Comparison of double filtration plasmapheresis with immunoadsorption therapy in patients with anti-glomerular basement membrane nephritis.

BACKGROUND: Double filtration plasmapheresis (DFPP) and (IA) are both used to clear antibody. However, the clinical efficacy and safety of DFPP in patients with anti-glomerular basement membrane (anti-GBM) disease are unclear. METHODS: The 28 enrolled patients diagnosed serologically and pathologically with anti-GBM disease from 2003 to 2013 included 16 treated with DFPP and 12 with IA, with all patients administered immunosuppressive agents. DFPP consisted of an EC50W filter for plasma separation and an EC20W filter for plasma fractionation. A double volume of plasma was processed, and each patient received a 30-40 g human albumin supplement during each session. IA consisted of 10 cycles per session, with 8-10 sessions performed daily or every other day and each session regenerating 30-60 L of plasma. Serum anti-GBM antibodies and IgG were measured, and urinary and blood tests were performed, before and after each procedure. Renal function and outcome were determined. RESULTS: The 28 patients consisted of 13 males and 15 females, of median age 44.5 years (range, 22.5-57 years). Six patients had pulmonary hemorrhage and 18 had serum creatinine concentrations >500 umol/L. The average serum creatinine concentration at early onset of disease was 525 umol/L while the peak concentration was 813 umol/L. All patients showed progressive increases in serum creatinine and required CRRT during the course of disease. Pathological examination showed an average 73.9% of crescents (range, 54.6-95.4%).The clinical and pathological features of the DPPP and IA groups were similar. Efficacy of clearing anti-GBM antibody was similar in the two groups (59.0 vs. 71.2%, P = 1.00), although fewer patients in the DFPP group experienced reduced IgG (62.7 vs. 83.5%, p = 0.002). One patient each had a pulmonary hemorrhage and a subcutaneous hemorrhage during treatment, but there were no other serious complications. At the end of follow-up, patient survival and renal survival were similar in the DFPP and IA groups. CONCLUSION: DPPP plus immunosuppressive therapy efficiently and safely removed anti-GBM antibodies. The fewer plasma-associated side effects and reduced loss of IgG suggest that DFPP may be a better treatment choice for anti-GBM disease, especially in patients with insufficient plasma.

[Effect of interleukin-10 level and human leukocyte antigen-DR expression as prognostic predictors in critically ill patients undergoing continuous renal replacement therapy].

OBJECTIVE: To inquire into interleukin-10 (IL--10) level and monocyte expression of human leukocyte antigen--DR (HLA--DR) are predictors of infection and prognosis in critically ill patients undergoing continuous renal replacement therapy (CRRT). METHODS: A total of 43 critically ill patients undergoing continuous veno-venous hemofiltration (CVVH) were recruited from the intensive care unit (ICU). Anti--coagulated blood was obtained at 1 day before and 4 days after undergoing CVVH, and plasma IL--10 level (enzyme linked immunosorbent assay) and HLA--DR expression (flow cytometry) were determined. Thirty healthy subjects were enrolled as controls. In addition, the correlation between IL--10 and acute physiology and chronic health evaluation II (APACHEII) score was assessed. RESULTS: (1)Altogether, 7 patients died among a total of 43 critically ill patients, the mortality was 16.3%. Eighteen patients had negative cultures during the study (group I), and 19 patients had positive cultures (group II), and in 6 patients positive bacterial culture appeared 72 hours after the beginning of the treatment (group III). (2) The IL--10 level (ng/L) was higher in patients than in healthy subjects [23.46 (46.71) vs. 0.32 (0.45), P < 0.01]. Compared with group I, the levels of IL--10 in group II and III were higher significantly [40.20 (46.44), 41.78 (49.63) vs. 7.33 (21.05), both P < 0.05]. Continuous observation revealed that IL--10 rapidly lowered in group I after treatment [4.50 (7.44) vs. 7.33 (21.05), P < 0.05], while there was no apparent change in patients of other two groups. It was found that IL--10 was significant positive correlation with the APACHEII score (r = 0.71, P < 0.01).(3) HLA--DR was lower in patients than in healthy individuals [21.65% (25.62%) vs. 90.39% (9.80%), P < 0.01]. After CVVH, HLA--DR expression was obviously increased in group I [64.95% (35.03%) vs. 32.45% (45.03%), P < 0.01]. However, there were no significant changes in the other two groups. The patients who died had persistent and extremely low HLA--DR expression. CONCLUSIONS: (1)A significant discriminative power of IL--10 levels in predicting disease severity was found among the patients receiving CRRT, and persistently high IL--10 level predicts poor prognosis. (2) Persistently low monocyte HLA--DR expression may indicate concomitant or impending infection in patients receiving CRRT.

Amelioration of hemodynamics and oxygen metabolism by continuous venovenous hemofiltration in experimental porcine pancreatitis.

AIM: To investigate the potential role of continuous venovenous hemofiltration (CVVH) in hemodynamics and oxygen metabolism in pigs with severe acute pancreatitis (SAP). METHODS: SAP model was produced by intraductal injection of sodium taurocholate (4%, 1 mL/kg body weight (BW)) and trypsin (2 U/kg BW). Animals were allocated either to untreated controls as group 1 or to one of two treatment groups as group 2 receiving a low-volume CVVH (20 mL/(kg.h)), and group 3 receiving a high-volume CVVH (100 (mL/kg.h)). Swan-Ganz catheter was inserted during the operation. Heart rate, arterial blood pressure, cardiac output, mean pulmonary arterial pressure, pulmonary arterial wedge pressure, central venous pressure, systemic vascular resistance, oxygen delivery, oxygen consumption, oxygen extraction ratio, as well as survival of pigs were evaluated in the study. RESULTS: Survival time was significantly prolonged by low-volume and high-volume CVVHs, which was more pronounced in the latter. High-volume CVVH was significantly superior compared with less intensive treatment modalities (low-volume CVVH) in systemic inflammatory reaction protection. The major hemodynamic finding was that pancreatitis-induced hypotension was significantly attenuated by intensive CVVH (87.4+/-12.5 kPa vs 116.3+/-7.8 kPa, P<0.01). The development of hyperdynamic circulatory failure was simultaneously attenuated, as reflected by a limited increase in cardiac output, an attenuated decrease in systemic vascular resistance and an elevation in oxygen extraction ratio. CONCLUSION: CVVH blunts the pancreatitis-induced cardiovascular response and increases tissue oxygen extraction. The high-volume CVVH is distinctly superior in preventing sepsis-related hemodynamic impairment.

[Continuous veno-venous hemofiltration in treatment of acute severe hyponatremia: a report of 6 cases].

OBJECTIVE: To investigate the effect of continuous veno-venous hemofiltration (CVVH) in the treatment of acute severe hyponatremia. METHODS: Six patients with acute severe hyponatremia were studied, including 5 males and 1 female, aged 48.5 (25 - 61) years. Clinical manifestations of hyponatremia included confusion (6/6), drowsiness (3/6), and delirium (3/6). The course of hyponatremia before the initiation of CVVH was 45 - 48 hours. AN69, AV600, FH66 and HF1200 hemofilters were applied and changed every 24 hours. The ultrafiltration rate was 2 000 ml/h, with a blood flow rate of 200 - 250 ml/min, and the substitute fluid was infused by a pre-dilution route. Low molecular weight heparin was used for anticoagulation. RESULTS: The average treatment duration of CVVH was 59.7 (45.6 - 86) hours. All the patients survived and tolerated CVVH well. During CVVH, the serum sodium increased significantly from (101.2 +/- 4.2) mmol/L before CVVH, to (115.0 +/- 2.7) mmol/L at the 6th hour of CVVH, (129.2 +/- 4.1) mmol/L at the 24th hour, and (140.3 +/- 1.6) mmol/L at the 48th hour of CVVH; with the correction rate of serum sodium controlled at (2.5 +/- 0.4) mmol.L(-1).h(-1) over the first 24 hours, (1.2 +/- 0.1) mmol.L(-1).h(-1) for the first 48th hour, and the correction rate of (0.82 +/- 0.10) mmol.L(-1).h(-1). The sodium concentrations in the replacement solution were (16.0 +/- 6.0) mmol/L higher than the serum sodium concentration at 0 hour, (11.6 +/- 4.3) mmol/L higher at 4th hour, (5.5 +/- 5.1) mmol/L higher at 24th hour, and (0.75 +/- 0.96) mmol/L higher at 48th hour of CVVH. After CVVH, the serum osmolarity increased significantly, from (216.7 +/- 7.4) mOsm/kgH(2)O pre-CVVH, to (245.0 +/- 5.5) mOsm/kgH(2)O at 6th hour, with a correction rate of (5.16 +/- 0.81) mOsm.kgH(2)O(-1).h(-1); (272.7 +/- 7.1) mOsm/kgH(2)O at 24th hour, with a correction rate of (2.33 +/- 0.28) mOsm.kgH(2)O(-1).h(-1); and (295.0 +/- 4.2) mOsm/kgH(2)O at 48th hour, with a correction rate of (1.63 +/- 0.20) mOsm.kgH(2)O(-1).h(-1). The Glasgow scores and APACHEII scores improved significantly as compared to pretreatment. CONCLUSION: CVVH is effective in the treatment of acute severe hyponatremia, and could be considered as a treatment option because of its slow and continuous nature. A low-sodium replacement solution should be prepared to minimize its sodium concentration difference from the serum concentration. We recommend that the serum sodium concentration be corrected at an average rate of (2.50 +/- 0.14) mmol.L(-1).h(-1) at 6 h, (1.2 +/- 0.1) mmol.L(-1).h(-1) at 24 h and (0.82 +/- 0.10) mmol.L(-1).h(-1) at 48 h.