Cytokine removal in septic patients with continuous venovenous hemofiltration

Early use of endotoxin absorption by oXiris in abdominal septic shock: A case report

RATIONALE

Septic shock leads to multiple organ failure and increases mortality rate. We reported a critical patient with abdominal septic shock, which was the first case successfully treated with continuous renal replacement therapy (CRRT) and a newly designed endotoxin removal device oXiris in mainland China.

PATIENT CONCERNS

A 51-year-old man developed gastric ulcer perforation after resection of a benign peritoneal tumor and had a second abdominal surgery. His blood pressure decreased to 70/40 mm Hg with oliguria, requiring large doses of noradrenaline and intravenous fluid for resuscitation. The abdominal cavity was not sutured after the second open surgery due to severe abdominal infection and distention. His leukocyte count was over 30109/L, while the blood lactic acid was 12.5 mmol/L and procalcitonin (PCT) was >100 ng/mL.

DIAGNOSIS

Since the bacterial culture of peritoneal exudate showed positive with Enterobacter aerogenes and Pseudomonas aeruginosa after the second surgery, and the patient had severe low blood pressure, hyoxemia and oliguria, combined with the laboratory tests results, he was diagnosed with Gram-negative related septic shock, acute kidney injury, and multiple organ dysfunction.

INTERVENTIONS

CRRT with oXiris membrane was performed for 80hours and followed by AN69 ST membranes during the subsequent 27 days. Antibiotics together with other medical treatment were applied to the patient in the meantime.

OUTCOMES

At the end of 80 hours treatment with oXiris, PCT of the patient had decreased to 14.52 ng/mL and lactic acid decreased to 4.2 mmol/L. The total sequential organ failure assessment (SOFA) score decreased from 15 to 11. Urine output steadily increased to 250 mL/h, and vital signs and blood pressure were stable without noradrenaline. At the end of the 27 days of conventional CRRT, his kidney function had completely recovered with a total sequential organ failure assessment score (SOFA score) of 6.

LESSONS

oXiris, with its enhanced endotoxin adsorption, appeared to accelerate improvement in organ dysfunction and ultimate survival in our patient. In critical patients with abdominal septic shock, oXiris is an important adjunctive consideration to supplement definitive source control and antimicrobial therapy.

Effect of high-volume hemofiltration on children with sepsis

BACKGROUND

Sepsis has always been a challenge in pediatric intensive care unit (PICU) with poor prognosis. In order to evaluate the effect between routine continuous renal replacement therapy (CRRT) and high-volume hemofiltration (HVHF) in children with sepsis, we performed out this prospective, randomized, controlled, open-label trial.

METHODS

Forty-seven children with sepsis were enrolled from January 2015 to December 2016. Twenty-two patients in Control group received routine CRRT and 25 patients in HVHF group received HVHF within 6 hours after the diagnosis of sepsis. The oxygenation index, serum creatinine, urea, lactate, inflammatory cytokines (IL-6, IL-10, and TNF-α), pediatric risk of mortality III (PRISM III) and 28-day mortality rate were collected and compared.

RESULTS

The oxygenation index in HVHF group and Control group was significantly increased at 48 hours (P<0.01) and 72 hours after treatment (P<0.05). The same result of arterial lactate was observed. Serum creatinine, urea, IL-6, IL-10, TNF-α and PRISM III score were significantly ameliorated after 72 hours treatment in HVHF group (P<0.01), while there was no significant difference in Control group. After 72 hours of treatment, the oxygenation index, lactate, serum creatinine, urea, TNF-α, IL-6, IL-10 and PRISM III score in HVHF group were significantly improved compared with Control group (P<0.01). There is no significant difference on 28-day mortality between the two groups (P>0.05).

CONCLUSIONS

HVHF might be an effective treatment for children with sepsis.

Hemoperfusion plus continuous veno-venous hemofiltration in the treatment of patients with multiple organ failure after wasp stings

PURPOSE

This study aimed to evaluate the clinical effects of hemoperfusion plus continuous veno-venous hemofiltration in the treatment of patients with multiple organ failure after wasp stings and investigate its impacts on cytokines.

METHODS

A total of 12 patients with multiple organ failure after wasp stings admitted to Xijing Hospital were included in the present study between January 2017 and January 2019. All patients received hemoperfusion plus continuous veno-venous hemofiltration treatment in addition to conventional treatment after admission. Procedure of treatment was conducted as the following: hemoperfusion (2 h/day) and followed by continuous veno-venous hemofiltration (22 h/day) for at least 5 days. Patients' clinical features, serum laboratory tests, and hemodynamic variables were monitored. The blood samples were taken to measure the changes of plasma cytokines.

RESULTS

All 12 patients survived in the observation period. After hemoperfusion plus continuous veno-venous hemofiltration treatment, there were significant improvements in indicators of liver function, renal function, state of consciousness, and mediators in blood circulation, including alanine transaminase, aspartate transaminase, creatine kinase, blood urea nitrogen, serum creatinine, myoglobin, C-reactive protein, and so on. In these patients, acid-base metabolism returned to normal levels; Acute Physiology and Chronic Health Evaluation II score, Simplified Acute Physiology Score II score, and Sequential Organ Failure Assessment score lowered markedly. Furthermore, the plasma levels of interleukin 1β, interleukin 4, interleukin 6, interleukin 8, and interleukin 10 in these patients were significantly decreased; no significant change was shown in the level of tumor necrosis factor α.

CONCLUSION

Our results revealed that hemoperfusion plus continuous veno-venous hemofiltration was effective in the management of patients with multiple organ failure after wasp sting via the non-specific removal of the wasp venom and inflammatory cytokines.

Cytokine adsorption is a promising tool in the therapy of hemophagocytic lymphohistiocytosis

Hemophagocytic lymphohistiocytosis is a life-threatening clinical syndrome caused by severe hypercytokinemia brought on by a highly stimulated but ineffective immune response. Animal studies and case series have demonstrated that a reduction in blood cytokine levels achieved with an extracorporeal adsorption cartridge that contains blood-compatible porous polymer beads (CytoSorb^®) can effectively attenuate the inflammatory response during sepsis and possibly improve outcomes. We report a case series of two patients in which three episodes of severe hemophagocytic lymphohistiocytosis triggered by infections with herpesviridae were treated successfully with cytokine adsorption. A marked decrease in interleukin-6 plasma levels and a stable or decreasing need of vasopressor therapy were the most significant results of this treatment. Importantly, treatment was safe and well-tolerated, without any adverse events.

Early High-Volume Hemofiltration versus Standard Care for Post-Cardiac Surgery Shock. The HEROICS Study

RATIONALE

Post-cardiac surgery shock is associated with high morbidity and mortality. By removing toxins and proinflammatory mediators and correcting metabolic acidosis, high-volume hemofiltration (HVHF) might halt the vicious circle leading to death by improving myocardial performance and reducing vasopressor dependence.

OBJECTIVES

To determine whether early HVHF decreases all-cause mortality 30 days after randomization.

METHODS

This prospective, multicenter randomized controlled trial included patients with severe shock requiring high-dose catecholamines 3-24 hours post-cardiac surgery who were randomized to early HVHF (80 ml/kg/h for 48 h), followed by standard-volume continuous venovenous hemodiafiltration (CVVHDF) until resolution of shock and recovery of renal function, or conservative standard care, with delayed CVVHDF only for persistent, severe acute kidney injury.

MEASUREMENTS AND MAIN RESULTS

On Day 30, 40 of 112 (36%) HVHF and 40 of 112 (36%) control subjects (odds ratio, 1.00; 95% confidence interval, 0.64-1.56; P = 1.00) had died; only 57% of the control subjects had received renal-replacement therapy. Between-group survivors' Day-60, Day-90, intensive care unit, and in-hospital mortality rates, Day-30 ventilator-free days, and renal function recovery were comparable. HVHF patients experienced faster correction of metabolic acidosis and tended to be more rapidly weaned off catecholamines but had more frequent hypophosphatemia, metabolic alkalosis, and thrombocytopenia.

CONCLUSIONS

For patients with post-cardiac surgery shock requiring high-dose catecholamines, the early HVHF onset for 48 hours, followed by standard volume until resolution of shock and recovery of renal function, did not lower Day-30 mortality and did not impact other important patient-centered outcomes compared with a conservative strategy with delayed CVVHDF initiation only for patients with persistent, severe acute kidney injury. Clinical trial registered with www.clinicaltrials.gov (NCT 01077349).

Tissue concentrations of vasoactive intestinal peptide are affected by peritonitis-induced sepsis and hemofiltration in pigs

Vasoactive intestinal peptide (VIP) is a neuropeptide released from the autonomic nerves exerting multiple antiinflammatory effects. The aim of the present study was to investigate the impact of severe sepsis and hemofiltration in two settings on plasma and tissue concentrations of VIP in a porcine model of sepsis. Thirty-two pigs were divided into 5 groups: 1) control group; 2) control group with conventional hemofiltration; 3) septic group; 4) septic group with conventional hemofiltration; 5) septic group with high-volume hemofiltration. Sepsis induced by faecal peritonitis continued for 22 hours. Hemofiltration was applied for the last 10 hours. Hemodynamic, inflammatory and oxidative stress parameters (heart rate, mean arterial pressure, cardiac output, systemic vascular resistance, plasma concentrations of tumor necrosis factor-alpha, interleukin-6, thiobarbituric acid reactive species, nitrate + nitrite, asymmetric dimethylarginine) and the systemic VIP concentrations were measured before faeces inoculation and at 12 and 22 hours of peritonitis. VIP tissue levels were determined in the left ventricle, mesenteric and coronary arteries. Sepsis induced significant increases in VIP concentrations in the plasma and mesenteric artery, but it decreased peptide levels in the coronary artery. Hemofiltration in both settings reduced concentrations of VIP in the mesenteric artery. In severe sepsis, VIP seems to be rapidly depleted from the coronary artery and, on the other hand, upregulated in the mesenteric artery. Hemofiltration in both settings has a tendency to drain away these upregulated tissue stores which could result in the limited secretory capacity of the peptide.

Evaluation of the effects of pulse high-volume hemofiltration in patients with severe sepsis: a preliminary study

OBJECTIVES

The aim of this study was to evaluate the effects of pulse high-volume hemofiltration (PHVHF) in patients with severe sepsis.

METHODS

Twenty-two patients with severe sepsis admitted to XiJing hospital between January 2009 and January 2010 were included in the present study. Patients were randomly divided into the control group (conventional treatment) and the PHVHF group. Patients in the PHVHF group received 72 h of PHVHF treatment in addition to conventional treatment after admission. PHVHF was conducted as follows: HVHF 85 ml/kg per hour for 6 h followed by continuous venovenous hemofiltration 35 ml/kg per hour for 18 h with an AN69 membrane. The hemofilter was replaced every 24 h and PHVHF was performed with 250 to 300 ml/min blood flow rate. The blood samples were taken to measure the changes of plasma cytokines (TNF-α, IL-1, IL-4, IL-6 and IL-10).

RESULTS

With 72 h of PHVHF treatment, there was an improvement in clinical features and hemodynamics variables in PHVHF-treated patients. All plasma cytokines after PHVHF treatment were significantly lower than those at the start of PHVHF treatment (p<0.05). In contrast, there was no significant change in control patients.

CONCLUSIONS

Our findings suggest that PHVHF is a feasible adjuvant modality in the treatment of patients with severe sepsis. With the application of PHVHF treatment, plasma cytokines are effectively removed. Considering the lower cost and better feasibility than continuous high-volume hemofiltration (CHVF), PHVHF shows promising prospects for the future.

Effectiveness of continuous hemodiafiltration using a polymethylmethacrylate membrane hemofilter after polymyxin B-immobilized fiber column therapy of septic shock

Septic shock is a condition associated with diffuse coagulopathy and multiple organ failure, and frequently ends in death. Direct hemoperfusion using a polymyxin B-immobilized fiber column (DHP-PMX) was first developed in Japan in 1994 and has since been used for the treatment of septic shock. On the other hand, the effectiveness of continuous hemodiafiltration using a polymethylmethacrylate membrane hemofilter (PMMA- CHDF) for critically ill patients has also been reported. We treated 27 septic shock patients by DHP-PMX. The patients, except for the nine in whom CHDF was not performed after DHP-PMX, were divided into two groups: namely, a group in which PMMA-CHDF therapy was added after DHP-PMX (11 cases), and a group in which continuous hemodiafiltration using a polyacrylonitrile membrane hemofilter (PAN-CHDF) therapy was added after DHP-PMX (7 cases). The outcomes in the two groups were compared. The average Acute Physiology and Chronic Health Evaluation (APACHE) II score and the average sepsis-related organ failure assessment (SOFA) score were not significantly different between the two groups. The PMMA-CHDF group showed significantly better outcomes, with significant improvements of the serum PAI-1, protein C, IL-6 and N-arachidonoylethanolamine (AEA) levels. We conclude that PMMA-CHDF may be more effective than PAN-CHDF in the management of septic shock.

Intermittent versus continuous renal replacement therapy: a matter of controversy

BACKGROUND

Acute Renal Failure (ARF) requiring some form of replacement therapy is a frequent complication in the critically ill patient. Despite potential therapeutic advantages the expectation of an improvement in patient outcomes using Continuous Renal Replacement Therapy (CRRT) compared to conventional Intermittent Haemodialysis (IHD) remains controversial.

AIMS AND METHOD

This article will review the literature on the issues surrounding the use of IHD versus CRRT in the management of the critically ill patient. Articles were selected according to level of evidence with priority given to meta-analyses and randomised controlled trials.

DISCUSSION

Several operational features of CRRT allow this technique to be tolerated more easily in critical illness than IHD. The gradual removal of fluid reduces the incidence of hypotension and the risk of volume overload. Decreased variability in the concentration of solutes enables greater azotemia control. However, CRRT is required to operate uninterrupted to achieve a treatment dose that is equivalent to a conventional IHD treatment schedule. In the absence of definitive evidence to validate superior patient survival and return of renal function there is disagreement as to the most appropriate form of Renal Replacement Therapy (RRT) for the critically ill patient. The introduction of 'hybrid' therapies offers a further alternative treatment strategy, which combine favourable aspects of IHD and CRRT.

CONCLUSION

The decision to use IHD or CRRT should be guided by the therapeutic needs of the patient rather than the operational differences between the two techniques. The resources and expertise available at the organisation are also important in determining the mode best able to manage the critically ill patient at any stage and may change according to the severity of illness. The emergence of hybrid therapies provides a compromise option which encompasses many of the features of both systems, but does not embrace all options of either approach.

Clinical responses and improvement of some laboratory parameters following polymyxin B-immobilized fiber treatment in septic shock

Direct hemoperfusion using a polymyxin B-immobilized fiber column (PMX; Toray Industries Inc., Tokyo, Japan) was first developed in 1994 and has since been used for the treatment of septic shock. Positive clinical data, such as an increase in systolic blood pressure (SBP) and an improved Pao2/Fio2 ratio, have also been reported. We treated 27 septic shock patients using DHP-PMX. The patients were separated into two groups for analysis: those whose Pao2/Fio2 ratio increased after DHP-PMX (9 cases) and those whose Pao2/Fio2 ratio did not increase after DHP-PMX (18 cases). The patients were also separated into two other groups for analysis: those whose SBP increased by more than 30 mm Hg immediately after DHP-PMX (15 cases) and those whose SBP did not increase by more than 30 mm Hg after DHP-PMX (12 cases). The Pao2/Fio2 ratio increased significantly after DHP-PMX in the groups showing improved 2AG and PAI-1 levels (p = 0.0040). The SBP increased significantly in the group showing improved HMGB-1 levels (p < 0.0001). We observed a relationship between hemodynamic improvement and increase of the serum HMGB-1 levels and between improvement of respiratory functions and increase of the serum 2-AG and PAI-1 levels in septic shock patients treated with DHP-PMX.

Evaluation of prognostic factors and scoring system in colonic perforation

AIM: To study the significance of scoring systems assessing severity and prognostic factors in patients with colonic perforation.

METHODS: A total of 26 patients (9 men, 17 women; mean age 72.7 ± 11.6 years) underwent emergency operation for colorectal perforation in our institution between 1993 and 2005. Several clinical factors were measured preoperatively and 24 h postoperatively. Acute physiology and chronic health evaluation II (APACHE II), Mannheim peritonitis index (MPI) and peritonitis index of Altona (PIA II) scores were calculated preoperatively.

RESULTS: Overall postoperative mortality rate was 23.1% (6 patients). Compared with survivors, non-survivors displayed low blood pressure, low serum protein and high serum creatinine preoperatively, and low blood pressure, low white blood cell count, low pH, low PaO₂/FiO₂, and high serum creatinine postoperatively. APACHE II score was significantly lower in survivors than in non-survivors (10.4 ± 3.84 vs 19.3 ± 2.87, P = 0.00003). Non-survivors tended to display high MPI score and low PIA II score, but no significant difference was identified.

CONCLUSION: Pre- and postoperative blood pressure and serum creatinine level appear related to prognosis of colonic perforation. APACHE II score is most associated with prognosis and scores ≥ 20 are associated with significantly increased mortality rate.

Effects of continuous high-volume hemofiltration on experimental severe acute pancreatitis in pigs

OBJECTIVE

To compare the effects of different doses of hemofiltration on severe acute pancreatitis (SAP) in pigs.

METHODS

The animal model of SAP was produced by intraductal injection of sodium taurocholate and trypsin. Animals in group 1 served as SAP control. Animals in group 2 received (20 mL/kg per hour) continuous low-volume hemofiltration (LVHF), and animals in group 3 received (100 mL/kg per hour) continuous high-volume hemofiltration (HVHF) immediately after the induction of SAP. After the instrumentation of the animals by arterial and Swan-Ganz catheters, hemodynamic indexes were monitored intermittently at different times. The rectal temperature and the concentration of amylase and cytokines in serum were measured at the same time.

RESULTS

The survival time of HVHF group was significantly prolonged (P < 0.01). The initial elevation of body temperature and the hypothermia in the late course of experiments were significantly ameliorated by HVHF (P < 0.01). Six hours after the induction of pancreatitis, the urine output of animals in HVHF group was obviously higher than that in control group (P < 0.05), which stayed behind 36 hours later (P < 0.05). The major hemodynamic finding was that pancreatitis-induced hypotension was significantly attenuated by HVHF (P < 0.01). The development of hyperdynamic circulatory failure was simultaneously attenuated, as reflected by a limited increase in CI, an attenuated decrease in systemic vascular resistance index. Plasma amylases in the HVHF group were significantly lower than those in control and LVHF groups (P < 0.01). The serum concentrations of cytokines such as tumor necrosis factor alpha (TNF-alpha), interleukin (IL) 6, and IL-10 all decreased significantly in treatment groups (P < 0.01), and those of HVHF group were less significant than the HVHF group (P < 0.01).

CONCLUSIONS

The HVHF was associated with a better hemodynamic profile, a less hyperkinetic state, and more prolonged survival than that of LVHF, which may result from the HVHF that can remove the inflammatory cytokines more efficiently.

Pilot study on the effects of high cutoff hemofiltration on the need for norepinephrine in septic patients with acute renal failure

OBJECTIVE

High cutoff hemofilters are characterized by an increased effective pore size designed to facilitate the elimination of inflammatory mediators in sepsis. Clinical data on this new renal replacement modality are lacking.

DESIGN

Prospective, randomized clinical trial.

SETTING

University hospital, intensive care units.

PATIENTS

: Thirty patients with sepsis-induced acute renal failure.

INTERVENTION

Patients were allocated to high cutoff (n = 20) or conventional (n = 10) hemofiltration in a 2:1 ratio. Median renal replacement dose was 31 mL/kg/hr. For high cutoff hemofiltration, a high-flux hemofilter with an in vivo cutoff point of approximately 60 kilodaltons was used. Conventional hemofiltration was performed with a standard high-flux hemofilter (PF11S). The impacts of high cutoff hemofiltration on the need for norepinephrine and on plasma levels and clearance rates for interleukin (IL)-6 and IL-1 receptor antagonist (IL-1ra) were analyzed. Absolute values, but also adjusted values (expressed as proportion of baseline), were analyzed. The observation period was restricted to 48 hrs.

MAIN RESULTS

Apart from higher antithrombin III levels at entry into the study, main clinical and laboratory parameters were comparable between both groups. The median norepinephrine dose at entry into the study was 0.30 microg/kg/min in the high cutoff group and 0.21 microg/kg/min in the conventional hemofiltration group (p = .448). Only the high cutoff group showed a significant decline (p = .0002) in "adjusted" norepinephrine dose over time. Clearance rates for IL-6 and IL-1ra were significantly higher in the high cutoff hemofiltration group (p < .0001), which translated into a significant decline of the corresponding plasma levels (p = .0465 for IL-6; p = .0293 for IL-1ra).

CONCLUSION

In this pilot study, high cutoff hemofiltration has been shown to exert a beneficial effect on the need for norepinephrine in septic patients with acute renal failure. In addition, we demonstrate that high cutoff hemofiltration is superior to conventional hemofiltration in the elimination of IL-6 and IL-1ra from the circulating blood of septic patients.

Anandamide absorption by direct hemoperfusion with polymixin B-immobilized fiber improves the prognosis and organ failure assessment score in patients with sepsis

PURPOSE

Direct hemoperfusion (DHP) with polymixin B-immobilized fiber (PMX) has been reported to be effective for patients with septic shock. The aim of this study was to clarify the mechanism of PMX-DHP effect on septic shock.

METHODS

The following parameters were measured in septic shock patients who were treated with PMX-DHP: survival rate, sepsis-related organ failure assessment (SOFA) score, acute physiology and chronic health evaluation II (APACHE-II) score, and plasma concentrations of cannabinoids [anandamide (ANA) and 2-arachidonyl glyceride (2-AG)], cytokines [interleukin (IL)-6, IL-8, IL-10], transforming growth factor beta (TGF-beta), and calcitonin gene-related peptide (CGRP)]. The primary end point was mortality from all causes at day 28 after intensive care unit (ICU) admission or discharge.

RESULTS

The survival rate of all patients at 28 days after ICU admission was 37.5% (9/24). The survival group showed significantly lower SOFA and APACHE-II scores than the nonsurvival group after PMX-DHP treatment (P = 0.008 and 0.028, respectively). The improved SOFA score group showed a better survival rate than the nonimproved SOFA score group (71.4% versus 23.5%, P = 0.028). Plasma ANA level significantly decreased after PMX-DHP treatment both in the improved SOFA score group and in the survival group. The level of 2-AG, however, showed no significant change in either group.

CONCLUSION

ANA, an intrinsic cannabinoid that induces hypotension in septic shock, is inferred to be the main mechanism of the PMX-DHP effect. Removal of ANA by PMX-DHP could be key to successful septic shock treatment.

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Toxic epidermal necrolysis: current evidence, practical management and future directions

Toxic epidermal necrolysis (TEN) is a rare disorder characterized by extensive epidermal death. Almost all cases appear to be caused by an idiosyncratic drug reaction. Proposed pathogenic mechanisms are conflicting, and the evidence for the benefits of individual treatments is inadequate, and in some cases contradictory. The mortality rate remains high. We review the literature pertaining to the pathogenesis of TEN and drug reactions in general. The rationale for therapeutic interventions, together with reported evidence of efficacy, are considered. We present a composite model of TEN, based on previous work and suggested pathogeneses of TEN, mechanisms of drug reactions and reported cytotoxic lymphocyte (CTL) cytolytic pathways. In this system, TEN, like some other cutaneous drug eruptions, is an HLA class I-restricted, specific drug sensitivity, resulting in clonal expansion of CD8+ CTLs. Cytotoxicity is mediated by CTL granzyme and possibly death receptor (DR) ligand (DR-L), probably Fas ligand (FasL). Particular to TEN, there is then an amplification sequence involving further DR-L expression. FasL is likely to be particularly important but tumour necrosis factor (TNF) may well contribute, via the TNF receptor 1 (TNF-R1) death pathway. Alternatively, we suggest the possibility of upregulation of an antiapoptotic TNF-R1-nuclear factor kappaB pathway, which would proscribe treatments which downregulate this pathway. None of the published data on individual treatment efficacies is sufficiently strong to suggest a definitive single treatment. Currently a multifaceted regimen appears indicated, targeting various likely intermediary mechanisms, including elimination of residual drug, immunosuppression, inhibition of DR pathways, general antiapoptotic strategies, and aggressive supportive care. Particular attention has been directed at avoiding potential conflicts between different treatments and avoiding agents that theoretically might have a net proapoptotic rather than antiapoptotic effect. Nursing on a specialized unit is of paramount importance.

Endotoxemic acute renal failure is attenuated in caspase-1-deficient mice

Caspase-1-deficient (-/-) mice are protected against sepsis-induced hypotension and mortality. We investigated the role of caspase-1 and its associated cytokines in a nonhypotensive model of endotoxemic acute renal failure (ARF). Mice were injected intraperitoneally with 2.5 mg of LPS that induces endotoxemic ARF. On immunoblot analysis of whole kidney, there was an increase in caspase-1 protein in LPS-treated mice compared with vehicle-treated controls. In LPS-treated mice, the glomerular filtration rate (GFR) was significantly higher in caspase-1 -/- vs. wild-type mice at 16 and 36 h after LPS. To determine the mechanism of this protection, the caspase-1-activated cytokines IL-1beta and IL-18 were investigated. IL-1beta and IL-18 protein were significantly increased in the kidneys of LPS- vs. vehicle-treated mice. To determine the role of these cytokines, mice were treated with recombinant IL-1 receptor antagonist (IL-1Ra) or IL-18-neutralizing antiserum. In LPS-treated mice, GFR was not different in IL-1Ra-treated or IL-18-neutralizing antiserum-treated or combination therapy (IL-1Ra plus IL-18-neutralizing antiserum-treated) compared with control mice. In addition, tubular cell apoptosis, neutrophil infiltration, myeloperoxidase activity, caspase-3 activity, and calpain activity were not different between wild-type and caspase-1 -/- mice with endotoxemic ARF. In LPS- vs. vehicle-treated wild-type mice, renal IL-1alpha was significantly increased. In both LPS- and vehicle-treated caspase-1 -/- mice, renal IL-1alpha was very low. In summary, caspase-1 -/- mice are functionally protected against endotoxemic ARF. Neutralization of IL-1beta and IL-18 is not functionally protective. The role of the intracellular proinflammatory cytokine IL-1alpha in endotoxemic ARF merits further study.

Continuous renal replacement therapy in acute renal failure

The management of acute renal failure in the critically ill patient is extremely variable and there are no published standards for the provision of renal replacement therapy in this population. Continuous renal replacement therapy seems to be the treatment of choice because of its superior metabolic and hemodynamic control. There is better organ protection by continuous treatment but no evidence for better survival or renal recovery due to continuous treatment. The debate about optimal membrane as well as about optimal dialysis dose is ongoing. An effluent flow rate of at least 35 ml/kg/h as well as lower BUN level at treatment initiation seem to be necessary to provide better survival rate. Peritoneal dialysis is a less suitable option in continuous renal replacement of the adult intensive care patient but hybrid methods such as extended daily dialysis and sustained low efficient daily dialysis need consideration with respect to continuous hemofiltration/dialysis.

Cytokine Adsorptive Property of Various Adsorbents in Immunoadsorption Columns and a Newly Developed Adsorbent: An in vitro Study

BACKGROUND/AIMS

Cytokines play important roles in the pathophysiology of systemic inflammatory response syndrome (SIRS) and sepsis. Therefore, some effective measures to remove cytokines from the bloodstream could be effective in the treatment of SIRS and sepsis. The aim of this study was to evaluate the cytokine adsorptive property of various adsorbents for the purpose of the development of new selective cytokine adsorption columns.

METHODS

The cytokine adsorptive property of adsorbent in a CF-X column, which consists of cellulose beads cross-linked with hexamethylene-di-isocyanate, was compared with those of various adsorbents in currently available immunoadsorption columns, such as Immusorba TR, Immusorba PH, Selesorb, and Lixelle, in vitro batchwise test using patients' plasma. A newly developed adsorbent, MPCF-X, which was modified by coating the surface of the adsorbent in CF-X with 2-methacryloyloxyethyl phosphorylcholine (MPC), was also tested for its cytokine adsorptive property.

RESULTS

The adsorbent in CF-X showed a significantly higher adsorption rate for TNF-alpha, interleukin (IL)-6 and IL-10 compared with other adsorbents (p < 0.05). Adsorbent in Lixelle showed good affinity to TNF-alpha and IL-8. Especially, the adsorbent in CF-X almost completely removed TNF-alpha, whereas it also had considerable affinity to normal IgG. MPCF-X showed decreased affinity to IgG with considerable adsorptive properties to cytokines.

CONCLUSION

Selective cytokine adsorption columns could be developed with improvement of currently available adsorbents. Such a new selective cytokine adsorption column could be clinically applied for the treatment of SIRS/sepsis.