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.

Clinical-pathological features and prognosis of thrombotic thrombocytopenic purpura in patients with lupus nephritis.

BACKGROUND: We investigated the clinical-pathological features and the prognosis of thrombotic thrombocytopenic purpura (TTP) in patients with lupus nephritis (LN). METHODS: A retrospective analysis was performed on the clinical-pathological data and prognosis in 8 patients with LN complicating with TTP. RESULTS: Thrombocytopenia and hemolytic anemia, neurologic symptoms, and renal dysfunction were the clinical manifestations in 8 patients. Six patients had fever. Eight patients presented with rapid progressive glomerulonephritis, and 1 patient with continuous gross hematuria. The histologic features of the 8 patients were thrombotic microangiopathy lesions. Immune-suppressive therapies were administrated in all patients, and blood purification therapy was applied in 7 patients. Three cases involved plasma exchange and/or immunoabsorption. Seven patients received a median follow-up of 12 months. One patient died, 3 cases received peritoneal dialysis, and 1 case failed to follow-up. During follow-up, 1 case was able to stop peritoneal dialysis, and 1 case changed to hemodialysis. The other 3 patients continued with stable renal function. CONCLUSION: The patients with LN with TTP have severe clinical-pathological changes. Active treatment including renal replacement therapy, plasma exchange, and immunoabsorption are promising.

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.

Spectrum of clinical features and type IV collagen alpha-chain distribution in Chinese patients with Alport syndrome.

BACKGROUND: Alport syndrome (AS) is a clinically and genetically heterogeneous nephropathy. The goal of the present study is to delineate clinical characteristics and the distribution of type IV collagen chains in Chinese AS patients and to identify any alpha(IV)-chain expression and clinical phenotype correlation. METHODS: A total of 126 biopsy-proven patients meeting immunofluorescence criteria for the diagnosis of AS were investigated retrospectively. RESULTS: Microscope haematuria associated with proteinuria was observed as the initial symptom in 77.8% of the patients; 59.8% showed hearing impairment and 22.9% had ocular abnormalities. Renal biopsies from 118 patients revealed mesangial proliferative glomerulonephritis (61.9%) and focal and segmental sclerosis glomerulonephritis (37.3%). Ten different distribution patterns for the type IV collagen alpha-chains were found in the kidney; six of these are presented here for the first time. Based on renal immunofluorescence findings, 113 patients (89.7%) were classified as X-linked dominant inherited AS (XLAS) and 13 (10.3%) as autosomal recessive AS (ARAS). The XLAS group was divided into typical and non-typical subgroups according to the expression patterns for the alpha3(IV)-chain. Clinical phenotypes were more severe in XLAS patients than in ARAS patients and the prognosis was poorer in typical XLAS patients than non-typical XLAS patients. CONCLUSION: In China, the incidence of XLAS is 89.7% and 10.3% for ARAS. Chinese patients with AS have various distribution patterns of type IV collagen alpha-chains. The distribution pattern of type IV collagen alpha-chains in the kidney may correspond to the severity of the clinical phenotype.

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.

Clinical-pathological features and prognosis of thrombotic tbrombocytopenic purpura in patients with lupus nephritis / 中华风湿病学杂志

Objective To investigate the clinical-pathological features, treatment and prognosis of thrombotic thrombocytopenic purpura in patients with lupus nephritis (LN). Methods A retrospective ana-lysis was carried out based on the clinical-pathological data for the treatment and prognosis of eight patients with LN related TIP. All patients had thrombocytopenia and hemolytic anemia, neurological symptoms and renal dysfunction. Six patients had fever. Results All 8 patients had sudden-onset of rapid progressive glomeurlonephritis (RPGN), one patient with continuous gross hematuria, the pathological features of these patients revealed TMA lesions. Immune suppressive therapy was initiated and blood purification therapy were applied in seven patients. Three cases had plasmapheresis and (or) immunoabsorption. One case was lost during follow-up, the other seven patients were followed with period at one year. One patient died, three patients went into peritoneal dialysis in which one of them was changed to hemodialysis finally. The other three patients had stable renal function. Conclusion The LN patients with TTP had severe clinical-patho-logical changes, rapid progressive and poor outcome, so we should diagnose and treat these patients as early as possible.

The relationship between renal histology,its mechanism and the treatment of Lupus nephutis / 中国实用内科杂志

This paper emphasizes the importance of the mechanism of renal tissue damage in conducting treatment of lupus nephritis in addition to the renal histology.There are at least 4 kinds of mechanisms related to the renal tissue damage of LN including circulating immune complex deposition,in situ immune complex formation,vasculitic change and thrombotic mircoangiopathy.Treatment according to the mechanisms of tissue damage will give rise to a much better result as compared with the classic treatment based on morphology alone.Multi-target immune theapy has been recommended for treatment of those severe and complicated LN.

Experimental Study on the Protection of Cordyceps Sinensis to Cydosporine A Nephrotoxicity / 第二军医大学学报

In order to further explore the protective effect of Cordyceps Sinensis (CS) on Cyclosponne A nephrotoxicity (CsA-Nx) and its possible mechanisms, SD rats were divided into two groups: CsA group and CsA + CS group. The results showed that: in different experiment period, serum BUN. Cr, Na. K and urine EOF excretion in CS group were lower than that in control group. In the third month, serum AT- |J in CS group was also lower than that in control group. Pathological examination showed that CS could protect the kidney from CsA-Nx and ameliorate the glomerular and interstitial injuries. It suggests that CS could protect the kidney from CsA-Nx, especially protect the proximal tubular function and ameliorate renal hemodynamics.

The clinical and pathological features of drug-associated acute interstitial nephritis / 中华肾脏病杂志

Objective To evaluate the clinical and pathological features of drug-associated acute interstitial nephritis. Methods Clinical presentations and pathological features were investigated in 14 patients with drug-associated acute interstitial nephritis. Lymphocyt; stimulation test was performed to confirm, the offending drugs. Results All patients presented with acute renal failure, but typical clinical features were often absent. Renal biopsy was therefore needed to establish the diagnosis. Conclusion Lymphocyte stimulation test is a very useful means in the determination of offending drugs.

The titer of ANCA in relation to disease activity in patients with microscopic potyarteritis / 中华肾脏病杂志

Objective To study whether ANCA liter is sensitive serological marker reflecting vasculitis disease activity. Methods MPO-ANCA and IF-ANCA tilers variation in five sera specimen with active MPA diseases were studied after methylprednisolone and cyclophosphamide pulse therapy. The clinical and pathological features of 5 patients with MPA were investigeted comparing pre-treatment with post-treatment. Results (1) Serum ANCA were found positive and increased liter in 5 patients wilh active MPA disease. (2) Titer decreased after Ireatment, while renal function improved. (3) After half year, MPO-ANCA was negative in 5 patients, IF-ANCA was negative in 2 patients. Conclusion There is a close correlation between serum ANCA titer and MPA renal disease activity.

Construction of an angiopoietin-like protein 2 expression vector and its expression in human endothelial cells / 医学研究生学报

Objective: To construct an angiopoietin-like protein 2(ANGPTL2) expression vector and obtain ANGPTL2 over-expression endothelial cell strains.Methods: Plasmid phrGFP-C was used to amplify hrGFP protein coding sequence by polymerase chain reaction.The amplified sequence was cloned into the A multiple cloning sites of pIRES to construct plasmid pIRES-hrGFP.Complementary oligonucleotides containing the recognition sequence of BamH I,Sal I,Xba I and SSe8387 I were synthesized,annealed and cloned into a BamH I site on the backbone of plasmid pIRES-hrGFP to obtain vector pIRES-hrGFP-MS.ANGPTL2 cDNA was cloned by RT-PCR while human renal RNA was used as the templet and then inserted into the B multiple cloning sites of the vector pIRES-hrGFP-MS.The newly constructed ANGPTL2 expression vector pIRES-hrGFP-MS-ANGPTL2 was linearized by Xba I and introduced into human umbilical vein endothelial cells.ANGPTL2 over-expressed endothelial clones were screened out by G418 selection and identified by the expression levels of both hrGFP and ANGPTL2 genes in these cell clones.Results: The ANGPTL2 expression vector pIRES-hrGFP-MS-ANGPTL2 was constructed successfully and two ANGPTL2 over-expression endothelial strains were obtained.The cells displayed a significantly extended appearance quite different from that of the control cells.Conclusion: The successful construction of the ANGPTL2 expression vector pIRES-hrGFP-MS-ANGPTL2 and the obtainment of two ANGPTL2 over-expression HUVEC strains have paved the way for further investigation into the function of ANGPTL2 and its possible role in diabetic nephropathy.

Eosinophil infiltration and peritubular capillary C4d deposition in acute renal allograft rejection / 中国免疫学杂志

Objective:To study the correlation between deposition of C4d along peritubular capillaries (PTC) and interstitial eosinophilic infiltration in renal allografts.Methods:Deposition of C4d in kidneys was assayed by indirect immunoflourescence of the renal allograft biopsies.Twenty-six patients were demonstrated strongly diffuse staining of PTC,who were defined as C4d+ group,while the biopsies of thirty patients with acute rejection exhibited negative for PTC C4d staining served as the controls,who were defined as C4d-group.Eosinophils were counted under microscope.Results:The C4d+group was demonstrated significantly greater interstitial eosinophilic infiltration than did the C4d-group(P

DETECTION OF PRE-S2 PROTEIN IN THE KIDNEY IN PATIENTS WITH GLOMERU-LONEPHRITIS / 解放军医学杂志

The presence of pre-S2 protein in the kidney was investigated in 30 patients with biopsy-proved glomerulonephritis (GN) using indirect immunoperoxidase technique and monoclonal antibody. HBsAg and HBeAg in the kidney were detected using the same techniques and HBsAg, HBeAg, anti-HBs, anti-HBe and anti-HBc in serum were assayed at the same time.It was shown that pre-S2 prtein was present in the kidney in 7/22 patients with primary GN and 6/8 with lupus nephritis. It was deposited along the glomerular capillary walls or within the mes-angium, depending on the type of GN as well as the deposition of immunoglobulins and complement components in the kidney. Deposition of pre-S2 protein in renal tissue was correlated with HBsAg deposition in the glomeruli, but not HBeAg deposition. In membranous GN, there was a good correlation between the presence of pre-S2 protein in the kidney and virus antigetiemia. It is concluded that pre-S2 protein detection in the kidney is of value in evaluating the hepatitis B virus associated GN.

THE SIGNIFICANCE OF URINARY INTERLEUKIN—6 IN PATIENTS WITH IgA NEPHROPATHY / 中华肾脏病杂志

Cytokines may play an important role in the development of IgA Nephropathy(IgAN). In this study, the levels of Interleukin—6(IL—6)activity in the urine and serum from 21 patients with IgAN were measured by using IL—6 dependent cell line, 7TD. IL—6 activities were detectable in both urine and serum in patients with IgAN(IL—6 detectable rate 47.6% and 25% respectively), while it was undetectable in normal volunteers. There was no correlationship between urinary and serum IL—6 activities. Also, we found that patients with elevated urinary IL—6 activity had heavy proteinuria and severe glomerular and tubular—interstitial histological changes. The results suggest that the measurement of IL—6 is useful in evaluating the degree of glomerular and interstitial damage in patients with IgAN.

Genetic variation of mannose-binding protein associated with glomerular immune deposition in IgA nephropathy / 中华医学杂志(英文版)

<p><b>OBJECTIVE</b>To investigate the relationship between codon 54 gene polymorphism of the host defense molecule, mannose-binding protein (MBP), and the patterns of glomerular immune deposition in IgA nephropathy (IgAN).</p><p><b>METHODS</b>IgAN patients with different patterns of glomerular immune deposition were selected and divided into two groups. Group A consisted of 77 patients with glomerular IgA and C3 deposits, and Group AGM consisted of 70 patients with glomerular IgA, IgG, IgM, C3 and Clq deposits. Clinical features and laboratory relevant data of all patients were collected. One-hundred and forty healthy adults were recruited as normal controls. The MBP gene codon 54 GGC/GAC polymorphism was investigated by using polymerase chain reaction and restriction fragment length polymorphism.</p><p><b>RESULTS</b>The genotype frequency of GGC/GAC heterozygotes was significantly higher in Group AGM as compared with that of Group A (41.4% vs 19.5%, P < 0.01) or normal subjects (41.4% vs. 26.4%, P < 0.05), while no difference was found in the distribution of MBP genotypes between Group A and normal subjects. GAC allele frequency was also higher in Group AGM than that in Group A (0.24 vs. 0.14, P < 0.05) or normal subjects (0.24 vs. 0.15, P < 0.05). The variant allele (GAC) was markedly associated with Group AGM (OR = 1.95, 95% CI: 1.06 - 3.58). In both Group A and Group AGM, more patients carrying the variant allele had episodes of upper respiratory or gastrointestinal infections prior to the onset of IgAN than those with wild homozygotes (GGC/GGC).</p><p><b>CONCLUSIONS</b>Genetic variation of the host defense molecule, MBP, may be involved in the formation of the diverse patterns of glomerular immune deposition in IgAN. The variant allele of the MBP gene may partially account for abundant immune deposits in some IgAN patients.</p>

Genetic variations in plasminogen activator inhibitor-1 gene and beta fibrinogen gene associated with glomerular microthrombosis in lupus nephritis and the gene dosage effect / 中华医学遗传学杂志

<p><b>OBJECTIVE</b>To explore the relationship of plasminogen activator inhibitor-1 (PAI-1) gene -675 4G/5G and beta fibrinogen gene -455 G/A variations to glomerular microthrombosis(T) in lupus nephritis(LN).</p><p><b>METHODS</b>One hundred and one patients with biopsy proven LN were divided into two groups according to the presence or absence of glomerular microthrombus, i.e. group LN+T(n=46) and group LN-T(n=55). The genotypes of PAI-1 gene and beta fibrinogen gene were profiled by polymerase chain reaction-sequence length polymorphism (PCR-SLP) and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) respectively. Clinical baseline data at the time of renal biopsy were collected. Normal controls consisted of 128 unrelated healthy adults. The etiologic fractions (EF) were calculated for estimating the contribution of risk genotypes of the two candidate genes to an increase in susceptibility to glomerular microthrombosis in LN patients.</p><p><b>RESULTS</b>Both the 4G/4G genotype and the 4G allele of PAI-1 gene occurred more frequently in group LN+T (47.83% and 0.685) than in group LN-T (23.64% and 0.507)(P<0.05) and normal controls (28.13% and 0.570) (P<0.05). The PAI-1 4G/4G genotype was significantly associated with microthrombosis (OR=2.96, 95%CI:1.26-6.92). Besides, the prevalence of the genotypes carrying the A allele of beta fibrinogen gene, i.e. G/A and A/A, as well as the prevalence of the A allele per se, was increased in group LN+T (47.83% and 0.261) versus group LN-T (27.27% and 0.145)(P<0.05). LN patients carrying the A allele had a high risk of glomerular thrombosis(OR=2.44, 95%CI:0.98-5.59). In addition, the presence of the PAI-1 4G/4G genotype together with the A allele of the beta fibrinogen gene was found to be a greater risk factor (OR=4.5, 95%CI: 1.34-15.12) for glomerular thrombosis in LN than the 4G/4G genotype or the A allele alone. The pooled EF (45.98%) for the risk genotypes of both PAI-1 gene and beta fibrinogen gene was also higher than that for the risk genotypes of either gene (31.67% and 28.23%).</p><p><b>CONCLUSION</b>The above findings indicated that genetic variations in PAI-1 and beta fibrinogen loci might represent risk factors for glomerular microthrombosis in LN. They may have synergetic impact and present gene dosage effect on the susceptibility to this pathological subphenotype.</p>

EFFECTS OF TR1TERYGIUM WILFORDII ON THE PRODUCTION OF INTERLEUKIN 2 IN SPLEEN CELL FROM MIC WITH NEPHROTOXIC SERUM NEPHRITIS / 解放军医学杂志

Interleukin 2 (IL-2) activity in spleen lymphocyte and anti-Rabbit IgG antibody from mice with nephrotoxic serum nephritis were examined to investigate immunosuppressive effect of Triterygium Wilfordii (TW), IL-2 bioactivity and serum anti-Rabbit IgG antibody were significantly higher in the group of nephrotoxic serum nephritis. The administration of TW prevented the overproduction of IL-2 and serum anti-Rabbit IgG antibody, and reduced excretion of urinary protein and renal histologic changes.

RENAL LESIONS IN MICROSCOPIC POLYARTERITIS NODOSA: A REPORT OF EIGHT CASES / 解放军医学杂志

A clinico-pathological study was carried out on 8 patients with microscopic polyar-teritis nodosa (MPAN). It was found that the renal lesions were very common and severe in this group of patients apart from the typical presentation of MPAN, including fever, myalgias, arteritis and the involvement of hematologic, gastrointestinal and cardiovascular systems. Laboratory pictures were characterized by leucocytosis, anemia and increased serum creatinine. The plasma anti-neutrophil cytoplasmic antibodies were present and thought to be of particular importance. On light microscopy, focal, segmental necrotising glomerulonephritis was discovered which was often associated with extensive crescence formation and vasculitis. We recommend renal biopsy as a valuable tool of investigation in the diagnosis of MPAN.

Preparation and characterization of monoclonal antibody against human angiopoietin-like protein 2 / 医学研究生学报

Objective:To prepare human angiopoietin like protein 2(ANGPTL2) monoclonal antibody.Methods:The purified recombinant human ANGPTL2 was used to immunize BALB/c mice.Then,the mouse spleen cells were isolated and fused with mouse myeloma cells.After selecting with HAT medium and analyzing with ELISA assay,the hybridoma cell clones stably secreting human ANGPTL2 antibody were screened out.The monoclonal antibody against humain ANGPTL2 was purified by ammonium sulfate precipitation method from the supernatant liquid of hybridoma cell culture.Western blotting,Cell immunostaining,and immunohistochemisty staining were used to characterize the antibody.Results:A strain of hybridoma cell clones stably secreting human ANGPTL2 antibody was screened out.The ANGPTL2 monoclonal antibody prepared was proven useful. Conclusion:A monoclonal antibody against human ANGPTL2 was successfully prepared,which provide a basis for basic study of ANGPLTL2.

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>