The effect of polymyxin B hemoperfusion on modulation of human leukocyte antigen DR in severe sepsis patients.

BACKGROUND: Recent randomized trials have not found that polymyxin B hemoperfusion (PMX-HP) improves outcomes for patients with sepsis. However, it remains unclear whether the therapy could provide benefit for highly selected patients. Monocyte human leukocyte antigen (mHLA-DR) expression, a critical step in the immune response, is decreased during sepsis and leads to worsening sepsis outcomes. One recent study found that PMX-HP increased mHLA-DR expression while another found that the treatment removed HLA-DR-positive cells. METHODS: We conducted a randomized controlled trial in patients with blood endotoxin activity assay (EAA) level ≥ 0.6. Patients in the PMX-HP group received a 2-h PMX-HP treatment plus standard treatment for 2 consecutive days. Patients in the non-PMX-HP group received only standard treatment. The primary outcome compared the groups on median change in mHLA-DR expression between day 3 and baseline. Secondary outcomes compared the groups on the mean or median change in CD11b expression, neutrophil chemotaxis, presepsin, cardiovascular Sequential Organ Failure Assessment (CVS SOFA) score, vasopressor dose, and EAA level between day 3 and baseline. We further compared the groups on mortality, ICU-free days, ventilator-free days, dialysis dependence status, renal recovery, serum creatinine, vasopressor-free days, and major adverse kidney events (MAKE 28), measured on day 28. RESULTS: Fifty-nine patients were randomized to PMX-HP (n = 29) and non-PMX-HP (n = 30) groups. At baseline, mHLA-DR expression, CD11b, neutrophil chemotaxis, and clinical parameters were comparable between groups. The median change in mHLA-DR expression between day 3 and baseline was higher in PMX-HP patients than in patients receiving standard therapy alone (P = 0.027). The mean change in CD11b between day 3 and baseline was significantly lower in the PMX-HP group than in the non-PMX-HP group (P = 0.002). There were no significant changes from baseline in neutrophil chemotaxis, presepsin, CVS SOFA scores, vasopressor doses, or EAA level between groups. On day 28 after enrollment, mortality, ICU-free days, ventilator-free days, dialysis dependence status, renal recovery, serum creatinine, vasopressor-free days, and MAKE 28 were comparable between groups. CONCLUSION: PMX-HP improved mHLA-DR expression in severe sepsis patients. Future studies should examine the potential benefit of PMX-HP in patients with low mHLA-DR expression. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02413541 . Registered on 3 March 2015.

Diagnostic Challenges of Acute Kidney Injury in Asia.

Early diagnosis of acute kidney injury (AKI) is an important step to improve AKI outcome. In Asia, several distinct conditions of this region such as environment (tropical climate), socioeconomic status (high-resource and low-resource settings), process of care (shortage of nephrologists), exposure factors (specific tropical infections such as leptospirosis, malaria, dengue), and inherent factor (aging) make the diagnosis of AKI in Asia more challenging than in other parts of the world. To improve the diagnosis of AKI, novel tools such as clinical risk scores, AKI alert systems, and telemedicine should be implemented into current clinical practice.

Current practice of diagnosis and management of acute kidney injury in intensive care unit in resource limited settings.

PURPOSE: In a resource limited settings, there is sparse information about the management of acute kidney injury (AKI) based on systemic data collection. This survey aimed to described the current management of AKI in intensive care units (ICUs) across Thailand. MATERIALS AND METHODS: Questionnaires were distributed to 160 physicians involved in the intensive care between January and December 2014 across Thailand. Distribution was done through an online survey platform or telephone interview. RESULTS: The response rate was 80.6% (129 physicians). AKI diagnosis was mostly made by using KDIGO criteria (36.7%). A common diagnostic investigation of AKI was urinalysis (86%). Nephrologists had a major role (86.4%) in deciding the initiation and selection of renal replacement therapy (RRT) modality. Intermittent hemodialysis is the preferable mode of RRT (72.0%), followed by continuous renal replacement therapy (CRRT, 12%), sustained low efficiency dialysis (10.0%) and peritoneal dialysis (6.0%). Catheter insertion was predominantly performed by nephrologist (51.1%) with ultrasound guidance. The right internal jugular vein was the most common site of insertion (70.4%). The most common indication for CRRT was hemodynamic instability. CONCLUSIONS: Amid increasing concern of AKI in the ICU, our study provides the insight into the management of AKI in resource limited settings.