorporeal adsorption of inflammatory mediators using specifically developed adsorption membranes, hemoperfusion sorbent cartridges or columns; these techniques are intended to decrease the level and early deleterious effects of circulating proinflammatory cytokines and endotoxins during the first hours and days of septic shock treatment, in order to improve patient outcomes. Several methods and devices, such as high cut-off membranes, the Oxiris®-AN69 membrane, CytoSorb® and HA380 cytokine hemoadsorption, polymyxin B endotoxin adsorption, and plasmapheresis have been examined in small study series or are under evaluation as ways of improving patient outcomes in septic shock. However, to date, the data on actual outcome benefits have remained controversial, as discussed in this review.
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Affiliation(s)
- Tapio Hellman
- Kidney Center, Turku University Hospital and University of Turku, Building 4, AA7, Kiinanmyllynkatu 4-8, FIN-20521 Turku, Finland;
| | - Panu Uusalo
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Building 18, TG3B, Hämeentie 11, FIN-20521 Turku, Finland;
- Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, Building 18, TG3B, Hämeentie 11, FIN-20521 Turku, Finland
| | - Mikko J. Järvisalo
- Kidney Center, Turku University Hospital and University of Turku, Building 4, AA7, Kiinanmyllynkatu 4-8, FIN-20521 Turku, Finland;
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Building 18, TG3B, Hämeentie 11, FIN-20521 Turku, Finland;
- Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, Building 18, TG3B, Hämeentie 11, FIN-20521 Turku, Finland
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Abstract
Patients with infection can develop sepsis, and their mortality can be high. An important aspect in the treatment of sepsis is adequate management of the infection.
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22
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Apheresis in patients with sepsis: A multicenter retrospective study. Transfus Apher Sci 2021; 60:103239. [PMID: 34412948 DOI: 10.1016/j.transci.2021.103239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES To consider the effectiveness of apheresis, which is a supportive treatment method, in sepsis. MATERIALS AND METHODS A hundred and eleven adults with sepsis or septic shock were included in this retrospective study. The demographic characteristics of the patients, the focus and source of infection causing sepsis or septic shock, characteristics of the pathogen, Acute Physiological and Chronic Health Assessment (APACHE) II score, routine laboratory values, which apheresis method was used, the characteristics of the replacement fluids used during the apheresis procedure, the number of apheresis procedures, complications related to the apheresis procedure, the follow-up time after the procedure, and mortality were recorded. The primary outcome was 28-day mortality. RESULTS Sixty-nine (62.2 %) of the patients were male. The mean age of the patients was 47.7 ± 18.6 years. The most common source of sepsis was hospital-acquired (79.3 %), the most common pathogen causing sepsis was gram-negative bacteria (41.4 %), and the most common infection site was the respiratory tract (58.7 %). The median APACHE II score was 19 (13-24). 92 (82.9 %) of the patients had septic shock. Theropeutic plasma exchange (TPE) was performed in 11.7 % of the patients and immunoabsorbtion IA in 88.3 %. The median number of sessions was 3 (3-5). No procedure-related fatal complication was observed in the study. While 28-day mortality was 61.3 % in all patients, when the mortality according to the apheresis procedures was examined, it was 11.3 % and 88.2 % in the patients who underwent TPE and IA, respectively. The most common cause of mortality was multiorgan failure. CONCLUSIONS Apheresis in sepsis can be considered as a salvage treatment. The indication for apheresis in sepsis is still at the level of patient-based individualized decision in line with the studies done so far, including our study. However, there is a need for a multicenter randomized controlled study with a large number of patients in order to give positive or negative recommendations about its effectiveness.
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Moriyama K, Nishida O. Targeting Cytokines, Pathogen-Associated Molecular Patterns, and Damage-Associated Molecular Patterns in Sepsis via Blood Purification. Int J Mol Sci 2021; 22:8882. [PMID: 34445610 PMCID: PMC8396222 DOI: 10.3390/ijms22168882] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 01/14/2023] Open
Abstract
Sepsis is characterized by a dysregulated immune response to infections that causes life-threatening organ dysfunction and even death. When infections occur, bacterial cell wall components (endotoxin or lipopolysaccharide), known as pathogen-associated molecular patterns, bind to pattern recognition receptors, such as toll-like receptors, to initiate an inflammatory response for pathogen elimination. However, strong activation of the immune system leads to cellular dysfunction and ultimately organ failure. Damage-associated molecular patterns (DAMPs), which are released by injured host cells, are well-recognized triggers that result in the elevation of inflammatory cytokine levels. A cytokine storm is thus amplified and sustained in this vicious cycle. Interestingly, during sepsis, neutrophils transition from powerful antimicrobial protectors into dangerous mediators of tissue injury and organ dysfunction. Thus, the concept of blood purification has evolved to include inflammatory cells and mediators. In this review, we summarize recent advances in knowledge regarding the role of lipopolysaccharides, cytokines, DAMPs, and neutrophils in the pathogenesis of sepsis. Additionally, we discuss the potential of blood purification, especially the adsorption technology, for removing immune cells and molecular mediators, thereby serving as a therapeutic strategy against sepsis. Finally, we describe the concept of our immune-modulating blood purification system.
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Affiliation(s)
- Kazuhiro Moriyama
- Laboratory for Immune Response and Regulatory Medicine, Fujita Health University School of Medicine, Toyoake 470-1192, Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake 470-1192, Japan;
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Abstract
BACKGROUND Circulating complement C3 fragments released during septic shock might contribute to the development of complications such as profound hypotension and disseminated intravascular coagulation. The role of C3 in the course of septic shock varies in the literature, possibly because circulating C3 exists in different forms indistinguishable via traditional ELISA-based methods. We sought to test the relationship between C3 forms, measured by Western blotting with its associated protein size differentiation feature, and clinical outcomes. METHODS Secondary analysis of two prospective cohorts of patients with septic shock: a discovery cohort of 24 patents and a validation cohort of 181 patients. C3 levels were measured by Western blotting in both cohorts using blood obtained at enrollment. Differences between survivors and non-survivors were compared, and the independent prognostic values of C3 forms were assessed. RESULTS In both cohorts there were significantly lower levels of the C3-alpha chain in non-survivors than in survivors, and persisted after controlling for sequential organ failure assessment score. Area under the receiver operating characteristics to predict survival was 0.65 (95% confidence interval: 0.56-0.75). At a best cutoff value (Youden) of 970.6 μg/mL, the test demonstrated a sensitivity of 68.5% and specificity of 61.5%. At this cutoff point, Kaplan-Meier survival analysis showed that patients with lower levels of C3-alpha chain had significantly lower survival than those with higher levels (P < 0.001). CONCLUSION Circulating C3-alpha chain levels is a significant independent predictor of survival in septic shock patients.
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25
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Extracorporeal Cytokine Adsorption: "Storm" in a Teacup. Crit Care Med 2021; 49:1372-1374. [PMID: 34261932 DOI: 10.1097/ccm.0000000000005046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Putzu A, Schorer R. Hemoadsorption in critically ill patients with or without COVID-19: A word of caution. J Crit Care 2021; 65:140-141. [PMID: 34148009 PMCID: PMC8196317 DOI: 10.1016/j.jcrc.2021.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/09/2021] [Indexed: 02/06/2023]
Affiliation(s)
- Alessandro Putzu
- Division of Anesthesiology, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland.
| | - Raoul Schorer
- Division of Anesthesiology, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland.
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Jarczak D, Kluge S, Nierhaus A. Sepsis-Pathophysiology and Therapeutic Concepts. Front Med (Lausanne) 2021; 8:628302. [PMID: 34055825 PMCID: PMC8160230 DOI: 10.3389/fmed.2021.628302] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 04/09/2021] [Indexed: 12/12/2022] Open
Abstract
Sepsis is a life-threatening condition and a global disease burden. Today, the heterogeneous syndrome is defined as severe organ dysfunction caused by a dysregulated host response to infection, with renewed emphasis on immune pathophysiology. Despite all efforts of experimental and clinical research during the last three decades, the ability to positively influence course and outcome of the syndrome remains limited. Evidence-based therapy still consists of basic causal and supportive measures, while adjuvant interventions such as blood purification or targeted immunotherapy largely remain without proof of effectiveness so far. With this review, we aim to provide an overview of sepsis immune pathophysiology, to update the choice of therapeutic approaches targeting different immunological mechanisms in the course of sepsis and septic shock, and to call for a paradigm shift from the pathogen to the host response as a potentially more promising angle.
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Affiliation(s)
- Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Nierhaus
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Chew CH, Huang WT, Yang TS, Chen A, Wu YM, Wu MS, Chen CC. Ultra-High Packing Density Next Generation Microtube Array Membrane for Absorption Based Applications. MEMBRANES 2021; 11:273. [PMID: 33917933 PMCID: PMC8068329 DOI: 10.3390/membranes11040273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/24/2021] [Accepted: 03/28/2021] [Indexed: 01/09/2023]
Abstract
Previously, we successfully developed an extracorporeal endotoxin removal device (EERD) that is based on the novel next generation alternating microtube array membrane (MTAM-A) that was superior to the commercial equivalent. In this article, we demonstrated multiple different parameter modifications that led to multiple different types of novel new MTAM structures, which ultimately led to the formation of the MTAM-A. Contrary to the single layered MTAM, the MTAM-A series consisted of a superior packing density fiber connected in a double layered, alternating position which allowed for the greater fiber count to be packed per unit area. The respective MTAM variants were electrospun by utilizing our internally developed tri-axial electrospinning set up to produce the novel microstructures as seen in the respective MTAM variants. A key uniqueness of this study is the ability to produce self-arranged fibers into the respective MTAM variants by utilizing a single spinneret, which has not been demonstrated before. Of the MTAM variants, we observed a change in the microstructure from a single layered MTAM to the MTAM-A series when the ratio of surfactant to shell flow rate approaches 1:1.92. MTAM-A registered the greatest surface area of 2.2 times compared to the traditional single layered MTAM, with the greatest tensile strength at 1.02 ± 0.13 MPa and a maximum elongation of 57.70 ± 9.42%. The MTAM-A was selected for downstream immobilization of polymyxin B (PMB) and assembly into our own internally developed and fabricated dialyzer housing. Subsequently, the entire setup was tested with whole blood spiked with endotoxin; and benchmarked against commercial Toraymyxin fibers of the same size. The results demonstrated that the EERD based on the MTAM-A performed superior to that of the commercial equivalent, registering a rapid reduction of 73.18% of endotoxin (vs. Toraymyxin at 38.78%) at time point 15 min and a final total endotoxin removal of 89.43% (vs. Toraymyxin at 65.03%).
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Affiliation(s)
- Chee Ho Chew
- Graduate Institute of Biomedical Materials & Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11052, Taiwan; (C.H.C.); (W.-T.H.); (Y.M.W.)
| | - Wan-Ting Huang
- Graduate Institute of Biomedical Materials & Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11052, Taiwan; (C.H.C.); (W.-T.H.); (Y.M.W.)
| | - Tzu-Sen Yang
- Graduate Institute of Biomedical Optomechatronics, Taipei Medical University, Taipei 11052, Taiwan;
| | - Amanda Chen
- Department of Biology, University of Washington, Seattle, WA 98195, USA;
| | - Yun Ming Wu
- Graduate Institute of Biomedical Materials & Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11052, Taiwan; (C.H.C.); (W.-T.H.); (Y.M.W.)
| | - Mai-Szu Wu
- Division of Nephrology, Taipei Medical University Shuang Ho Hospital, New Taipei City 23561, Taiwan;
- Research Center of Urology and Kidney, Taipei Medical University, Taipei 11052, Taiwan
- Masters and Ph.D. Programs of Mind Brain and Consciousness, College of Humanities and Social Sciences, Taipei Medical University, Taipei 11052, Taiwan
- Center for Cell Therapy and Regeneration Medicine, Taipei Medical University, Taipei 11052, Taiwan
- The Ph.D. Program for Translational Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei 11052, Taiwan
| | - Chien-Chung Chen
- Graduate Institute of Biomedical Materials & Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11052, Taiwan; (C.H.C.); (W.-T.H.); (Y.M.W.)
- The Ph.D. Program for Translational Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei 11052, Taiwan
- College of Biomedical Engineering, Taipei Medical University, Taipei 11052, Taiwan
- College of Medicine, Taipei Medical University, Taipei 11052, Taiwan
- College of Pharmacy, Taipei Medical University, Taipei 11052, Taiwan
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29
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Uncertain Clinical Effect of Polymyxin B Hemoperfusion in Patients with Septic Acute Kidney Injury Requiring Continuous Renal Replacement Therapy. Shock 2021; 56:551-556. [PMID: 33606479 DOI: 10.1097/shk.0000000000001752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Polymyxin B hemoperfusion (PMX-HP) may improve the clinical outcomes of patients with sepsis and gram-negative bacteremia by reducing endotoxin levels. However, the recent studies with the variable degree of renal support have shown that the improvement of survival rate by PMX-HP remains unclear in such patients. Therefore, we investigated whether the addition of PMX-HP to continuous renal replacement therapy (CRRT) could improve the survival rate than CRRT alone. This study included 231 patients with sepsis undergoing CRRT alone or PMX-HP with CRRT. Primary outcomes were 28-day and 90-day all-cause mortality. Urine output, ventilator support, and Sequential Organ Failure Assessment (SOFA) score were not significantly different between the two groups. Crude 28-day and 90-day mortality rates were higher in the PMX-HP with CRRT group than in the CRRT alone group. To correct for disease severity, propensity score (PS) matching was performed with acute respiratory distress syndrome, mechanical ventilation support, extracorporeal membrane oxygenation, infection source (abdomen), age, inotropic score, SOFA score, C-reactive protein, and procalcitonin levels. Sixty-six PS-matched pairs revealed significantly higher 28-day and 90-day mortality rates in the PMX-HP with CRRT group than in the CRRT alone group. Considering the mortality rates after PS matching, the additional use of PMX-HP does not improve the clinical outcomes of patients with sepsis and acute kidney injury requiring CRRT.
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Casarotta E, Damiani E, Domizi R, Carsetti A, Scorcella C, Adrario E, Bolognini S, Di Falco D, Pantanetti S, Vannicola S, Damia Paciarini A, Donati A. Variation in the Outcome of Norepinephrine-Dependent Septic Patients After the Institution of a Patient-Tailored Therapy Protocol in an Italian Intensive Care Unit: Retrospective Observational Study. Front Med (Lausanne) 2020; 7:592282. [PMID: 33251238 PMCID: PMC7674935 DOI: 10.3389/fmed.2020.592282] [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: 08/06/2020] [Accepted: 10/13/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: To evaluate the outcome of patients with septic shock after the institution of a patient tailored therapy protocol in our Intensive Care Unit (ICU). Methods: Single-center retrospective observational study including 100 consecutive septic patients (≥ 16 years) requiring norepinephrine infusion, admitted to our ICU between 2018 and 2019 after the institution of a patient-tailored therapy protocol, compared with a historical control group of 100 patients admitted between 2010 and 2013 (historical controls). The patient-tailored therapy protocol included the use of IgM-enriched immunoglobulins for patients with low plasma IgM levels, blood purification strategies for patients with high plasma levels of cytokines or endotoxin, albumin correction and modulation of vasoactive agents. Clinical and therapeutic parameters were noted at the time of initiation of norepinephrine infusion and for the 1st 24 h. The primary outcome was ICU mortality. Results: ICU-mortality was lower in the patient-tailored therapy cohort as compared to historical controls (32 vs. 57%, p < 0.001). Patient-tailored therapy was associated with a lower risk of ICU-mortality even after adjusting for the main clinical severity indices (adjusted odds ratio 0.331 [95% confidence interval 0.166–0.658], p = 0.002). After propensity score matching, 48 patients in historical control group and 48 patients in the patient-tailored therapy cohort with similar general characteristics were selected. ICU-mortality was lower in the patient-tailored therapy matched subgroup as compared to historical controls (40 vs. 60%, p = 0.037). Conclusions: An individualized therapeutic approach in septic patients may be associated with a survival benefit. However, the use of an historical control group of patients admitted between 2010 and 2013 may introduce substantial bias. Further adequately designed studies are needed to demonstrate the impact of patient-tailored therapy on outcome.
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Affiliation(s)
- Erika Casarotta
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
| | - Elisa Damiani
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
| | - Roberta Domizi
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera Universitaria “Ospedali Riuniti” of Ancona, Ancona, Italy
| | - Andrea Carsetti
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera Universitaria “Ospedali Riuniti” of Ancona, Ancona, Italy
| | - Claudia Scorcella
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera Universitaria “Ospedali Riuniti” of Ancona, Ancona, Italy
| | - Erica Adrario
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera Universitaria “Ospedali Riuniti” of Ancona, Ancona, Italy
| | - Sandra Bolognini
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
| | - Domenico Di Falco
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
| | - Simona Pantanetti
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera Universitaria “Ospedali Riuniti” of Ancona, Ancona, Italy
| | - Sara Vannicola
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
| | - Agnese Damia Paciarini
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
| | - Abele Donati
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera Universitaria “Ospedali Riuniti” of Ancona, Ancona, Italy
- *Correspondence: Abele Donati
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Kamijo H, Mochizuki K, Nakamura Y, Mori K, Ichikawa M, Nitta K, Imamura H. Nafamostat Mesylate Improved Survival Outcomes of Sepsis Patients Who Underwent Blood Purification: A Nationwide Registry Study in Japan. J Clin Med 2020; 9:jcm9082629. [PMID: 32823637 PMCID: PMC7464767 DOI: 10.3390/jcm9082629] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 12/29/2022] Open
Abstract
Nafamostat mesylate (NM) is a synthetic serine protease inhibitor that can be used as an anticoagulant during blood purification in critically ill patients, as well as a treatment for disseminated intravascular coagulation. Although NM has been reported to reduce the risk of bleeding during blood purification, its effect on survival outcomes of patients who received blood purification treatments is unclear. We hypothesized that administration of NM during blood purification can reduce mortality in patients with sepsis. A post hoc analysis was conducted on a nationwide retrospective registry that included data from 3195 sepsis patients registered at 42 intensive care units throughout Japan. We evaluated the effect of NM on hospital mortality and bleeding complications using propensity score matching in 1216 sepsis patients who underwent blood purification in the intensive care unit (ICU). Two-hundred-and-sixty-eight pairs of propensity score-matched patients who received NM and conventional therapy were compared. Hospital and ICU mortality rates in the NM group were significantly lower than those in the conventional therapy group. However, rates of bleeding complications did not differ significantly between the two groups. These data suggest that administration of NM improved the survival outcomes of sepsis patients who underwent blood purification in the ICU.
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Affiliation(s)
- Hiroshi Kamijo
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan; (H.K.); (K.M.); (M.I.); (K.N.); (H.I.)
| | - Katsunori Mochizuki
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan; (H.K.); (K.M.); (M.I.); (K.N.); (H.I.)
- Correspondence: ; Tel.: +81-263-37-3018
| | - Yuta Nakamura
- Department of Emergency Medicine, Saiseikai Kumamoto Hospital, 5-3-1 Chikami Minami-ku, Kumamoto 861-4193, Japan;
| | - Kotaro Mori
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan; (H.K.); (K.M.); (M.I.); (K.N.); (H.I.)
| | - Michitaro Ichikawa
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan; (H.K.); (K.M.); (M.I.); (K.N.); (H.I.)
| | - Kenichi Nitta
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan; (H.K.); (K.M.); (M.I.); (K.N.); (H.I.)
| | - Hiroshi Imamura
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan; (H.K.); (K.M.); (M.I.); (K.N.); (H.I.)
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32
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Peng X, Yan X, Zhu L, Gu Y, Sun Z, Zhan X. Preparation of polymyxin B-loaded gellan-polylysine polyion complex fibers with high affinity to endotoxin. Int J Biol Macromol 2020; 160:703-710. [PMID: 32497663 DOI: 10.1016/j.ijbiomac.2020.05.263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/29/2020] [Indexed: 02/04/2023]
Abstract
Endotoxemia, a life-threatening disease affecting people worldwide, can be treated by hemoperfusion alone. New hemoperfusion materials with high biocompatibility and endotoxin-combination ability are always in demand. Herein, polymyxin B (PMB), a specific endotoxin binding molecule, was loaded onto gellan-polylysine polyion complex, and the obtained material was used in preparing wet-spun fibers. The tensile strength of the as-spun yarns (100 fibers) ranged from 1.49 N to -1.58 N and that of the dried and rewetted yarns ranged from 1.45 N to 1.56 N. The adsorption ability of the fibers with lipopolysaccharides from E. coli was 2.784 ± 0.036 EU/mg in simulated human body fluid and 2.452 ± 0.107 EU/mg in mouse plasma. The fibers showed no cytotoxicity toward U2OS cells and no hemolysis toward mouse blood. The influence of the fibers on the clotting time of mouse blood was negligible, and the blood cells were not adhesive to the fibers. Thus, the PMB-loaded gellan-polylysine complex fiber and its derivate fabrics can be used in hemoperfusion.
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Affiliation(s)
- Xingqiao Peng
- Key Laboratory of Carbohydrate Chemistry and Biotechnology of Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, Jiangsu 214122, China
| | - Xingyue Yan
- Key Laboratory of Carbohydrate Chemistry and Biotechnology of Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, Jiangsu 214122, China
| | - Li Zhu
- Wuxi Galaxy Biotech Co., Ltd., Wuxi, Jiangsu 214125, China
| | - Yiran Gu
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, Jiangsu 215163, China
| | - Zhenglong Sun
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, Jiangsu 215163, China
| | - Xiaobei Zhan
- Key Laboratory of Carbohydrate Chemistry and Biotechnology of Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, Jiangsu 214122, China.
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Mousseaux C, Joly BS, Mohamadou I, Arrestier R, Hertig A, Rafat C. Severe HELLP syndrome masquerading as thrombocytopenic thrombotic purpura: a case report. BMC Nephrol 2020; 21:204. [PMID: 32471388 PMCID: PMC7260815 DOI: 10.1186/s12882-020-01865-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 05/25/2020] [Indexed: 11/24/2022] Open
Abstract
Background Thrombotic microangiopathies (TMAs) occurring in the postpartum period may be difficult to manage. They present as the combination of mechanical hemolytic anemia and consumption thrombocytopenia due to endothelial dysfunction. The cause of this endothelial aggression can be multiple: thrombocytopenic thrombotic purpura (TTP), HELLP syndrome, antiphospholipid syndrome, atypical hemolytic and uremic syndrome or acute fatty liver of pregnancy. TTP results from a severe deficiency of ADAMTS13, which is a protease cleaving specifically von Willebrand factor chiefly produced by liver cells. There are two main causes, the production of anti-ADAMTS13 auto-antibodies and, more rarely, a genetic deficiency in ADAMTS13. First-line treatment is based on plasma exchange. HELLP syndrome occurs in the third trimester of pregnancy usually in association with preeclampsia and represents a form of TMA characterized by damage to the sinusoidal capillaries of the liver. Prompt delivery is the main treatment. We present a case illustrating the challenges in discriminating between different postpartum TMAs, with a focus on the distinction between TTP and HELLP syndrome. Specifically, we highlight how acute liver failure (ALF) stemming from HELLP may lead to TTP with a spectacular response to plasma exchanges. Case A 28-year-old, 33 + 4 weeks pregnant woman presented with severe preeclampsia complicated by ALF in the setting of partial liver necrosis, disseminated intravascular coagulation, microangiopathic hemolytic anemia and acute kidney injury. Greatly diminished levels of ADAMTS13 (< 5%) activity and neurological impairment suggested an initial diagnosis of thrombotic thrombocytopenic purpura (TTP). Therapeutic plasma exchange (TPE) was initiated and complete renal, neurological, hematological and hepatic recovery was observed. Secondary TTP induced by ALF due to HELLP syndrome was the final diagnosis. Conclusion Our case addresses the overlapping nature of postpartum TMAs and raises the possibility that HELLP-induced ALF may constitute an additional mechanism resulting in TTP, thereby opening a possible indication for TPE.
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Affiliation(s)
- Cyril Mousseaux
- Department of Nephrology, CHU Tenon, Assistance Publique-Hopitaux de Paris, Paris, France.
| | - Bérangère S Joly
- Hematology Laboratory, French Reference Center for Thrombotic Microangiopathies, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Inna Mohamadou
- Department of Nephrology, CHU Tenon, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Romain Arrestier
- Department of Nephrology, CHU Tenon, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Alexandre Hertig
- Department of Nephrology, CHU Tenon, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Cédric Rafat
- Department of Nephrology, CHU Tenon, Assistance Publique-Hopitaux de Paris, Paris, France
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Liu H, Zhang Q, Liu L, Cao Y, Ye Q, Liu F, Liang J, Wen J, Li Y, Han T. Effect of artificial liver support system on short-term prognosis of patients with hepatitis B virus-related acute-on-chronic liver failure. Artif Organs 2020; 44:E434-E447. [PMID: 32320491 DOI: 10.1111/aor.13710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 03/10/2020] [Accepted: 04/16/2020] [Indexed: 02/06/2023]
Abstract
Hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is difficult to treat and carries a high risk of short-term mortality. This study aimed to explore the effect of artificial liver support system (ALSS) on the survival of HBV-ACLF patients and to investigate which HBV-ACLF patients may benefit from ALSS treatment. We enrolled 132 patients hospitalized for HBV-ACLF according to the criteria of the Chinese Group on the Study of Severe Hepatitis B-ACLF (COSSH-ACLF) from 425 ACLF patients who were determined to at least meet the Asian Pacific Association for the Study of the Liver criteria and followed up for 90 days. Overall 132 eligible patients were divided into two groups: standard medical treatment (SMT) group, which included 54 patients who underwent SMT alone, and ALSS group, which included 78 patients who underwent ALSS treatment plus SMT. The proportion of HBV-ACLF grade 1, 2, and 3 was 57.69%, 37.18%, and 5.13% in the ALSS group and 51.85%, 35.19%, and 12.96% in the SMT group, respectively. Bacterial infection was present in 43.6% of patients in the ALSS group and in 55.6% of patients in the SMT group. The mortality rates in the ALSS group at 28 and 90 days were significantly lower than those in the SMT group (23.08% vs. 48.15% and 33.33% vs. 57.41%, P < 0.05). ALSS was an independent factor related to both the 28- and 90-day survival of HBV-ACLF patients. Particularly, a higher cumulative survival rate in either patients with HBV-ACLF grade 1 or those with HBV-ACLF with bacterial infection was observed in the ALSS group. Moreover, ALSS had an independent influence on mortality. Based on the COSSH-ACLF criteria, ALSS could better improve the short-term survival of HBV-ACLF patients than SMT alone, especially in those with HBV-ACLF grade 1 or HBV-ACLF with infection.
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Affiliation(s)
- Hua Liu
- Department of Hepatology, The Third Central Clinical College of Tianjin Medical University, Tianjin, China.,Department of Hepatology, The Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Artificial Cell Engineering Technology Research Center, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Qian Zhang
- Department of Hepatology, The Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Artificial Cell Engineering Technology Research Center, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Lei Liu
- Department of Hepatology, The Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Artificial Cell Engineering Technology Research Center, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Yingying Cao
- Department of Hepatology, The Third Central Clinical College of Tianjin Medical University, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Artificial Cell Engineering Technology Research Center, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Qing Ye
- Department of Hepatology, The Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Artificial Cell Engineering Technology Research Center, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Fang Liu
- Department of Hepatology, The Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Artificial Cell Engineering Technology Research Center, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Jing Liang
- Department of Hepatology, The Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Artificial Cell Engineering Technology Research Center, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Jing Wen
- Department of Hepatology, The Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Artificial Cell Engineering Technology Research Center, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Ying Li
- Department of Hepatology, The Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Artificial Cell Engineering Technology Research Center, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Tao Han
- Department of Hepatology, The Third Central Clinical College of Tianjin Medical University, Tianjin, China.,Department of Hepatology, The Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Artificial Cell Engineering Technology Research Center, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Department of Hepatology, Tianjin Third Central Hospital Affiliated to Nankai University, Tianjin, China
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Song JC, Wang G, Zhang W, Zhang Y, Li WQ, Zhou Z. Chinese expert consensus on diagnosis and treatment of coagulation dysfunction in COVID-19. Mil Med Res 2020; 7:19. [PMID: 32307014 PMCID: PMC7167301 DOI: 10.1186/s40779-020-00247-7] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 03/25/2020] [Indexed: 12/15/2022] Open
Abstract
Since December 2019, a novel type of coronavirus disease (COVID-19) in Wuhan led to an outbreak throughout China and the rest of the world. To date, there have been more than 1,260,000 COVID-19 patients, with a mortality rate of approximately 5.44%. Studies have shown that coagulation dysfunction is a major cause of death in patients with severe COVID-19. Therefore, the People's Liberation Army Professional Committee of Critical Care Medicine and Chinese Society on Thrombosis and Hemostasis grouped experts from the frontline of the Wuhan epidemic to come together and develop an expert consensus on diagnosis and treatment of coagulation dysfunction associated with a severe COVID-19 infection. This consensus includes an overview of COVID-19-related coagulation dysfunction, tests for coagulation, anticoagulation therapy, replacement therapy, supportive therapy and prevention. The consensus produced 18 recommendations which are being used to guide clinical work.
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Affiliation(s)
- Jing-Chun Song
- Department of Critical Care Medicine, the 908th Hospital of Joint Logistics Support Forces of Chinese PLA, Nanchang, 330002, China.
| | - Gang Wang
- Department of Critical Care Medicine, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710001, China
| | - Wei Zhang
- Department of Emergency Medicine, the 900th Hospital of Joint Logistics Support Forces of Chinese PLA, Fuzhou, 350000, China
| | - Yang Zhang
- Department of Laboratory Medicine, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, China
| | - Wei-Qin Li
- Department of Critical Care Medicine, General Hospital of Eastern Theater Command of Chinese PLA, Nanjing, 210002, China.
| | - Zhou Zhou
- Department of Laboratory Medicine, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, China.
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36
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Song JC, Liu SY, Zhu F, Wen AQ, Ma LH, Li WQ, Wu J. Expert consensus on the diagnosis and treatment of thrombocytopenia in adult critical care patients in China. Mil Med Res 2020; 7:15. [PMID: 32241296 PMCID: PMC7118900 DOI: 10.1186/s40779-020-00244-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/20/2020] [Indexed: 01/14/2023] Open
Abstract
Thrombocytopenia is a common complication of critical care patients. The rates of bleeding events and mortality are also significantly increased in critical care patients with thrombocytopenia. Therefore, the Critical Care Medicine Committee of Chinese People's Liberation Army (PLA) worked with Chinese Society of Laboratory Medicine, Chinese Medical Association to develop this consensus to provide guidance for clinical practice. The consensus includes five sections and 27 items: the definition of thrombocytopenia, etiology and pathophysiology, diagnosis and differential diagnosis, treatment and prevention.
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Affiliation(s)
- Jing-Chun Song
- Department of Critical Care Medicine, the 908th Hospital of Joint Logistics Support Forces of Chinese PLA, Nanchang, 360104, China.
| | - Shu-Yuan Liu
- Emergency Department, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China
| | - Feng Zhu
- Burns and Trauma ICU, Changhai Hospital, Naval Medical University, Shanghai, 200003, China
| | - Ai-Qing Wen
- Department of Blood Transfusion, Daping Hospital of Army Medical University, Chongqing, 400042, China
| | - Lin-Hao Ma
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Wei-Qin Li
- Surgery Intensive Care Unit, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China.
| | - Jun Wu
- Department of Clinical Laboratory, Peking University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing, 100035, China.
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Bioassay for Endothelial Damage Mediators Retrieved by Hemoadsorption. Sci Rep 2019; 9:14522. [PMID: 31601835 PMCID: PMC6787199 DOI: 10.1038/s41598-019-50517-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 09/05/2019] [Indexed: 12/13/2022] Open
Abstract
Hemoadsorption devices are used to treat septic shock by adsorbing inflammatory cytokines and as yet incompletely defined danger and pathogen associated molecular patterns. In an ideal case, hemoadsorption results in immediate recovery of microvascular endothelial cells’ (mEC) function and rapid recovery from catecholamine-dependency and septic shock. We here tested a single device, which consists of polystyrene-divinylbenzene core particles of 450 μm diameter with a high affinity for hydrophobic compounds. The current study aimed at the proof of concept that endothelial-specific damage mediators are adsorbed and can be recovered from hemoadsorption devices. Because of excellent clinical experience, we tested protein fractions released from a hemoadsorber in a novel endothelial bioassay. Video-based, long-term imaging of mEC proliferation and cell death were evaluated and combined with apoptosis and ATP measurements. Out of a total of 39 fractions recovered from column fractionation, we identified 3 fractions that caused i) inhibition of mEC proliferation, ii) increased cell death and iii) induction of apoptosis in mEC. When adding these 3 fractions to mEC, their ATP contents were reduced. These fractions contained proteins of approximately 15 kDa, and high amounts of nucleic acid, which was at least in part oxidized. The efficacy for endothelial cell damage prevention by hemoadsorption can be addressed by a novel endothelial bioassay and long-term video observation procedures. Protein fractionation of the hemoadsorption devices used is feasible to study and define endothelial damage ligands on a molecular level. The results suggest a significant effect by circulating nucleic acids – bound to an as yet undefined protein, which may constitute a major danger-associated molecular pattern (DAMP) in the exacerbation of inflammation when patients experience septic shock. Hemoadsorption devices may thus limit endothelial damage, through the binding of nucleic acid-bearing aggregates and thus contribute to improved endothelial barrier function.
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Venkatesh B, Khanna AK, Cohen J. Less is more: catecholamine-sparing strategies in septic shock. Intensive Care Med 2019; 45:1810-1812. [PMID: 31520103 DOI: 10.1007/s00134-019-05770-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/27/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Balasubramanian Venkatesh
- The Wesley Hospital, Brisbane, QLD, Australia. .,Princess Alexandra Hospital, Brisbane, Australia. .,University of Queensland, Brisbane, Australia. .,University of New South Wales, Sydney, Australia. .,The George Institute for Global Health, Sydney, NSW, Australia.
| | - Ashish K Khanna
- Department of Anesthesiology, Section On Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Baptist Health, Winston-Salem, NC, 27157, USA
| | - Jeremy Cohen
- The Wesley Hospital, Brisbane, QLD, Australia.,University of Queensland, Brisbane, Australia.,The George Institute for Global Health, Sydney, NSW, Australia.,The Royal Brisbane and Women's Hospital, Herston, Australia
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