Endothelial Dysfunction in Patients with Severe Acute Pancreatitis: Improved by Continuous Blood Purification Therapy

The Impact of the COVID-19 Pandemic on Outcomes in Acute Pancreatitis: A Propensity Score Matched Study Comparing before and during the Pandemic

We aimed to evaluate the outcomes and survival of patients with acute pancreatitis who shared the same clinical form, age, and sex before the pandemic, during the pandemic, and among those with confirmed COVID-19 infection upon hospital admission. This consideration used the sparse data in the existing literature on the influence of the pandemic and COVID-19 infection on patients with acute pancreatitis. To accomplish this, we conducted a multicentric, retrospective case-control study using propensity score matching with a 2:1 match of 28 patients with SARS-CoV-2 infection and acute pancreatitis, with 56 patients with acute pancreatitis pre-pandemic, and 56 patients with acute pancreatitis during the pandemic. The study outcome demonstrated a six-fold relative risk of death in patients with acute pancreatitis and SARS-CoV-2 infection compared to those with acute pancreatitis before the pandemic. Furthermore, restrictive measures implemented during the pandemic period led to a partial delay in the care of patients with acute pancreatitis, which likely resulted in an impairment of their immune state. This, in certain circumstances, resulted in a restriction of surgical treatment indications, leading to a three-fold relative risk of death in patients with acute pancreatitis during the pandemic compared to those with acute pancreatitis before the pandemic.

Effect of Early Continuous Veno-Venous Haemofiltration in Severe Acute Pancreatitis for the Prevention of Local Pancreatic Complications

Objective

To compare the conventional treatment and continuous veno-venous haemofiltration (CVVH) in severe acute pancreatitis (SAP) for the prevention of pseudocyst and walled-off necrosis. Patients and Methods. Forty-two patients were divided into two treatment groups: conventional treatment group contained 24 patients and CVVH had 18. Conventional treatment group patients were treated symptomatically and according to the causes. CVVH group patients were treated symptomatically, and CVVH was done within 2 hours of admission.

Results

In both groups, there was a decrease in amylase, lipase, CRP, IL-6, IL-10, TNF-alpha, Ranson score, Balthazar score, and APACHE-II score after 72 hours, but the decrease was significantly greater in CVVH patients. There were no any local pancreatic complications in CVVH patients, but 1 patient had an acute peripancreatic fluid collection, 2 patients had pseudocyst, and 2 patients had walled-off necrosis (WON), and a mortality one was seen in the conventional treatment group.

Conclusion

The present study shows that early CVVH may be able to prevent the formation of pseudocyst and win in SAP patients.

[Acute kidney injury following acute pancreatitis (AP-AKI): Definition, Pathophysiology, Diagnosis and Therapy]

Acute pancreatitis (AP) is the most frequent gastrointestinal cause for hospitalization and one of the leading causes of in-hospital deaths. Severe acute pancreatitis is often associated with multiorgan failure and especially with acute kidney injury (AKI). AKI can develop early or late in the course of the disease and is a strong determinator of outcome. The mortality in the case of dialysis-dependent AKI and acute pancreatitis raises exponentially in the affected patients. AP-induced AKI (AP-AKI) shows many similarities but also distinct differences to other causes of AKI occurring in the intensive care unit setting. The knowledge of the exact pathophysiology can help to adjust, control and improve therapeutic approaches to the disease. Unfortunately, there are only a few studies dealing with AP and AKI.In this review, we discuss recent data about pathogenesis, causes and management of AP-AKI in patients with severe acute pancreatitis and exploit in this regard the diagnostic and prognostic potential of respective newer serum and urine markers.

AKI Associated with Acute Pancreatitis

Acute pancreatitis is a common disorder of the pancreas. It is the most frequent gastrointestinal cause for hospitalization and one of the leading causes of in-hospital deaths. Its severity ranges from mild self-limited disease to severe acute necrotizing pancreatitis characterized by systemic complications and multiorgan failure. Severe acute pancreatitis develops in about 20% of patients with acute pancreatitis and may be associated with multiorgan failure (respiratory, cardiovascular, and kidney). AKI is a frequent complication of severe acute pancreatitis and develops late in the course of the disease, usually after the failure of other organs. It carries a very poor prognosis, particularly if kidney replacement therapy is required, with mortality rates exceeding 75%. The exact pathophysiology of AKI in acute pancreatitis remains unclear but appears to result from initial volume depletion followed by complex vascular and humoral factors. Here, we provide an overview of the epidemiology, pathogenesis, causes, and management of AKI in patients with severe acute pancreatitis.

Research Progress on the Relationship Between Acute Pancreatitis and Calcium Overload in Acinar Cells

Acute pancreatitis is a human disease with multiple causes that leads to autodigestion of the pancreas. There is sufficient evidence to support the key role of sustained increase in cytosolic calcium concentrations in the early pathogenesis of the disease. To clarify the mechanism of maintaining calcium homeostasis in the cell and pathological processes caused by calcium overload would help to research directly targeted therapeutic agents. We will specifically review the following: intracellular calcium homeostasis and regulation, the occurrence of calcium overload in acinar cells, the role of calcium overload in the pathogenesis of AP, the treatment strategy proposed for calcium overload.

Adhesion molecules and pancreatitis

Acute and chronic pancreatitises are gastrointestinal inflammatory diseases, the incidence of which is increasing worldwide. Most (~ 80%) acute pancreatitis (AP) patients have mild disease, and about 20% have severe disease, which causes multiple organ failure and has a high mortality rate. Chronic pancreatitis (CP) is characterized by chronic inflammation and destruction of normal pancreatic parenchyma, which leads to loss of exocrine and endocrine tissues. Patients with CP also have a higher incidence of pancreatic ductal adenocarcinoma. Although a number of factors are associated with the development and progression of AP and CP, the underlying mechanism is unclear. Adhesion molecules play important roles in cell migration, proliferation, and signal transduction, as well as in development and tissue repair. Loosening of cell-cell adhesion between pancreatic acinar cells and/or endothelial cells increases solute permeability, resulting in interstitial edema, which promotes inflammatory cell migration and disrupts tissue structure. Oxidative stress, which is one of the important pathogenesis of pancreatitis, leads to upregulation of adhesion molecules. Soluble adhesion molecules are reportedly involved in AP. In this review, we focus on the roles of tight junctions (occludin, tricellulin, claudin, junctional adhesion molecule, and zonula occludin), adherens junctions (E-cadherin and p120-, α-, and β-catenin), and other adhesion molecules (selectin and intercellular adhesion molecules) in the progression of AP and CP. Maintaining the normal function of adhesion molecules and preventing their abnormal activation maintain the structure of the pancreas and prevent the development of pancreatitis.

Effects of hemodialysis combined with hemoperfusion on severe acute pancreatitis

BACKGROUND/AIMS

Severe acute pancreatitis (SAP) is characterized by persistent organ failure. This research aimed to evaluate the effect of hemodialysis combined with hemoperfusion on SAP.

MATERIALS AND METHODS

Thirty-seven patients who were treated with hemoperfusion combined with hemodialysis were included in group O, and 31 patients treated with conventional therapy and hemoperfusion were included as control (group C). Leukocyte count, neutrophil percentage, amylase (AMY), blood urine nitrogen (BUN), creatinine (Cr), and total bilirubin (TBIL) were noted. The time when symptoms disappeared as well as complications after treatment was recorded.

RESULTS

Leukocyte count, neutrophil percentage, AMY, BUN, Cr, and TBIL in two groups were remarkably decreased after treatment. However, these indexes were significantly lower in group O than those in group C after treatment, especially the neutrophil percentage, AMY, BUN, Cr, and TBIL. The time when the symptoms disappeared was 3.01±1.02 days in group O, which was shorter than 5.56±1.88 days in group C. There were 4 patients with acute renal failure and 2 patients had multiple organ failure in group C after treatment. But only 1 patient developed acute renal failure in group O. The difference in complications between two groups was significant (p<0.024).

CONCLUSION

The combination of hemodialysis and hemoperfusion could have a better effect on SAP in removing toxic metabolites and inflammation mediators. It not only shortens the time of symptoms disappearing but also decreases the incidence of complications and the mortality.

Improvement of Immune Dysfunction in Patients with Severe Acute Pancreatitis by High-Volume Hemofiltration: A Preliminary Report

Objective

The aim of this study was to investigate the effect of high-volume hemofiltration (HVHF) on ameliorating immune dysfunction in patients with severe acute pancreatitis (SAP).

Methods

Twelve patients diagnosed with SAP admitted to the intensive care unit of general surgery, Jinling Hospital, from January 2004 to December 2006 were included in this study. They were assigned to the standard medical therapy group (SMT group, n=4) or HVHF group (n=8) immediately after enrollment, in a 1:2 ratio. The SMT group were given standard treatment for SAP, while the HVHF group were given standard as well as 72-hour HVHF treatment initiated within 2 hours after enrollment. Patients in the 2 groups were comparable for the baseline clinical parameters. All patients were monitored over a 72-hour observation period for continuous clinical status, blood cell counts including monocytes, CD4+ and CD8+ T cells, and HLA-DR expression on monocytes. Blood samples were collected from those patients at 0, 6, 12, 24, 48, and 72 hour after enrollment for measurement of plasma Th1-type cytokines (interleukin-1 [IL-1], IL-2, interferon-γ [IFN-γ], and tumor necrosis factor-α [TNF-α]) and Th2-type cytokines (IL-4, IL-5, IL-6, IL-10, and IL-13) using ELISA.

Results

Within 72 hours, all measured cytokines except IL-4 were maintained at high levels, accompanied with a low level of peripheral monocytes, CD4+ and CD8+ T cell counts, and HLA-DR expression. Seventy-two hours later, plasma cytokines IFN-γ, IL-1, IL-2, IL-5, IL-10, and IL-13 (p<0.05), but not TNF-α and IL-6, in patients in the HVHF group were significantly reduced, while there was no change for these parameters in the SMT group. Plasma levels of IFN-γ, TNF-α, IL-1, IL-2, IL-5, and IL-13 in the HVHF group were significantly lower than those in the SMT group. Peripheral CD4+ and CD8+ T cells, monocyte count, and HLA-DR expression were increased significantly (p<0.05) only in the HVHF group, not in the SMT group. HLA-DR expression in the HVHF group was significant higher than that in the SMT group (p<0.05).

Conclusions

HVHF significantly reduced plasma inflammatory cytokine concentrations including those of IFN-γ, TNF-α, IL-1, IL-2, IL-5, and IL-13, while it increased monocyte HLA-DR expression in patients with SAP. The association of plasma cytokine reduction and cellular immune function recovery and clinical outcome needs further investigation.

Early Gut Barrier Dysfunction in Patients with Severe Acute Pancreatitis: Attenuated by Continuous Blood Purification Treatment

Objectives

The aim of this study was to investigate the effect of continuous blood purification (CBP) on early gut mucosal dysfunction in patients with severe acute pancreatitis (SAP).

Methods

Patients with SAP were randomized to receive 24 hours of continuous veno-venous hemofiltration (CVVH; n=33) or no CVVH (n=30). Blood samples were taken from the patients at 0, 6, 12, and 24 hours during CVVH therapy. Serum diamine oxidase (DAO) and endotoxin, epithelial permeability, transepithelial electrical resistance (TER) and F-actin rearrangement of the epithelial monolayer were used as the markers for the assessment of gut barrier function and the effect of CBP therapy in patients with SAP.

Results

Patients with SAP had increased levels of serum DAO, endotoxin, and epithelial permeability when compared with normal controls, and the increase was more pronounced in patients with organ dysfunction (p<0.01). F-actin rearrangement, loose cell-cell junction, and iNOS mRNA upregulation were found in all patients. After CBP treatment, Acute Physiology and Chronic Health Evaluation II score and SOFA score improved significantly; levels of serum DAO, endotoxin, and epithelial permeability decreased (p<0.05). CBP also significantly attenuated reorganization of actin and downregulated iNOS mRNA expression and NO production (p<0.05).

Conclusions

CBP can not only improve the general conditions but also effectively improve gut barrier dysfunction. The beneficial effect of CBP on gut barrier dysfunction is associated with the improvement of cytoskeletal instability, by downregulating iNOS through the removal of excess proinflammatory factors.

Crush Syndrome after the Wenchuan Earthquake: New Experience with Regional Citrate Anticoagulation Continuous Veno-Venous Hemofiltration

Purpose

Acute renal failure (ARF) related to crush syndrome is usually treated with hemodialysis. Continuous veno-venous hemofiltration (CVVH) has seldom been adopted in this situation due to the main drawback of continuous anticoagulation. The purpose of this study was to evaluate the effectiveness and safety of regional citrate anticoagulation (RCA)-CVVH in two crush syndrome patients following the Wenchaun earthquake.

Methods

Two victims from the Wenchuan earthquake in Southwest China were admitted to our hospital on May 23, 2008, 11 days after their injury. The total entrapment time under the rubble was 5.5 and 22.5 hrs respectively. They remained oliguric on admission, in spite of vigorous treatment in the local hospital including aggressive fluid infusion, fasciotomy and intermittent hemodialysis. On admission, their serum myoglobin levels were 765 and 829 ng/mL, respectively. Further debridement and drainage were performed. RCA-CVVH was conducted; the citrate containing substitution fluid was infused in a pre-dilution manner at a rate of 4 l/h; calcium was infused through a separate access to the venous inlet of the double lumen catheter. The infusion rate was adjusted according to the serum ionized calcium and whole blood activated clotting time (WBACT). A low dose of low molecular weight heparin (LMWH) was infused at the rate of 150∼300 U/h simultaneously for anticoagulation after anemia had been corrected and their wounds were stable. RCA-CVVH was substituted by conventional CVVH and LMWH anticoagulation when case 2 complicated with hypoxia.

Results

RCA-CVVH was well tolerated, hemodynamic status was stable, and no complications related with RCA-CVVH were noted. The body temperature and WBC decreased to normal range, while anemia and hypoalbuminia were corrected. The levels of serum myoglobin and creatine phosphokinase were also decreased to normal range. Their urine volume increased after 20 and 22 days of oliguria and the tubular function of the patients recovered well. Although the second case encountered acute cholecystitis and acute lung injury in the hospital, both the patients recuperated and neither of them underwent amputation.

Conclusions

The present two crush patients have been successfully treated, but due to the limits of the small sample, it is difficult to generalize whether RCA-CVVH is safe enough for crush syndrome with a high risk of bleeding diathesis. Additional investigation with a larger number of patients is required. Fluid equilibrium, nutritional support, prevention of bleeding and infection are fundamental in this situation.

Effect of Coupled Plasma Filtration Adsorption on Endothelial Cell Function in Patients with Multiple Organ Dysfunction Syndrome

Objective

The purpose of our study was to investigate the effect of coupled plasma filtration adsorption (CPFA) on endothelial cell (EC) function in patients with multiple organ dysfunction syndrome (MODS).

Methods

Besides routine therapy, the 24 MODS patients underwent both CPFA and high volume hemofiltration (HVHF), scheduled randomly at intervals of 12 hours. Patient serum from 0, 5, and 10 hours of therapy was collected to measure soluble E-selectin (sE-selectin) and soluble thrombomodulin (sTM) by the ELISA method. Human umbilical vein endothelial cells (HUVEC) were incubated for 24 hours with the patient serum and the supernatant liquid was gathered to detect sTM and sE-selectin. The proliferation function of the ECs was detected by methyl thiazolyl tetrazolium (MTT) method.

Results

1. The serum levels of sE-selectin and sTM were significantly higher in MODS patients than in controls; serum sE-selectin and sTM decreased remarkably after a single circulation in CPFA (p<0. 05) but not in HVHF (p>0. 05); the level of sE-selectin and sTM in systemic circulation had no change during CPFA or HVHF (p>0.05); 2. sTM in supernatant liquid incubated with serum from 5 hours of CPFA and 10 hours of HVHF decreased remarkably (p<0.05), while sE-selectin decreased significantly (p<0. 05) from 10 hours of CPFA, but there was no change from 5 hours and 10 hours of HVHF (p>0. 05); 3. when incubated with serum taken from the device pre- or post-CPFA, the optical density (OD) value of the latter was higher. The OD value increased gradually when incubated with serum from 0, 5, and 10 hours of CPFA (p<0.05), but changed little from HVHF.

Conclusions

CPFA can eliminate sE-selectin and sTM and improve the secretion function of ECs. CPFA was somewhat better and earlier than HVHF, while to a certain degree it can weaken the inhibitory effect of serum on the proliferation function of ECs.

Intestinal mucosal barrier dysfunction in SAP patients with MODS ameliorated by continuous blood purification

BACKGROUND

Dysfunction of the intestinal mucosal barrier plays an important role in the pathophysiology of severe acute pancreatitis (SAP). Continuous blood purification (CBP) has been shown to improve the prognosis of SAP patients. In order to investigate the effect of CBP on intestinal mucosal barrier dysfunction in SAP patients with MODS, we conducted in vivo and in vitro experiments to explore the underlying mechanisms.

METHODS

The markers for the assessment of intestinal mucosal barrier function including serum diamine oxidase (DAO), endotoxin and intestinal epithelial monolayer permeability were detected during CBP therapy. The distribution and expression of cytoskeleton protein F-actin and tight junction proteins claudin-1 were observed. In addition, Rho kinase (ROCK) mRNA expression and serum tumor necrosis factor-alpha (TNF-α) levels during CBP were determined.

RESULTS

SAP patients with MODS had increased levels of serum DAO, endotoxin and intestinal epithelial monolayer permeability when compared with normal controls. While the distribution of F-actin and claudin-1 was rearranged, and the expression of claudin-1 significantly decreased, but F-actin had no change. Meanwhile, ROCK mRNA expression and serum TNF-α level were increased. However, after CBP treatment, levels of serum DAO, endotoxin and intestinal epithelial monolayer permeability decreased. The F-actin and claudin-1 reorganization attenuated and the expression of claudin-1 increased. At the same time, ROCK mRNA expression and serum TNF-α level were decreased.

CONCLUSIONS

CBP can effectively improve intestinal mucosal barrier dysfunction. The beneficial effect is associated with the improvement of cytoskeleton and tight junction proteins in stability by downregulation of ROCK mRNA expression through the removal of excess proinflammatory factors.

Endothelial markers are associated with pancreatic necrosis and overall prognosis in acute pancreatitis: A preliminary cohort study

BACKGROUND

Endothelial injury is believed to play an important role in the evolution of pancreatic microcirculatory dysfunction and pancreatic necrosis (PN) in patients with acute pancreatitis (AP). The aim of this study was to investigate the role of three endothelial markers (von Willebrand factor, vWF; E-selectin; endothelial protein C receptor, EPCR) in the early phase of AP, especially the relationship between endothelial markers and PN.

METHODS

From March 2015 to March 2016, 57 AP patients admitted within 72 h of symptom onset in our hospital were included for this study. Blood samples were taken on admission and the clinical characteristics and outcomes of these patients were recorded. The levels of vWF, E-selectin and EPCR were measured using ELISA for analysis and compared with other severity markers of AP.

RESULTS

All the three markers were significantly different in healthy control, mild, moderate and severe AP patients. Moreover, the endothelial markers, especially vWF, also showed significant difference in patients with different extent of PN, as well as those with or without MODS. Additionally, the levels of endothelial markers correlated well with other commonly used markers of AP severity.

CONCLUSION

Elevated endothelium-related mediators (vWF, E-selectin and EPCR) appear to participate in the development of PN and may be a potential indicator of overall prognosis. Our results may help clinicians better understand the pathophysiological process of the development of PN.

Effects of Early Continuous Venovenous Hemofiltration on E-Selectin, Hemodynamic Stability, and Ventilatory Function in Patients with Septic-Shock-Induced Acute Respiratory Distress Syndrome

Objective. To investigate the effects of 72-hour early-initiated continuous venovenous hemofiltration (ECVVH) treatment in patients with septic-shock-induced acute respiratory distress syndrome (ARDS) (not acute kidney injury, AKI) with regard to serum E-selectin and measurements of lung function and hemodynamic stability. Methods. This prospective nonblinded single institutional randomized study involved 51 patients who were randomly assigned to receive or not receive ECVVH, an ECVVH group (n = 24) and a non-ECVVH group (n = 27). Besides standard therapies, patients in ECVVH group underwent CVVH for 72 h. Results. At 0 and 24 h after initiation of treatment, arterial partial pressure of oxygen/fraction of inspired oxygen (PaO₂/FiO₂) ratio, extravascular lung water index (EVLWI), and E-selectin level were not significantly different between groups (all P > 0.05). Compared to non-ECVVH group, PaO₂/FiO₂ is significantly higher and EVLWI and E-selectin level are significantly lower in ECVVH group (all P < 0.05) at 48 h and 72 h after initiation of treatment. The lengths of mechanical ventilation and stay in intensive care unit (ICU) were shorter in ECVVH group (all P < 0.05), but there was no difference in 28-day mortality between two groups. Conclusions. In patients with septic-shock-induced ARDS (not AKI), treatment with ECVVH in addition to standard therapies improves endothelial function, lung function, and hemodynamic stability and reduces the lengths of mechanical ventilation and stay in ICU.

Serum interleukin 17 as an early prognostic biomarker of severe acute pancreatitis receiving continuous blood purification

BACKGROUND

Severe acute pancreatitis (SAP) is associated with systemic inflammation, immunoparalysis, and sepsis, and may lead to vital organ failure and death. We evaluated the efficacy of serum interleukin 17 (IL-17) concentration for predicting eventual SAP severity and the clinical benefits of removing IL-17 by continuous veno-venous hemofiltration (CVVH).

METHODS

Patients were divided into 2 groups according to severity: Grade 1 (n = 18, SAP without organ dysfunction) and Grade 2 (n = 18, SAP with organ dysfunction). 20 healthy volunteers served as controls. All patients underwent 24-h CVVH and blood samples were taken at 0, 6, 12, and 24 h for measurement of bacterial load and serum IL-17, IL-6, and endotoxin. Clinical condition was graded by the sequential organ failure assessment (SOFA) score.

RESULTS

Baseline IL-17, IL-6, endotoxin, and bacterial load were higher in Grade 2 patients. SOFA scores improved significantly, and serum IL-17, IL-6, endotoxin, and bacterial load decreased significantly in all patients after CVVH. Serum IL-17 was significantly and positively correlated with IL-6, bacterial load, and endotoxin during CVVH treatment. In addition, post-CVVH serum IL-17 was directly correlated with SOFA scores on days 1 and 7, and with duration of hospital stay. Non-survivors showed both higher SOFA scores on day 1 and higher baseline IL-17 than survivors.

CONCLUSIONS

Earlier and higher serum IL-17 elevation predicted prolonged hospitalization, organ failure, and death, possibly by disrupting gut barrier function. CVVH can remove inflammatory cytokines from serum, including IL-17 and IL-6, thereby attenuating the inflammatory response and diminishing associated systemic complications.

Choices in fluid type and volume during resuscitation: impact on patient outcomes

We summarize the emerging new literature regarding the pathophysiological principles underlying the beneficial and deleterious effects of fluid administration during resuscitation, as well as current recommendations and recent clinical evidence regarding specific colloids and crystalloids. This systematic review allows us to conclude that there is no clear benefit associated with the use of colloids compared to crystalloids and no evidence to support the unique benefit of albumin as a resuscitation fluid. Hydroxyethyl starch use has been associated with increased acute kidney injury (AKI) and use of renal replacement therapy. Other synthetic colloids (dextran and gelatins) though not well studied do not appear superior to crystalloids. Normal saline (NS) use is associated with hyperchloremic metabolic acidosis and increased risk of AKI. This risk is decreased when balanced salt solutions are used. Balanced crystalloid solutions have shown no harmful effects, and there is evidence for benefit over NS. Finally, fluid resuscitation should be applied in a goal-directed manner and targeted to physiologic needs of individual patients. The evidence supports use of fluids in volume-responsive patients whose end-organ perfusion parameters have not been met.

Improving RhoA-mediated intestinal epithelial permeability by continuous blood purification in patients with severe acute pancreatitis

BACKGROUND

Early dysfunction of the intestinal mucosal barrier contributes to increasing intestinal permeability. It may play an important role in the pathophysiology of severe acute pancreatitis (SAP). A rising number of clinical data have showed that continuous blood purification (CBP) may improve the prognosis of SAP. However, the therapeutic effects of CBP on intestinal epithelial permeability have been rarely reported.

METHODS

Intestinal epithelial monolayer (Caco-2) was incubated with serum samples collected at specific time points from SAP patients during CBP. Changes in intestinal epithelial monolayer permeability and configuration, and levels of cellular tight junction structural proteins including occludin and ZO-1, and RhoA mRNA expression level were recorded, respectively. In addition, serum tumor necrosis factor-alpha (TNF-α) levels at specific time points during CBP were determined.

RESULTS

Before CBP initiation, intestinal epithelial permeability was increased and tight junction structural protein level was decreased and reorganized, but RhoA mRNA expression and serum TNF-α were increased. However, after CBP treatment, intestinal epithelial permeability was reduced and tight junction protein levels were increased, with reorganization attenuated. Meanwhile, RhoA mRNA expression and serum TNF-α level was decreased.

CONCLUSIONS

After CBP treatment, intestinal epithelial permeability was reduced by increasing occludin and ZO-1 protein level and attenuating reorganization. This beneficial effect of CBP on intestinal epithelial permeability is associated with down-regulation of RhoA mRNA expression, and it may be related to the removal of TNF-α by CBP.

Efficient removal of serum bilirubin by a novel artificial liver support system using albumin convection: a pilot study

BACKGROUND/AIMS

To compare the efficacy of a new artificial liver support system, fractionated plasma separation and adsorption integrated with hemofiltration, with the old system, plasma adsorption.

METHODS

Sixteen patients with acute liver failure each received a first session of treatment using the old system, in which plasma was perfused through an adsorber. They then received a second session using the new system, in which albumin-rich plasma separated using a fraction plasma separator was ultrafiltrated using a hemofilter and perfused through an adsorber before being returned to blood.

RESULTS

The new system had a higher clearance of bilirubin and slower decline of clearance over time. There was a lower reduction ratio of bilirubin, bile acid, urea, and creatinine; longer prolongation of coagulation parameters; and greater decline in albumin level using the old system compared with the new one.

CONCLUSIONS

Use of the novel system results in more efficient removal of toxins and fewer deterious effects than the old system.

Acute kidney injury following acute pancreatitis: A review

BACKROUND. Acute kidney injury (AKI) is a common serious complication of severe acute pancreatitis (SAP) and an important marker of morbidity and mortality in critically ill septic patients. AKI due to severe acute pancreatitis can be the result of hypoxemia, release of pancreatic amylase from the injured pancreas with impairment of renal microcirculation, decrease in renal perfusion pressure due to abdominal compartment syndrome, intraabdominal hypertension or hypovolemia. Endotoxins and reactive oxygen species (ROS) also play an important role in the pathophysiology of SAP and AKI. Knowledge of the pathophysiology and diagnosis of AKI following SAP might improve the therapeutic outcome of critically ill patients.

METHODS AND RESULTS

An overview of the pathophysiology, diagnosis and potential treatment options based on a literature search of clinical human and experimental studies from 1987 to 2013.

CONCLUSIONS

Early recognition of AKI and SAP in order to prevent severe complication like septic shock, intraabdominal hypertension or abdominal compartment syndrome leading to multiple organ dysfunction syndrome is a crucial tool of therapeutic measures in intensive care.

Is continuous venovenous hemofiltration effective against severe acute pancreatitis?

Our aim was to investigate the efficacy of continuous venovenous hemofiltration (CVVH) in treating severe acute pancreatitis (SAP). A literature search was performed using PubMed (1992-present), and all studies investigating the efficacy of CVVH in treating SAP were included. Four comparative studies and seven case series comprising a total of 354 patients were included. The overall mortality rate of patients receiving CVVH was 20% (55/275). A decreased mortality rate and decreased serum cytokine levels were reported in the CVVH groups in only two studies. The starting time point, substitution fluid flow rate, filter membrane type, hemofilter change interval, anticoagulation, and sustaining times of CVVH varied among the studies, and the impact of these parameters on the efficacy of CVVH was poorly reported. High-volume CVVH, when started early, was demonstrated to be more effective in eliminating cytokines in only one study. After the application of CVVH, the patient conditions started to improve between the 6th and 72nd hours. In conclusion, no solid clinical evidence has proven the efficacy of CVVH in treating SAP. High-volume CVVH that is started early and sustained for at least 72 h may be adopted to investigate the efficacy of CVVH for treating SAP.

Evaluation of serum TWEAK concentration in patients with acute pancreatitis

BACKGROUND AND AIM

Tumor necrosis factor-like weak inducer of apoptosis (TWEAK) is a member of the tumor necrosis factor super family of structurally-related cytokines. The aim of this study was to determine the diagnostic and prognostic role of serum TWEAK concentration in patients with acute pancreatitis.

METHODS

Twenty four patients with acute pancreatitis and 24 consecutive healthy age- and sex-matched control subjects were included in the study. The serum concentrations of TWEAK were measured at admission and then at remission. The average time between admission and remission was 7-10 days.

RESULTS

At admission, TWEAK concentration was significantly lower in patients with acute pancreatitis compared to control subjects (p < 0.001). Serum TWEAK concentrations were elevated after the remission period, however the differences were not statistically significant. In addition, serum TWEAK concentration showed a significant, inverse correlation with amylase, lipase, CRP, AST, fibrinogen, LDH and a positive correlation with calcium, albumin and platelet count.

CONCLUSIONS

Patients with acute pancreatitis have lower serum TWEAK concentration than healthy subjects. These results suggest that serum TWEAK concentration could be a potential biomarker of acute pancreatitis.

Continuous blood purification ameliorates RhoA-mediated endothelial permeability in severe acute pancreatitis patients with lung injury

BACKGROUND

In the early phase of severe acute pancreatitis (SAP), serious pulmonary complications which are directly correlated with mortality are very common. Endothelial injury has been shown to play a key role in the pathogenesis of ALI/ARDS. Continuous blood purification (CBP) has been widely used in treating patients with multiple organ dysfunction syndrome (MODS) including ARDS. However, the impact of CBP on endothelial function has been little studied.

METHODS

Human umbilical vein endothelial cells (HUVECs) were exposed to serum samples or replacement fluid taken from patients at specific time points during CBP, or pretreated with Y-27632 followed by treatment with serum, then, changes in cytoskeletal configuration, endothelial monolayer permeability, and RhoA activation were studied.

RESULTS

Endothelial permeability, RhoA activity, and stress fiber reorganization increased in HUVECs treated with serum from patients before CBP initiation, and lessened in HUVECs treated with serum from patients after CBP initiation. Endothelial hyperpermeability and stress fiber reorganization reduced in HUVECs pretreated with Rho-kinase inhibitor, Y-27632, and in a dose-dependent fashion. Endothelial permeability and RhoA activity increased in HUVECs treated with waste replacement fluid collected 2 h after CBP initiation.

CONCLUSIONS

After CBP treatment, endothelial hyperpermeability induced by serum from SAP patients with lung injury was reduced. The inhibition of RhoA-mediated F-actin remodeling might be the mechanism.

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.