Continuous arteriovenous hemofiltration in the elderly patients

The outcome of continuous arteriovenous hemofiltration (CAVH) treatment was evaluated in fifty one critically ill elderly with acute renal failure (ARF). They were admitted into our University Hospital's intensive-care units (ICU) during January 1987 and December 1990. Mean age (± SD) was 70.7 ± 5 (range 65–84) years. Elderly patients (>65 years old) comprised 44% of the ICU-ARF patients. The causes of ARF were cardiac surgery (41%), medical (31%), aneurysm of the resection of abdominal aorta (20%), and general surgery (8%). In the majority of the patients ARF was complicated by multiple organ failure. A survival of 60% was obtained with CAVH treatment. The highest survival rate (69%) was noted among cardiac surgery ARF patients, while the lowest survival (25%) was seen among patients with ARF following aneurysm of the resection of abdominal aorta. From the results of this study we conclude that CAVH serves a benificial role if it is considered in the management of ARF in the elderly intensive care patients with multiple organ failure.     

Hemorrhagic cardiac tamponade in critically ill patients with acute renal failure

PURPOSE: The purpose of this study was to report the development, management, and follow up of tamponading uremic pericardial effusion in critically ill patients with acute renal failure. SETTING: The setting for this study was an adult, 24-bed tertiary multidisciplinary intensive care unit (ICU) of a university hospital. PATIENTS: The subjects were 5 critically ill patients with multiple organ failure including acute renal failure (ARF) that was slow to resolve. RESULTS: Renal involvement was attributed to renal hypoperfusion, sepsis and myoglobinuria. Continuous veno-venous hemofiltration (CVVH) was instituted early during hospitalization in 4 cases and lasted for 35 to 48 days; renal replacement therapy was not used in 1 case. Tamponade developed late in the course of ARF, after CVVH was discontinued in the 4 cases and was effectively managed with percutaneous pericardiocentesis under echocardiography and continuous catheter drainage of the pericardial sac for 48 to 72 hours. Hemorrhagic fluid (Hb 2.2-5.9 g/dL) with lymphocyte predominance was detected. Transient constrictive-like pericarditis findings were present in all patients after the procedure. All patients were discharged from the hospital in a good condition with normal serum and creatinine levels; 1-year follow up showed a normal echocardiogram. CONCLUSION: Awareness for the possibility of hemorrhagic pericarditis and cardiac tamponade is needed in ICU patients with ARF slow to resolve. Transient constrictive-like pericarditis may present after pericardiocentesis.     

连续肾脏替代治疗在肝移植中的应用

目的探讨连续肾脏替代治疗(CRRT)在肝移植术后急性肾功能衰竭(ARF)合并多器官功能不全(MODS)治疗中的应用价值。方法分析连续静脉静脉血液滤过(CVVH)治疗7例肝移植术后ARF、成人呼吸窘迫综合征(ARDS)、急性心衰、全身炎症反应综合征(SIRS)等患者。3例合并ARDS患者同时进行呼吸机辅助呼吸治疗。结果4例治愈,另3例ARF合并MODS患者死亡。经CVVH治疗后,患者血清中的肌酐、尿素氮、血钾较治疗前降低(P<0.05),凝血酶原时间变化无意义。结论CVVH能有效控制氮质血症和高血钾等高分解状态,而不影响凝血功能。早期应用可以改善肝移植术后ARF、ARDS、充血性心力衰竭、SIRS等MODS患者的预后。     

Continuous arteriovenous hemodialysis and continuous venovenous hemofiltration in burn patients with acute renal failure

Acute renal failure (ARF) is a very common condition that may occur in patients with major burn injuries. The majority of burn patients with ARF have a high mortality rate, ranging from 73% to 100%. There are several ways to treat ARF in burn patients, including peritoneal dialysis (PD), intermittent hemodialysis, and continuous renal replacement therapy (CRRT). CRRT is generally used in patients in whom intermittent hemodialysis has failed to control hypovolemia, as well as in patients who cannot tolerate intermittent hemodialysis. Additionally, PD is not suitable for patients with burns within the abdominal area. For these reasons, most patients with unstable hemodynamic conditions receive CRRT. In this study (conducted in our burn unit between 1997 and 2004), six burn patients received CRRT: three received continuous arteriovenous hemodialysis (CAVHD) and the other three received continuous venovenous hemofiltration (CVVH). The patients were all males, with a mean age of 49.8 years (range, 27-80 years), and a mean burnt surface area of 65.1% (range, 30-95%). Four patients died due to multiple organ failure, and two patients recovered from severe ARF. CRRT has been proven safe and useful for burn patients with ARF. According to this study, we conclude that CVVH is an appropriate tool for treating ARF, with a lower incidence of vascular complications than CAVHD.     

连续性血液净化在ICU多器官功能障碍综合征合并急性肾衰竭患者的应用及预后分析

目的探讨连续性血液净化治疗（CBPT）在ICU多器官功能障碍综合征（MODS）合并急性肾衰竭（APF）患者的疗效及影响预后的相关因素。方法回顾性分析2004年1月至2008年2月该院ICU中行连续性静-静脉血液滤过（CVVH）治疗的245例MODS合并ARF患者一般资料、血液生化检查、疾病严重程度评分等，对比分析CVVH治疗前后临床参数的变化及影响预后的因素。结果CVVH对容量负荷、溶质清除效果明显；反映疾病严重程度如氧合指数、APACHEⅡ评分、MODS评分、SOFA评分CVVH治疗前后比较无明显差异；全部患者死亡率为64．9％，病死率随着衰竭器官数目的增加而显著升高。多因素回归分析显示，患者CVVH治疗前衰竭器官数、医院获得性ARF、CVVH前APACHEⅡ评分、平均动脉压是独立危险因素。结论对于MODS合并ARF患者，CVVH治疗前患者疾病的严重程度是影响预后的重要因素，依据患者临床病情早期积极CBPT可能改善MODS合并ARF患者的预后。     

Efficacy of separated system continuous venovenous hemofiltration in critical acute kidney injury

Integrated system continuous venovenous hemofiltration (CVVH), the most popularly utilized mode for continuous renal replacement therapy (CRRT), needs a sophisticated and expensive machine that is available only in limited critical care units. Separated system CVVH, which can be simply set up, might be an effectively alternative to CRRT. A one-year prospective observational study regarding the efficacy of separated system CVVH was conducted with 192 critically ill patients with acute kidney injury. All patients underwent separated system CVVH with the pre-dilution mode and a mean CVVH dose of 34.9±2.7mL/kg/h. The APACHEII score was 23.2±8.4 and the Sequential Organ Failure Assessment score was 12.0±4.3. No complications, including air-embolism or circuit clotting, were observed and the survival rate was 32.3%. Separated system CVVH is simple, safe, and efficient and could provide cheaper treatments than the integrated system. It could thus be an effective, alternative treatment for critical acute kidney injury patients when the integrated mode is unavailable.     

Renal replacement strategies in the ICU

Acute renal failure (ARF) with the concomitant need for renal replacement therapy (RRT) is a common complication of critical care medicine that is still associated with high mortality. Different RRT strategies, like intermittent hemodialysis, continuous venovenous hemofiltration, or hybrid forms that combine the advantages of both techniques, are available and will be discussed in this article. Since a general survival benefit has not been demonstrated for either method, it is the task of the nephrologist or intensivist to choose the RRT strategy that is most advantageous for each individual patient. The underlying disease, its severity and stage, the etiology of ARF, the clinical and hemodynamic status of the patient, the resources available, and the different costs of therapy may all influence the choice of the RRT strategy. ARF, with its risk of uremic complications, represents an independent risk factor for outcome in critically ill patients. In addition, the early initiation of RRT with adequate doses is associated with improved survival. Therefore, the "undertreatment" of ARF should be avoided, and higher RRT doses than those in patients with chronic renal insufficiency, independent of whether convective or diffusive methods are used, are indicated in critically ill patients. However, clear guidelines on the dose of RRT and the timing of initiation are still lacking. In particular, it remains unclear whether hemodynamically unstable patients with septic shock benefit from early RRT initiation and the use of increased RRT doses, and whether RRT can lead to a clinically relevant removal of inflammatory mediators.     

无肝素抗凝技术在连续性静脉-静脉血液滤过中的应用

目的对连续性静脉-静脉血液滤过治疗过程中无肝素抗凝技术进行综合评价。方法2005年1月至4月对四川大学华西医院的42例危重患者行连续性静脉-静脉血液滤过(CVVH)治疗,其中高危出血患者19例采用无肝素技术抗凝,设为观察组;23例采用低分子肝素抗凝,设为对照组(其中3例因故改用无肝素抗凝)。两组置换液速度均为3000mL/h,持续时间12h/d,碳酸氢盐置换液前稀释方式输入。计算溶质下降率,治疗前后检测电解质、酸碱指标、凝血指标;记录心率、平均动脉压、跨膜压及滤器寿命。结果两组治疗后血尿素氮、肌酐均显著下降,但组间比较溶质下降率差异并无显著性意义(P>0.05),对照组活化部分凝血时间(APTT)显著延长(P<0.05)。观察组跨膜压在7h明显升高,而对照组在9h明显升高;观察组滤器的平均寿命短于对照组(P<0.05)。结论CVVH中应用无肝素抗凝技术同样高效、稳定、安全,对于高危出血患者,是保障CVVH治疗持续进行的重要措施。     

Evaluation of Plasma Exchange and Continuous Veno‐Venous Hemofiltration for the Treatment of Severe Avian Influenza A (H7N9): A Cohort Study

Avian influenza A (H7N9) is a severe disease with high mortality. Hypercytokinemia is thought to play an important role in the pathogenesis. This study was to investigate the efficiency of plasma exchange (PE) + continuous veno‐venous hemofiltration (CVVH) on the removal of inflammatory mediators and their benefits in the management of fluid overload and metabolic disturbance. In total, 40 H7N9‐infected patients were admitted to our hospital. Sixteen critically ill H7N9‐infected patients received combination of PE and CVVH. Data from these 16 patients were collected and analyzed. The effects of PE + CVVH on plasma cytokine/chemokine levels and clinical outcomes were examined. H7N9‐infected patients had increased plasma levels compared to healthy controls. After 3 h of PE + CVVH treatment, the cytokine/chemokine levels descended remarkably to lower levels and were maintained thereafter. PE + CVVH also benefited the management of fluid, cardiovascular dysfunction and metabolic disturbance. Of the 16 critically ill patients who received PE + CVVH, 10 patients survived. PE + CVVH decreased the plasma cytokine/chemokine levels significantly. PE + CVVH were also beneficial to the management of severe avian influenza A (H7N9).     

连续静脉-静脉血液滤过治疗难治性心力衰竭临床疗效观察

目的 观察连续静脉-静脉血液滤过（CVVH）治疗难治性充血性心力衰竭（CHF）的疗效及安全性.方法 21例难治性心力衰竭患者,行床边CVVH治疗,观察治疗前、后心衰症状改善情况、血流动力学和实验室检测指标变化情况.结果 经CVVH治疗后,所有患者心衰症状均有不同程度改善,血流动力学及电解质稳定,尿素氮（BUN）、肌酐（Cr）、血尿酸、NT-proBNP较治疗前降低（P＜0.05）,且无严重并发症.结论 CVVH治疗充血性心力衰竭患者水钠潴留的近期疗效是有效和安全的.     

Regional citrate anticoagulation reduces polymorphonuclear cell degranulation in critically ill patients treated with continuous venovenous hemofiltration

Citrate which chelates ionized calcium can be used as regional anticoagulation in continuous venovenous hemofiltration (CVVH). This is the first study conducted to examine the potentially additive benefit effect of regional citrate anticoagulation (RCA) on polymorphonuclear (PMN) cell degranulation of myeloperoxidase (MPO) and cytokines production in patients with critically acute kidney injury (AKI) undergoing CVVH treatment. This prospective randomized controlled trial was conducted in 20 critically ill patients with AKI who underwent CVVH. The patients were randomized into regional citrate group (n=10) and heparin group (n=10). The pre-dilution CVVH with polyethersulfone dialyzers were utilized in both groups. The levels of pre-filter and post-filter MPO as well as inflammatory and anti-inflammatory cytokines were measured at baseline, 6h, and 24 h after initiating CVVH. In the heparin group, the post-filter serum MPO levels were significantly higher than the pre-filter (median 49.0 vs. 60.5 ng/mL, P<0.05) at 6 h. There were no significant differences between pre- and post-dialyzer MPO levels in the citrate group. Citrate could significantly decrease systemic pre-filter serum MPO levels from baseline at 6 h (median 43.5 vs. 17.3 ng/mL, P<0.01) as well as IL-8 levels (P<0.05) whereas heparin provided only significant TNF-α reduction (P<0.05). The CVVH circuit survival in the citrate group was longer than the heparin group. In conclusion, citrate, utilized as a regional anticoagulant in CVVH, can reduce both membrane bioincompatibility-induced and systemic oxidative stress and inflammation, and can prolong CVVH circuit survival time.     

Clinical Effects of Pulse High‐Volume Hemofiltration on Severe Acute Pancreatitis Complicated With Multiple Organ Dysfunction Syndrome

To evaluate the effects of pulse high‐volume hemofiltration (PHVHF) on severe acute pancreatitis (SAP) with multiple organ dysfunction syndrome (MODS). Thirty patients were divided into two groups: PHVHF group and continuous venovenous hemofiltration (CVVH) group. They were evaluated in terms of clinical symptoms, acute physiology and chronic health evaluation (APACHE) II score, sequential organ failure assessment (SOFA) score, simplified acute physiology (SAPS) II score and biochemical changes. The levels of IL‐6, IL‐10 and TNF‐α in plasma were assessed by ELISA before and after treatment. The doses of dopamine used in shock patients were also analyzed. In the two groups, symptoms were markedly improved after treatment. Body temperature (BT), breath rate (BR), heart rate (HR), APACHE II score, SOFA score, SAPS II score, serum amylase, white blood cell count and C‐reactive protein were decreased after hemofiltration (P < 0.05). The PHVHF group was superior to the CVVH group, especially in APACHE II score, CRP (P < 0.01), HR, temperature, SOFA score and SAPS II score (P < 0.05). The doses of dopamine for shock patients were also decreased in the two groups (P < 0.05), with more reduction in the PHVHF group than the CVVH group (P < 0.05). The levels of IL‐6, IL‐10 and TNF‐α decreased (P < 0.05) in the PHVHF group more significantly than the CVVH group (P < 0.01). PHVHF appears to be superior to CVVH in the treatment of SAP with MODS.     

心脏临时起搏支持严重心率缓慢患者的血液净化

目的观察心脏临时起搏对严重心率缓慢患者血液净化的作用。方法7例因各种病因引起的急慢性肾功能衰竭患者伴严重心率缓慢时,经右颈内静脉、左锁骨下静脉途径穿刺置管行气囊电极床边紧急心脏临时起搏,支持血液净化。结果7例中5例行右颈内静脉置管,2例行左锁骨下静脉置管,起搏均成功,效果肯定,起搏时间2～16天,支持血液净化共32次,其中连续性静脉血液滤过(CVVH)2次,8例次行血液透析滤过(HDF),22例次行常规血透(HD),未发现心脏穿孔、气胸、血胸,1例发生导管感染。1例扩张型心肌病患者因低血压心力衰竭不能控制自动出院,其余6例均抢救成功。结论球囊电极床边心脏临时起搏,操作简便快捷,安全有效,可以提高严重心动过缓合并有肾功能不全的重危患者的抢救成功率。     

Nierenersatztherapie in der Intensivmedizin

Acute renal failure (ARF) can be treated since the end of the 1970s either by continuous forms of extracorporeal treatment (CRRT) or by intermittent dialysis (IHD). There is no difference in the mortality comparing CRRT and IHD neither in meta-analyses nor in prospective randomized trials. There are a few critically ill patients, especially those with severe sepsis and septic shock who should only be treated by CRRT. Every form of treatment should be started early as it is necessary to avoid further damage of other vital function disorders due to the loss of exocrine renal function. Independent of the treatment form all critically ill patients need a dosage of dialysis enabling control over the negative effects of the hypercatabolic situation in these patients. An increase of the dosage above the minimal requirements did not lead to a better survival rate in this inhomogenous group of patients. In continuous forms of treatment an exchange amount of 20?ml/kg body weight/h should be achieved and for intermittent dialysis a minimal Kt/V of 4?C4.5 per week is necessary. Fluid balancing often leads to the necessity of daily dialysis in the intensive care unit.     

连续性静脉静脉血液滤过治疗肝肾综合征的临床研究

目的:观察连续性静脉静脉血液滤过(continuous venovenous hemofiltration,CVVH)治疗肝肾综合征(hepatorenal syndrome,HRS)的疗效。方法:32例HRS患者随机分为两组,治疗组16例采用CVVH治疗,对照组16例采用单纯药物治疗,两组患者均接收一般内科治疗。结果:治疗后治疗组患者肾功能、电解质、平均动脉压的改善水平与对照组相比,差异有显著性意义(P<0.05);生存率较对照组高,差异有显著性意义(P<0.05)。结论:CV-VH是治疗肝硬化并发HRS的有效方法。     

Continuous veno-venous hemofiltration for the treatment of contrast-induced acute renal failure after percutaneous coronary interventions.

Acute renal failure (ARF) requiring hemodialysis after percutaneous coronary interventions (PCI) is a serious complication with poor prognosis. Hemodialysis-induced hypotension may have deleterious cardiovascular effects, especially in high-risk patients. Ultrafiltrate removal and simultaneous fluid replacement with a solution similar to plasma for high-volume controlled hydration can be obtained with hemodynamic stability by continuous veno-venous hemofiltration (CVVH). We prospectively assessed the safety and effectiveness of percutaneous CVVH (Y-shaped double-lumen catheter, circuit originating from and terminating in the femoral vein) in 33 consecutive patients (23 men and 10 women; mean age, 69 +/- 9 years) who, after PCI, developed oligo-anuric ARF, associated in 20 of them with congestive heart failure. All patients received a concomitant infusion of furosemide (500-1000 mg/day) and dopamine (2 microg/kg/min). During CVVH, the average fluid volume replacement and body fluid net reduction were 1000 +/- 247 and 75 +/- 48 ml/hr, respectively. Treatment with CVVH continued for 4.7 +/- 2.7 days and corrected fluid overload in all cases. No patient experienced systemic hypotension or hypovolemia. Diuresis recovered in 32 (97%) patients, who showed a parallel improvement of renal function parameters. One patient required chronic dialysis. In-hospital and 1-year mortality was 9.1% and 27.3%, respectively. In conclusion, our data indicate that CVVH is a safe and effective therapy of radiocontrast-induced ARF following PCI. It temporarily replaces renal function without deleterious cardiovascular effects, allowing the kidney to recover from the nephrotoxic injury. However, despite promising early results, large randomized trials are required to define the role of CVVH in ARF after PCI.     

Current Topics on Cytokine Removal Technologies

Abstract: It has been widely accepted that cytokines play important roles in the development of organ failure in various pathophysiological conditions of critically ill patients. Various new technologies, including continuous renal replacement therapy, have been developed for the removal of causative humoral mediators in sepsis or other critical conditions. Nonselective blood purification technologies, such as hemofiltration and plasma exchange, are applied in cytokine removal technology. However, the more selective blood purification technologies, such as adsorption, and the combination of those technologies, should be considered in future applications. Only through a prospective randomized controlled study can it be elucidated whether or not these technologies have efficacy in the treatment of sepsis and critically ill patients with hypercytokinemia. We should join and discuss the design of future clinical trials with a standardized strategy for the evaluation of the technologies.     

Serum cytokine level during continuous venovenous hemofiltration in toxic shock-like syndrome due to group G beta Streptococcus bacteremia in a patient with idiopathic thrombocytopenic purpura

We report a case of toxic shock-like syndrome due to a rare infection of group G Streptococcus bacteremia in a patient with idiopathic thrombocytopenic purpura and its successful treatment with continuous venovenous hemofiltration (CVVH). As the result of sepsis treatment with CVVH, in addition to administration of vasopressors and antibiotics, serum levels of interleukin-1beta, interleukin-10 and tumor necrosis factor-a fell and shock was controlled.     

连续性肾脏替代治疗剂量对溶质清除率的影响

目的比较不同剂量的连续性静脉-静脉血液滤过(CVVH),连续性静脉-静脉血液透析(CVVHD)及连续性静脉-静脉血液透析滤过(CVVHDF)对各种溶质清除率的影响，以及理论推测与计算溶质清除率值之间的差异。方法选择确诊为急性肾功能衰竭患者5例，采用PRISMA机器行前稀释型连续性肾脏替代治疗（CRRT），测定不同透析液及置换液流量下尿素氮(UN)、肌酐(Cr)、尿酸(Ua)、磷(P)及β2-微球蛋白（β2-M）的清除率。结果不同流量下测得的CVVH和CVVHD对小分子清除率计算值与理论推测值之间呈非常显著线性相关（P<0.001）。相同流量下，CVVH对β2-M清除效果好，而CVVHD对尿素氮、肌酐、尿酸及磷清除效果好。在CVVHDF中测得的溶质清除率较相应流量的CVVH及CVVHD清除率之和要小。结论理论推测公式基本反映不同流量下CVVH、CVVHD对小分子溶质的实际清除率，CVVH、CVVHD对大、小分子溶质的清除各有所长，临床可据此来确定不同CRRT模式及剂量。但在CVVHDF中应考虑到弥散与对流互相作用对总清除率的影响。     

连续性静脉-静脉血液滤过对心脏瓣膜置换术后多脏器功能障碍综合征患者机体免疫功能和氧化应激的影响

目的 观察连续性静脉-静脉血液滤过（CVVH）对心脏瓣膜置换术后多脏器功能障碍综合征（MODS）患者机体免疫功能和氧化应激的影响.方法 31例心脏术后MODS伴急性肾衰竭（ARF）的患者使用AV600型聚砜膜血滤器行CVVH治疗,分别在治疗0、2、6、12、24和48小时取血,检测存活（A组）和死亡（B组）患者促炎因子[肿瘤坏死因子（TNF）-α和白细胞介素（IL）-6]、抗炎因子（IL-10）、单核细胞人类白细胞（HLA）-DR抗原表达、过氧化指标[丙二醛（MDA）]和抗氧化指标[过氧化物歧化酶（SOD）、谷胱甘肽过氧化物酶（GSH-px）和血浆总抗氧化能力（TAC）]的变化.结果 （1）A组患者治疗前单核细胞分泌活跃,治疗后单核细胞分泌TNF-α、IL-6和IL-10均明显减少,B组患者则表现为分泌抑制状态,治疗后无明显变化;（2）与正常人比较,两组患者单核细胞表达HLA-DR明显降低;治疗后,A组患者明显改善,B组患者无改善;（3） CVVH治疗后,A组患者红细胞内MDA明显降低,SOD和GSH-px明显增高,而B组患者在整个治疗期间基本维持治疗前水平.结论 CVVH有助于改善心脏术后MODS患者机体的免疫功能状态和氧化应激损伤.