Successful treatment of patients with lipoprotein glomerulopathy by protein A immunoadsorption: a pilot study.

BACKGROUND: No established therapy is available for patients with lipoprotein glomerulopathy (LPG). Protein A immunoadsorption has been proved to be effective in reducing proteinuria in patients with nephrotic syndrome. In this uncontrolled pilot study, we investigated the efficiency of immunoadsorption onto staphylococcal protein A as treatment for LPG. METHODS: Thirteen patients with renal biopsy-proven LPG were treated with staphylococcal protein A immunoadsorption. Immunoadsorption was administered for 10 cycles per session and 10 sessions as a course. A total of 30 l of plasma was regenerated in each course. RESULTS: Single immunoadsorption course led to a rapid decline in proteinuria from 4.01 +/- 3.09 g/24 h to 1.21 +/- 0.97 g/24 h (mean +/- SD) (n = 13, P = 0.001), along with a dramatic decline in apolipoprotein E (apo E) from 9.79 +/- 5.04 mg/dl to 6.20 +/- 2.22 mg/dl (P = 0.004). A repeated renal biopsy (n = 12) showed that intraglomerular lipoprotein thrombi almost disappeared. Six patients were enrolled in the investigation of long-term outcome, and proteinuria returned to baseline levels within 12 months. Four recurrent patients received repeat immunoadsorption treatment; proteinuria decreased from 5.02 +/- 1.85 g/24 h to 1.64 +/- 0.55 g/24 h at the end of the treatment, serum apo E decreased from 14.65 +/- 11.17 mg/dl to 7.90 +/- 1.72 mg/dl. No patients suffered from severe complications. CONCLUSION: Our observations suggest that immunoadsorption onto protein A might be an effective treatment for resolving intraglomerular thrombi and improving nephrotic syndrome in patients with LPG. Further studies are required to define the influence of immunoadsorption on long-term effects in LPG patients.

Application of bioelectrical impedance vector analysis to evaluate volume status of hemodialysis patients with hypertension / 中华肾脏病杂志

Objective:To evaluate the volume status of hemodialysis patients with hypertension by bioelectrical impedance vector analysis, and investigate the effect of high volume status on the prognosis of patients with hypertension.Methods:The study subjects came from the patients with pre-dialysis systolic blood pressure>160 mmHg (mean systolic blood pressure of 6 times of treatment) in the Affiliated BenQ Hospital of Nanjing Medical University. According to the volume status assessed by bioelectrical impedance vector analysis, patients were divided into two groups: fluid overload group and non-overload group (including normal fluid status and fluid decline). The clinical data, laboratory test results, ratio of intracellular and extracellular water (ICW and ECW), body cell mass, lean body mass and the percentage of total body weight, fat percentage of body weight, resistance/height, reactance/height, phase angle and illmarker were compared between two groups. Kaplan-Meier survival curve was used to compare the difference of survival rate between the two groups.Results:A total of 51 hemodialysis patients with hypertension were enrolled in this study, including 19 patients in fluid overload group and 32 patients in non-overload group (27 patients with normal volume status and 5 patients with decreased volume). The levels of albumin, prealbumin, hemoglobin, hematocrit and serum phosphorus in patients with fluid overload decreased significantly compared with non-overload patients (all P<0.05), and the proportion of lymphocytes increased in fluid-overload patients ( P<0.05). The ratio of extracellular water and illmarker index in fluid overload group were significantly higher than those in the other group (both P<0.01). However, phase angle, resistance/height, reactance/height were lower than those in patients with non-overload (all P<0.01). After 20 months of clinical observation, the control rate of blood pressure (pre-dialysis systolic blood pressure<160 mmHg) in fluid overload group was lower than that in the non-overload group (26.3% vs 43.8%), but not statistically significant ( P=0.218). The all-cause mortality rate of patients in the fluid overload group was higher than non-overload group (26.3% vs 15.6%). Kaplan-Meier survival curve analysis suggested that the difference in survival rate between the two groups was not statistically significant. Conclusions:The extracellular fluid of hemodialysis patients with hypertension and fluid overload increases significantly, and the nutritional status evaluation index decreases compared with that of patients without increased volume. Increased proportion of lymphocytes may be related to the micro-inflammatory status. Blood pressure is more difficult to control in hypertensive patients with fluid overload and the clinical prognosis can be worse in patients without increased volume.

Hemodialysis and hyperkalemia / 中国基层医药

Hyperkalemia is the most common complication of patients with chronic kidney disease (CKD), which is more common in hemodialysis ( HD) patients.The reason of hyperkalemia in HD patients are related to excessive intake of K +,insufficient clearance of K +and K+transferring from intracellular to extracellualr .Clinically, most of the patients don't have any obvious symptoms ,a few of patients appear heart and neuromuscular symptoms .To prevent hyperkalemia ,the patients should control the daily potassium intake strictly ,and take adequate dialysis and drug therapy .

Sequential hemoperfusion and continuous venovenous hemofiltration in treatment of severe tetramine poisoning.

OBJECTIVE: It was the aim of this study to observe the effects of sequential hemoperfusion (HP) and continuous venovenous hemofiltration (CVVH) on patients with severe tetramine poisoning and to evaluate the ability of these modalities to remove tetramine. METHODS: Eighteen patients diagnosed as having severe tetramine poisoning were treated by blood purification, additional to routine medical therapy. Blood purification procedures included HP using activated charcoal for 3-5 h and consecutive CVVH for 24-36 h. Patients' clinical conditions, blood routine tests and serum chemical tests were evaluated every day after admission. Plasma tetramine concentrations were determined before and after HP. During CVVH, tetramine concentrations in plasma before and after passing through the filter and ultrafiltration at 2 and 12 h were also determined. RESULTS: Eight patients received blood purification within 12 h after onset of poisoning, and 10 patients received blood purification more than 12 h later. Early-treated patients showed a higher cure rate (100 vs. 60.0%; p < 0.05, chi(2) test) and shorter coma time than late-treated patients (26.0 +/- 23.2 h, range 5-70, vs. 59.7 +/- 27.7 h, range 20-96; p < 0.01, rank test). The mean plasma tetramine concentrations in early- and late-treated patients were comparable (0.095 +/- 0.036 vs. 0.134 +/- 0.110 mg/l; p > 0.05). Mean plasma tetramine concentration was reduced from 0.124 +/- 0.082 to 0.080 +/- 0.055 mg/l after HP. At 2 h of CVVH, mean plasma tetramine concentration was 0.078 +/- 0.064 mg/l, at 12 h of CVVH, 0.074 +/- 0.059 mg/l, and the ultrafiltration sieving coefficient at 2 and 12 h was 0.839 +/- 0.409 and 0.686 +/- 0.253 mg/l, respectively. CONCLUSION: Early sequential HP and CVVH therapy may significantly improve the outcome of patients with severe tetramine intoxication. HP can rapidly reduce the plasma concentration of tetramine, and CVVH can attenuate the plasma tetramine concentration rebound after HP by continuously removing tetramine from the plasma.

Novel rescue therapy for C4d-positive acute humoral renal allograft rejection.

OBJECTIVE: To investigate the efficacy of immunoadsorption (IA) in combination with tacrolimus (TAC) and mycophenolate mofetil (MMF) rescue therapy for C4d-positive acute humoral rejection (AHR) of renal transplants. METHODOLOGY: Six of 185 cadaveric renal allograft recipients transplanted at our institute developed AHR over a mean period of 4.8 +/- 0.8 d after operation. The ages ranged from 35 to 51 yr (mean 42.6 +/- 5.6 yr). C4d deposits in peritubular capillaries (PTC) and accumulation of granulocytes in PTC were observed. IA with staphylococcal protein A and TAC-MMF combination therapy were given. RESULTS: After subjected to IA for 6.3 +/- 1.03 sessions combined with TAC (0.14-0.16 mg/kg/d) and MMF (1.5 g/d) therapy, renal function recovered in all the patients. The mean duration of treatment when serum creatinine decreased was 14 +/- 2.9 d. The pre-IA panel reactive antibody reactivity was as high as 50.2 +/- 6.1%, and was significantly reduced to 8.3 +/- 2.9% after IA. Repeated allograft kidney biopsy in four of six patients revealed a favorable remission of AHR. With a mean follow-up of 18.8 +/- 5.46 months, patient and allograft survival are 100%, renal function remained stable with a mean serum creatinine of 1.2 +/- 0.22 mg/dL. CONCLUSION: The optimal treatment for alloantibody-mediated AHR remains undefined. Our findings suggest that a therapeutic approach combining IA and TAC-MMF rescue has excellence to improve the outcome of AHR.

Regional citrate anticoagulation in critically ill patients during continuous blood purification / 中华医学杂志(英文版)

<p><b>OBJECTIVES</b>To evaluate the safety and define the contraindication of regional citrate anticoagulation treatment on various critically ill patients being treated by continuous blood purification, who also had bleeding tendencies.</p><p><b>METHODS</b>Forty critically ill patients being treated by continuous blood purification (CBP) were involved in this study. Due to their bleeding tendencies, regional citrate anticoagulation treatment was given to all of them. Those with hepatic function impairment (n = 10) were classified as Group A, those with hypoxemia were classified as Group B (n = 10), and the others as Group C (n = 20). Blood samples were collected before treatment, and at 4, 12, 24, 36, and 48 hour intervals during CBP. These samples then were used arterial blood gas analysis, whole blood activated clotting time (WBACT) pre- and post-filter, and serum ionized calcium examination.</p><p><b>RESULTS</b>WBACT pre-filter showed little fluctuant through the 48 hr period of CBP, and WBACT post-filter showed obvious prolongation than that of the pre-filter (P < 0.05) at all time points. Metabolic acidosis was found in Group A patients before CBP, and improved during CBP. Normal acid-base conditions of patients were disturbed and deteriorated in Group B during CBP, but not in Group C. Serum ionized calcium was maintained at a normal range during CBP in Group A and C patients, but declined significantly in Group B patients (vs. pre-treatment, P < 0.05).</p><p><b>CONCLUSIONS</b>Regional citrate anticoagulation can be safely used in conjunction with CBP treatment for patients with hepatic function impairment, but may induce acidosis and a decline in serum ionized calcium when used with hypoxemic patients.</p>

Continuous veno venous hemofiltration in treatment of acute necrotizing pancreatitis / 中华医学杂志(英文版)

<p><b>OBJECTIVE</b>To investigate the effectiveness of using continuous veno venous hemofiltration (CVVH) in the treatment of acute necrotizing pancreatitis (ANP).</p><p><b>METHODS</b>Thirteen ANP patients were involved in this study, including 4 females and 9 males, averaging 50.6 +/- 10.8 years old. CT scans upon admission revealed 33% necrosis involving the body of the pancreas in 2 patients, 67% necrosis in 3 patients and 100% necrosis in the other 8; the CT severity score was 8.9 +/- 2.1. CVVH was maintained for at least 72 hours and the AN69 hemofilter (1.2 m(2)) was changed every 24 hours. The ultrafiltration rate during CVVH was 2993.9 +/- 983.0 ml/h, the blood flow rate was 250 - 300 ml/min, and the substitute fluid was infused in a pre-diluted manner. Low molecular weight heparin was used as anticoagulant.</p><p><b>RESULTS</b>CVVH was well tolerated in all the patients. Bloody abdominal cavity drainage fluid was observed in 2 patients, but no other side-effects related with CVVH were observed. Two patients died of systemic fungal infections and another died of intracranial fungi infection, resulting in an ICU mortality of 23.1%. Ten of the patients survived in the ICU, but one of them died for other reasons unrelated to the SAP before discharge. The APACHE II score before CVVH was 15.2 +/- 6.5, but decreased significantly to 8.1 +/- 5.3, 7.5 +/- 4.9 and 8.0 +/- 5.2 at the 24th, 48th and 72nd hour after CVVH, respectively (P < 0.01). Serum concentration of IL-1beta and TNFalpha decreased to the trough at the 6th hour after a new hemofilter was used and increased slowly to pre-CVVH levels 12 hours later. After CVVH had ceased, the serum levels of two cytokines increased to their peaks at the 120th hour and decreased eventually at the 144th hour. The sieving coefficient (SC) of IL-1beta and TNFalpha was 0.33 +/- 0.11 and 0.16 +/- 0.08.</p><p><b>CONCLUSION</b>CVVH offered therapeutic options for ANP and was well tolerated resulting in clearance of IL-1beta and TNFalpha; CVVH at early stages of SAP may contribute to the improvement of outcome.</p>