The Dose of Nafamostat Mesilate During Plasma Exchange With Continuous Hemodiafiltration in the Series-Parallel Circuit

Efficacy and safety of nafamostat mesilate anticoagulation in blood purification treatment of critically ill patients: a systematic review and meta-analysis

Background

Nafamostat mesilate (NM), a broad-spectrum and potent serine protease inhibitor, can be used as an anticoagulant during extracorporeal circulation, as well as a promising drug effective against coronavirus disease 2019 (COVID-19). We conducted a systematic meta-analysis to evaluate the safety and efficacy of NM administration in critically ill patients who underwent blood purification therapy (BPT).

Methods

The Cochrane Library, Web of Science and PubMed were comprehensively searched from inception to August 20, 2021, for potential studies.

Results

Four randomized controlled trials (RCTs) and seven observational studies with 2723 patients met the inclusion criteria. The meta-analysis demonstrated that conventional therapy (CT) significantly increased hospital mortality compared with NM administration (RR = 1.25, p = 0.0007). In subgroup analyses, the in-hospital mortality of the NM group was significantly lower than that of the anticoagulant-free (NA) group (RR = 1.31, p = 0.002). The CT interventions markedly elevated the risk ratio of bleeding complications by 45% (RR = 1.45, p = 0.010) compared with NM interventions. In another subgroup analysis, NM used exhibited a significantly lower risk of bleeding complications than those of the low-molecular-weight heparin (LMWH) used (RR = 4.58, p = 0.020). The filter lifespan was decreased significantly (MD = −10.59, p < 0.0001) in the NA groups compared with the NM groups. Due to the poor quality of the included RCTs, these results should be interpreted with caution.

Conclusion

Given the better survival outcomes, lower risk of bleeding, NM anticoagulation seems to be a safe and efficient approach for BPT patients and could yield a favorable filter lifespan. More multi-center RCTs with large samples are required for further validation of this study.

Multicenter study of plasma diafiltration in patients with acute liver failure

Plasma diafiltration (PDF) is a blood purification therapy in which simple plasma exchange (PE) is performed using a selective membrane plasma separator while the dialysate flows outside the hollow fibers. A prospective, multicenter study was undertaken to evaluate the changes in bilirubin, IL-18, and cystatin C, as well as the 28-day and 90-day survival rates, with the use of PDF according to the level of severity as measured by the Model for End-Stage Liver Disease (MELD) score. Twenty-one patients with liver failure were studied: 10 patients had fulminant hepatitis and PDF therapies were performed 28 times; 11 had acute liver failure with the therapy performed 96 times. Levels of total bilirubin, IL-18, and cystatin C decreased significantly after treatment. The 28-day survival rate was 70.0% and that at 90 days was 16.7%. According to the severity of the MELD score, each of the results compared well with the use of Molecular Adsorbent Recirculating System or Prometheus therapy. In conclusion, PDF appears to be one of the most useful blood purification therapies for use in cases of acute liver failure in terms of medical economics and the removal of water-soluble and albumin-bound toxins.

A Case Report of Hepatorenal Syndrome Treated With Plasma Diafiltration (Selective Plasma Filtration with Dialysis)

Plasma diafiltration (PDF) (selective plasma filtration with dialysis) is blood purification therapy in which simple plasma exchange is performed using a membrane plasma separator (Evacure EC-2A) while dialysate flows outside of the hollow-fibers. A 74-year old man with hepatorenal syndrome underwent four sessions of PDF and three sessions of HDF. Finally he recovered from hepatorenal syndrome. In this therapy, the levels of total bilirubin, interleukin-18, creatinine, and cystatin C were significantly reduced. On the other hand, there were no significant differences in the total protein and albumin levels before and after PDF. PDF may be one of the most useful blood purification therapies for hepatorenal syndrome in terms of medical economics.