Hemoadsorption: Consensus report of the 30th Acute Disease Quality Initiative workgroup.

Adsorption-based extracorporeal therapies have been subject to technical developments and clinical application for close to five decades. More recently, new technological developments in membrane and sorbent manipulation have made it possible to deliver more biocompatible extracorporeal adsorption therapies to patients with a variety of conditions. There are several key rationales based on physicochemical principles and clinical considerations that justify the application and investigation of such therapies as evidenced by multiple ex-vivo, experimental, and clinical observations. Accordingly, unspecific adsorptive extracorporeal therapies have now been applied to the treatment of a wide array of conditions from poisoning to drug overdoses, to inflammatory states and sepsis, and acute or chronic liver and kidney failure. In response to the rapidly expanding knowledge base and increased clinical evidence, we convened an Acute Disease Quality Initiative (ADQI) consensus conference dedicated to such treatment. The data show that hemoadsorption has clinically acceptable short-term biocompatibility and safety, technical feasibility, and experimental demonstration of specified target molecule removal. Pilot studies demonstrate potentially beneficial effects on physiology and larger studies of endotoxin-based hemoadsorption have identified possible target phenotypes for larger randomized controlled trials (RCTs). Moreover, in a variety of endogenous and exogenous intoxications, removal of target molecules has been confirmed in vivo. However, some studies have raised concerns about harm or failed to deliver benefits. Thus, despite many achievements, modern hemoadsorption remains a novel and experimental intervention with limited data, and a large research agenda.

Hemoadsorption therapy for myoglobin removal in rhabdomyolysis: consensus of the hemoadsorption in rhabdomyolysis task force.

BACKGROUND: Rhabdomyolysis describes a syndrome characterized by muscle necrosis and the subsequent release of creatine kinase and myoglobin into the circulation. Myoglobin elimination with extracorporeal hemoadsorption has been shown to effectively remove myoglobin from the circulation. Our aim was to provide best practice consensus statements developed by the Hemoadsorption in Rhabdomyolysis Task Force (HRTF) regarding the use of hemadsorption for myoglobin elimination. METHODS: A systematic literature search was performed until 11th of January 2023, after which the Rhabdomyolysis RTF was assembled comprising international experts from 6 European countries. Online conferences were held between 18th April - 4th September 2023, during which 37 consensus questions were formulated and using the Delphi process, HRTF members voted online on an anonymised platform. In cases of 75 to 90% agreement a second round of voting was performed. RESULTS: Using the Delphi process on the 37 questions, strong consensus (> 90% agreement) was achieved in 12, consensus (75 to 90% agreement) in 10, majority (50 to 74%) agreement in 13 and no consensus (< 50% agreement) in 2 cases. The HRTF formulated the following recommendations: (1) Myoglobin contributes to the development of acute kidney injury; (2) Patients with myoglobin levels of > 10,000 ng/ml should be considered for extracorporeal myoglobin removal by hemoadsorption; (3) Hemoadsorption should ideally be started within 24 h of admission; (4) If myoglobin cannot be measured then hemoadsorption may be indicated based on clinical picture and creatinine kinase levels; (5) Cartridges should be replaced every 8-12 h until myoglobin levels < 10,000 ng/ml; (6) In patients with acute kidney injury, hemoadsorption can be discontinued before dialysis is terminated and should be maintained until the myoglobin concentration values are consistently < 5000 ng/ml. CONCLUSIONS: The current consensus of the HRTF support that adjuvant hemoadsorption therapy in severe rhabdomyolysis is both feasible and safe and may be an effective method to reduce elevated circulating levels of myoglobin.

Sequential Extracorporeal Blood Purification Is Associated with Prolonged Survival among ICU Patients with COVID-19 and Confirmed Bacterial Superinfection.

INTRODUCTION: This study investigates the impact of sequential extracorporeal treatments with oXiris® or CytoSorb® plus Seraph-100® on the clinical and laboratory parameters of critically ill COVID-19 patients with bacterial superinfection. METHODS: Patients admitted to the intensive care unit with COVID-19, bacterial superinfection, and undergoing blood purification (BP) were enrolled in this prospective, single-center, observational study. "standard BP" with oXiris® or CytoSorb® were used in 35 COVID-19 patients with bacterial infection. Seraph-100® was added in 33 patients when available serially in the same oXiris® circuit or as sequential treatment with CytoSorb® as a sequential BP. RESULTS: A significant reduction in SOFA score 3 days after treatment was observed in patients undergoing sequential BP (11.3 vs. 8.17, p < 0.01) compared to those undergoing "standard BP" (11.0 vs. 10.3, p > 0.05). The difference between the observed and expected mortality rate based on APACHE IV was greater in the sequential BP group (42.4% vs. 81.7%, p < 0.001) than the "standard BP" (74.2% vs. 81.7%, p > 0.05). Patients treated with sequential BP had a longer survival than those treated with "standard BP" (22.4 vs. 18.7 months; p < 0.001). CONCLUSIONS: The sequential approach may enhance the positive effect of BP on organ dysfunction among critically ill patients with COVID-19 and bacterial superinfection.

Association of polymorphisms in genes encoding prothrombotic and cardiovascular risk factors with disease severity in COVID-19 patients: A pilot study.

The present study aimed to assess the association of 16 polymorphisms in genes encoding prothrombotic and cardiovascular risk factors with COVID-19 disease severity: FV G1691A, FV H1299R, FII G20210A, MTHFR C677T, MTHFR A1298, factor XIII V34L, PAI-1 4G/5G, EPCR haplotypes (A1/A2/A3), eNOS -786 T > C, eNOS G894T, LTA C804A, ACE I/D, ITGB3 PIA1/A2, ITGA2B Baka/b, ß-Fbg -455 G > A and ApoB R3500Q. The study included 30 patients with severe COVID-19 and 49 non-severe COVID-19 patients. All studied polymorphisms except ITGA2B Baka/b were determined using multilocus genotyping assays CVD StripAssays (ViennaLab Diagnostics), while ITGA2B was genotyped using a real-time PCR method based on TaqMan technology. A higher frequency of carriers of at least one ITGB3 PIA2 allele was found in severe COVID-19 patients (p = 0.009). The distribution of genotypes was significantly different for ß-Fbg -455 G > A (p = 0.042), with only three homozygous AA genotypes found among severe COVID-19 patients. The association with an increased risk for severe COVID-19 was found for ITGB3, with carriers of at least one ITGB3 PIA2 allele having a 3.5-fold greater risk of severe COVID-19 (p = 0.011). Genotype distribution differences were obtained for the combinations of FV H1299R and FXIII V34L (p = 0.026), ITGB3 PIA1/A2 and ITGA2B Baka/b (p = 0.024), and ACE I/D and PAI-1 4G/5G (p = 0.046). ITGB3 polymorphism emerged as an independent risk factor for severe COVID-19 and homozygosity for ß-Fbg -455 G > A mutation could contribute to disease severity. The combined effect of polymorphisms in genes encoding prothrombotic and cardiovascular risk factors could further contribute to disease severity.

Interim analysis of the COSA (COVID-19 patients treated with the Seraph® 100 Microbind® Affinity filter) registry.

BACKGROUND: The Seraph® 100 Microbind® Affinity Blood Filter is a haemoperfusion device that is licensed for the reduction of pathogens, including several viruses, in the blood. It received Emergency Use Authorization for the treatment of severe coronavirus disease 2019 (COVID-19) by the Food and Drug Administration (FDA). Several studies have shown that the blood viral load of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) correlates with adverse outcomes and removal of the nucleocapsid of the SARS-CoV-2 virus by the Seraph® 100 has been recently demonstrated. The aim of this registry was to evaluate the safety and efficacy of Seraph® 100 treatment for COVID-19 patients. METHODS: Twelve hospitals from six countries representing two continents documented patient and treatment characteristics as well as outcome parameters without reimbursement. Additionally, mortality and safety results of the device were reported. A total of 102 treatment sessions in 82 patients were documented in the registry. Four patients were excluded from mortality analysis due to incomplete outcome data, which were available in the other 78 patients. RESULTS: Overall, a 30-day mortality rate of 46.2% in the 78 patients with complete follow-up was reported. The median treatment time was 5.00 h (4.00-13.42) and 43.1% of the treatments were performed as haemoperfusion only. Adverse events of the Seraph® 100 treatment were reported in 8.8% of the 102 treatments and represented the premature end of treatment due to circuit failure. Patients who died were treated later in their intensive care unit (ICU) stay and onset of COVID symptoms. They also had higher ferritin levels. Multivariate Cox regression revealed that delayed Seraph® 100 treatment after ICU admission (>60 h), as well as bacterial superinfection, were associated with mortality. While average predicted mortality rate according to Sequential Organ Failure Assessment (SOFA) score in ICU patients was 56.7%, the observed mortality was 50.7%. In non-ICU patients, Coronavirus Clinical Characterisation Consortium (4C) score average predicted a mortality rate of 38.0%, while the observed mortality rate was 11.1%. CONCLUSIONS: The treatment of COVID-19 patients with Seraph® 100 is well tolerated and the circuit failure rate was lower than previously reported for kidney replacement therapy (KRT) in COVID-19 patients. Mortality correlated with late initiation of Seraph treatment after ICU admission and bacterial superinfection. Compared with predicted mortality according to 4C and SOFA scores, mortality of Seraph® 100-treated patients reported in the registry was lower.

Prophylactic therapeutic plasma exchange in pregnant woman with Familial Chylomicronemia Syndrome - A case report.

CONTEXT: Familial Chylomicronemia Syndrome (FCS) is an inherited disease where lack of lipoprotein lipase results in severe hypertriglyceridemia that frequently leads to recurrent acute pancreatitis. Pregnancy in patients with familial chylomicronemia syndrome (FCS) post a risk for mother and baby with potential complications (pancreatitis, miscarriage and death). Therapeutic approach includes strict dietary measures and plasma exchange. Despite the development of new drugs for FCS, their safety in pregnancy has not yet been confirmed. CASE DESCRIPTION: We present a case of a young, pregnant female with FCS who had miscarriage in the past during one episode of acute pancreatitis. Due to the inability to achieve lower TG levels with current therapy, from 27-th week of pregnancy we have started prophylactic therapeutic plasma exchange (two times per week). Patient was followed up until the delivery of a healthy baby boy and did not experience an episode of acute pancreatitis. CONCLUSIONS: With adequate supervision and monitoring therapeutic plasma exchange represents a safe approach in pregnant women with FCS in order to reduce TGs and prevent pancreatitis. Therefore, we prevented potential complications for both mother and child.

CHRONIC KIDNEY DISEASE IN RURAL POPULATION.

The aims of the study were to provide data on chronic kidney disease (CKD) prevalence in rural population and to analyze the association with cardiovascular risk factors and aging. A random sample of 2193 farmers (1333 female (F) and 860 male (M), mean age 50.61±17.12) were enrolled. Questionnaire and clinical examination were conducted. Participants provided a spot urine and fasting blood sample. Estimated glomerular filtration rate (eGFR) was estimated using Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Subjects were classified according to the KDIGO guidelines. The overall prevalence of CKD (eGFR <60 mL/min/1.73 m2) was 8.83% (F vs. M 9.9% vs. 6.3%; p<0.001). Albuminuria (albumin-to-creatinine ratio >30 mg/g) was found in 8.45% (F vs. M p>0.05). Sharp increase in CKD prevalence was found to begin after the sixth decade (29.44% in subjects older than 65 years; F vs. M 30.9% vs. 26.8%; p<0.01). The strongest predictor factors for CKD were age >65 years (OR 22.12), hypertension (OR 6.53), albuminuria (OR 5.71), fasting blood glucose >7 mmol/L (OR 5.49), diabetes (OR 3.07), abdominal obesity (OR 2.05) and non-smoking (OR 0.41). In multivariate analysis, age (OR 1.13), female gender (OR 0.60) and diabetes (OR 1.75) were the independent predictor factors for CKD. In conclusion, CKD prevalence is high in rural population, being higher in women than in men. In both genders, eGFR significantly decreased with aging. Aging is a significant independent predictor of CKD.

Comparison between stenting and conservative management of posterior circulation perforator aneurysms: Systematic review and case series.

PURPOSE: Posterior circulation perforator aneurysms (PCPAs) are a rare type of intracranial aneurysms whose natural history and optimal clinical management are still largely unexplored. This study aims to report our experience with treating ruptured PCPAs and to provide a systematic review of the literature to compare the two most established treatment options, endovascular stenting, and conservative management including administration of antifibrinolytic drugs and watchful waiting. METHODS: We performed a systematic review of the literature following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Major databases were searched for case reports and case report series written in the English language between 1995 and 2020. Additionally, we retrospectively reviewed our stroke center database for cases of ruptured PCPAs between January 2014 and July 2020. Endovascular stenting and conservative treatment were compared using endpoints, including favorable outcome rate (mRS 0-2), occlusion rate, mortality rate, periinterventional complication rate, and re-hemorrhage rate. RESULTS: We identified 31 patients treated endovascularly using stents and 33 patients treated conservatively, with the administration of antifibrinolytic drugs in 3 of them. Our analysis showed no statistically significant difference between the groups, except for the occlusion rate. CONCLUSIONS: The optimal management strategy of PCPAs is still unknown, but stenting can be considered as an effective occlusion method with an acceptable complication rate. Preventive ventricular drainage may be necessary due to the high hydrocephalus rate encountered in ruptured PCPAs.

Prevalence of Gestational Diabetes Mellitus and Perinatal Outcomes According to the Old Who Criteria and IADPSG Criteria.

BACKGROUND: Gestational diabetes mellitus (GDM) is the most common metabolic disorder in pregnancy. Pregnancies with GDM have worse outcomes compared to pregnancies with normal glucose tolerance. The objectives of the study were to determine the prevalence of GDM and perinatal outcomes according to the old WHO criteria and IADPSG criteria. SUBJECTS AND METHODS: A retrospective study included 2,405 pregnant women who delivered between January 2009 and December 2010. According to the OGTT results, pregnant women were divided into 4 groups. We analyzed the prevalence of GDM, characteristics of pregnant women and their newborns and perinatal outcomes. RESULTS: We found significantly higher prevalence of GDM according to the IADPSG criteria compared to the WHO criteria. Pregnant women with GDM were significantly older, had higher pre-pregnancy BMI, fasting and 2-h plasma glucose. Pregnant women with GDM had worse pregnancy outcomes compared to control group. The overall proportion of overweight and obese pregnant women was the highest in the group of untreated pregnant women with GDM according to the IADPSG criteria. In this group we found significantly higher rate of fetal macrosomia and LGA. The rate of caesarean section was significantly higher in comparison to control group. Pre-eclampsia was significantly more common in groups of pregnant women with GDM compared to control group. CONCLUSION: IADPSG diagnostic criteria reveals more women with hyperglycemic disorders in pregnancy. A group of pregnant women who were normoglycemic according to the WHO criteria, but according to the IADPSG were diagnosed GDM, had adverse pregnancy outcomes. Lower values of glycemia, than those defined for diabetes in pregnancy, are associated with adverse pregnancy outcomes.

Hypoproteinemia as a factor in assessing malnutrition and predicting survival on hemodialysis.

Series of studies have described malnutrition as one of the main non-traditional risk factors associated with poor prognosis and treatment outcome in patients on hemodialysis (HD). The aims of this study were to evaluate the link between HD treatment quality and the nutritional status and to additionally investigate the association of malnutrition and overall survival. A total of 134 adult out-patients (56.4% male, mean age 60.8 ± 16.15 years) were enrolled in the study. Clinical and laboratory data were obtained from the medical records. Anthropometric measurements were performed prior to HD. Malnutrition-Inflammation Score (MIS) was used as a scoring system representing the severity of protein-energy wasting (PEW). Malnourished patients were significantly older when compared to non-malnourished patients. They had significantly longer dialysis vintage and lower residual diuresis, BMI, serum proteins, and albumins and lean tissue index (LTI). Malnourished patients survived significantly shorter than non-malnourished patients. Hypoproteinemic patients had significantly lower values of serum albumins and LTI and survived shorter than normoproteinemic patients. Only malnourishment and age were associated with higher overall mortality in all groups of patients. By focusing on MIS and serum protein status rather than dialysis-related factors and different treatment techniques, we could accomplish better nutrition status and improved overall outcomes. While anticipating new and more effective measures for preventing malnutrition, our results clearly demonstrate that striving for the highest possible nutrition status should be one of the key strategies in improving the outcomes in this specific group of patients.

OSTIAL VERSUS TRUNCAL RENAL ARTERY STENOSIS: PREDICTOR OF LARGE ARTERY ATHEROSCLEROSIS SEVERITY AND HIGHER MORTALITY.

The aim of this study was to determine arterial stiffness and the effect of stenting in patients with renal artery stenosis. We hypothesized that ostial renal artery stenosis is not only a marker of more pronounced atherosclerosis of large arteries, but is also a predictor of higher cardiovascular mortality. We enrolled 33 patients with renal artery stenosis refractory to pharmacological treatment and divided them according to the renal artery stenosis location, ostial and truncal (23 vs. 10 patients). We analyzed patient survival at five-year follow up. After the intervention and at six-month follow up, there was a significant decrease in blood pressure values, as well as in pulse wave velocity (PWV) and augmentation index. PWV was significantly lower in patients with truncal renal artery stenosis and these patients were significantly younger. Twelve patients with ostial and one patient with truncal renal artery stenosis (52% vs. 10%, p<0.001) died from cardiovascular events. Our study is the first to confirm the predictive role of PWV and arterial stiffness in patients with renal artery stenosis, especially ostial one, and to emphasize its ability of detecting future higher incidence of cardiovascular events.

Increased arterial stiffness - similar findings in patients with inflammatory bowel disease without prior hypertension or diabetes and in patients with well-controlled hypertension.

PURPOSE: Chronic inflammatory diseases are related with earlier onset of atherosclerosis. We hypothesized that inflammatory bowel disease patients with chronic, systemic inflammation have an increased arterial stiffness associated with the disease duration. Also, we wanted to compare arterial stiffness markers between inflammatory bowel disease and well-controlled hypertension patients. MATERIALS AND METHODS: A total of 89 inflammatory bowel disease patients (60 patients with Crohn's disease and 29 patients with ulcerative colitis, age range 20-64 years) without history of arterial hypertension or diabetes were enrolled and age matched with a control group of patients (73 patients, age range 25-69 years, 41 (56.1%) males) with known history of well-controlled arterial hypertension. We have used a noninvasive device that simultaneously measures brachial blood pressure and estimates PWV and AIx in inflammatory bowel disease and hypertension groups of patients. RESULTS: Patients with pathological PWV values were significantly older, had significantly longer duration of inflammatory bowel disease, higher values of serum cholesterol and HDL-cholesterol, and higher AIx (17.4% vs. 9.8%) (all p < .05). Higher PWV was associated with age and duration of inflammatory bowel disease in the linear regression model. PWV values were higher in hypertensive patients in the first two age quartiles while interestingly, in the last two quartiles, PWV was lower than in inflammatory bowel disease group of patients. CONCLUSIONS: Chronic subclinical inflammation is responsible for dyslipidemia and accelerated atherosclerosis which consequently alterates arterial elasticity. Inflammatory bowel disease and its duration should also be considered a risk factor for subclinical organ damage, as well as hypertension.

The Different Impacts on the Long-Term Survival of Tunneled Internal Jugular Hemodialysis Catheters Based on Tip Position and Laterality.

BACKGROUND/AIMS: The aim of this study was to examine the impact of different catheter tip positions on the life of the catheter, dysfunction, infection, and quality of hemodialysis and possible differences between the access site laterality in jugular-tunneled hemodialysis catheters. METHODS: Catheters were evaluated for the following parameters: place of insertion, time of insertion, duration of use, and reason for removal. In all patients, the catheter tip position was checked using an X-ray. RESULTS: The mean duration of implanted catheters with the tip placed in the cavo-atrial junction and right atrium was significantly longer. There were no differences in catheter functionality at follow-up or complications based on catheter laterality for each catheter tip position. CONCLUSION: According to our results, the localization of the catheter tip in superior vena cava still remains the least preferable method. Our results showed that the main factor responsible for better catheter functionality was not laterality but the depth to which the catheter tip is inserted into the body.

Membrane therapeutic plasma exchange with and without heparin anticoagulation.

BACKGROUND: Administration of an anticoagulant during therapeutic plasma exchange (TPE) is necessary to avoid circuit clotting and impaired treatment effectiveness. Citrate is the preferred anticoagulant for apheresis worldwide, and unfractionated heparin (UH) is the second most preferred, yet there are only a few published studies regarding the use of UH during TPE. There are even fewer studies regarding the use of low-molecular-weight heparin (LMWH) and TPE performed without anticoagulation. MATERIALS AND METHODS: We retrospectively analyzed the database of the Department of Nephrology at Zagreb University Hospital Center from 1982 to 2014 to test the safety of various heparin anticoagulation in TPE. We grouped procedures according to anticoagulation type (UH, LMWH, and no anticoagulation) and compared differences in the use of anticoagulants during our study period, patient populations, replacement fluids, and complications. RESULTS: Complications were recorded during 11.1% of the 9,501 procedures. The incidence of any recorded complication was significantly higher in the LMWH group (21.2%) compared to the group with no anticoagulation (16.3%) and the UH group (9.5%) (P < 0.001). Similarly, the blood clotting in the extracorporeal circuit was most common in the LMWH group (LMWH, 12.0%; no anticoagulation, 6.3%; UH, 2.4%; P < 0.001). Incidents of bleeding complications were very low and occurred during or after 13 TPE sessions (0.1% of all procedures). CONCLUSIONS: Our findings indicate that TPE procedures can be conducted safely with UH and, when necessary, without anticoagulation. The use of LMWH was associated with more complications when compared with use of UH and to TPE done without anticoagulation. Further studies are necessary to study its use during TPE procedures.

Differences in CVVH vs. CVVHDF in the management of sepsis-induced acute kidney injury in critically ill patients.

We hypothesized that patients with sepsis and AKI, especially patients without preserved renal function, and treated with continuous veno-venous hemodiafiltration (CVVHDF), have lower risk for mortality than patients treated with continuous veno-venous hemofiltration (CVVH). Patients were included if they fulfilled the diagnosis of severe sepsis or septic shock, suffered AKI and received continuous renal replacement therapy (CRRT) in intensive care unit. There were 62 patients treated by CVVH and 75 treated by CVVHDF. Mean survival time was longer in CVVHDF group with oliguric/anuric patients than in CVVH group. CVVH, and not classic risk factors, was associated with higher overall mortality in oliguric/anuric patients. In the linear regression model, hourly urine output was the strongest and positive predictor of longer survival. CVVHDF is according to our results a CRRT modality of choice for the treatment and lower mortality of septic patients with AKI where renal function is no longer preserved. CRRT has been associated with improved renal recovery, but it should be started earlier in AKI evolution with still preserved hourly urine output which is the most sensitive and prognostic marker of survival in septic patients with AKI.

[Temporary and permanent central venous catheters for hemodialysis]. / Primjena trajnih i privremenih centralnih venskih katetera za hemodijalizu.

The usage of temporary and permanent dialysis catheters for hemodialysis vascular access has been on continual increase. The reason for this increase is aging population on hemodialysis with blood vessels inappropriate for arteriovenous fistula creation. Complications may occur during catheter insertion as well as in the already inserted catheters, e.g., thrombosis and infections. The severity of complications is determined by experience of the operator as well as the quality and localization of blood vessels. Monitoring of dialysis catheter function, choice of the site of catheter insertion and methods of salvaging catheters from thrombosis and treating catheter-related local and systemic infections are described in this paper. Constant evaluation, proper care and hygiene of dialysis catheters are highly recommended.

[Treatment of resistant primary glomerulopathies]. / Lijecenje rezistentnih primarnih glomerulopatija.

Considerable progress in understanding of the pathogenesis of a number of primary glomerular diseases is evident. Scientific achievements in this field led to reclassification of certain types of glomerulonephritides, development of new diagnostic tests, as well as new therapeutic approaches. These new findings will enable us to treat primary glomerulopathies more efficiently thus reducing incidence of resistant disease. Novelties in diagnostics, treatment algorithm, characteristics of the resistant disease and the possibilities of specific treatment are shown in this review.

[Blood pressure measurement--do not sweat the small stuff and it is all small stuff?! Position paper of the Croatian national referral center for hypertension, center of excellence of the European Society of Hypertension]. / Mjerenje arterijskoga tlaka--ne mari za male stvari i ostat ce male stvari?! Preporuke Hrvatskoga referalnog centra za hipertenziju centra izvrsnosti Europskog drustva za hipertenziju.

Office blood pressure measurement using mercury sphygmomanometer is the gold standard for making diagnoses of hypertension, evaluation of cardiovascular risk and estimation of obtained control of treated hypertensives. The vast majority of epidemiologic data are based on this method. However, the importance of blood pressure variability, white coat effect as well as availability of simple devices, home and ambulatory blood pressure measurements became routine parts in routine clinical work. As mercury will be soon forbidden in clinical work such devices and methodology will be even more important. In everyday clinical practice all three techniques should be implemented and in this paper advantages and drawbacks of all techniques are discussed. In the end, based on recent data and recommendations of international societies, diagnostic algorithm was proposed. Additionally, we described the technique of non-invasive central blood pressure measurement, determination of pulse wave velocity and calculation of augmentation index, new proposed risk factors.

The addition of Cytosorb in patients on VA-ECMO improves urinary output and ICU survival.

INTRODUCTION: The aim of this study was to analyze the efficiency of CytoSorb adsorber in patients presenting with cardiogenic shock and treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO). METHODS: Sixteen patients put on VA ECMO due to cardiogenic shock were included, stratified according to the use of Cytosorb adsorber in the first 24 h and compared across different clinical outcomes. RESULTS: Significantly lower vasopressor doses were required among patients treated with Cytosorb at the initiation and before weaning from ECMO. Furthermore, these patients showed significantly higher urine output before weaning and lower lactate levels during the extracorporeal support. Finally, the mortality rate was lower among the Cytosorb therapy group (22.2% vs 57.1%). CONCLUSION: While a decrease in vasopressor doses was already associated with CytoSorb use, this is the first study showing an increase in urinary output and a trend towards better survival among patients on VA ECMO treated with CytoSorb.

Efficacy and Safety of High PEEP NIV in COVID-19 Patients.

OBJECTIVE: To investigate the efficacy and safety of non-invasive ventilation (NIV) with high PEEP levels application in patients with COVID-19-related acute respiratory distress syndrome (ARDS). METHODS: This is a retrospective cohort study with data collected from 95 patients who were administered NIV as part of their treatment in the COVID-19 intensive care unit (ICU) at University Hospital Centre Zagreb between October 2021 and February 2022. The definite outcome was NIV failure. RESULTS: High PEEP NIV was applied in all 95 patients; 54 (56.84%) patients could be kept solely on NIV, while 41 (43.16%) patients required intubation. ICU mortality of patients solely on NIV was 3.70%, while total ICU mortality was 35.79%. The most significant difference in the dynamic of respiratory parameters between 2 patient groups was visible on Day 3 of ICU stay: By that day, patients kept solely on NIV required significantly lower PEEP levels and had better improvement in PaO2, P/F ratio, and HACOR score. CONCLUSION: High PEEP applied by NIV was a safe option for the initial respiratory treatment of all patients, despite the severity of ARDS. For some patients, it was also shown to be the only necessary form of oxygen supplementation.