Single Pass Albumin Dialysis—A Dose‐Finding Study to Define Optimal Albumin Concentration and Dialysate Flow

Several artificial liver support concepts have been evaluated both in vitro and clinically. Single pass albumin dialysis (SPAD) has shown to be one of the most simple approaches for removing albumin‐bound toxins and water‐soluble substances. Being faced with acute liver failure (ALF) in everyday practice encouraged our attempt to define the optimal conditions for SPAD more precisely in a standardized experimental setup. Albumin concentration was adjusted to either 1%, 2%, 3%, or 4%, while the flow rate of the dialysate was kept constant at a speed of 700 mL/h. The flow rate of the dialysate was altered between 350, 500, 700, and 1000 mL/h, whereas the albumin concentration was continuously kept at 3%. This study revealed that the detoxification of albumin‐bound substances could be improved by increasing the concentration of albumin in the dialysate with an optimum at 3%. A further increase of the albumin concentration to 4% did not lead to a significant increase in detoxification. Furthermore, we observed a gradual increase of the detoxification efficiency for albumin‐bound substances, from 350 mL/h to 700 mL/h (for bilirubin) or 1000 mL/h (for bile acids) of dialysate flow. Water‐soluble toxins (ammonia, creatinine, urea, uric acid) were removed almost completely, regardless of albumin concentration or flow rate. In conclusion, this study confirmed that SPAD is effective in eliminating albumin‐bound as well as water‐soluble toxins using a simulation of ALF. Furthermore, this project was successful in evaluating the most effective combination of albumin concentration (3%) and dialysate flow (700 mL/h–1000 mL/h) in SPAD for the first time.     

Single pass albumin dialysis (SPAD) in fulminant Wilsonian liver failure: a case report

Since fulminant Wilsonian liver failure has an extremely poor prognosis, the use of a liver support system that can bridge patients to liver transplant is life saving. We report here the case of a 17-year-old female who presented with fulminant Wilsonian liver failure and intravascular hemolysis. With the subsequent development of encephalopathy and oliguria, single pass albumin dialysis (SPAD) was initiated for 5 days to augment copper removal. Continuous venovenous hemodialysis (CVVHD) was performed using the PRISMA machine, with a blood flow of 100 ml/min and a dialysate flow of 2 L/h for 8 h, then 1 L/h. A 5% albumin dialysate was made by exchanging 1 L of 25% albumin for 1 L of Hemosol BO in a 5-L bag. Single pass albumin dialysis resulted in reductions in serum copper (154 to 59 μg/dL), conjugated bilirubin (37 to 23 mg/dL), lactate dehydrogenase (1305 to 729 units/L), and creatinine (1.1 to 0.9 mg/dL) as well as reduced blood transfusion requirements. Cessation of SPAD was followed by three plasmapheresis treatments for further copper removal. We conclude that SPAD is potentially an effective treatment in fulminant Wilson disease with hemolysis but that it should be used in combination with chelation to optimize the removal of copper.     

Use of peritoneal dialysis in the treatment of patients with renal failure and paraproteinemia

The effect of alterations in dwell time, dialysate dextrose concentration, and nitroprusside on immunoglobulin removal during peritoneal dialysis and a comparison of plasmapheresis versus peritoneal dialysis on immunoglobulin removal was studied. 1 h of plasmapheresis removed approximately 100 times as much IgG and 50 times as much IgM and IgA as 1 h of peritoneal dialysis. Nitroprusside added to peritoneal dialysate doubled the hourly removal rate of IgG using 1- and 8-hour cycles and increased IgA and IgM removal by 25 and 10%, respectively, using 8-hour cycles. It was estimated that peritoneal dialysis with nitroprusside added to peritoneal dialysate augments intact immunoglobulin clearance (above endogenous clearance) by approximately 10%. We hypothesized that peritoneal dialysis could significantly increase light-chain removal and thereby may be efficacious in the treatment of light chain related amyloid formation and light chain induced renal failure.     

Intermittent high-flux albumin dialysis with continuous venovenous hemodialysis for acute-on-chronic liver failure and acute kidney injury

Acute-on-chronic liver failure (ACLF) requiring intensive medical care and associated with acute kidney injury (AKI) has a mortality rate as high as 90% due to the lack of effective therapies. In this study, we assessed the effects of intermittent high-flux single-pass albumin dialysis (SPAD) coupled with continuous venovenous hemodialysis (CVVHD) on 28-day and 90-day survival and an array of clinical and laboratory parameters in patients with severe ACLF and renal insufficiency. Sixteen patients were studied. The diagnosis of ACLF and AKI was made in accordance with current EASL Clinical Practice Guidelines, including the recommendations of the International Club of Ascites. All patients received SPAD/CVVHD treatments as the blood purification therapy to support liver, kidneys, and other organs. Five patients were transplanted and 11 were not listed for transplantation because of active alcoholism. Data at the initiation of SPAD/CVVHD were compared with early morning data after the termination of the extracorporeal treatment phase. All patients had ACLF and renal insufficiency with 13/16 additionally fulfilling the AKI criteria. A total of 37 SPAD/CVVHD treatments were performed [2.3 ± 1.4]. The baseline MELD-Na score was 37.6 ± 6.6 and decreased to 33.4 ± 8.7 after SPAD/CVVHD (P < 0.001). In parallel, the CLIF-C ACLF grade and OF score, estimated at 28- and 90-day mortality, AKI stage, hepatic encephalopathy grade, and liver function tests were lowered (P = 0.001–0.032). The 28- and 90-day survivals were 56.2% overall and 53.8% in AKI. Survival in patients not transplanted (n = 11) was 45.4%. In patients with severe ACLF and AKI, the renal replacement therapy coupled with high-performance albumin dialysis improved estimated 28- and 90-day survival and several key clinical and laboratory parameters. It is postulated that these results may be further improved with earlier intervention and more SPAD treatments per patient. High-performance albumin dialysis improves survival and key clinical and laboratory parameters in severe ACLF and AKI.     

Dialysis membrane-dependent removal of middle molecules during hemodiafiltration: the beta2-microglobulin/albumin relationship

AIM: Current hemodialysis therapy modalities such as online hemodiafiltration (HDF) attempt to enhance solute removal over a wide molecular weight range through a combination of diffusion and convection. While the effects of variations of treatment modalities and conditions have been studied reasonably well, few studies have examined the efficacy of HDF to remove middle molecules in relation to the dialyzer and membrane characteristics. In this investigation, diverse high-flux dialyzers, covering a wide range of membrane permeabilities, were compared under identical in vivo conditions to assess their ability to eliminate larger uremic retention solutes (using beta2-microglobulin as a surrogate of middle molecules) without simultaneously causing excessive leakage of useful proteins such as albumin. PATIENTS AND METHODS: In a prospective, crossover study, 3 ESRD patients were treated with 8 different brands of high-flux dialyzers at 4 different ultrafiltration (UF)/substitution flow rates (QS: 0, 30, 60, 90 ml/min) in post-dilution HDF mode. Thus, each patient underwent 32 treatment sessions, with a total of 96 treatment sessions conducted during the entire clinical study. Albumin and beta2-microglobulin levels were measured in both, dialysate and blood. Both, albumin and beta2-microglobulin elimination was dependent upon the permeability of the dialysis membrane as well as on the ultrafiltration/substitution flow rates applied. RESULTS: At the maximum UF rate of 90 ml/min, the total albumin loss (measured in the dialysate) ranged from 300 mg/4 h (for the FLX-15 GWS dialyzers) to 7,000 mg/4 h (for the BS-1.3U dialyzers). Up to 50% reduction of albumin occurred within the first 30 minutes of the dialysis treatment, and the leakage of albumin increased exponentially with increasing UF rates as well as increasing transmembrane pressure (TMP). The various dialyzers could be classified according to their UFR-dependent beta2-m reduction rates (RR), into low (< 50%; FLX-15 GWS, CT 150G), medium (50-70%; Polyflux 14 S, BLS 814SD, H4) and high (> 70%; BS-1.3U, APS 650, FX 60) removers of middle molecules. One dialyzer type (CT 150G) showed extremely low beta2-m RR and relatively high albumin losses. Most membranes, however, showed either low albumin leakage coupled with low beta2-m removal, or high beta2-m RR but at the expense of considerable albumin leakage. Only 2 membrane types approached the desired balance between high to medium beta2-m RR while simultaneously restricting the albumin leakage especially at higher filtration/substitution rates. CONCLUSION: Our investigations demonstrate that not all dialysis membranes classified as "high-flux" are comparable in their ability to specifically and efficiently remove middle molecules, or curtail the unwanted excessive leakage of essential proteins from the patient's blood. Thus, the selection of appropriate high-flux dialyzers for specific patient requirements should be based more upon clinical evaluations and analyses rather than on product specifications alone.     

Effective Bilirubin Reduction by Single-Pass Albumin Dialysis in Liver Failure

Albumin dialysis is widely accepted as a liver-support technique for patients with liver failure. The Molecular Adsorbent Recirculating System, the widely accepted albumin dialysis technique, has limited use in developing countries because of its technical difficulties and high cost. Therefore, we assessed the efficacy of the more practical modality, the single-pass albumin dialysis (SPAD), in terms of bilirubin reduction, as a marker of albumin-bound toxins removal, as well as the patient outcomes. Twelve acute or acute-on-chronic patients with liver failure who had hyperbilirubinemia (total bilirubin > 20 mg/dL) were treated with SPAD by using 2% human serum albumin dialysate for 6 h. SPAD treatment significantly improved the levels of total bilirubin, conjugated bilirubin, urea, and creatinine ( P  < 0.001 for all parameters). The reduction ratios of these four parameters were 22.9 ± 3.8%, 20.9 ± 5%, 19.0 ± 4.1%, and 27.7 ±  3.2%, respectively. No significant difference was observed between serum ammonia before and after treatment. No significant changes in mean arterial pressures were noted during the maneuver, representing cardiovascular tolerability. No treatment-related complications were found. The 15-day in-hospital survival was 16.7%. However, a subgroup of the patients who had moderate severity showed 100% 15-day-survival rate (2 of 2 patients). In conclusion, SPAD is salutarily effective in reducing bilirubin in patients with liver failure. The procedure is safe and simply set up.     

A case of minimal change nephrotic syndrome with acute renal failure complicating Hashimotoâs disease

A 63-year-old man was admitted to our hospital for evaluation of generalized edema. Coexistence of severe hypothyroidism and nephrotic syndrome was detected by laboratory examination. High titer of both antimicrosomal antibody and antithyroid peroxidase antibody indicated Hashimotoas disease. Renal biopsy showed minimal change glomerular abnormality, but no findings of membranous nephropathy. A series of medical treatments, including steroid therapy, thyroid hormone and human albumin replacement therapy, were administered. However, acute renal failure accompanied by hypotension, was not sufficiently prevented. After 9 sessions of plasmapheresis therapy, the severe proteinuria and low serum albumin levels were improved. Even after resting hypotension was normalized, neither renal function nor thyroid function were fully recovered. After discharge, renal function gradually returned to normal, and the blood pressure developed into a hypertensive state concomitant with the normalization of thyroid function. This report is a rare case of autoimmune thyroid disease complicated with minimal change nephrotic syndrome. In most cases of nephritic syndrome, acute renal failure (ARF) has been reported to coexist with hypertension. Although pseudohypothyroidism is well-known in nephrotic pathophysiology, complications of actual hypothyroidism are uncommon. It is suggested that the development of hypotension and ARF could be enhanced not only by hypoproteinemia, but also by severe hypothyroidism.     

We Use Impure Water to Make Dialysate for Hemodialysis

Patients receiving hemodialysis are exposed to a large volume of water, used to prepare dialysate for each treatment session. Technological advancements now make it possible to generate ultrapure dialysate that has substantially lower bacterial and endotoxin counts than the standard dialysate used in the United States. Low‐level water contamination is thought to propagate a state of chronic inflammation seen in hemodialysis patients, and a number of studies demonstrate that the use of ultrapure dialysate has a favorable effect on laboratory parameters of inflammation, nutrition, erythropoietin responsiveness, dialysis‐associated amyloidosis, and atherosclerosis. Few studies even suggest a direct clinical benefit of adopting ultrapure dialysate. As there is no proven harm with use of ultrapure dialysate and the economic implication appears to be minimal when using modern dialysis machines, it is imperative for regulatory agencies and the dialysis community to ensure that our vulnerable patients are no longer exposed to impure water during their hemodialysis treatments.     

A New Application for Albumin Dialysis in Extracorporeal Organ Support: Characterization of a Putative Interaction Between Human Albumin and Proinflammatory Cytokines IL‐6 and TNFα

Albumin dialysis in extracorporeal organ support is often performed in the treatment of liver failure as it facilitates the removal of toxic components from the blood. Here, we describe a possible effect of albumin dialysis on proinflammatory cytokine levels in vitro. Initially, albumin samples were incubated with different amounts of cytokines and analyzed by enzyme‐linked immunosorbent assay (ELISA). Analysis of interleukin 6 (IL‐6) and tumor necrosis factor alpha (TNFα) levels indicated that increased concentrations of albumin reduce the measureable amount of the respective cytokines. This led to the hypothesis that the used proinflammatory cytokines may interact with albumin. Size exclusion chromatography of albumin spiked with cytokines was carried out using high‐performance liquid chromatography analysis. The corresponding fractions were evaluated by immunoblotting. We detected albumin and cytokines in the same fractions indicating an interaction of the small‐sized cytokines IL‐6 and TNFα with the larger‐sized albumin. Finally, a two‐compartment albumin dialysis in vitro model was used to analyze the effect of albumin on proinflammatory cytokines in the recirculation circuit during 6‐h treatment. These in vitro albumin dialysis experiments indicated a significant decrease of IL‐6, but not of TNFα, when albumin was added to the dialysate solution. Taken together, we were able to show a putative in vitro interaction of human albumin with the proinflammatory cytokine IL‐6, but with less evidence for TNFα, and demonstrated an additional application for albumin dialysis in liver support therapy where IL‐6 removal might be indicated.     

Innovation in the Treatment of Uremia: Proceedings from the Cleveland Clinic Workshop: Bottom‐Up Nanotechnology: The Human Nephron Filter

Over one million patients worldwide have end‐stage renal disease and require dialysis or kidney transplantation. Despite the availability of these forms of renal replacement therapy for nearly four decades, mortality and morbidity are high and patients often have a poor quality of life. We have developed a human nephron filter (HNF) utilizing bottom‐up nanotechnology that would eventually make feasible a continuously functioning, wearable or implantable artificial kidney. The device consists of two membranes operating in series within one device cartridge. The first membrane mimics the function of the glomerulus, using convective transport to generate a plasma ultra filtrate, which contains all solutes approaching the molecular weight of albumin. The second membrane mimics the function of the renal tubules, selectively reclaiming designated solutes to maintain body homeostasis. No dialysis solution is used in this device. The HNF has been computer modeled, and operating 12 hour per day, 7 days per week the HNF provides the equivalent of 30 ml/min glomerular filtration rate (compared to half that amount for conventional thrice‐weekly hemodialysis). The HNF system, by eliminating dialysate and utilizing a novel membrane system created through applied nanotechnology, represents a breakthrough in renal replacement therapy based on the functioning of native kidneys. The enhanced solute removal and wearable design should substantially improve patient outcomes and quality of life.     

Hyperbaric Oxygenation, Plasma Exchange, and Hemodialysis for Treatment of Acute Liver Failure in a 3-Year-Old Child

A girl aged 3 years and 4 months weighing 16 kg was treated with plasma exchange (PE), hemodialysis (HD), and hyperbaric oxygenation (HBO) for acute hepatic failure and coma. She was given a total of 13 PEs, 13 HD sessions, and 9 HBO treatments over a period of 1 month. The initial 4 PEs were followed by HD sessions while the other 8 PE treatments were given simultaneously with HD. There was no renal failure; HD was instituted to improve ammonia elimination. In 1 HD session, 20% human albumin (370 ml) was used as the dialysate to enhance bilirubin elimination. Three volumes of plasma (2,000 ml) per PE were exchanged and replaced with fresh frozen plasma (FFP). The Bellco BL 791 plasmapheresis monitor and Gambro PF1000 and PF2000 plasma filters were used. Heparin was added to prevent clotting. A dual lumen pediatric HD catheter (7 Fr) placed percutaneously into the femoral vein was used as a blood access. The Fresenius 2008 C HD monitor and the Filtral 10 dialyzer were used for HD. PE and HD were instituted simultaneously to prevent the tetanic (hypocalcemic) cramps observed with 2 previous PEs due to citrate in the FFP. The extracorporeal circuit was primed with a mixture of concentrated red cells, human albumin, and saline solution and was discarded at the end of the procedure. The average blood flow rate in PE and/or HD circuits was 80 ml/min. During HBO, the girl breathed 100% oxygen at 2.5 atm for 90 min. Throughout the treatment, the patient was in good clinical, physical, and mental condition, but she was dependent on blood purification procedures. She was referred to a liver transplant center and successfully transplanted. The etiology of liver failure has not been clarified.     

Hypersensitivity reactions during hemodialysis related to the use of acetate dialysate. A case report.

A patient developed a hypersensitivity reaction two weeks after being put on hemodialysis with acetate dialysate. The reactions appeared exclusively during hemodialysis and were relieved immediately after its termination. These allergic manifestations disappeared with substitution of bicarbonate for acetate dialysate and reappeared upon rechallenge with acetate dialysate. The rest of the dialysis materials were excluded as possible causes of allergy by scheduled dialysis sessions with varying materials. Acetate dialysate is implicated as the cause of allergy reaction in this case.     

Sodium balance in hemodialysis therapy

Water and sodium overload is the predominant factor in the pathogenesis of hypertension in dialysis patients. In many dialysis patients, dry weight is not reached because of an imbalance between the interdialytic accumulation of water and sodium and the brief and discontinuous nature of routine dialysis therapy. During dialysis, sodium is removed by convection and to a lesser degree by diffusion. However, with supraphysiologic dialysate sodium concentrations, diffusive influx from dialysate may occur, especially in patients with low predialytic plasma sodium concentrations. Measuring sodium removal during dialysis is difficult and hampered by the variability in conventional sodium measurements. Ionic mass removal by continuous measurement of conductivity in the dialysate ports appears to be a promising tool for the approximation of sodium removal during dialysis. While the beneficial effects of concomitant water and sodium removal on blood pressure control in dialysis patients are undisputed, it is less well known whether a change in hydrosodium balance solely by reducing dialysate sodium is beneficial. Considering the inherent dangers of such an approach (intradialytic hemodynamic instability), the beneficial effects of strict dietary sodium restriction appear to be of much larger clinical benefit. It has become possible to individualize dialysate sodium concentration by means of online measurements of plasma conductivity and adjustment of dialysate conductivity by feedback technologies. The clinical benefits of this approach deserve further study. Still, reducing dietary sodium intake remains the most important tool in improving blood control in dialysis patients.     

Peripheral gangrene complicating hemolytic uremic syndrome in a child

A patient with hemolytic uremic syndrome (HUS) developed peripheral gangrene involving all fingers and toes. There was no history of bloody diarrhea. Hypocomplementemia was present, with a serum C3 concentration of 41 mg/dl. Acute renal failure was treated with peritoneal dialysis for 4 months. He received daily fresh-frozen plasma infusions and plasmapheresis on alternate days for ten sessions, followed by once-weekly sessions. He was anuric for 9 weeks. All medial and distal phalanxes became necrotic and were removed surgically. The renal biopsy findings were consistent with HUS. This is the second report of peripheral gangrene during the course of HUS in childhood.     

Impact of sodium and ultrafiltration profiling on hemodialysis-related symptoms

Dialysate sodium and ultrafiltration profiling are two methods to reduce symptoms during hemodialysis. The objective of the study was to determine the efficacy of combining these techniques to reduce symptoms in chronic hemodialysis patients. Blood volume changes were measured to determine whether any benefit of profiling could be explained through this mechanism. Patients were randomized to profiled dialysate sodium and ultrafiltration or constant dialysate sodium and ultrafiltration. The study was a two-period, two-treatment, crossover design with repeated measures. The primary outcome was hypotension and/or symptomatic events observed by the dialysis nurse. Secondary outcomes were symptom survey scores, weights, BP, and blood volume changes. Thirty-three patients were randomized. On standard treatment, 30.6% of dialysis sessions were symptomatic compared with 20.4% on profiled treatments. The odds ratio for the development of hypotension or symptomatic event on profiled treatments was 0.61 (95% confidence interval, 0.39 to 0.96) compared with standard treatment. Patients had lower symptom scores by questionnaire in both the intradialytic and the interdialytic periods during profiled treatments. Predialysis weight was greater during profiled treatments by 0.3 kg (P: = 0.008), but there were no differences in postdialysis weight, BP, or thirst. There was no difference in maximum decrease in blood volume during the two treatments (standard, -11.2%; profiled, -10.0%; P: = 0.08), but there was a significant difference in the rate of change in blood volume (standard, -2.96%/h; profiled, -1.96%/h; P: < 0.001). Decrease in blood volume, rate of change in blood volume, and predialysis weights were not associated with hypotension or symptomatic dialysis sessions. In conclusion, dialysate sodium and ultrafiltration profiling significantly reduces hemodialysis-related symptoms. Profiling reduces the slope of the blood volume curve during dialysis, but blood volume changes are not predictive of symptomatic events for an individual patient.     

Center-specific variations of thyroid hormone serum levels in hemodialysis patients

Thyroid hormone (free and total thyroxine, total 3,5,3'- and 3,3'5'-triiodothyronine, thyroxine-binding globulin, thyrotropin) serum concentrations were measured in 107 uremic patients of 4 hemodialysis centers, in order to study the prevalence of hypothyroidism in hemodialysis patients. In accordance with the clinical impression there was no laboratory evidence of thyroid dysfunction. In spite of the fact that all patients had the expected low-T3 syndrome, there were highly significant differences between the mean thyroid hormone concentrations of the 4 different centers. The center with the highest thyroid hormone levels (all normal except for borderline low 3,5,3'-triiodothyronine) also had the lowest urea levels, indicating the relatively best metabolic control. One center had significantly lower hormone levels than the other 3 centers (all hormones except free thyroxine were below normal) with urea levels that did not differ significantly from one of these centers. A retrospective analysis of patients and of the techniques of dialysis of 3 centers excluded factors like heparin or the length of time on dialysis to be the reason for the low values of this center. Finally, only the significantly higher proportion of unsuccessfully transplanted patients and some technical differences (lack of water treatment, regenerated cellulose as dialyser membrane, and low magnesium content in the dialysate) unique for this center remained as possible factors that may speculatively explain the observed low thyroid hormone values.(ABSTRACT TRUNCATED AT 250 WORDS)     

Serum and peritoneal dialysate thyroid hormone levels in patients on continuous ambulatory peritoneal dialysis

Thyroid function tests were performed on 16 clinically euthyroid patients with end-stage renal failure undergoing regular haemodialysis or continuous ambulatory peritoneal dialysis and compared with 8 healthy subjects. The patient groups were carefully matched, especially regarding relative duration of dialysis (mean of 24 months). Total serum thyroxine, total triiodothyronine, free thyroxine, free triiodothyronine and reverse triiodothyronine were significantly lower in both patient groups than control. The thyrothrophin response to the standard thyrotrophin-releasing hormone test was delayed and blunted. Using a novel concentration technique we measured loss of T4 in peritoneal dialysate effluent and found it to be approximately 10% of daily thyroidal T4 release.     

Infusion-free hemodiafiltration: simultaneous hemofiltration and dialysis with no need for infusion fluid

A new simultaneous hemofiltration and dialysis system was developed which has no need of infusion fluid. The system employs two hemodiafilters in a direct series. An ultrafiltration rate and dialysate flow rate control system was employed to control the dialysate flow at the inlet and outlet, and the difference in volume was arranged to be the amount of water removed from the body. When the blood circuit was narrowed between the two hemodiafilters, the ultrafiltration was performed at the first hemodiafilter; at the second one, the dialysate moved to the blood side as a dilution fluid. To remove pyrogens and bacteria, tap water was subjected to activated charcoal, ion exchange and reverse osmosis treatment, followed by preparation of the dialysate. In clinical evaluation, this system showed marked improvement in clearance of middle and large molecules.     

A dual-chambered hemodialyzer for convection-enhanced hemodialysis

Convective clearance during hemodialysis (HD) improves dialysis outcomes in kidney failure patients, and, thus, trials have been undertaken to increase convective mass transfer, which is directly related to internal filtration rates. The authors designed a new hemodialyzer to increase the internal filtration rates, and here describe the hemodialytic efficacy of the devised unit. The developed dual‐chambered hemodialyzer (DCH) contains two separate chambers for dialysate flow within a single housing. By placing a flow restrictor on the dialysate stream between these two chambers, dialysate pressures are regulated independently. Dialysate is maintained at a higher pressure than blood pressure in one chamber, and at a lower pressure in the other chamber. The dialysis performance of the DCH was investigated using an acute canine renal failure model. Urea and creatinine reductions and albumin loss were monitored, and forward and backward filtration rates were measured. No procedurally related malfunction was encountered, and animals remained stable without any complications. Urea and creatinine reductions after 4‐h dialysis treatments were 75.2 ± 6.5% and 67.7 ± 8.9%, respectively. Post‐treatment total protein and albumin levels remained at pretreatment values. Total filtration volume was 4.98 ± 0.5 L over 4 h, whereas the corresponding backfiltration (BF) volume was 4.77 ± 0.6 L. The developed dual‐chamber dialyzer has the benefit of providing independent control of forward filtration and BF rates. HD using this dialyzer provides a straightforward means of increasing the internal filtration and convective dose.     

Subacute thyroiditis causing thyrotoxic crisis; a case report with literature review

IntroductionSubacute thyroiditis is a self-limited, inflammatory viral thyroid disease which presents with neck pain, usually accompanied by systemic symptoms. On the other hand, thyroid storm is a clinical condition of severe sudden hyperthyroidism accompanied by physiologic de-compensation. We presented a 29-year-old male with features of subacute thyroiditis and thyroid storm who is the third reported case managed by steroid, beta-blocker and analgesics.Conclusionsubacute thyroiditis may present with thyrotoxic crisis which respond dramatically to corticosteroid therapy.