bluuebunny/crossref_metadata_2025 huggingface dataset:
Is β2-Microglobulin-Related Amyloidosis of Hemodialysis Patients a Multifactorial Disease? a New Pathogenetic Approach
Authors: Cianciolo G. , Colì L. , La Manna G. , Donati G. , D'addio F. , Comai G. , Ricci D. , Dormi A. , Wratten M. , Feliciangeli G. , Stefoni S.
Published: January 2018

Purpose

β2-microglobulin amyloidosis (Aβ2M) is one of the main long-term complications of dialysis treatment. The incidence and the onset of Aβ2M has been related to membrane composition and/or dialysis technique, with non-homogeneous results. This study was carried out to detect: i) the incidence of bone cysts and CTS from Aβ2M; ii) the difference in Aβ2M onset between cellulosic and synthetic membranes; iii) other risk factors besides the membrane.

Methods

480 HD patients were selected between 1986 to 2005 and grouped according to the 4 types of membranes used (cellulose, synthetically modified cellulose, synthetic low-flux, synthetic high-flux). The patients were analyzed before and after 1995, when the reverse osmosis treatment for dialysis water was started at our center, and the incidence of Aβ2M was compared between the two periods. Routine plain radiography, computer tomography (CT) and nuclear magnetic resonance imaging (MRI) as well as electromyography were used to investigate the clinical symptoms.

Results

Bone cysts occurred in 29.2% of patients before 1995 vs. 12.2% after 1995 (p<0.0001). CTS occurred in 24% of patients before 1995 vs. 7.1% after 1995 (p<0.0001). Bone cysts and CTS occurred in older patients, who began dialysis at a late age, with high CRP, low albumin, low residual GFR, and low Hb. Cox regression analysis showed that the risk factor for bone cysts was high CRP (RR 1.3, p<0.01), while albumin (RR 0.14, p<0.0001) and residual GFR (RR 0.81, p<0.0001) were revealed to be protective factors. Cox analysis for CTS confirmed CRP as a risk factor (RR 1.2, p<0.01), and albumin (RR 0.59, p<0.0001) and residual GFR (RR 0.75, p<0.0001) as protective factors. The comparison obtained between membranes did not suggest any protective effect on Aβ2M.

Conclusions

The findings that the inflammatory status as well as low albumin and the residual GFR of the uremic patient are predictive of Aβ2M lesions suggests that Aβ2M has a multifactorial origin rather than being solely a membrane- or technique-related side effect.
The Curative Effect of ALSS on 1-month Mortality in AoCLF Patients after 72 to 120 Hours
Authors: Chen Y.-S. , Wu Z.-W. , He J.-Q. , Yu J. , Yang S.-G. , Zhang Y.-M. , Du W.-B. , Cao H.-C. , Li L.-J.
Published: January 2018

Background

Hepatitis B virus (HBV)-related acute-on-chronic liver failure (AoCLF) is associated with a high mortality rate. An artificial liver support system (ALSS) creates a better environment for the self-regeneration of retained hepatocytes.

Aim and Patients

We investigated the curative effect of ALSS on 1-month mortality at 72–120 h post-ALSS in 289 AoCLF patients.

Methods

Of the 289 patients, 117 who survived for at least 1 month post-ALSS comprised the survival group; the remaining cases who died within 1 month served as controls. The improvements in laboratory data and clinical syndromes at 72–120 h post-ALSS were compared with those at 24 h.

Results

Total bilirubin, international normalized ratio, and creatinine levels, and encephalopathy were significantly improved at 24 h post-ALSS in both the groups (p<0.05); however, these variables showed deterioration at 72–120 h; a rebound occurred in the nonsurvivors (p>0.05). The improvements in these variables in the nonsurvivors were considerably smaller than those in the survivors (p<0.05), particularly at 72–120 h. One-month mortality was more accurately predicted by the logistic regression model at 72–120 h than at 24 h.

Conclusions

The prognosis of AoCLF patients was highly dependent on the improvement in encephalopathy, total bilirubin, international normalized ratio, and creatinine levels at 72–120 h post-ALSS. These variables are useful, therefore, as disease severity indexes to determine organ allocation priorities for liver transplant.
Rheopheresis in Vascular Diseases
Authors: Ferrannini M. , Vischini G. , Staffolani E. , Scaccia F. , Miani N. , Parravano M.C. , Louis M.M. , Splendiani G. , Di Daniele N.
Published: January 2018

Background

Endothelial dysfunction is a common condition in many microvascular diseases, such as Age-related Macular Degeneration (AMD) and Peripheral Arterial Occlusive Disease (PAOD). Rheopheresis therapy improves ematic viscosity, shear stress and endothelial function while decreasing fibrinogen, LDL-cholesterol and alpha-2-macroglobulin levels.

Objective

To evaluate the therapeutic efficacy of rheopheresis in patients with microcirculatory diseases.

Materials and Methods

Eight patients (7 male and 1 female) were treated with rheopheresis: 3 males were affected by AMD, 4 male and 1 female by uremia and PAOD. We used Membrane Differential Filtration (MDF) with an ethinylvinylalcohol copolymer membrane as plasmafiltrator. Patients with AMD were treated once a week for ten weeks. Patients affected with PAOD were treated twice weekly for 3 weeks and then were placed on a once-a-week program.

Results

In all treated patients with AMD, visual acuity improved. In all patients affected with PAOD, we observed a complete resolution of pain; 3 out of 5 had a complete remission of ulcers. There was partial reduction of ulcers in the other patients and no adverse effects were observed. Conclusion: Rheopheresis is a safe, effective form of hemorheotherapy
Dialysis in the 1960s and the First Hollow Fiber Dialyzer
Authors: Sargent J. A.
Published: January 2018

The history of the development of the first hollow fiber dialyzer as part of a federally funded project at Dow Chemical in Walnut Creek, California is interesting, as this project represented an initial step in the technical advances that dialysis has experienced over the last 40 years. The project, important in its own right, was revolutionary; the predominant design of dialyzers in use at the time employed either flat membranes or collapsed large cellulose tubing. The hollow fiber dialyzer project, in addition to being technologically important, brought together several individuals who over the intervening four decades have launched careers and collaborations that have had a profound impact, as well as resulting in major advances and contributions to a greater understanding of the dialysis process and adequate delivery of care.
The Association of the Sodium “Setpoint” to Interdialytic Weight Gain and Blood Pressure in Hemodialysis Patients
Authors: Keen M. L. , Gotch F. A.
Published: January 2018

Introduction

Hemodialysis patients lack the normal mechanisms to regulate body water volume and osmolality The dialysis treatment is expected to adequately regulate both body water volume and body Na+ content, which is the primary action determining body water osmolality Data in subjects with normal renal function indicate that an individual has a specific osmolality value above which thirst is generated and fluid will be ingested. This specific osmolality value or “setpoint” varies among individuals, but is quite reproducible within an individual. It was postulated that hemodialysis patients also may have a Na+ “setpoint”, which if increased by the use of higher dialysate Na+ concentration, might be associated with increased interdialytic weight gain and blood pressure.

Methods

Monthly laboratory and treatment data were abstracted on 58 hemodialysis patients and included pre- and post-dialysis serum Na+ concentrations, interdialytic weight gain and blood pressure over 9 to 16 months. The Na+ concentrations were averaged to determine the individual Na+ “setpoint” and the Na+ gradient (Dialysis Na+ concentration - mean Na+ concentraton) was determined for each patient.

Results

Linear regression analyses showed that there was a statistically significant association between the magnitude of the Na+ gradient and interdialytic weight gain and blood pressure.

Conclusions

These data suggest that interdialytic weight gain in individual patients may be associated with the use of dialysate Na+ concentration in excess of the patient's desired Na+ “setpoint”. More individualization of dialysate Na+ concentration may be indicated.
The Impact of Visceral Mass on Survival in Chronic Hemodialysis Patients
Authors: Kotanko P. , Levin N. W.
Published: January 2018

In chronic hemodialysis, patient survival is positively correlated with body weight and body mass index (BMI). This relationship extends even to obese patients with a BMI >30 kg/m. We have put forward the hypothesis that this survival benefit may be due to a lower average synthesis rate of uremic toxins (expressed as amount per time per unit of body weight) in larger patients, because the relative contribution of the high metabolic rate organs (HMRO) to body weight in these patients is lower and HMRO are most likely to be the prime source of uremic toxins. In addition, the average uremic toxin concentration in larger patients may be lower because of the larger distribution volume. Based on these assumptions, a better survival in patients with a lower HMRO to body weight fraction (HMRO%BW) can be predicted.

To test this hypothesis we estimated gender- and race-specific HMRO mass by means of recently published regression models in 2,004 incident hemodialysis patients. Cox proportional hazards models were used to assess the association between age, serum albumin concentration, eKt/V, and HMRO%BW and mortality. High HMRO%BW was significantly associated with increased mortality (hazard ratio 1.323 [95% CI: 1.186 to 1.477]). Mean survival time was longest in the low HMRO%BW tertile (1,031 days [95%CI: 974 to 1,087]), 935 days [95%CI: 886 to 984] in the middle, and 876 days [95%CI: 825 to 926] in the high HMRO%BW tertile (p<0.0001; log rank test).

These results support the hypothesis predicting that a low HMRO mass per unit of weight confers a beneficial effect on survival.
Cardiovascular Risk in Hemodialysis Patients: A Mechanistic Approach
Authors: House A. A. , Ronco C.
Published: January 2018

A new formula is proposed to express the excess burden of cardiovascular risk faced by hemodialysis patients as a function of various inherent, acquired and potentially modifiable factors. The proposed equation CVRHD = CVRB X f(([CKD+HD]/[HDtech+Dr])+X) includes the terms: CVRHD (cardiovascular risk in hemodialysis patients); CVRB (baseline cardiovascular risk); CKD (risk associated with chronic kidney disease); HD (risks associated with the process of hemodialysis); HDtech (benefits of new hemodialysis technologies); Dr (benefits of drug therapies) and X (unknown or putative factors influencing cardiovascular morbidity).

We review the various factors included in this proposed formula, touching upon the epidemiology, pathophysiology and therapeutic implications, including possible strategies to modify risk. As is apparent from the formula, CKD and HD in particular act as risk multipliers in augmenting or amplifying the baseline cardiovascular risk, while new hemodialysis technologies may provide an opportunity for “cardioprotective dialysis.” Drug treatment may serve to mitigate some of the risk unique to this population.
Gas Exchange in a Virtual Respiratory System -Simulation of Ventilation without Lung Movement
Authors: Golczewski T.
Published: January 2018

Aims

The aim of this study was to supplement a previously developed virtual respiratory system (RS) with gas exchange and gas transfer in airways and circulation (GETAC); and to analyze arterial blood oxygenation during apnea when pure O2 is the ambient gas, with and without extracorporeal CO2 removal (ER), for different inspiratory O2 fractions (FiO2) before respiratory halt.

Methods

The virtual RS consists of the RS mechanics model and a model of GETAC consisting of three modules. The values of the model parameters correspond to the average values for a human being, which gave the “standard” virtual patient. This patient was artificially ventilated in supine position with FiO2=20%, 27%, and 34%, and then the respiration was stopped, FiO2 was changed to 99%, and ER was activated or not. The percent of oxygenated hemoglobin (HbO2%) and alveolar partial pressure of O2 (PAO2) were analyzed during 40 minutes after the beginning of apnea. Both cardiac output and oxygen consumption was assumed to be independent from HbO2%.

Results

Without ER, HbO2% decreased from 98% to 90% when FiO2=34% before apnea, while it decreased below the safety level (70%) for smaller FiO2. However, if ER was activated, HbO2% fell to 76%, 94%, and 97% from 95%, 97%, and 98%, respectively. For FiO2=27%, PAO2 was equal to 15.9, 15.1, 14.3, and 13.6 kPa after 10, 20, 30, and 40 minutes after the beginning of apnea, respectively. Thus, in the case of this particular (“standard”) patient, FiO2=27% before apnea and FiO2=99% during apnea provides proper blood oxygenation with approximately normal PAO2 if ER is activated.

Conclusions

If ER is available, it is possible to keep both sufficient blood oxygenation and a normal level of CO2 in the blood as well as a relatively low partial pressure of toxic O2 in the lungs without cyclic mechanical action on the diseased lungs or chest.
A Pilot Randomized Controlled Comparison of Extended Daily Dialysis with Filtration and Continuous Veno-Venous Hemofiltration: Fluid Removal and Hemodynamics
Authors: Baldwin I. , Bellomo R. , Naka T. , Koch B. , Fealy N.
Published: January 2018

Objectives

Extended intermittent dialytic techniques are increasingly being reported in the treatment of ARF in the ICU but few randomized controlled trials exist. We compared one such technique to a technique of continuous renal replacement therapy with regard to fluid removal and hemodynamics.

Methods

Sixteen critically ill patients with ARF were enrolled in a randomized controlled trial at the ICU of a tertiary hospital. We randomized eight patients to three consecutive days of treatment with either Extended Daily Dialysis with filtration (EDDf) or Continuous Veno-Venous Hemofiltration (CVVH) and compared fluid removal and hemodynamics during treatment.

Results

A total of 16.6 liters of fluid were removed during EDDf (830 mL/day over 20 treatment days) compared with 15.4 liters (700 ml/day over 22 treatment days) during CVVH. Median fluid removal per day was 1837 mL in the EDDf group compared with 1410 mL per day in the CVVH group, p=0.674. Median hourly fluid removal rate was 252 mL for EDDf and 128 mL for CVVH (p<0.01). Mean arterial pressure in the EDDf group was lower at two hours after starting treatment (76 mmHg vs. 94 mmHg) in the CVVH group; p= 0.031. There was no significant difference between groups for heart rate, CVP and noradrenaline dose at all time intervals measured.

Conclusions

Adequate prescribed fluid removal was achieved with both techniques. However, as expected, fluid was removed at a faster rate during EDDf. This was initially associated with a lower blood pressure than during CVVH where blood pressure increased.
Comparison of Middle-Molecule Clearance between Convective Control Double High-Flux Hemodiafiltration and On-Line Hemodiafiltration
Authors: Tiranathanagul K. , Yossundharakul C. , Techawathanawanna N. , Katavetin P. , Hanvivatvong O. , Praditpornsilp K. , Tungsanga K. , Eiam-Ong S.
Published: January 2018

Hemodiafiltration (HDF) is now a well-recognized treatment modality for end-stage renal disease (ESRD) patients. It provides superior characteristics over conventional hemodialysis in many respects. On-line HDF, however, which has been mainly used in clinical practice, requires a special machine. Interestingly, the recently innovated convective-control double high-flux hemodiafiltration (CC-DHF) machine can provide HDF treatment with an adjustable convection rate by using the conventional volume-controlled dialysate flow hemodialysis machine in a modified way. The present study was conducted to compare the efficacy of CC-DHF compared to on-line HDF in terms of middle and small solute clearances in 12 stable, chronic hemodialysis patients who underwent hemodialysis three times a week for at least 6 months. The results showed that the β2-microglobulin (β2M) removal represented by the β2M clearance in CC-DHF was comparable to that in on-line HDF (112.4±17.0 vs. 119.4±15.5 ml/min respectively, NS). Also, the β2M reduction ratio in the CC-DHF group did not differ from the on-line HDF group (85.5±4.2% vs. 86.1±6.7%, NS). With regard to small solute clearances, the values of single-pool Kt/V and phosphate clearance did not differ between CC-DHF and on-line HDF groups. In conclusion, CC-DHF provides removal of β2M and small molecule uremic toxins that is comparable to on-line HDF. An on-line HDF machine may not be available in all hemodialysis centers, whereas CC-DHF can be easily set up, with proper precautions regarding the fluid quality. Therefore, CC-DHF can provide the benefits of convective therapy to patients in situations where use of an on-line HDF machine is limited.
The Effect of Vascular Access Location and Size on Circuit Survival in Pediatric Continuous Renal Replacement Therapy: A Report from the PPCRRT Registry
Authors: Hackbarth R. , Bunchman T. E. , Chua A. N. , Somers M. J. , Baum M. A. , Symons J. M. , Brophy P. D. , Blowey D. , Fortenberry J. D. , Chand D. , Flores F. X. , Alexander S. R. , Mahan J. D. , McBryde K. D. , Benfield M. R. , Goldstein S. L.
Published: January 2018

Purpose

Well-functioning vascular access is essential for the provision of adequate CRRT However, few data exist to describe the effect of catheter size or location on CRRT performance in the pediatric population.

Methods

Data for vascular access site, size, and location, as well as type of anticoagulant used and patient demographic data were gathered from the ppCRRT registry. Kaplan-Meier curves were generated and then analyzed by log-rank test or Cox Proportional Hazards model.

Results

Access diameter was found to significantly affect circuit survival. None of the 5 French catheters lasted longer than 20 hours. Seven and 9 French, but not 8 French, catheters fared worse than larger diameter catheters (p=0.002). Circuits associated with internal jugular access survived longer than subclavian or femoral access associated circuits (p<0.05). Circuit survival was also found to be favorably associated with the CVVHD modality (p<0.001).

Conclusions

Functional CRRT circuit survival in children is favored by larger catheter diameter, internal jugular vein insertion site and CVVHD. For patients requiring catheter diameters less than 10 French, CRRT circuit survival might be optimized if internal jugular vein insertion is feasible. Conversely, when a vascular access site other than the internal jugular vein is most prudent, consideration should be given to using the largest diameter catheter appropriate for the size of the child. The CVVHD modality was associated with longer circuit survival, but the mechanism by which this occurs is unclear.
Successful Pregnancy in a Uremic Patient Treated with Single Needle Hemodialysis
Authors: Ferrannini M. , Vischini G. , Miani N. , Staffolani E. , Di Daniele N.
Published: January 2018

Background

Pregnancy is uncommon in patients on maintenance hemodialysis (HD) and it carries a high risk of fetal and maternal complications. Several reports have shown that application of an intensive dialysis regimen is associated with improved infant survival and better clinical conditions of the mother.

Methods

We report the case of a 35-year-old black woman with a prosthesic cardiac valve who was treated daily with single needle HD because of difficult vascular access.

Result

A healthy full-term female infant with a normal birth weight was electively delivered at 37 weeks. We did not register any complications during or after pregnancy.

Conclusion

In our experience, single needle HD is able to provide the patient with adequate depuration during pregnancy, the delivery of a full-term healthy infant, and preservation of the arterial-venous fistula from twice-daily vein puncture.
Impaired Brachial Artery Endothelial Flow-Mediated Dilation and Orthostatic Stress in Hemodialysis Patients
Authors: Gallieni M. , Butti A. , Guazzi M. , Galassi A. , Cozzolino M. , Brancaccio D.
Published: January 2018

Purpose

Chronic kidney disease (CKD) is associated with an impaired endothelial function, which may contribute to cardiovascular events. Whether impairment in endothelial function is involved in the circulatory response to orthostatic stress is unknown. We assessed endothelial function via brachial artery flow-mediated dilation (BAFMD), an index of endothelial-dependent vasodilation.

Methods

We measured changes in brachial artery diameter (BAD) and blood flow by Doppler ultrasound in 35 CKD patients on hemodialysis, 37 young healthy controls (HC) and 50 non-uremic matched controls (MC), in the supine position and after 60° head-up tilting (HUT). Results: In the supine position, endothelial flow-mediated BAD was significantly increased in HC (P<0.001) and MC (P<0.01) while no significant changes were detected in CKD. Mean percent blood flow changes were HC+323.5%, MC+195.1% and CKD+158.8% (HC vs. CKD P<0.001; HC vs. MC P<0.001; MC vs. CKD p=0.04). Similarly, during HUT mean BAD and blood flow increases were significantly impaired in CKD patients.

Conclusion

In CKD patients, an impaired response in the physiologic vascular reactivity, suggesting endothelial dysfunction, was found in the supine position and after orthostasis by BAFMD. Our results are in favor of a possible adjunctive role of uremia in the abnormal brachial artery response. (Int J Artif Organs 2008; 31: 34–42)
Evaluation of a Hybrid Artificial Liver Module with Liver Lobule-Like Structure in Rats with Liver Failure
Authors: Aoki K. , Mizumoto H. , Nakazawa K. , Funatsu K. , Kajiwara T.
Published: January 2018

We studied the recovery of rats with fulminant hepatic failure (FHF) by treating them with our original hybrid artificial liver support system (HALSS). We developed an original artificial liver module having a liver lobule-like structure (LLS). This module consists of many hollow fibers regularly arranged in close proximity and hepatocyte aggregates (organoids) induced into the extra capillary space of the module by centrifugal force. The LLS module can express some liver specific functions at high levels and maintain them for several months in vitro.

In this study, we evaluated the efficacy of our LLS-HALSS by using rats with FHF induced by a method that combined partial hepatectomy with hepatic ischemia. In the animal experiments, blood ammonia levels rapidly increased in the control group (sham-HALSS group). These rats died during or immediately after application of the sham-HALLS. On the other hand, in the LLS module application group (LLS-control group), the increase in blood ammonia was completely suppressed and all rats recovered. Blood constituents at 4 weeks after application were at normal levels, and the weight of the liver was the same as that of a normal rat. These results indicate that HALSS may be useful for treating liver failure patients until liver transplantation can be performed or until regeneration of the native liver occurs. (Int J Artif Organs 2008; 31: 55–61)
Electrospun Bioresorbable Heart Valve Scaffold for Tissue Engineering
Authors: Del Gaudio C. , Grigioni M. , Bianco A. , De Angelis G.
Published: January 2018

Currently marketed mechanical or biological prosthetic heart valves are regarded as valid substitutes for native heart valves suffering from degenerative pathologies. These devices require strict follow-up due to dysfunctions or post-surgical complications. Potential drawbacks of these medical devices are calcification, tearing of the cusps, thromboembolism and hemolysis. In this context, a tissue engineering approach offers a promising alternative scenario. In this paper, a trileaflet poly(∊-caprolactone) (PCL) heart valve scaffold prototype has been manufactured by electrospinning technique using a custom-made rotating target. Process parameters were selected in order to achieve suitable microstructure and mechanical performance. The electrospun heart valve prototype was functionally characterized by means of a pulse duplicator in order to evaluate the mechanical/hydraulic response to the imposed testing conditions. Leaflets synchronously opened in the ejection phase and the proper apposition of the leaflets prevented high leakage volumes in the diastolic phase.

This preliminary study suggests a successful perspective for the proposed approach in designing a novel tissue engineered bioresorbable heart valve.
Acute Dialysis Quality Initiative (ADQI): Methodology
Authors: Kellum J.A. , Bellomo R. , Ronco C.
Published: January 2018

The Acute Dialysis Quality Initiative (ADQI) is an ongoing process that seeks to produce evidence-based recommendations for the prevention and management of acute kidney injury (AKI) and on different issues concerning acute dialysis. Our methods involve a combination of both expert panel and evidence appraisal, and this approach was chosen to achieve the best of both options. This approach has led to important practice guidelines with wide acceptance and adoption into clinical practice. We further recognize that additional research will be needed and have proposed specific studies that will help move this field forward.
Fluids for Prevention and Management of Acute Kidney Injury
Authors: Kellum J. A. , Cerda J. , Kaplan L. J. , Nadim M. K. , Palevsky P. M.
Published: January 2018

Fluids are the only known method of attenuating renal injury. Furthermore, whether for hydration, resuscitation or renal replacement therapy, fluid prescriptions must be tailored to the fluid and electrolyte, cardiovascular status and residual renal function of the patient. Different fluids have significantly different effects both on volume expansion as well as on the electrolyte and acid-base balance; while controversial, different fluids may even influence renal function differently. This systematic review focuses on fluids for prevention and management of acute kidney injury. We have reviewed the available evidence and have made recommendations for clinical practice and future studies.
Pharmacologic Approaches for Volume Excess in Acute Kidney Injury (AKI)
Authors: Mehta R. L. , Cantarovich F. , Shaw A. , Hoste E. , Murray P.
Published: January 2018

Volume management is an integral component of the care of patients with acute kidney injury (AKI). Considerable controversy exists regarding the use of pharmacological agents for volume management. Although overt fluid overload is often seen in AKI and may prompt attention for the use of diuretics, often these agents are used in the absence of fluid retention. Over the last decade several new agents have become available for volume removal. We reviewed the literature on this topic and addressed four key questions for the appropriate utilization of these agents. These include the drug targets and mechanism of action of available agents; clinical goals and criteria for timing of intervention; adaptation of therapy for specific clinical settings and measures required for monitoring effectiveness and patient safety. This report details our current knowledge in this area, provides evidence-based clinical practice recommendations where appropriate, and formulates a research agenda to address unanswered questions. (Int J Artif Organs 2008; 31: 127–44)
Volume Management by Renal Replacement Therapy in Acute Kidney Injury
Authors: Gibney N. , Cerda J. , Davenport A. , Ramirez J. , Singbartl K. , Leblanc M. , Ronco C.
Published: January 2018

Management of fluid balance is one of the basic but vital tasks in the care of critically ill patients. Hypovolemia results in a decrease in cardiac output and tissue perfusion and may lead to progressive multiple organ dysfunction, including the development of acute renal injury (AKI). However, in an effort to reverse pre-renal oliguria, it is not uncommon for patients with established oliguric acute renal failure, particularly when associated with sepsis, to receive excessive fluid resuscitation, leading to fluid overload. In patients with established oliguria, renal replacement therapy may be required to treat hypervolemia. Safe prescription of fluid loss during RRT requires intimate knowledge of the patient's underlying condition, understanding of the process of ultrafiltration and close monitoring of the patient's cardiovascular response to fluid removal. To preserve tissue perfusion in patients with AKI, it is important that RRT be prescribed in a way that optimizes fluid balance by removing fluid without compromising the effective circulating fluid volume. In patients who are clinically fluid overloaded, it is equally important that the amount of fluid removed be as exact as possible. Fluid balance errors can occur as a result of inappropriate prescription, operator error or machine error. Some CRRT machines have potential for significant fluid errors if alarms can be overridden. Threshold values for fluid balance error have been developed which can be used to predict the severity of harm. It is important that RRT education programs emphasize the risk associated with fluid balance errors and with overriding machine alarms.
High-Intensity Hemodialysis: The Wave of the Future?
Authors: Ing T. S. , Ronco C. , Blagg C. R.
Published: January 2018

Various modalities of high-intensity hemodialysis are gathering increasing popularity. Some of the advantages of these new dialysis regimens are presented. Time and the increasing use of these novel approaches will ultimately determine their role in the overall management of patients with end-stage renal disease.
Switching from Three Times a Week to Short Daily Online Hemodiafiltration: Effects on Acid-Base Balance
Authors: HernáNdez-Jaras J. , Torregrosa De Juan E. , Pons-Prades R. , RÍus-Peris A. , Fenollosa-Segarra M.A.
Published: January 2018

Aims

This study examines the effect of a change from the standard 4–5 hours 3 times a week of online hemodiafiltration (OL-HDF) to 2–2.5 hours daily (6 times a week) OL-HDF, on acid-base balance, and attempts assess the modifications of acid-base parameters, ionic concentration, and electrical charges of albumin and phosphate available for diffusion and convection mechanisms across the membrane and subsequent infusion.

Methods

In 18 patients on online HDF, blood gas, electrolytes (Na, K, Cl), lactate, phosphate, albumin, apparent strong ion difference (SIDa), effective strong ion difference (SIDe), strong ion gap (SIG), anion gap (AG), and bicarbonate and pH time-averaged concentration (TAC) and time-averaged deviation (TAD) variables were evaluated at baseline, and 1, 3, 6, 9, and 12 months after patients were switched to daily OL-HDF. Additionally, in 12 patients, the same parameters measured simultaneously at dialyzer inlet, outlet, and after reinfusion were studied.

Results

Throughout the study, weekly single-pool Kt/V, equilibrated Kt/V, and TAC urea remained constant. However, standard Kt/V increased and TAD urea decreased on daily OL-HDF. There were no statistical differences during the time span of 12 months in pH, cations (Na, K), anions (Cl, HCO–3 AG, and lactate), or SIDa, SIDe, and SIG pre-HDF; while pH and HCO3– TAD decreased from 0.02 and 1.02 ± 0.74 mEq/L, to 0.01 and 0.64 ± 0.52 mEq/L, respectively (p<0.01). Net albumin charge and AG increased significantly at dialyzer outlet and decreased after reinfusion.

Conclusions

We did not observe changes in the acid-base balance in patients who switched from 3 times a week to short daily OL-HDF. The main benefit observed was a lower pH and bicarbonate TAD. This shows a better physiology for daily OL-HDF.
Tracking of Primary Human Hepatocytes with Clinical MRI: Initial Results with Tat-Peptide Modified Superparamagnetic Iron Oxide Particles
Authors: Morgul M. H. , Raschzok N. , Schwartlander R. , Vondran F.W. , Michel R. , Stelter L. , Pinkernelle J. , Jordan A. , Teichgraber U. , Sauer I. M.
Published: January 2018

The transplantation of primary human hepatocytes is a promising approach in the treatment of specific liver diseases. However, little is known about the fate of the cells following application. Magnetic resonance imaging (MRI) could enable real-time tracking and long-term detection of transplanted hepatocytes. The use of superparamagnetic iron oxide particles as cellular contrast agents should allow for the non-invasive detection of labelled cells on high-resolution magnetic resonance images. Experiments were performed on primary human hepatocytes to transfer the method of detecting labelled cells via clinical MRI into human hepatocyte transplantation. For labelling, Tat-peptide modified nano-sized superparamagnetic MagForce particles were used. Cells were investigated via a clinical MR scanner at 3.0 Tesla and the particle uptake within single hepatocytes was estimated using microscopic examinations. The labelled primary human hepatocytes were clearly detectable by MRI, proving the feasibility of this new concept. Therefore, this method is a useful tool to investigate the effects of human hepatocyte transplantation and to improve safety aspects of this method.
Disturbed Cerebral Circulation during Opening of the Venoarterial Bypass Bridge in Extracorporeal Membrane Oxygenation
Authors: De Mol A. C. , Van Heijst A. F. , Van Der Staak F. H. , Liem K. D.
Published: January 2018

Purpose

To describe the effects on cerebral blood flow velocity (CBFV) of intermittent opening of the venoarterial bridge (VA bridge) during venoarterial extracorporeal membrane oxygenation (VA-ECMO).

Study design

Prospective study in 22 newborns during VA-ECMO. CBFV was measured in the perical-losal artery by Doppler ultrasound. Changes in peak systolic flow velocity (PSV), end diastolic flow velocity (EDV) and time-averaged mean flow velocity (TAM) on day 1, 2, 3, and 5 and at low ECMO flow (50–150 ml/min) were analyzed (mean percentage±standard deviation (t-tests, p<0.05)). Changes >25% were considered relevant. The relationship between changes in CBFV and ECMO flow rate (Pearson correlation, p<0.01) was studied.

Results

Opening of the VA bridge resulted in statistically significant and relevant decreases in PSV (35 ± 18%), EDV (93 ± 15%) and TAM (68 ± 13%), persisting during the consecutive days of treatment. Smaller changes in CBFV at low ECMO flow were statistically significant and mostly relevant: PSV (15 ± 7%), EDV (76 ± 21%) and TAM (40 ± 12%). Changes in CBFV were positively correlated to the ECMO flow. Conclusion: Use of the VA bridge results in significant and relevant ECMO flow-dependent changes in CBFV, persisting during the treatment. The VA bridge should be used in such a way as to allow regular unclamping to be omitted.
Pumpless Extracorporeal Lung Assist as Supportive Therapy in a Patient with Diffuse Alveolar Hemorrhage
Authors: Renner A. , Neukam K. , RÖsner T. , Elert O. , Lange V.
Published: January 2018

Our 18-year old female patient suffered from microscopic polyangiitis. After invasive diagnostics, a diffuse alveolar hemorrhage occurred, leading to acute lung failure. In spite of differential ventilation, respiratory insufficiency and lactate-acidosis increased quickly. Due to the massive hemorrhage, a pumpless extracorporeal lung assist was implanted and, after six hours, low-dose heparinization was started. In response to this therapy, hypercapnia and acidosis improved quickly and were completely eliminated within 24 hours. Simultaneously, treatment with prednisolon and cyclophosphamid was started. After 7 days, the patient's conditions allowed weaning from the pumpless extracorporeal lung assist and after 9 days she was extubated.

In conclusion, the pumpless lung assist was shown to be a very practical option to treat the most serious forms of hypercapnia, especially for patients disposed to diffuse bleeding.
Hyperglycemia and the Outcome of Pediatric Cardiac Surgery Patients Requiring Peritoneal Dialysis
Authors: Egi M. , Morimatsu H. , Toda Y. , Matsusaki T. , Suzuki S. , Shimizu K. , Iwasaki T. , Takeuchi M. , Bellomo R. , Morita K.
Published: January 2018

Objective

To study the nature of the association between glycemia and ICU mortality in pediatric cardiac surgery patients treated with peritoneal dialysis (PD).

Materials and methods

Retrospective observational study in the ICU of a tertiary hospital involving forty pediatric cardiac surgery patients treated with PD. We selected patients requiring PD, extracted glucose measurements and nutritional intake data during ICU stay and calculated mean and maximum blood glucose values i) during ICU stay; ii) during dependence on PD; and iii) during independence from PD. We statistically assessed the relationship between glycemia-related variables and ICU mortality.

Measurements and Results

Twenty-two patients treated with PD died (mortality 55%). In the PD cohort, 9725 blood glucose measurements were performed (every 3.3 hours on average). The mean glycemia during dependence on PD was significantly higher in non-survivors than survivors (p<0.0001), but not during independence from PD (p=0.49). The area under the receiver operator characteristic curve for the mean glycemia during dependence on PD was significantly greater than that obtained during independence from PD. Even after adjustment for severity of illness using multivariate logistic analysis, the mean glycemia and calorie intake during PD were significant and independent predictors of ICU mortality.

Conclusions

A higher mean blood glucose concentration during PD, but not during PD-free periods was associated with greater ICU mortality. Mean glycemia and calorie intake during PD were significant and independent predictors of ICU mortality.
Citrate Anticoagulation for Postdilutional Online Hemodiafiltration with Calcium-Containing Dialysate and Infusate: Significant Clotting in the Venous Bubble Trap
Authors: Buturovic-Ponikvar J. , Gubensek J. , Ponikvar R.
Published: January 2018

Background

The aim of this prospective clinical study was to assess safety and antithrombotic efficacy of a regional citrate anticoagulation protocol for postdilutional online hemodiafiltration (HDF) with calcium-containing dialysate and infusate.

Methods

Nineteen postdilutional online HDF procedures with citrate anticoagulation were performed in 9 end-stage renal disease patients. Calcium-containing (1.25 mmol/L) dialysate/infusate, 15% (0.51 mol/L) trisodium citrate and 1 mol/L calcium chloride (when necessary) were used; the blood flow was 300 ml/min. Antithrombotic effect was assessed visually after HDF at 3 points: the dialyzer, arterial bubble trap, and venous bubble trap, using a score of 5 (excellent anticoagulation) to 1 (total clotting). The study was terminated prematurely due to frequent clotting in the venous bubble trap.

Results

The mean duration of HDF was 4.3 ± 0.9 hours; infusion volume was 13 ± 2 L. Almost half of the HDF procedures (9/19, 47%) were completed with some difficulty: in 1 case (1/19, 5%) there was total system clotting; in the other 8 cases, system clotting was threatening and dialysis was terminated prematurely, but in only 4/19 cases (21%) prior to 4-hour duration. The main point of clot formation was the venous bubble trap (score 2.6 ± 1.0), while anticoagulation was very good at the dialyzer (4.0 ± 1.2) and excellent at the arterial bubble trap (4.8 ± 0.9). No side effects were noted, and metabolic consequences were moderate.

Conclusions

Regional citrate anticoagulation using calcium-containing dialysate/infusate during postdilutional online hemodiafiltration results in a high incidence of venous bubble trap clotting.
Willingness of Nigerian Healthcare Workers to Donate Kidneys
Authors: Agaba E. I. , Ocheke I. E. , Agaba P. A. , Idoko O. T. , Ugoya S. O. , Yerima Y. , Iroezindu M.
Published: January 2018

Background

The attitude of healthcare workers (HCW) towards organ donation is cardinal to the successful implementation and sustainability of transplant programs. We present the outcome of a survey among HCW in a single tertiary institution in Nigeria regarding their willingness to be living-related kidney donors.

Methods

Self-administered questionnaires were randomly distributed to HCW evaluating their attitude towards living-related kidney donation.

Results

Of the 650 questionnaires distributed only 502 responded (clinical medical students 51%, physicians 31.7% and nurses 17.3%); 75.6% of respondents were willing to be living donors while 5.8% were against it, and 18.5% were undecided. Multivariate analysis identified willingness to receive, perceived risk associated with kidney donation, and attitude towards cadaveric donation as independent predictors of willingness of HCW to be living donors.

Conclusion

Nigerian HCW have a positive attitude toward kidney donation.
Continuous Hemofiltration for Anasarca: Recovery of Renal Function after 71 Liters of net Ultrafiltration
Authors: Prowle J. , Bellomo R. , Buckmaster J. , Gutteridge G. , Hart G. , Opdam H. , Silvester W. , Warrillow S.
Published: January 2018

We report on a 64-year-old female presenting with anasarca secondary to volume loading in the setting of chronic liver disease, acute on chronic renal failure, circulatory failure and sepsis. Over 37 days, a net negative fluid balance of 71 L was achieved using continuous hemofiltration, with spontaneous recovery of urine output, vasopressor independence and resolution of coagulopathy. This case report underlines the pathophysiological role of tissue edema in the downward spiral of hepato-renal and cardio-renal dysfunction and illustrates that very large volumes of tissue fluid can be safely and effectively removed with continuous renal replacement therapy, thereby permitting recovery of organ function. To our knowledge, there have been no previous reports of such large volume net fluid removal by progressive ultrafiltration in the intensive care unit.
Hepatitis B Virus Infection in the Dialysis Population: Current Perspectives
Authors: Fabrizi F. , Marzano A. , Messa P. , Martin P. , Lampertico P.
Published: January 2018

One of the major advances in the management of patients on regular dialysis has been the control of the spread of hepatitis B virus (HBV) infection in dialysis units. The rate of HBsAg positive patients on regular dialysis in the developed world is currently low, but outbreaks of HBV continue to occur. The diffusion of HBV in dialysis units in developing countries is higher, although available information is not abundant. There are limited data on the natural history of HBV in the dialysis population; they support a detrimental effect of HBV on survival in dialysis patients. The HBV viral load in HbsAg-positive dialysis patients appears low and stable over time and numerous mechanisms have been posited to explain it. Several assays for detecting HBV DNA in serum are available but they should not be used for purposes of routine screening within dialysis units. The epidemiology and clinical significance of occult HBV infection in the dialysis population needs to be addressed adequately - this remains an area of active research. Recent recommendations for the management of HBsAg chronic carriers on maintenance dialysis have been issued. No controlled trials for the treatment of hepatitis B with either interferon or lamivudine in dialysis patients are currently available.
Selective Albumin Exchange: A Novel and Simple Method to Remove Bilirubin
Authors: Gong D. , Ren B. , Ji D. , Tao J. , Xu B. , Liu Z. , Li L.
Published: January 2018

Purpose

Owing to its non-selectivity, plasma exchange has limited use in the treatment of patients with hepatic failure, although it is effective in removal of protein-bound toxins. This study reports a novel way to perform selective albumin exchange (SAE) by using a secondary plasma separator and aims to study its depurative capacity in the removal of bilirubin.

Method

In ex vivo experiments, the sieving coefficients (SCs) of plasma proteins for two secondary plasma separators, EC20W and EC30W (Asahi Medical, Tokyo, Japan), were measured. The EC20W membrane was chosen for use in clinical treatment because of its higher selectivity in separating albumin from plasma than the EC30W. The SCs of albumin, immunoglobumin G, A and M (IgG, IgA, IgM) for the EC20W were 0.3±0.021, 0.017±0.012, and 0, respectively. Five inpatients with plasma total bilirubin (TB) more than 200 μmol/L were enrolled in the present study and received a total of 10 SAE therapy sessions. Each session lasted 10 hours. SAE using the EC20W was conducted, making it similar to post-dilution continuous veno-venous hemofiltration (CVVH), with a filtrate rate of 2000 ml/h. Replacement fluid was composed by adding human albumin into conventional CVVH replacement fluid, with a final albumin concentration of 0.6%. During each treatment, the parameters of plasma and filtrate TB, direct bilirubin (DB), indirect bilirubin (IDB), and proteins were dynamically monitored. Hemostasis parameters were measured before and after sessions.

Results

The reduction ratio of plasma TB, DB, and IDB after a single session was 29.1±3.0%, 31.3±4.5%, and 18.7±10.2%, respectively. The clearance of TB at initiation was 11.1±1.3 mL/min and declined to 4.4±0.5 ml/min at the end (p<0.01). This decline was accompanied by a reduction in albumin SC from 0.3±0.021 to 0.13±0.05. The molar ratio of bilirubin to albumin in filtrate was comparable to that in plasma. After a single treatment, plasma protein concentration including total protein, albumin, IgA and IgM remained unaffected, except for globulin and IgG, which were reduced by 11.5±7.8% and 11.1±2.3%, respectively. An improvement in hemostasis parameters, including plasma fibrinogen, prothrombase time and INR, was found after treatment. No obvious side effects were reported during any of the sessions.

Conclusion

Selective albumin exchange is a simple and effective method to remove bilirubin. However, further studies are required to verify its effects on clinical outcome.
Functional Hepatocyte-Like Cells Derived from Human Bone Marrow Mesenchymal Stem Cells on a Novel 3-Dimensional Biocompatible Nanofibrous Scaffold
Authors: Kazemnejad S. , Allameh A. , Soleimani M. , Gharehbaghian A. , Mohammadi Y. , Amirizadeh N. , Esmaeili S.
Published: January 2018

Aim

To supporting growth and functional differentiation of adult stem cells into hepatocytes in a well-controlled manner, we performed differentiation of human bone marrow mesenchymal stem cells (hBMSCs) to hepatocytes-like cells on a constructed 3-dimensional (3D) nanofibrous biocompatible scaffold.

Methods

After characterization of the hBMSCs isolated from human bone marrow, the performance of the cells seeded and their proliferation on the scaffold was evaluated by scanning electron microscopy (SEM) and 3-(4,5-dimethylthiazole-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. Different approaches such as immunocytochemistry, reverse transcriptase polymerase chain reaction (RT-PCR), and biochemical assays were used to estimate the ability of hBMSC-derived cells to express hepatocyte-specific markers.

Results

Scanning electron micrographs and MTT analysis revealed the cells were able to expand and remained biologically and metabolically active for 21 days. Immunocytochemical analysis of albumin and α-fetoprotein showing the accumulation of these markers in differentiated cells was confirmed by RT-PCR. Additional markers such as cytochrome P450 3A4, cytokeratin-18, and cytokeratin-19 detected by RT-PCR showed progressive expression during 3 weeks of differentiation on 3D scaffold. The hepatocyte-like cells displayed several characteristics of metabolic functions as judged by production of albumin, urea, transferrin, serum glutamic pyruvic transaminase (SGPT), and serum oxaloacetate aminotransferase (SGOT). Levels of above-mentioned markers, except SGOT in differentiated cells on scaffold, were found to be significantly greater than in the 2D culture system (p<0.05).

Conclusion

Overall data suggest that the engineered nanofibrous scaffold is a conductive matrix for functional hBMSC-derived hepatocyte-like cells and is promising for maintenance of hepatocytes suitable for implantation.