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Blood Purification 2019Extracorporeal blood purification is proposed as an adjuvant therapy for sepsis, aiming at controlling the associated dysregulation of the immune system, which is known... (Review)
Review
Extracorporeal blood purification is proposed as an adjuvant therapy for sepsis, aiming at controlling the associated dysregulation of the immune system, which is known to induce organ dysfunctions. Different therapies have been developed to address certain steps of the immune dysregulation. Most of the available blood purification devices focus on a single target, such as the endotoxin that triggers the immune cascade, or the cytokine storm that causes organ damages. However, the highly adsorptive membrane named oXiris® is a unique 4-in-1 device that combines cytokine and endotoxin removal properties, renal replacement function, and antithrombogenic properties. More recently, promising treatments that focus on the pathogen itself or the immune cells have been developed and are currently under investigation. In this review, we aim to summarize, according to their target, the different extracorporeal blood purification techniques that are already available for use. We will also briefly introduce the most recent techniques that are still under development. Because of its unique ability to remove both endotoxins and cytokines, we will particularly discuss the highly adsorptive preheparinized oXiris® membrane. We will present its properties, advantages, pitfalls, as well as therapeutic perspectives based on experimental and clinical data. Video Journal Club "Cappuccino with Claudio Ronco" at https://www.karger.com/Journal/ArticleNews/223997?sponsor=52.
Topics: Cytokines; Endotoxins; Hemofiltration; Humans; Sepsis
PubMed: 30974444
DOI: 10.1159/000499520 -
Journal of the American College of... Sep 2020Acute kidney injury (AKI) and cardiorenal syndrome (CRS) are increasingly prevalent in hospitalized patients with cardiovascular disease and remain associated with poor... (Review)
Review
Acute kidney injury (AKI) and cardiorenal syndrome (CRS) are increasingly prevalent in hospitalized patients with cardiovascular disease and remain associated with poor short- and long-term outcomes. There are no specific therapies to reduce mortality related to either AKI or CRS, apart from supportive care and volume status management. Acute renal replacement therapies (RRTs), including ultrafiltration, intermittent hemodialysis, and continuous RRT are used to manage complications of medically refractory AKI and CRS and may restore normal electrolyte, acid-base, and fluid balance before renal recovery. Patients who require acute RRT have a significant risk of mortality and long-term dialysis dependence, emphasizing the importance of appropriate patient selection. Despite the growing use of RRT in the cardiac intensive care unit, there are few resources for the cardiovascular specialist that integrate the epidemiology, diagnostic workup, and medical management of AKI and CRS with an overview of indications, multidisciplinary team management, and transition off of RRT.
Topics: Acute Kidney Injury; Cardio-Renal Syndrome; Cardiology; Disease Management; Hemofiltration; Humans; Renal Dialysis; Renal Replacement Therapy; Severity of Illness Index; United States; Water-Electrolyte Balance
PubMed: 32854844
DOI: 10.1016/j.jacc.2020.06.070 -
Blood Purification 2015
Topics: Hemodiafiltration; Humans
PubMed: 26344506
DOI: 10.1159/000437402 -
Revista Espanola de Quimioterapia :... Oct 2022Sepsis represents a serious risk to the life of any patient, which is why it is crucial to start an effective treatment in all its extremes as soon as possible, that is,... (Review)
Review
Sepsis represents a serious risk to the life of any patient, which is why it is crucial to start an effective treatment in all its extremes as soon as possible, that is, the chosen antibiotics must have activity against the pathogen that produces the condition and, in addition, they must be dosed considering the patient's situation in all its extremes. It should be considered that it will be necessary to adjust the dose when there is edema (drugs with reduced volume of distribution), hypoproteinemia (drugs bound to proteins in a high proportion), obesity, and also when they require the use of external techniques such as ECMO or any of the different types of hemodialysis and hemofiltration.
Topics: Humans; Sepsis; Hemofiltration; Critical Care; Anti-Bacterial Agents; Treatment Outcome
PubMed: 36285854
DOI: 10.37201/req/s03.07.2022 -
Blood Purification 2021The real issue with the COVID-19 pandemic is that a rapidly increasing number of patients with life-threatening complications are admitted in hospitals and are not... (Review)
Review
The real issue with the COVID-19 pandemic is that a rapidly increasing number of patients with life-threatening complications are admitted in hospitals and are not well-administered. Although a limited number of patients use the intensive care unit (ICU), they consume medical resources, safety equipment, and enormous equipment with little possibility of rapid recovery and ICU discharge. This work reviews effective methods of using filtration devices in treatment to reduce the level of various inflammatory mediators and discharge patients from the ICU faster. Extracorporeal technologies have been reviewed as a medical approach to absorb cytokines. Although these devices do not kill or remove the virus, they are a promising solution for treating patients and their faster removal from the ICU, thus relieving the bottleneck.
Topics: Acute Kidney Injury; Anti-Bacterial Agents; COVID-19; Coated Materials, Biocompatible; Combined Modality Therapy; Continuous Renal Replacement Therapy; Cross-Over Studies; Cytokine Release Syndrome; Cytokines; Double-Blind Method; Equipment Design; Hemofiltration; Humans; Membranes, Artificial; Microspheres; Multiple Organ Failure; Plasmapheresis; Randomized Controlled Trials as Topic; Respiration, Artificial; Respiratory Distress Syndrome; SARS-CoV-2; Shock, Septic; Sorption Detoxification
PubMed: 32464624
DOI: 10.1159/000508278 -
Kidney International. Supplement Aug 2000The use of sorbents in different blood purification techniques is reviewed. The sorbents used in these therapies are divided into two groups: (1) Adsorption occurs... (Review)
Review
The use of sorbents in different blood purification techniques is reviewed. The sorbents used in these therapies are divided into two groups: (1) Adsorption occurs fundamentally because of the hydrophobic properties of the sorbents. In this group, the sorbents used in different dialysis techniques are charcoal and nonionic macroporous resins. (2) Adsorption occurs by chemical affinity, such as ion exchange resins and chemisorbents. Sorbents were initially used in hemoperfusion, which caused many adverse events; later, with the use of coated charcoal, these undesired effects decreased or disappeared, but the adsorptive properties, water control, and acid-base balance still created problems. For these reasons, the use of sorbents in the treatment of chronic renal failure was almost totally discontinued. Little by little, interest in these substances has reappeared, and at present, they have been used in combination with other blood purification techniques such as hemodialysis, hemofiltration, peritoneal dialysis, and finally, hemodiafiltration. Within the various hemodiafiltration techniques, paired filtration dialysis-charcoal is being used to regenerate the ultrafiltrate, which is used as the replacement fluid. Charcoal regenerates the ultrafiltrate and transforms it into a physiological solution with a normal electrolyte composition, calcium, bicarbonate, and glucose, having eliminated the majority of both middle and large molecule uremic toxins. If regeneration is done properly, this replacement fluid is bacteria and endotoxin free. Studies currently are underway on the adsorption of different inflammatory substances in the ultrafiltrate, which could lead to improvement in the biocompatibility of the system.
Topics: Adsorption; Charcoal; Hemodiafiltration; Humans; Kidney Failure, Chronic; Urea
PubMed: 10936800
DOI: 10.1046/j.1523-1755.2000.07607.x -
Critical Care Clinics Apr 2013Sepsis remains an important challenge in pediatric critical care medicine. This review provides an appraisal of adjunctive therapies for sepsis and highlights... (Review)
Review
Sepsis remains an important challenge in pediatric critical care medicine. This review provides an appraisal of adjunctive therapies for sepsis and highlights opportunities for meeting selected challenges in the field. Future clinical studies should address long-term and functional outcomes as well as acute outcomes. Potential adjunctive therapies such as corticosteroids, hemofiltration, hemoadsorption, and plasmapheresis may have important roles, but still require formal and more rigorous testing by way of clinical trials. Finally, the design of future clinical trials should consider novel approaches for stratifying outcome risks as a means of improving the risk-to-benefit ratio of experimental therapies.
Topics: Adrenal Cortex Hormones; Anti-Bacterial Agents; Biomarkers; Child; Combined Modality Therapy; Critical Care; Extracorporeal Circulation; Fluid Therapy; Hemofiltration; Hemoperfusion; Hospital Mortality; Humans; Hydrocortisone; Plasmapheresis; Risk Assessment; Sepsis; Severity of Illness Index; United States
PubMed: 23537672
DOI: 10.1016/j.ccc.2012.11.003 -
Peritoneal Dialysis International :... Nov 2015Heart failure (HF) is a common and important cause of morbidity and mortality in the elderly, imposing a significant burden on healthcare systems. Better management of... (Comparative Study)
Comparative Study Review
Heart failure (HF) is a common and important cause of morbidity and mortality in the elderly, imposing a significant burden on healthcare systems. Better management of ischemic heart disease has resulted in increased survival and growth in the number of prevalent heart failure patients, but co-existing renal impairment complicates management and limits traditional therapeutic options. Ultrafiltration (UF) techniques have shown promise in the treatment of diuretic-resistant HF, but the early successes of extracorporeal treatments has not been confirmed by randomized trials. Peritoneal dialysis (PD) may be cheaper and provide more effective UF therapy in selected patients and this review examines the issues surrounding the use of PD for such patients. Whist many nephrologists are enthusiastic about the use of this technique, making a more cogent case for PD in this setting for cardiologists is likely to need a combined strategy of demonstrating improvement in individual cases and further study of potential medicoeconomic benefits.
Topics: Age Factors; Aged; Aged, 80 and over; Australia; Cause of Death; Comorbidity; Cost Savings; Female; Geriatric Assessment; Heart Failure; Hemofiltration; Humans; Male; Patient Selection; Peritoneal Dialysis; Prognosis; Renal Insufficiency, Chronic; Risk Assessment; Severity of Illness Index; Survival Analysis; Treatment Outcome
PubMed: 26702006
DOI: 10.3747/pdi.2014.00340 -
Critical Care (London, England) Aug 2012The objective of this systematic review and meta-analysis was to determine the effect of renal replacement therapy (RRT), delivered as hemofiltration vs. hemodialysis,... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
The objective of this systematic review and meta-analysis was to determine the effect of renal replacement therapy (RRT), delivered as hemofiltration vs. hemodialysis, on clinical outcomes in patients with acute kidney injury (AKI).
METHODS
MEDLINE, EMBASE and CENTRAL databases and conference abstracts were searched to June 2012 for parallel-group or crossover randomized and quasi-randomized controlled trials (RCTs) evaluating hemofiltration vs. hemodialysis in patients with AKI. Two authors independently selected studies and abstracted data on study quality and outcomes. Additional information was obtained from trial authors. We pooled data using random-effects models.
RESULTS
Of 6,657 citations, 19 RCTs (10 parallel-group and 9 crossover) met inclusion criteria. Sixteen trials used continuous RRT. Study quality was variable. The primary analysis included three parallel-group trials comparing similar doses of hemofiltration and hemodialysis; sensitivity analyses included trials comparing combined hemofiltration-hemodialysis or dissimilar doses. We found no effect of hemofiltration on mortality (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.73 to 1.25, P = 0.76; three trials, n = 121 (primary analysis); RR 1.10, 95% CI 0.88 to 1.38, P = 0.38; eight trials, n = 540 (sensitivity analysis)) or other clinical outcomes (RRT dependence in survivors, vasopressor use, organ dysfunction) compared to hemodialysis. Hemofiltration appeared to shorten time to filter failure (mean difference (MD) -7 hours, 95% CI (-19,+5), P = 0.24; two trials, n = 50 (primary analysis); MD -5 hours, 95% CI (-10, -1), P = 0.01; three trials, n = 113 (including combined hemofiltration-hemodialysis trials comparing similar doses); MD -6 hours, 95% CI (-10, -1), P = 0.02; five trials, n = 383 (sensitivity analysis)). Data primarily from crossover RCTs suggested that hemofiltration increased clearance of medium to larger molecules, including inflammatory cytokines, compared to hemodialysis, although almost no studies measured changes in serum concentrations. Meta-analyses were based on very limited data.
CONCLUSIONS
Data from small RCTs do not suggest beneficial clinical outcomes from hemofiltration, but confidence intervals were wide. Hemofiltration may increase clearance of medium to larger molecules. Larger trials are required to evaluate effects on clinical outcomes.
Topics: Acute Kidney Injury; Hemofiltration; Humans; Randomized Controlled Trials as Topic; Renal Dialysis; Treatment Outcome
PubMed: 22867021
DOI: 10.1186/cc11458 -
The Cochrane Database of Systematic... Jan 2017Severe sepsis and septic shock are leading causes of death in the intensive care unit (ICU), despite advances in the treatment of patients with severe sepsis and septic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Severe sepsis and septic shock are leading causes of death in the intensive care unit (ICU), despite advances in the treatment of patients with severe sepsis and septic shock, including early recognition, appropriate treatment with antibiotics and support of organs that may have been affected by the illness. High-volume haemofiltration (HVHF) is a blood purification technique that may improve outcomes in severe sepsis or septic shock. The technique of HVHF has evolved from renal replacement therapies used in the ICU to treat critically ill patients with acute kidney injury (AKI). This review was first published in 2013 and was updated in 2016.
OBJECTIVES
To investigate whether HVHF improves outcomes in critically ill adults admitted to the intensive care unit with severe sepsis or septic shock. The primary outcome of this systematic review is patient mortality; secondary outcomes include duration of stay, severity of organ dysfunction and adverse events.
SEARCH METHODS
For this updated version, we extended searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Latin American Caribbean Health Sciences Literature (LILACS), Web of Science and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) to 31 December 2015. The original search was performed in 2011. We also searched trials registers.
SELECTION CRITERIA
We included randomized controlled trials (RCTs) and quasi-randomized trials comparing HVHF or high-volume haemodiafiltration versus standard or usual dialysis therapy, as well as RCTs and quasi-randomized trials comparing HVHF or high-volume haemodiafiltration versus no similar dialysis therapy. These studies involved adults treated in critical care units.
DATA COLLECTION AND ANALYSIS
Three review authors independently extracted data and assessed trial quality. We sought additional information from trialists as required.
MAIN RESULTS
We included four randomized trials involving 200 participants. Owing to small numbers of studies and participants, it was not possible to combine data for all outcomes. Two trials reported 28-day mortality, and one trial reported hospital mortality; in the third trial, the number of deaths stated did not match the quoted mortality rates. The pooled risk ratio (95% confidence interval) for 28-day mortality associated with HVHF was 0.89 (0.60 to 1.32, two trials, 146 participants, low-quality evidence). One study (137 participants, low-quality evidence) reported length of stay in the ICU. Two trials (170 participants, low-quality evidence) reported organ dysfunction, but we could not pool results owing to reporting differences. Three studies (189 participants, low-quality evidence) reported on haemodynamic changes, but we could not pool results owing to reporting differences. Investigators reported no adverse events. Overall, the included studies had low risk of bias.
AUTHORS' CONCLUSIONS
Investigators reported no adverse effects of HVHF (low-quality evidence). The results of this meta-analysis show that very few studies have been conducted to investigate the use of HVHF in critically ill patients with severe sepsis or septic shock (four studies, 201 participants, low-quality evidence). Researchers should consider additional randomized controlled trials that are large and multi-centred and have clinically relevant outcome measures. The cost-effectiveness of HVHF should also be studied. .
Topics: Adult; Critical Illness; Hemodiafiltration; Hemofiltration; Hospital Mortality; Humans; Intensive Care Units; Organ Dysfunction Scores; Randomized Controlled Trials as Topic; Sepsis; Shock, Septic; Time Factors
PubMed: 28141912
DOI: 10.1002/14651858.CD008075.pub3