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PubMed2004

The effect of isolated ultrafiltration on Doppler-derived indices of left ventricular diastolic function.

BACKGROUND: Haemodialysis (HD) is associated with acute changes simultaneously in fluid status (ultrafiltration) and in many biochemical parameters (dialysis). Reports on the effects of these changes on left ventricular (LV) diastolic function are scant. This study evaluated the effect of isolated ultrafiltration (UF) and subsequent HD with minimal fluid removal on Doppler-derived indices of LV diastolic function in patients who were asymptomatic and stable on HD. METHODS: In 11 HD cases, the 5 h treatment session was divided into a 2.5 h period of fluid removal without dialysis (UF phase) and 2.5 h of dialysis with minimal fluid removal (HD phase). We examined the following parameters of LV diastolic function echocardiographically: early rapid filling (Emax), atrial peak filling (Amax), Emax/Amax ratio, isovolumic relaxation time (IVRT) and deceleration time of the E-wave (DT). RESULTS: During the UF phase, Emax decreased from 0.82 +/- 0.2 to 0.62 +/- 0.2 m/s (P = 0.003), Amax decreased from 0.72 +/- 0.2 to 0.63 +/- 0.2 m/s (P = 0.042) and the ratio Emax/Amax did not change (P = NS). During the HD phase, Emax increased from 0.62 +/- 0.2 to 0.72 +/- 0.2 m/s (P = 0.018), Amax increased from 0.63 +/- 0.2 to 0.70 +/- 0.3 m/s (P = NS) and the Emax/Amax ratio remained unchanged (P = NS). IVRT was prolonged in 10 out of 11 patients at the start of the UF phase and it was further prolonged from 142 +/- 40 to 171 +/- 55 ms (P = 0.03) during the UF phase. IVRT did not alter during the HD phase (P = NS). During the UF phase, DT increased from 175 +/- 83 to 244 +/- 119 and it decreased from 244+/-119 to 209 +/- 98 in the HD phase, but both changes were statistically insignificant. No statistically significant correlations were observed between the changes in the Doppler indices of diastolic function and changes in biochemical parameters during the HD phase. CONCLUSIONS: UF affects the parameters Emax, Amax and IVRT used to evaluate LV diastolic function. The changes in Emax and Amax during the HD phase are due to fluid refilling from tissues into the blood space, HD as such having no effect on Doppler indices. However, isolated UF or HD does not affect the Emax/Amax ratio. Emax and IVRT seem to be the most volume-sensitive parameters.

Female↗
PubMed2000

Elimination of recombinant hirudin by modified ultrafiltration during simulated cardiopulmonary bypass: assessment of different filter systems.

UNLABELLED: Recombinant hirudin (r-hirudin) is being used increasingly in patients with heparin-induced thrombocytopenia type II. Renal failure has been demonstrated to prolong the half-life of r-hirudin and to cause bleeding in patients who have undergone cardiopulmonary bypass (CPB). We assessed the ability of different filter systems for modified ultrafiltration to eliminate r-hirudin in vitro using simulated CPB. r-Hirudin concentration was measured (chromogenic laboratory standard plus ecarin clotting time) before and after filtration, and its elimination was calculated using both controlled system flow and arterial inflow (separate pump). Four hemofilters (Renoflow II, Baxter; Arylane H4, Cobe; Ultraflux AV 600, Fresenius; and BCS 110 Plus, Iostra) and two plasmapheresis filter systems (ASAHI Plasmaflow OP, Diamed; and PF 2000 N, Gambro) were assessed (5 filters of each brand = 30 filters) in a closed in vitro CPB system applying conditions usually occurring during CPB. Ten plasmapheresis filters showed a greater ability than 20 hemofilters to eliminate r-hirudin (60%-70% vs 15%-42%) within the shortest time (80 vs 180 s). Among the four hemofilter systems, the Arylane H4 filter provided the most effective (42%) r-hirudin elimination. Elimination of r-hirudin was markedly improved using plasmapheresis systems, compared with hemofilter systems. Our findings may be relevant to patients with impaired renal function, who have been administered r-hirudin during CPB. IMPLICATIONS: Modified ultrafiltration may enhance the elimination of recombinant-hirudin, although plasmapheresis systems provide the most rapid and complete elimination of recombinant-hirudin during simulated cardiopulmonary bypass. The decision to use a specific system will ultimately depend on the prevailing clinical situation and overall health of the patient.

Adult↗
PubMedDate not supplied

A new method to control ultrafiltration in conventional continuous renal replacement therapy.

Conventional continuous arteriovenous hemofiltration/hemodialysis (CAVH/D) and slow continuous ultrafiltration (SCUF) are types of continuous renal replacement therapy (CRRT) in which the ultrafiltrate (UF) volume is controlled imprecisely with a UF clamp, which is labor intensive, demanding frequent adjustment to preclude excessive fluid removal. We devised a simple method for precise control of the UF volume. Seven CRRTs in the form of CAVH, CAVHD, and SCUF were performed in four patients with massive edema. A standard circuit was created in each case using blood tubing sets and an HF 400 hemofilter obtained from MinnTech. Standard intravenous infusion tubing connected to an infusion pump (IMED, Gemini PC-2 volumetric pump/controller) with its proximal end inserted into the dialysate port at the venous end of the hemofilter, and the distal end draining into a plastic bag, was used to control the UF rate. Dialysis was added to the circuit using another pump connected to the dialysate port at the arterial end of the hemofilter. Treatment time ranged from 27 to 78 hours. Target fluid removal was achieved in all treatments, and the net UF rate required only once daily adjustment for total fluid intake. Mean time to reporting a problem by the intensive care nurse was 30 hours (range, 25-30 hours), and mean time to filter clotting was 38 hours (range, 27-40 hours). This set-up is less labor intensive, more cost effective, and is applicable in areas lacking automated machines. Future development of tubing for UF designed as above may further reduce cost.

Adult↗
PubMedDate not supplied

Technique and results for integration of the quest MPS all-blood cardioplegia delivery unit for modified ultrafiltration.

All blood cardioplegia delivery units offer the advantage of removing additional crystalloid volumes associated with multidose crystalloid or 4:1 blood cardioplegia. Further reductions in crystalloid and prime volumes can be achieved if the cardioplegia delivery unit can be integrated as the modified ultrafiltration (MUF) unit as well. This article reports our technique and results for integration of the Quest MPS all-blood cardioplegia delivery unit (Quest Medical, Allen, TX) for modified ultrafiltration. The charts of 50 consecutive patients were reviewed. Patient age ranged from 3 days to 5 years. There were nine neonates. Patient weight ranged from 1.7 to 20.4 kg. Standard prime volumes were 400 cc for patients weighing less than 12 kg, and 800 cc for patients weighing more than 12 kg. Cardiopulmonary bypass time ranged from 32 to 231 minutes. All patients were perfused with corporeal temperatures above 31 degrees C except Norwood cases. MUF time ranged from 5 to 15 minutes with an average of 10.2 minutes. Volume removed ranged from 100 to 600 cc with an average of 239 cc. There was one mortality (2%), which was unrelated to MUF. Additional prime volume was not required to initiate MUF through the MPS cardioplegia unit. The Quest MPS all-blood CPG unit can be safely and effectively integrated as a MUF unit without additional prime volumes. This approach allows for mild hypothermic cardiopulmonary bypass, multidose all-blood CPG, and MUF to be used with tremendous limitation of crystalloid usage.

Cardiopulmonary Bypass↗
PubMedDate not supplied

Slow continuous ultrafiltration with bound solute dialysis.

Bound solute dialysis (BSD), often referred to as "albumin dialysis" (practiced clinically as the molecular adsorbents recirculating system, MARS, or single-pass albumin dialysis, SPAD) or "sorbent dialysis" (practiced clinically as the charcoal-based Biologic-DT), is based upon the thermodynamic principle that the driving force for solute mass transfer across a dialysis membrane is the difference in free solute concentration across the membrane. The clinically relevant practice of slow continuous ultrafiltration (SCUF) for maintenance of patients with liver failure is analyzed in conjunction with BSD. The primary dimensionless operating parameters that describe SCUF-BSD include (1) beta, the dialysate/blood binder concentration ratio; (2) kappa, the dialyzer mass transfer/blood flow rate ratio; (3) alpha, the dialysate/blood flow rate ratio; and, (4) gamma, the ultrafiltration/blood flow rate ratio. Results from mathematical modeling of solute removal during a single pass through a dialyzer and solute removal from a one-compartment model indicate that solute removal is remarkably insensitive to gamma. Solute removal approaches an asymptote (improvement in theoretical clearance over that obtainable with no binder in the dialysate) with increasing beta that is dependent on kappa and independent of alpha. The amount of binder required to approach the asymptote decreases with increasing solute-binder equilibrium constant, i.e., more strongly bound solutes require less binder in the dialysate. The results of experimental observations over a range of blood flow rates, 100 to 180 mL/min, dialysate flow rates, 600 to 2150 mL/h, ultrafiltration rates, 0 to 220 mL/h, and dialysate/blood albumin concentration ratios, beta = 0.01 to 0.04, were independently predicted remarkably well by the one-compartment model (with no adjustable parameters) based on BSD principles.

Albumins↗
PubMed2004

Vector length as a proxy for the adequacy of ultrafiltration in hemodialysis.

BACKGROUND: Evaluation of dialysis adequacy has focused on parameters of solute (principally urea) clearance. Relatively little attention has been paid to the adequacy of ultrafiltration. At a given phase angle, the bioimpedance vector length reflects the degree of tissue hydration, as the vector lengthens with ultrafiltration. METHODS: We determined the relative risk of death associated with different bioimpedance vector lengths in a 3009 patient hemodialysis cohort using proportional hazards regression. RESULTS: The mean phase angle was 4.8 degrees, and the mean vector length 300 +/- 70 ohm/m (range 140 to 630 ohm/m). Vector length was much longer in women than men (mean 340 vs. 270 ohm/m) and significantly longer in African Americans and patients without diabetes. Adjusted for the effects of age, gender, race, diabetes, vintage, weight, albumin, prealbumin, creatinine, hemoglobin, ferritin, and dialysis dose, the relative risk (RR) of death was 0.75 (95% CI 0.57 to 0.88) per 100 ohm/m decrease in vector length. The effect of vector length on RR was somewhat more pronounced among men (vector length x gender interaction, P= 0.07). Considering vector length of 300 to 350 ohm/m as the referent category, the RRs of death were 1.54 (95% CI 1.08 to 2.21) and 2.83 (95% CI 1.55 to 5.14) for patients with vector length 200 to 250 and <200 ohm/m, respectively. CONCLUSION: Shorter predialysis bioimpedance vectors, indicating greater soft tissue hydration, were associated with diminished survival in hemodialysis patients. These findings validate clinical observations linking longevity to maintenance of dry body weight.

Adult↗
PubMed1978

Tolerance to high ultrafiltration rates during closed batch hemodialysis.

The tolerance to high levels of ultrafiltration that has been observed when using a RP-6 dialyzer with polyacrylonitrile membrane and a closed batch dialysate delivery system has led the authors to put patients on a free sodium and fluid intake. Eight patients were put on such a diet for six months. They have been dialyzed four to five hours, three times per week, on a RP-6-Rhodial 75. The mean intersession weight gain was 4.29+/-0.18 Kg after three days for a mean predialytic body weight of 63.55+/-2.54 Kg. Mean predialytic blood pressure was 1.38+/-4 mmHg for systolic pressure and 82+/-5 mmHg for diastolic pressure. Mean ultrafiltrate volume was 4.86+/-0.36 liters which corresponds to a sodium output of 661.3+/-49.5 mEq. Total plasma protein and hematocrit increased 18.8+/-3.34% and 19.13+/-3.22%, respectively, when the pre and post-dialytic values were compared. No clinical sign of fluid overload (dyspnea, edema, etc.) was noted in these patients. Cardiothoracic index remained in the normal range. This tolerance is due, possibly, to the high sodium concentration (145 mEq/L) in the dialysate. The free sodium and water diet may contribute to a better rehabilitation.

Adult↗
PubMed1992

Antithrombogenicity of polyacrylonitrile-polyethyleneoxide hollow fiber membrane developed for designing an antithrombogenic continuous ultrafiltration system.

To develop a continuous arteriovenous hemofiltration (CAVH) system, which does not need systemic anticoagulation, for patients of acute renal failure having bleeding tendencies, a totally antithrombogenic continuous ultrafiltration system (ACUS) was designed, which consists of an antithrombogenic polyacrylonitrile-polyethyleneoxide (PAN-PEO) hollow fiber membrane and ionically heparin-bound catheter, tubing, and module header. Antithrombogenicity of PAN-PEO membrane, which occupies more than 90% of total inner surface area of ACUS, was considered to be due to highly concentrated PEO near the inner surface of the membrane and the finely dispersed (less than 500 A) microstructure of the inner surface. ACUS was applied to 24 patients without systemic anticoagulation, and one filter worked for an average of 32 h without deteriorating their bleeding tendencies. Any significant changes in major parameters of biocompatibility during those treatments were not observed. More than 200 ml/h of ultrafiltrate was obtained even under very low mean blood pressure, less than 70 mm Hg. Based upon these results, ACUS was concluded to be suitable for mild and sustained treatment to control fluid and electrolyte balance in patients of acute renal failure with bleeding complications.

Acrylic Resins↗
PubMed2005

Switch from bicarbonate hemodialysis to hemodiafiltration with online regeneration of the ultrafiltrate (HFR): effects on nutritional status, microinflammation, and beta-microglobulin.

BACKGROUND: Hemodiafiltration (HFR) with on-line regeneration of the ultrafiltrate, a technique of hemodiafiltration in which the ultrafiltrate passes through a cartridge containing uncoated charcoal, has been shown to be safe, simple, and well tolerated and has been claimed to improve nutritional status or to prevent its deterioration while decreasing the inflammatory response via a reduced production of proinflammatory cytokines. The purpose of the present prospective study was to ascertain whether HRF improves the nutritional status, reduces microinflammation, and decreases serum beta2-microglobulin levels in patients with end-stage renal disease (ESRD). METHODS: Eight patients, four males and four females, with a mean age of 49.4 +/- 16.8 years, stable on hemodialysis over a period of 8.7 +/- 6.1 years and on standard 4-4.5 h three-times-a-week bicarbonate hemodialysis, were switched to three-times-a-week, 4-h HFR. At baseline and every two months for 12 months at mid-week, serum levels of urea, creatinine, albumin, total cholesterol, C-reactive protein, fibrinogen, complement, ferritin, beta2-microglobulin, intact parathyroid hormone (PTH), hemoglobin concentrations, and hematocrit and the EPO weekly dose were determined. At baseline and at the end of the study, the Malnutrition Inflammatory Score (MIS) was calculated. RESULTS: Nutritional and inflammatory parameters remained constant during the 12-month period of the study. After 12 months of HFR, the MIS trended to be lower, but the difference was not statistically significant. Serum beta2-microglobulin and PTH levels remained constant during all time intervals. Neither hematocrit nor hemoglobin changed over the course of the study as well as the weekly EPO dose. CONCLUSION: The change from bicarbonate hemodialysis to HFR was safe and well tolerated but was not associated with an improvement of nutritional and inflammatory parameters or a reduction of serum beta2-microglobulin levels.

Analysis of Variance↗
PubMedDate not supplied

The effect of profiling dialysate sodium and ultrafiltration on patient comfort and cardiovascular stability during haemodialysis.

The aim of this study was to investigate what affect profiling dialysate sodium and ultrafiltration rate had on cardiovascular stability during haemodialysis, and if there was any effect on patients' fluid balance, thirst, serum sodium levels, blood pressure, or comfort and tolerance. The past decade has seen major advances in haemodialysis machine technology. Parallel developments have included profiling dialysate sodium levels and fluid removal during dialysis. However, some dialysis centres do not use profiling due to fears of long-term detrimental effects, especially with regard to hypertension and fluid control. Within my own workplace, approximately 30% of haemodialysis treatments utilise either sodium or ultrafiltration profiling, or a combination of both. Anecdotally, we have seen an increase in cardiovascular stability and haemodialysis tolerance. The aim of this study was to identify the effects of profiling haemodialysis, to ensure that the treatment we offer patients is safe and effective.

Analysis of Variance↗
PubMed1989

Enhancing effect of serum ultrafiltrate on the activity of cephalosporins against gram-negative bacilli.

A few studies have suggested that the inhibitory effect of serum on activity of broad-spectrum cephalosporins is less than that predicted by the degree of protein binding. Microdilution MICs of ceftriaxone, cefoperazone, moxalactam, and ceftizoxime were therefore determined against ATCC and clinical strains of Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus in Mueller-Hinton broth containing either human albumin (as 0, 2.5, or 5% solution) or heat-inactivated human serum (as 0, 25, 50, or 95% solution). Arithmetic linear dilutions were used to improve accuracy. For standard bacterial strains, MICs in the presence of 5% albumin were higher than in broth alone by multiples of 10.9 to 21 for ceftriaxone, 5.5 to 16.4 for cefoperazone, 1.9 to 3.7 for moxalactam, and 1.1 to 1.4 for ceftizoxime, as expected by their protein binding. MICs in the presence of 95% serum were similar to those in 5% albumin for all four drugs against S. aureus and P. aeruginosa but were 2.2- to 4.8-fold lower (P less than 0.001) against E. coli and K. pneumoniae. Similar findings were observed at lower protein concentrations and with clinical isolates, except that for some strains of P. aeruginosa MICs were lower in serum than in albumin. Individual sera from five subjects gave comparable results. The addition of serum ultrafiltrate to albumin-containing solutions reduced MICs of ceftriaxone and cefoperazone 1.6- to 7.4-fold against E. coli and K. pneumoniae (P less than 0.01) but did not alter the MICs for S. aureus. Serum may contain an ultrafiltrable component(s) that enhances the activity of third-generation cephalosporins against many gram-negative bacilli.

Blood Proteins↗
PubMed1972

Acute asymmetrical neuritis associated with rapid ultrafiltration dialysis.

Three patients with chronic renal failure treated by haemodialysis developed acute asymmetrical sensory and motor neuropathies when ultrafiltration was induced to treat oedema. The neuropathies were characteristic of acute mononeuritis multiplex rather than uraemic polyneuritis, and we give our reasons for believing that they were not caused by toxic uraemic metabolites but by an ischaemic process due to vasoconstriction resulting from ultrafiltration.

Acute Disease↗
PubMed1978

Influence of parathyroid hormone on glomerular ultrafiltration in the rat.

Experiments were performed on 22 plasma-expanded Munich-Wistar rats to investigated the effects of parathyroid hormone (PTH) on the determinants of glomerular ultrafiltration. Mean values for single nephron filtration rate (SNGFR), glomerular plasma flow rate (QA), systemic oncotic pressure, and transglomerular hydraulic pressure difference (deltaP) were similar in acutely thyroparathyroidectomized (TPTX) rats and non-TPTX rats. Nevertheless, the glomerular capillary ultrafiltration coefficient (Kf) was uniformly higher in TPTX rats (greater than 0.113 +/- 0.005 (SE) nl/(s.mmHg)] than in non-TPTX controls (0.088 +/- 0.005). In TPTX rats, infusion of a submaximal dose (1 U/kg per min) of PTH resulted in significant decreases in SNGFR at constant QA and deltaP, due primarily to return of Kf to non-TPTX levels. Infusion of 10 U/kg per min of PTH to non-TPTX rats further reduced Kf, on average to 0.042 +/- 0.001 nl/(s.mmHg), leading to further reduction in SNGFR, whereas QA and deltaP again remained constant. These findings suggest that PTH may play an important role in modulating Kf, and consequently, SNGFR.

Animals↗
PubMed2000

Growth factor ultrafiltration in experimental diabetic nephropathy contributes to interstitial fibrosis.

Glomerular proteinuria is a risk factor for progression of chronic renal failure and contributes to renal interstitial fibrosis. In experimental diabetic glomerular sclerosis, there is translocation of high-molecular-weight growth factors, namely, hepatocyte growth factor (HGF) and transforming growth factor (TGF)-beta, from plasma into tubular fluid, both of which act on tubular cells through apical membrane receptors. In the present studies, the hypothesis is examined that ultrafiltered HGF and TGF-beta induce increased expression of extracellular matrix (ECM) proteins directly in tubular cells, or induce increased expression of cytokines that may act on interstitial myofibroblasts. Incubation of cultured tubular cells with recombinant human (rh) TGF-beta modestly raises expression of collagen type III, but rhHGF dose dependently blocks expression of this ECM protein. Both growth factors raise fibronectin expression up to fourfold and increase expression of platelet-derived growth factor (PDGF)-BB up to sixfold, but not of fibroblast growth factor-2. Pooled, diluted glomerular ultrafiltrate that had been collected by nephron micropuncture from rats with diabetic nephropathy (24-30 wk) also raises expression of fibronectin as well as PDGF-BB in proximal tubular cells. In the presence of neutralizing antibodies that block actions of HGF and TGF-beta, diabetic rat glomerular ultrafiltrate fails to increase tubular cell PDGF-BB expression. In NRK-49F renal interstitial myofibroblasts, rhPDGF-BB, in turn, raises the expression of collagen type III but not type I or fibronectin. The findings provide evidence for ultrafiltered HGF and TGF-beta to contribute to interstitial accumulation of ECM proteins by direct effects on tubular cells as well as indirect mechanisms, via PDGF-BB and its action on myofibroblasts. These events may be important mechanisms of proteinuria-induced renal interstitial fibrosis and accelerated progression of chronic renal failure in diabetic nephropathy and perhaps other proteinuric glomerular diseases.

Animals↗
PubMed2001

Ultrafiltration in diuretic-resistant volume overload in nephrotic syndrome and patients with ascites due to chronic liver disease.

Patients with nephrotic syndrome and those with cirrhosis are predisposed to salt and water retention due to reduced renal sodium excretion. Despite the prescription of low-sodium diets and diuretics, some patients develop refractory oedema. When other medical treatments have been ineffective, isolated ultrafiltration and hemofiltration have been successfully used to treat refractory nephrotic patients. Following fluid removal, patients become responsive to diuretics. In cirrhotic patients, re-infusion of ascites and paracentesis with albumin infusion have been reported to be equally effective in managing ascites refractory to diuretic and other standard therapies. Although isolated ultrafiltration has not been successful in controlling ascitic fluid, hemofiltration has been shown to be beneficial, whereas standard intermittent hemodialysis has been reported to be ineffective.

Ascites↗
PubMed2005

Slow continuous intravenous plasmapheresis (SCIP): clinical applications and hemostability of extracorporeal ultrafiltration.

An intravenous plasmapheresis catheter which excludes >99.4% of platelets from external ultrafiltration circuits is currently undergoing safety and efficacy trials for fluid removal from NYHA class II-IV congestive heart failure patients resistant to diuretic drug therapy. In animals, the SCIP catheter allowed a four fold increase in ultrafiltration efficiency without hemolysis, hemoinstability or external cartridge changes in 72 hours of treatment. Further, systemic anticoagulation was not required. These techniques might be envisioned for treatment of fluid overload in heart failure, surgery or trauma and may have applications in therapeutic apheresis, venous thrombosis, liver disease or autologous tissue engineering.

Animals↗
PubMed1982

Compensatory renal hypertrophy in Sprague-Dawley rats: glomerular ultrafiltration dynamics.

The factors responsible for the increase in glomerular filtration rate associated with compensatory hypertrophy in Sprague-Dawley rats were studied 2 weeks following uninephrectomy. In sham-operated rats, the single nephron glomerular filtration rate (SNGFR) was 40 nl/min and the calculated glomerular plasma flow (GPF) was 138 nl/min. Proximal intratubular free-flow (PT) and stop-flow (PSF) hydrostatic pressures were 12 and 34 mm/Hg, respectively. The estimated glomerular capillary hydrostatic pressure (PGC) was 49 mm Hg and the estimated efferent effective ultrafiltration pressure (PUFEA) was 12 mm Hg, indicatng filtration pressure disequilibrium. The specific ultrafiltration coefficient was calculated to be 0.039 nl/s . mm Hg per glomerulus. In uninephrectomized rats, SNGFR increased to 61 nl/min and the calculated GPF increased to 266 nl/min. PT was 12 mm Hg; PGCe was 49 mm Hg and PUFEA was 15 mm Hg. Kf was calculated to be 0.053 nl/s . mm Hg per glomerulus. These data indicate that in Sprague-Dawley rats under conditions of filtration pressure disequilibrium, the increase in GFR associated with compensatory hypertrophy is in part related to a significant change in Kf.

Adaptation, Physiological↗
PubMed1989

Ultrafiltration: a rational treatment for heart failure.

Patients with late-stage congestive heart failure with significant fluid overload respond well to ultrafiltration. The response is relatively long-standing and includes enhanced responsiveness to diuretics. Ultrafiltration is simple and highly cost effective. Furthermore, it possesses many advantages over massive or drastic pharmacological therapy. In the following paper, we report our own experience and review the world literature.

Blood Volume↗