Treatment of life-threatening lithium toxicity with continuous arterio-venous hemodiafiltration.
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Female↗
Biomedical subjects
N Boyce
Publications and source records attributed to N Boyce.
Clearance of vancomycin during continuous arteriovenous hemodiafiltration.
The clearance of vancomycin during therapy with continuous arteriovenous hemodiafiltration (CAVHD) has been measured in vivo. Vancomycin clearances (n = 16) were 0.636 +/- 0.269 L/h (10.5 +/- 4.46 ml/min). Effective drug clearances were proportional to ultrafiltrate volumes, reflecting convective clearance. Clearances of vancomycin on CAVHD were approximately twice the values seen with continuous arteriovenous hemofiltration. These data allow construction of a dosing schedule for vancomycin therapy in patients receiving renal support via CAVHD.
Acute Kidney Injury↗
Continuous arteriovenous haemodiafiltration: optimal therapy for acute renal failure in an intensive care setting?
We report the results of continuous arteriovenous haemodiafiltration (CAVHD) treatment in 12 critically ill intensive care patients with acute renal failure (eight males, four females - mean age 60.9 years - range 47 to 76) (APACHE II score 28.8, range 18-37). All patients were oligoanuric or had a rising creatinine (greater than or equal to 100 microM/L per day). Vascular access was obtained by Scribner shunt or wide-bore femoral arterial and venous cannulae. At the beginning of CAVHD therapy the mean plasma urea was 38 mM/L (SE 4.5, 95% confidence interval (CI) 25.1 to 75.6 mM/L) and the mean creatinine was 604 microM/L (SE 70, 95% CI 450-756 microM/L). After 72 hours of therapy, despite oligoanuria, urea concentration had fallen to a mean of 15.7 mM/L (SE 2.4, 95% CI 12.5-22.9 mM/L) and the creatinine concentration to 297 microM/L (SE 25, 95% CI 243-351 microM/L), respectively. The mean ultrafiltrate volume was 441 mL/hr (SE 33, 95%, range 50-1050 mL/hr). There were no complications related to the extracorporeal circuit, the filter, anticoagulant therapy, electrolyte status or changes in patients' haemodynamic state. Excellent biochemical control of azotaemia was uniformly achieved during CAVHD therapy. Five patients (41.6%) survived to be discharged from the Intensive Care Unit. CAVHD is a simple, safe and effective continuous renal replacement therapy. CAVHD offers technical advantages over alternative therapy while providing equivalent or better biochemical control of azotaemia and volume status in critically ill patients with acute renal failure.
Acute Kidney Injury↗
Life-threatening sepsis complicating heavy metal chelation therapy with desferrioxamine.
A case of severe Yersinia enterocolitica septicemia in a hemodialysis patient receiving desferrioxamine (DFX) therapy is reported. The association between systemic yersiniosis and DFX chelation therapy is reviewed. The increasing application of DFX chelation, in iron overload states and for aluminium overload in dialysis patients, provides an increasing number of patients at risk for this unusual drug side effect. An awareness of the association between Yersinia sepsis and DFX therapy allows appropriate therapeutic intervention which may prove lifesaving.
Adult↗
De-novo anti-GBM-antibody-induced glomerulonephritis in a renal transplant.
We report a case of de-novo anti-glomerular basement membrane antibody induced glomerulonephritis (anti-GBM GN) in a renal cadaveric transplant. The 52 year old male patient had developed end-stage renal failure secondary to malignant hypertension. His initial renal transplant lost function within two months because of severe allograft rejection without evidence of anti-glomerular basement membrane (anti-GBM) antibody formation. Eight months after his second cadaveric transplant he developed the nephrotic syndrome. This was followed by a rapid deterioration in graft function associated with the development of diffuse proliferative glomerulonephritis with 100% crescent formation. Linear staining of the GBM with IgG and C3 and the presence of circulating anti-GBM antibodies confirmed the anti-GBM antibody etiology of the glomerular lesion. Thus anti-GBM antibody induced glomerulonephritis can occur de-novo in a transplanted kidney despite routine immunosuppression. This represents either coincidental autoantibody production after transplantation or specific alloantibody production, stimulated by the introduction, by transplantation, of GBM neoantigens.
Antibodies↗
The clinical spectrum of acute glomerulonephritis and lung haemorrhage (Goodpasture's syndrome).
The aetiology, clinical features and outcome of 40 patients presenting with Goodpasture's syndrome (glomerulonephritis with haemoptysis and pulmonary infiltrates) are reviewed. The diseases of the patients studied could be divided into three groups: antiglomerular basement membrane (anti-GBM) antibody-induced disease (7/40); systemic vasculitis (22/40) and idiopathic Goodpasture's syndrome (i.e. no systemic disease or anti-GBM antibody detected) (11/40). Overall mortality was 57.5 per cent (anti-GBM disease 4/7; systemic vasculitis 15/22; and idiopathic Goodpasture's syndrome 4/11). Most patients died of disease progression or infection. End-stage renal failure developed in 26 patients (anti-GBM (7), vasculitis (14) and idiopathic Goodpasture's syndrome (5). End-stage renal failure developed in 23 of 24 patients presenting with a creatinine of greater than 600 microM/l regardless of the aetiology of Goodpasture's syndrome or treatment used. Review of renal histology showed that all had proliferative nephritis, with 80 per cent of patients having more than 30 per cent crescents. Thus Goodpasture's syndrome was associated with a wide variety of underlying disease. It had a poor prognosis, with the degree of renal impairment at presentation, the extent of crescent formation and the nature of the underlying disease being the major determinants of outcome.
Adult↗
Acute renal failure in critical illness. Conventional dialysis versus acute continuous hemodiafiltration.
The dialytic therapy of choice in critically ill patients with acute renal failure (ARF) is a matter of controversy. The clinical outcome of such patients managed with either conventional dialytic therapy (CDT) or acute continuous hemodiafiltration (ACHD) was compared through retrospective review of medical records from the intensive care unit of a tertiary institution. Records from 167 critically ill patients with ARF consecutively treated in the same intensive care unit were reviewed. Eighty-four patients with ARF treated by CDT were compared to 83 treated with ACHD. The etiology of ARF and the degree of illness severity were similar in both groups (failing organs: CDT 3.9 vs. ACHD 4.1; mean APACHE II score: CDT 25.8 vs. ACHD 28.1). Overall survival was 29.8% for the CDT patients and 41% for the ACHD group (NS). In those with two to four failing organs, survival was greater in the ACHD group (53.8% vs. 31.1%; p < 0.025). This was also true for patients with an intermediate APACHE II score (24-29) who demonstrated better survival when treated by ACHD (46.4% vs. 12.5%; p < 0.025). Acute continuous hemodiafiltration was associated with better control of azotemia and hyperphosphatemia and increased nutritional intake. This retrospective study suggests that ACHD may offer clinically significant advantages over CDT, particularly in patients with an intermediate degree of critical illness severity.
Acute Kidney Injury↗
A prospective study of continuous venovenous hemodiafiltration in critically ill patients with acute renal failure.
UNLABELLED: We studied the biochemical and the clinical consequences of the application of continuous venovenous hemodiafiltration to the management of acute renal failure in critically ill patients. One hundred consecutive surgical and medical ICU patients with acute renal failure were entered into a prospective clinical study at an intensive care unit of tertiary institution. INTERVENTION: included assessment of illness severity by APACHE II score on admission and by organ failure score prior to initiation of renal replacement therapy; treatment of patients with continuous venovenous hemodiafiltration; and measurement of biochemical variables prior to and after therapy. Outcome assessment included incidence of complications, duration of oliguria, duration of intensive care and hospital stays, and survival to hospital discharge. MEASUREMENTS AND MAIN RESULTS: included the following: mean patient age was 60.9 years (range 21-81 yr); mean APACHE II score, 28.6 (95% confidence interval; 27.4-29.8); and number of failing organs, mean, 4.1 (95% confidence interval; 3.8-4.4). At commencement of continuous venovenous hemofiltration with dialysis, 79% of patients were receiving inotropic drugs and 72% were septic, and, in 35%, bacteremia or fungemia was demonstrated. Renal replacement therapy was applied for a mean duration of 186.2 hours (95% confidence interval; 149.2-223.7), with a mean hourly net ultrafiltrate production of 621 mL (95% confidence interval; 594-648) and a mean urea clearance of 28.1 mL/min (95% confidence interval; 26.7-29.5). Azotemia was controlled in all patients (plasma urea < 30 mmol/L). During the more than 18,000 hours of treatment, there was no therapy-associated hemodynamic instability. Complications were rare. They included two cases of hemofilter rupture with minor blood loss and a single case of bleeding at the site of the vascular-access catheter. Forty-three patients survived to ICU discharge, and 40 survived to hospital discharge. Continuous venovenous hemodiafiltration is a safe and an effective form of renal replacement therapy in critically ill patients. In such patients, who have a high predicted mortality rate, it was associated with a 40% survival rate. These findings suggests that continuous venovenous hemodiafiltration may be ideally suited to patients with multisystem organ failure with acute renal failure.
APACHE↗
The God game no more. The feds crack down on a human cloning lab.
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Cloning, Organism↗
Tumor necrosis factor clearances during veno-venous hemodiafiltration in the critically ill.
Tumor necrosis factor alpha (TNF) is a mediator of injury in the critically ill. Its small molecular size (17 kd) should allow its clearance during continuous hemodiafiltration (CHD). The authors studied TNF extraction in 12 critically ill patients (APACHE II score 26.3 mean; range, 19-34) receiving CHD. Tumor necrosis factor levels were measured in prefiltered and filtered blood and ultradiafiltrate at 0.4 and 24 hours of therapy. Before CHD, mean plasma TNF levels were 261 pg/ml (95% confidence interval [CI]: 184-578) and 291 pg/ml (95% CI: 0-589) after 24 hours. There were no statistically significant differences between prefilter and postfilter TNF levels. Most ultradiafiltrate samples (74%) contained demonstrable TNF (mean, 314 pg/ml; 95% CI: 67-561). Daily TNF excretion was a mean of 15.9 micrograms (+5.6 standard error [SE]), with a mean daily clearance of 27.5 L (95% CI: 2.5-52.5). The authors conclude that significant amounts of TNF are excreted in the ultradiafiltrate during CHD. This observation may provide a rationale for use of similar therapies in critically ill patients in the absence of conventional indications for dialytic support.
Critical Care↗
In vivo catecholamine extraction during continuous hemodiafiltration in inotrope-dependent patients.
Many critically ill patients require inotropic or vasopressor support to maintain adequate oxygen delivery. Removal of catecholamines by continuous hemodiafiltration (CHD) could alter exogenous catecholamine requirements. The authors have studied hemodynamic state, catecholamine clearances, and catecholamine requirements in 12 critically ill patients (mean APACHE II score, 24.5) receiving CHD. Hemodynamic parameters were assessed before CHD initiation, and at 4 and 24 hours of therapy. Simultaneous determinations of serum and ultradiafiltrate dopamine (D), norepinephrine (NE), and epinephrine (E) concentrations were obtained. There were no significant changes in any of many hemodynamic parameters measured during CHD. Mean catecholamine requirements were not altered by CHD. Plasma catecholamine levels were not significantly affected by CHD (mean values at 0, 4, and 24 hours: D: 10,801, 12,056, and 8,797 pg/ml; NE: 1124, 566, and 926 pg/ml; E: 1,420, 1,383, and 843 pg/ml). Catecholamine clearances from CHD (D:43.7 ml/min; NE: 43.5 ml/min; and E: 46.6 ml/min) resulted in daily excretion of only 379 micrograms D, 32.9 micrograms NE, and 37.2 micrograms E. Clearances of catecholamines by CHD represented a daily loss of less than 0.1% of the administered load. In conclusion, although CHD can remove circulating catecholamines, cumulative daily catecholamine extraction is minimal in pharmacologic terms, and has no impact on hemodynamic status.
Acute Kidney Injury↗
Continuous venovenous hemodiafiltration compared with conventional dialysis in critically ill patients with acute renal failure.
The morbidity and mortality benefits of new forms of continuous renal replacement therapy remain controversial. The authors have compared a cohort of consecutive prospectively studied critically ill patients with acute renal failure treated with continuous venovenous hemodiafiltration (CVVHD) (n = 76) to a previously described antecedent group of patients treated in intensive care with intermittent hemodialysis or peritoneal dialysis (conventional dialysis [CD]) (n = 84). Patients were comparable for mean age, gender distribution, and mean number of failing organs (CVVHD: 4; CD: 3.9). CVVHD patients were more severely ill as measured by APACHE II score (CVVHD: score of 29; CD: score of 25.8). Despite their greater illness severity, CVVHD patients more often survived to hospital discharge (CVVHD: 40.8%) than did CD patients (CD: 29.8%; NS). After adjustment for illness severity, in patients with two, three, or four failing organs, survival was 54.3% for CVVHD versus 29.3% for CD (p < 0.01). Survival was 48% for CVVHD patients with an intermediate APACHE II score (24 to 29), compared with 12.5% for comparable CD patients (p < 0.01). No statistically significant differences were seen at either extreme of illness severity. Complications were significantly fewer during CVVHD (1 vs. 18). These data support the view that CVVHD reduces morbidity and mortality in critically ill patients with acute renal failure.
Acute Kidney Injury↗