Benefit of Hemoadsorption Therapy in Patients Suffering Sepsis-Associated Acute Kidney Injury: A Case Series.
Blood purification
INTRODUCTION:Sepsis is defined as life-threatening organ dysfunction in result of the host's dysregulated response to infection and septic shock. Sepsis-associated kidney injury is usually defined as concurrent presence of acute kidney injury (AKI) and sepsis without other significant causative factors. METHOD:The current retrospective study was conducted to elucidate beneficial and side effects of CytoSorb®. A total of 17 patients were primarily treated with continuous renal replacement therapy in combination with CytoSorb. The demand for norepinephrine, mean arterial pressure, lactate, and procalcitonin (PCT) levels, as well as ICU length of stay, was measured. RESULT:The blood lactate levels decreased by 32.30% when comparing mean levels before and after treatment. All patients who survived (n = 14) had reduction in vasopressor demand to 68.96% of their initial dose before the start of treatment. Hospital survival was greater in patients who initially had higher vasopressor demand compared to their nonsurviving counterparts, but in whom vasopressor dosages were reduced significantly during their treatments. Mortality as predicted by APACHE II score in the overall patient population was 79.9%, whereas, the observed ICU mortality was 31%. The baseline PCT levels on patients received 1, 2, and 3 CytoSorbs were 27.08 ± 5.81 ng/mL, 13.28 ± 2.62 ng/mL, and 21.03 ± 6.56 ng/mL, respectively. Observed PCT levels at 24 h after the last treatment on patients received 1, 2, and 3 CytoSorb were 31.55 ± 15.70 ng/mL, 5.61 ± 1.77 ng/mL, and 8.11 ± 3.62 ng/mL, respectively. CONCLUSION:In conclusion, it seems that applying the CytoSorb in combination with CRRT in ICU septic patients with AKI, is related to a significant decrease in mortality, if the integrity and continuity of the treatment be kept, as much as possible. This study presented an effectively positive outcome with cytokine adsorber treatment as an adjuvant along with standard treatment in a high-risk mortality case of septic shock with organ failure.
10.1159/000521228
Efficacy of continuous renal replacement on acute renal injury developed in severe sepsis.
Zhang Y,Shao D R,He Z P,Ma X X,Shi C J
Journal of biological regulators and homeostatic agents
Sepsis is a systemic inflammatory response that can further develop into severe sepsis (septic shock), which eventually leads to multiple organ dysfunction syndrome (MODS). This study aimed to assess the effects of continuous renal replacement therapy (CRRT) on acute renal injury caused by severe sepsis by monitoring biochemical parameters. A total of 60 patients with septic shock and acute kidney injury were included. The control group (30 cases) was treated with routine treatment and intermittent renal replacement therapy (IRRT). The experimental group (30 cases) was treated with routine treatment and continuous renal replacement therapy CRRT. The changes in inflammation and biochemical indexes and APACHE- II score were evaluated before the treatment and 1, 3, and 7days after the treatment. The inflammatory markers (neutrophil percentage, C-reactive protein (CRP) and procalcitonin (PCT) levels) in the experimental group decreased significantly after treatment. In the control group, the index of inflammation still increased one day after treatment and decreased on day 3 of treatment. After treatment, blood lactate, serum creatinine and urea nitrogen levels decreased, but the urine volume increased. After treatment, the vasoactive dose in the experimental group was significantly lower than that of the control group (P less than 0.05). CRRT is a good treatment for septic shock-related acute kidney injury, which improves biochemical indicators and protects kidney function.
Continuous renal replacement therapy in sepsis and multisystem organ failure.
Joannidis Michael
Seminars in dialysis
This study reviews the role of continuous renal replacement therapy (CRRT) in sepsis with acute kidney injury (AKI) and septic shock with multiple organ failure. In addition to the conventional aim of replacing renal function in AKI, CRRT is often used with the concept of modulating immune response in sepsis. With the intention of influencing circulating levels of inflammatory mediators like cytokines and chemokines, the complement system, as well as factors of the coagulation system, several modifications of CRRT have been developed over the last years. These include high volume hemofiltration, high adsorption hemofiltration, use of high cut-off membranes, and hybrid systems like coupled plasma filtration absorbance. One of the most promising concepts may be the development of renal assist devices using renal tubular cells for implementing renal tubular function into CRRT.
10.1111/j.1525-139X.2008.00552.x
Clinical impact of continuous renal replacement therapy on multiple organ failure.
Dunham C M
World journal of surgery
Because continuous renal replacement therapy (CRRT) may enhance inflammatory mediator removal, this review assesses its impact on multiple organ failure (MOF). Regarding MOF with acute renal failure (ARF), the overall mortality of 2313 CRRT patients (43 studies) was 62.8% compared with 59.1% (p = 0.046) in 961 intermittent hemodialysis (IHD) patients (12 other studies). Of 13 CRRT studies with an IHD comparison group, 3 showed that the groups had a similar risk, but IHD mortality was higher; 1 noted that CRRT had lower mortality (risk not stated); and 4 showed similar mortality and greater CRRT risk. Aggregate mortality was IHD 69.5% and CRRT 63.9% (p = 0.02). Of the six studies with matched groups (age and APACHE II scores), IHD mortality was higher (70.9% vs. 60.1%, p = 0.01). CRRT pulmonary gas exchange, hemodynamic instability, azotemia control, fluid overload, and nutritional support were better. Regarding MOF without ARF, of 14 CRRT studies (14.5 patients per study), only 4 had comparison groups. Patient conditions were as follows: acute respiratory distress syndrome, six studies; sepsis, three studies; septic shock, two studies; pancreatitis, one study; critically ill patients, one study; and cardiac surgery with respiratory failure, one study. Of the three studies with a control group, the mortality was the same. There was minimal evidence that CRRT improved pulmonary gas exchange or hemodynamic instability. For MOF patients with ARF, there is compelling evidence that CRRT provides better survival than IHD and more improvement in pulmonary gas exchange, hemodynamic instability, azotemia control, fluid overload, and nutritional support. In patients with MOF and no renal failure, there is little evidence that CRRT enhances survival, oxygenation, or perfusion. Controlled trials demonstrating a CRRT benefit are necessary before CRRT can be recommended for MOF without ARF.
Septic shock after liver transplantation successfully treated with endotoxin and cytokine adsorption continuous renal replacement therapy: a case report and literature review.
Li Yining,Zhou Linshan,Yang Lingzhi,Yuan Fang
The Journal of international medical research
Endotoxins and cytokines play an important role in multiple organ failure pathogenesis in patients with severe Gram-negative bacterial infection. We present a clinical case where an oXiris hemofilter was used for continuous renal replacement therapy (CRRT) treatment in a patient with septic shock after liver transplantation. A 35-year-old man with a 20-year history of hepatitis B presented with jaundice, loss of appetite, and decreased urine output. He was diagnosed with decompensated cirrhosis with acute-on-chronic liver failure, and liver transplantation was indicated. The day after surgery, he developed hyperthermia, hypotension, anuria, and a progressive increase in blood inflammatory markers and creatinine. Combined with the donor source and blood culture results, septic shock after transplantation was considered. The patient was immediately treated with endotoxin and cytokine adsorption CRRT (oXiris hemofilter) with tigecycline, caspofungin, and ganciclovir as anti-infectives. After 48 hours on CRRT, his blood pressure gradually stabilized, the CLIF Consortium Acute-on-Chronic Liver Failure score decreased from 63 to 43. Procalcitonin, endotoxin, and the inflammatory factors interleukin (IL)-6 and IL-10 also decreased gradually. The patient's liver and kidney functions were completely restored. Our experience suggests that oXiris CRRT combined with antibacterial therapy is an effective treatment for septic shock after liver transplantation.
10.1177/0300060520940439
Application of Different Continuous Renal Replacement Therapy Hemofilter in Patients with Septic Shock Complicated with Acute Renal Injury.
Iranian journal of public health
Background:We aimed to compare the clinical effects of continuous renal replacement therapy (CRRT) with different hemofilters in patients with septic shock and acute kidney injury (AKI). Methods:Thirty patients with septic shock complicated with AKI admitted to The Fourth Affiliated Hospital of Anhui Medical University from 2018-2020 were selected and divided into the control and observation groups. The control group was treated with CRRT using the conventional ST-100 hemofilter. The observation group was treated with CRRT using the oXiris hemofilter for 48 hours, followed by CRRT with the conventional ST-100 hemofilter. Infection indexes, sepsis-related organ failure assessment (SOFA), changes in corresponding organ function indexes, duration of each treatment, and death were compared between the two groups during CRRT. Results:The white blood cells (WBC) count, high-sensitivity C-reactive protein (hs-CRP), and procalcitonin (PCT) levels were significantly decreased in the oXiris group 48 hours after CRRT (= 0.048, 0.036, 0.031, respectively). After 48 hours of CRRT, SOFA score, serum lactic acid, and norepinephrine dose in the oXiris group were significantly lower than those in the control group ( 0.039, 0.002, 0.021, respectively). The use time of vasoactive drugs and the treatment time of CRRT in the oXiris group was significantly shortened (= 0.031 and 0.029, respectively). However, there were no significant differences in mechanical ventilation duration, intensive care unit (ICU) hospitalization time, total hospitalization time, ICU mortality, and in-hospital mortality. Conclusion:For patients with septic shock complicated by AKI, CRRT treatment with the oXiris hemofilter could effectively clear inflammatory cytokine levels and quickly correct hemodynamic disorders, thus accelerating the recovery of organ function.
10.18502/ijph.v51i10.10990
[Extracorporeal therapy in sepsis].
Pozzato Marco,Livigni Sergio,Roccatello Dario
Giornale italiano di nefrologia : organo ufficiale della Societa italiana di nefrologia
Acute renal injury (AKI) occurs in 19% of patients with sepsis, 23% of those with severe sepsis and up to 50% of patients with septic shock. AKI represents an independent prognostic factor of mortality (about 45%); epidemiological studies have pointed out that the onset of AKI in sepsis (S-AKI) correlates with an unfavourable outcome, reaching a mortality of 75%. Over the years, efforts have been made to prevent and treat "low flow" hemodynamic damage resulting from shock by increasing renal blood flow, improving cardiac output and perfusion pressure. New experimental studies in S-AKI have shown that renal blood flow is maintained, and indeed increases, in the course of septic shock. Recently, a "single theory" has been proposed that defines acute renal injury as the final result of the interaction between inflammation, oxidative stress, apoptosis, microcirculatory dysfunction and the adaptive response of tubular epithelial cells to the septic insult. The type of treatment, the dose and the starting time of RRT are of strategic importance in the recovery of AKI in septic patients. The use of new anticoagulation strategies in critically ill patients with S-AKI has allowed treatments to be carried out for enough time to reach the correct dose of purification prescribed, minimizing down-time and bleeding risk. The availability of new technologies allows to customize treatments more and more; the collaboration between nephrologists and intensivists must always increase in order to implement modern precision medicine in critical care.
Effect of CRRT with oXiris filter on hemodynamic instability in surgical septic shock with AKI: A pilot randomized controlled trial.
The International journal of artificial organs
BACKGROUND:Early identification and timely management of septic AKI continue to represent clinical challenges for intensive care. The aim was to evaluate the effect of renal replacement with oXiris filter on clinical outcomes in septic AKI. METHODS:This was a single-center randomized controlled trial that enrolled surgical septic shock with AKI patients admitted in the ICU, Renji Hospital, Shanghai Jiao Tong University, School of Medicine from Jan 1, 2021 to Sep 30, 2021, were screened. RESULTS:Sixteen subjects that met the inclusion and exclusion criteria were randomized into CRRT with AN69-oXiris group ( = 8) and AN69-ST group ( = 8). The PCT and IL-6 concentration decreased significantly after the first treatment compared to pre-CRRT levels in the oXiris group (PCT: 23.46 [4.18, 84.90] vs 52.79 [9.03, 100.00] µg/L, = 0.046; IL-6: 3080.15 [527.62, 9806.61] vs 10,457.17 [8150.00, 15,528.87] pg/mL, = 0.043). The levels of lactate decreased by 1.70 [1.03, 2.83] mmol/L after the first CRRT in the oXiris group ( = 0.028). The norepinephrine infusion rate was decreased by 0.06 [0, 0.09], 0.05 [0, 0.23] and 0.11 [0, 0.23] μg/kg/min at 4, 6, and 8 h in the oXiris group compared to the ST group ( = 0.005, 0.038, and 0.017). CONCLUSION:Using the oXiris filter may improve hemodynamic status during initial CRRT in severe surgical septic shock with AKI. Further large multicenter RCTs are needed to determine the effect of the oXiris filter on patient outcomes. (http://www.chictr.org.cn/index.aspx (ChiCTR2200055732)).
10.1177/03913988221107947
Continuous renal replacement therapy: Principles, modalities, and prescription.
Karkar Ayman
Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia
The mortality rate of critically ill patients with severe acute kidney injury (AKI) remains high. The associated sepsis and septic shock, as well as the presence of multiorgan failure, further increase the risk of death. Renal replacement therapy (RRT) represents the cornerstone of the management of severe AKI. Continuous RRT (CRRT) has been considered the predominant form of dialysis in the intensive care unit due to its accurate volume control, steady acid-base, and electrolyte correction and achievement of hemodynamic stability. This narrative review covers an introduction to CRRT, its physiologic principles, modalities, requirements, indications, and different elements of adequate prescription.
10.4103/1319-2442.275463
Renal replacement therapy neutralizes elevated MIF levels in septic shock.
Pohl Julia,Papathanasiou Maria,Heisler Martin,Stock Pia,Kelm Malte,Hendgen-Cotta Ulrike B,Rassaf Tienush,Luedike Peter
Journal of intensive care
BACKGROUND:Macrophage migration inhibitory factor (MIF) is known to amplify the immune response in septic animal models. Few clinical data support this pro-inflammatory role in septic patients. Renal replacement therapy (RRT) as adjuvants in the complex therapy of sepsis has been proposed as a possible approach to eliminate elevated circulating cytokines. Since recent data suggest that MIF can be effectively removed from the circulating blood pool in patients with chronic kidney disease, we here aimed to investigate whether RRT in septic shock can lower plasma levels of this pro-inflammatory cytokine in septic shock patients. METHODS:An observational single-center study on an internist intensive care unit (ICU) was conducted. MIF plasma levels and mortality of n = 25 patients with septic shock were assessed with a previously validated method for reliable MIF values. The effect of continuous renal replacement therapy (CRRT) on daily MIF levels and mortality was assessed by comparing patients with and without need for CRRT due to acute kidney injury (AKI). RESULTS:MIF plasma levels in patients undergoing CRRT due to septic AKI were steadily decreased compared to those from patients without CRRT hinting at a MIF removal by hemodialysis. MIF release during ICU stay as assessed by MIFAUC was lower in patients undergoing CRRT, and Kaplan-Meier analysis revealed a distinctly lower mortality in patients undergoing CRRT. Analysis of daily MIF levels showed that patients who did not survive septic shock exhibited steadily higher MIF plasma levels and higher MIFAUC compared to those surviving sepsis. Low MIF levels were closely associated with improved survival. CONCLUSIONS:This is the first study investigating the effect of efficient MIF removal from the plasma pool of patients with septic shock. Reduction of high circulating MIF by CRRT therapy was accompanied by improved survival. Thus, targeted removal of MIF from the circulating blood pool might be a promising approach to reduce mortality in severe sepsis.
10.1186/s40560-016-0163-2