Effect of Continuous Renal Replacement Therapy with the oXiris Hemofilter on Critically Ill Patients: A Narrative Review

A hypothesis on treatment strategy of severe multicentric Castleman disease with continuous renal replacement therapy

Castleman disease (CD) is a rare lymphoproliferative disorder, with non-specific clinical manifestations, often delayed diagnosis and treatment, which pose a significant challenge in the present times. Patients diagnosed with this disease have poor prognosis due to the limited treatment options. Multicentric CD occurs at multiple lymph node stations and is associated with a proinflammatory response that leads to the development of the so-called 'B symptoms'. IL-6 seems to be a key cytokine involved in various manifestations such as lymphadenopathies, hepatosplenomegaly, and polyclonal hypergammaglobulinemia. Its levels correlate with the activity of the disease. Other consequences of MCD include increased fibrinogen levels leading to deep vein thrombosis and thromboembolic disorders, high hepcidin levels causing anaemia, elevated VEGF levels promoting angiogenesis and vascular permeability, which, along with hypoalbuminemia, induce oedema, ascites, pleural and pericardial effusions, and in severe cases, generalized anasarca. In extreme cases multiple organ failure can occur, often resulting in death. We propose the use of continuous renal replacement therapy (CRRT) in managing severe multicentric CD. Our arguments are based on the principles that CRRT is able to remove IL-6 from circulation thus attenuating the cytokine storm, can influence hepcidin levels, and reduction in oedema, and is often used in multiple organ failure to regain homeostasis control. Therefore, it could be used as a therapy or bridge therapy in severe cases. To sustain our hypothesis with evidence, we have gathered several studies from the literature confirming the successful removal of cytokines, especially IL-6 from circulation, which can be used as a starting point.

Emerging therapeutic strategies targeting extracellular histones for critical and inflammatory diseases: an updated narrative review

Extracellular histones are crucial damage-associated molecular patterns involved in the development and progression of multiple critical and inflammatory diseases, such as sepsis, pancreatitis, trauma, acute liver failure, acute respiratory distress syndrome, vasculitis and arthritis. During the past decade, the physiopathologic mechanisms of histone-mediated hyperinflammation, endothelial dysfunction, coagulation activation, neuroimmune injury and organ dysfunction in diseases have been systematically elucidated. Emerging preclinical evidence further shows that anti-histone strategies with either their neutralizers (heparin, heparinoids, nature plasma proteins, small anion molecules and nanomedicines, etc.) or extracorporeal blood purification techniques can significantly alleviate histone-induced deleterious effects, and thus improve the outcomes of histone-related critical and inflammatory animal models. However, a systemic evaluation of the efficacy and safety of these histone-targeting therapeutic strategies is currently lacking. In this review, we first update our latest understanding of the underlying molecular mechanisms of histone-induced hyperinflammation, endothelial dysfunction, coagulopathy, and organ dysfunction. Then, we summarize the latest advances in histone-targeting therapy strategies with heparin, anti-histone antibodies, histone-binding proteins or molecules, and histone-affinity hemoadsorption in pre-clinical studies. Finally, challenges and future perspectives for improving the clinical translation of histone-targeting therapeutic strategies are also discussed to promote better management of patients with histone-related diseases.

Capnocytophaga canimorsus Meningitis Complicated by Septic Shock: The Use of Extracorporeal Blood Purification Techniques

Capnocytophaga canimorsus is a Gram-negative bacterium, commonly found as a commensal germ in the oral cavity of dogs and cats. It is an opportunistic pathogen, but, in specific situations, it can cause very severe diseases, including arthritis, pleuritis, endocarditis, sepsis, and, in extremely rare cases, meningoencephalitis. The predisposing situations include immunosuppression, liver cirrhosis, splenectomy, hemochromatosis, beta thalassemia major (Cooley's anemia), and alcohol abuse. In this report, we describe the case of a 48-year-old male patient, with a medical history of several predisposing conditions, who developed a severe case of meningoencephalitis caused by C. canimorsus, following a dog bite on his hand. The patient was successfully treated for his meningitis, but subsequently he developed a hospital-acquired septic shock from Acinetobacter baumannii, which was treated with targeted antibiotic therapy and sequential extracorporeal blood purification therapies using Oxiris™ and Toraymyxin™ hemofilters.

Challenges in Septic Shock: From New Hemodynamics to Blood Purification Therapies

Sepsis and septic shock are associated with high mortality, with diagnosis and treatment remaining a challenge for clinicians. Their management classically encompasses hemodynamic resuscitation, antibiotic treatment, life support, and focus control; however, there are aspects that have changed. This narrative review highlights current and avant-garde methods of handling patients experiencing septic shock based on the experience of its authors and the best available evidence in a context of uncertainty. Following the first recommendation of the Surviving Sepsis Campaign guidelines, it is recommended that specific sepsis care performance improvement programs are implemented in hospitals, i.e., "Sepsis Code" programs, designed ad hoc, to achieve this goal. Regarding hemodynamics, the importance of perfusion and hemodynamic coherence stand out, which allow for the recognition of different phenotypes, determination of the ideal time for commencing vasopressor treatment, and the appropriate fluid therapy dosage. At present, this is not only important for the initial timing, but also for de-resuscitation, which involves the early weaning of support therapies, directed elimination of fluids, and fluid tolerance concept. Finally, regarding blood purification therapies, those aimed at eliminating endotoxins and cytokines are attractive in the early management of patients in septic shock.

Pathogen evolution, prevention/control strategy and clinical features of COVID-19: experiences from China

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was reported at the end of 2019 as a worldwide health concern causing a pandemic of unusual viral pneumonia and many other organ damages, which was defined by the World Health Organization as coronavirus disease 2019 (COVID-19). The pandemic is considered a significant threat to global public health till now. In this review, we have summarized the lessons learnt during the emergence and spread of SARS-CoV-2, including its prototype and variants. The overall clinical features of variants of concern (VOC), heterogeneity in the clinical manifestations, radiology and pathology of COVID-19 patients are also discussed, along with advances in therapeutic agents.

Exploring disease axes as an alternative to distinct clusters for characterizing sepsis heterogeneity

PURPOSE

Various studies have analyzed sepsis subtypes, yet the reproducibility of such results remains unclear. This study aimed to determine the reproducibility of sepsis subtypes across multiple cohorts.

METHODS

The study examined 63,547 sepsis patients from six distinct cohorts who had similar sepsis-related characteristics (vital signs, lactate, sequential organ failure assessment score, bilirubin, serum, urine output, and Glasgow coma scale). Identical cluster analysis techniques were used, employing 27 clustering schemes, and normalized mutual information (NMI), a metric ranging from 0 to 1 with higher values indicating better concordance, was employed to quantify the clustering solutions' reproducibility. Principal component analysis (PCA) was utilized to obtain the disease axis, and its uniformity across cohorts was evaluated through patterns of feature loading and correlation.

RESULTS

The reproducibility of sepsis clustering subtypes across the various studies was modest (median NMI ranging from 0.08 to 0.54). The top-down transfer learning method (model trained on cohorts with greater severity was transferred to cohorts with lower severity score) had a higher NMI value than the bottom-up approach (median [Q1, Q3]: 0.64 [0.49, 0.78] vs. 0.23 [0.2, 0.31], p < 0.001). The reproducibility was greater when the transfer solution was performed within United States (US) cohorts. The PCA analysis revealed that the correlation pattern between variables was consistent across all cohorts, and the first two disease axes were the "shock axis" and "systemic inflammatory response syndrome (SIRS) axis."

CONCLUSIONS

Cluster analysis of sepsis patients across various cohorts showed modest reproducibility. Sepsis heterogeneity is better characterized through continuous disease axes that coexist to varying degrees within the same individual instead of mutually exclusive subtypes.

Effects of early repeated hemoperfusion combined with hemodialysis on the prognosis of patients with paraquat poisoning

OBJECTIVE

To investigate the effect of early, repeated hemoperfusion in conjunction with hemodialysis on the health status, blood-gas indices, and prognosis of patients with paraquat (PQ) poisoning.

METHODS

In this retrospective study, clinical data of 149 PQ-poisoned patients treated at Xianyang First People's Hospital between January 2019 and January 2022 were analysed. Sixty-two patients who received conventional treatment coupled with early, repeated hemoperfusion were designated as the control group. The remaining 87 patients, who were subjected to additional hemodialysis on the basis of the control group, were designated in the experimental group. A comparison was made between the two groups regarding the changes in liver function, renal function, and blood-gas indices before and after the treatment. Three-month survival outcomes of both groups were analyzed using Cox regression, with survival curves drawn for different prognostic factors.

RESULTS

The experimental group exhibited significantly lower levels of indirect bilirubin (IBiL) and glutamic-pyruvic transaminase (ALT) after the treatment compared to the control group (all P < 0.05), as well as markedly lower levels of total bilirubin (TBil), direct bilirubin (DBil), glutamic-oxaloacetic transaminase (AST), alkaline phosphatase (ALP), urea nitrogen (BUN), and creatinine (Cr) (all P < 0.01). The experimental group also demonstrated significantly improved arterial partial pressure of oxygen (PaO2) and PaO2/inspired oxygen (FIO2) ratios, along with reduced arterial carbon dioxide partial pressure (PaCO2) after the treatment (all P < 0.05). Moreover, a significantly higher three-month survival rate was observed in the experimental group compared to the control group (P < 0.001). According to Cox regression analysis, blood purification mode, age, urine PQ concentration upon admission, the timing of initial gastric lavage and bowl cleanse, and the timing of initial blood purification were identified as independent factors affecting the patients' 90-day prognosis.

CONCLUSION

Early, repeated hemoperfusion coupled with hemodialysis significantly improves the blood-gas indices and liver and kidney function in patients with PQ poisoning, while also extending their short-term survival.

Acute Kidney Failure: Current Challenges and New Perspectives

Acute kidney failure, also called acute kidney injury (AKI), is defined by a sudden loss of kidney function that is conventionally determined on the basis of increased serum creatinine levels and reduced urinary output [...].

Advances in Enhancing Hemocompatibility of Hemodialysis Hollow-Fiber Membranes

Hemodialysis, the most common modality of renal replacement therapy, is critically required to remove uremic toxins from the blood of patients with end-stage kidney disease. However, the chronic inflammation, oxidative stress as well as thrombosis induced by the long-term contact of hemoincompatible hollow-fiber membranes (HFMs) contribute to the increase in cardiovascular diseases and mortality in this patient population. This review first retrospectively analyzes the current clinical and laboratory research progress in improving the hemocompatibility of HFMs. Details on different HFMs currently in clinical use and their design are described. Subsequently, we elaborate on the adverse interactions between blood and HFMs, involving protein adsorption, platelet adhesion and activation, and the activation of immune and coagulation systems, and the focus is on how to improve the hemocompatibility of HFMs in these aspects. Finally, challenges and future perspectives for improving the hemocompatibility of HFMs are also discussed to promote the development and clinical application of new hemocompatible HFMs.

Graphical Abstract

Targeting circulating high mobility group box-1 and histones by extracorporeal blood purification as an immunomodulation strategy against critical illnesses

Both high mobility group box-1 (HMGB1) and histones are major damage-associated molecular patterns (DAPMs) that mediate lethal systemic inflammation, activation of the complement and coagulation system, endothelial injury and multiple organ dysfunction syndrome in critical illnesses. Although accumulating evidence collectively shows that targeting HMGB1 or histones by their specific antibodies or inhibitors could significantly mitigate aberrant immune responses in multiple critically ill animal models, routine clinical use of such agents is still not recommended by any guideline. In contrast, extracorporeal blood purification, which has been widely used to replace dysfunctional organs and remove exogenous or endogenous toxins in intensive care units, may also exert an immunomodulatory effect by eliminating inflammatory mediators such as cytokines, endotoxin, HMGB1 and histones in patients with critical illnesses. In this review, we summarize the multiple immunopathological roles of HMGB1 and histones in mediating inflammation, immune thrombosis and organ dysfunction and discuss the rationale for the removal of these DAMPs using various hemofilters. The latest preclinical and clinical evidence for the use of extracorporeal blood purification to improve the clinical outcome of critically ill patients by targeting circulating HMGB1 and histones is also gathered.

The Techniques of Blood Purification in the Treatment of Sepsis and Other Hyperinflammatory Conditions

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.