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PubMed1995

Continuous hemofiltration as blood purification in sepsis.

Continuous hemofiltration was first described as a new form of renal replacement for critically ill patients in the late 1970s. Since then, it has undergone remarkable technical and conceptual modifications and has become a widely used form of dialytic therapy in the ICU. More recent insights into the pathogenesis of sepsis and the role of soluble molecules in the mediation of organ injury during septic shock have led to a resurgence of the concept of blood purification during life-threatening infection. Recent studies have confirmed that cytokine extraction occurs in vivo in humans during continuous hemofiltration and that other smaller, potentially noxious molecules such as platelet-activating factor, complement factors C5a and C3a, and thromboxane are also removed from the circulation of septic patients or animals. Experimental studies have shown that continuous hemofiltration has beneficial hemodynamic effects in septic animals and that such effects may correlate with the intensity of ultrafiltration. Cardiac function also appears to improve and myocardial depressant factors are removed from the circulation. Continuous hemofiltration offers some promise as an adjunctive form of treatment in severe sepsis.

Animals↗

PubMedDate not supplied

Regional chemotherapy with hemofiltration: a rationale for a different treatment approach to advanced pancreatic cancer.

BACKGROUND/AIMS: Since 1989, thirty-two patients with advanced, intra-abdominal pancreatic cancer were treated with regional chemotherapy in combination with extracorporeal hemofiltration. PATIENTS AND METHODS: Eleven patients had locally advanced, unresectable cancer, and ten had advanced disease with liver metastases. Three patients had developed liver metastases following a radical resection. One patient had an incomplete resection with local residual disease, and a second had developed a local recurrence after a radical resection. One patient had an unresectable cystadenocarcinoma. Five patients had failed prior systemic therapies for unresectable pancreatic cancer. The patients underwent 85 treatments with regional chemotherapy plus hemofiltration, an average of 2.7 treatments per patient. RESULTS: Of 21 patients treated primarily with regional chemotherapy plus hemofiltration, there were two complete responses (9%) and eight partial responses (38%), an overall total response rate of 47%. The average survival for patients with Stage II/III localized, unresectable disease is 13 months and that for Stage IV unresectable disease with liver metastases is 9 months. CONCLUSIONS: Patients with recurrent disease following a radical resection or having failed prior systemic therapies generally had no benefit from regional chemotherapy plus hemofiltration.

Adenocarcinoma↗

PubMed1997

Effects of continuous venovenous hemofiltration on cardiopulmonary function in a porcine model of endotoxin-induced shock.

OBJECTIVE: To determine whether continuous venovenous hemofiltration, proposed to remove inflammatory mediators from circulation, would resolve cardiopulmonary derangements in a model of established endotoxic shock. ANIMALS: 16 clinically normal pigs. PROCEDURE: Endotoxin was infused, IV, into anesthetized pigs for a total of 50 minutes. Thirty minutes after termination of the infusion period, extracorporeal circulation was initiated through a 50-kd diafilter, or past the filter without ultrafiltrate formation. Cardiac and respiratory variables were monitored for a period of 4 hours. RESULTS: Infusion of lipopolysaccharide resulted in a severe hypodynamic circulatory state, with significant decreases in mean arterial pressure and cardiac output concurrent with a significant increase in pulmonary arterial pressure. Hemofiltration was not associated with any correction of lipopolysaccharide-induced cardiopulmonary derangements. CONCLUSIONS: Continuous venovenous hemofiltration, as used in this acute experiment, did not improve cardiopulmonary dysfunction during endotoxic shock. CLINICAL RELEVANCE: Continuous venovenous hemofiltration needs further investigation before it can be recommended as a clinically effective treatment.

Animals↗

PubMed1998

Biocompatibility evaluation of polyamide hemofiltration.

INTRODUCTION: Postdilution hemofiltration with a polyamide membrane is a renal replacement technique widely used, but very little information is available regarding the biocompatibility of this treatment. In this paper we report the results of an acute study of the biocompatibility of polyamide hemofiltration. PATIENTS AND METHODS: Complement activation such as C3a and C5a Des Arg (RIA), granulocyte degranulation like alpha 1 elastase intradialytic increase (ELISA) and the expression of high affinity membrane receptors for IL-2 (anti-TAC) were determined. Beta 2-microglobulin (RIA) intradialytic decrease, as well as its convective removal, was evaluated. The nature of protein layer adsorbed onto the polyamide membrane, at the end of the dialytic session was investigated with a new immunohistochemical technique. Cell-associated cytokine concentration (like IL-1 beta and IL-1Ra - ELISA) was determined on mononuclear cell lysates. RESULTS: A low degree of complement activation was detected with the polyamide membrane when data were adjusted for hemoconcentration and for 1 m2 of membrane surface area. An important convective removal not only of Beta 2-microglobulin (258+/-20 mg/session), but also of the activated anaphylatoxins (225+/-76 ng/ml for C3a and 22.5+/-4 ng/ml for C5a) was revealed. A marked deposition of all coagulation factors with no detectable amount of immunoglobulins and complement factors was revealed on the polyamide membrane at the end of the dialytic session. No intradialytic (for IL-1beta) (from 14. 1+/-3.0 to 13.5+/-2.9 pg/2.5 x 10(6) cell) and interdialytic (for IL-1Ra) (from 4572+/-1076 to 5408+/-615 pg/2.5 x 10(6) cell) cell-associated cytokine expression was induced by hemofiltration. DISCUSSION AND CONCLUSION: Polyamide hemofiltration is a highly biocompatible technique due to the use of a synthetic membrane with a sterile reinfusion fluid and the convective removal of the activated anaphylatoxins and Beta 2-microglobulin.

Adult↗

PubMed1998

High-volume continuous hemofiltration during cardiopulmonary bypass attenuates pulmonary dysfunction in neonatal lambs after deep hypothermic circulatory arrest.

BACKGROUND: Cardiopulmonary bypass (CPB) induces an inflammatory reaction that activates neutrophils and releases free radicals in tissue. Ischemia-reperfusion further aggravates inflammation. Hemofiltration (HF) could potentially remove inflammatory mediators and reduce injury. This study assessed the effect of continuous high-volume HF during CPB on systemic edema formation and pulmonary function after deep hypothermic circulatory arrest (DHCA). METHODS AND RESULTS: Anesthetized lambs (n = 16) underwent CPB with systemic cooling (40 minutes), DHCA (120 minutes at 18 degrees C), and rewarming (40 minutes). All animals were weaned from CPB and observed for 3 hours after reperfusion. Continuous HF was used in 8 lambs at a flow rate of 300 mL/kg per hour throughout CPB, simultaneously replacing hemofiltration volume with a balanced salt solution (HF group). In 8 control animals, no hemofiltration was performed. Hematocrit remained at 23% to 25% during the experiment in both groups. Pulmonary vascular resistance (PVR), lung dynamic compliance (Cdyn), alveolar-arterial oxygen difference (AaDO2), and total body water content (bioimpedance) were measured. Malondialdehyde (MDA), a product of lipid peroxidation, was assayed in lung tissue. Percent increase of body water content at 180 minutes of reperfusion was significantly lower in the HF group than in control (132 +/- 2% vs 152 +/- 5%, P < 0.005). There was less of a rise in PVR compared with baseline at 180 minutes of reperfusion in the HF group than in control (131 +/- 8% vs 238 +/- 26%, P < 0.005). In addition, percent recovery of Cdyn and AaDO2 in the HF group was preserved significantly (respectively, P < 0.05) 2 hours after reperfusion than in the control group. Lung tissue MDA in the HF group (46.2 +/- 12.6 vs 65.3 +/- 17.1 nmol/L per gram of tissue, P < 0.05) was significantly lower than in the control group. CONCLUSIONS: High-volume, continuous hemofiltration during CPB attenuates systemic edema formation, pulmonary hypertension, the extent of lung dysfunction, and depression of cardiac output and reduces free radical-mediated tissue injury after CPB with DHCA. This technique may have a clinical application to reduce the morbidity rate of CPB.

Animals↗

PubMed1987

Hemofiltration as short-term treatment for refractory congestive heart failure.

Hemofiltration has been suggested as a new therapeutic tool in refractory heart failure. In this study, 11 patients with primary or ischemic heart disease in New York Heart Association class IV, in whom there was no response to medical treatment, were subjected to hemofiltration. The pathophysiologic adjustments promoted by subtraction of plasma water were investigated, and guidelines for an appropriate use of this procedure in heart failure are provided. Fluid was removed from plasma at a rate of 500 ml/hour until either normalization of the right atrial pressure (which was increased in all cases) was achieved or the hematocrit exceeded 50 percent. According to these criteria, the duration of treatment ranged from four to six hours and the total amount of fluid removed was 2,000 to 3,000 ml. In each case, hemofiltration promoted relief of dyspnea and of clinical and radiographic evidence of lung congestion and pleural effusion, and substantially reduced the dependent edema and abdominal girth. These effects were paralleled by progressive decrease of the right (-70 percent) and left (-45 percent) ventricular filling pressures and of the pulmonary arterial pressure and arteriolar resistance, without significant variations in heart rate, aortic pressure, cardiac index, and systemic vascular resistance. Changes in the right atrial and wedge pulmonary pressures are interpreted as reflecting a combined effect of a decrease in pressure on the outside of the heart due to fluid reabsorption (from lung interstitial spaces and pericardial, pleural and abdominal cavities) and of intravascular volume subtraction. The arterial partial pressure of oxygen was raised, the partial pressure of carbon dioxide and pH were unchanged, and urinary output was substantially enhanced by the procedure. The study indicates that: hemofiltration may be a short-term treatment for refractory cardiac insufficiency with overhydration; a filtration rate of 500 ml/hour is effective and safe; and the central venous pressure may be a reliable guide to volume subtraction.

Aged↗

PubMed1986

Fulminant Wilson's disease treated with postdilution hemofiltration and orthotopic liver transplantation.

A 22-yr-old woman presented with fulminant Wilson's disease. The diagnosis was suspected clinically and was later confirmed with chemical and pathologic studies. She presented with acute hepatic failure, hemolysis, and acute anuric renal failure. Postdilution hemofiltration and continuous arteriovenous hemofiltration with oral D-penicillamine allowed removal of a total of 95,700 micrograms of copper; 78,665 micrograms of the total were removed via postdilution hemofiltration alone. On the 57th day, the patient received successful liver and renal transplants. We found that the determination of serum copper was instrumental in the diagnosis of fulminant Wilson's disease, that postdilution hemofiltration allowed a rapid removal of copper in the presence of renal failure, and that, finally, orthotopic liver transplantation should be performed early in the clinical course of these patients. This patient is the longest survivor of this serious condition.

Acute Disease↗

PubMed1982

Hemofiltration treatment of psoriasis.

Eleven patients with severe psoriasis were treated with hemofiltration once weekly for 4 consecutive weeks. Hemofiltration is a method of extracorporeal dialysis that uses a pressure gradient, rather than passive diffusion, to remove small and medium molecular weight substances from the blood. Six of the patients had very substantial clearing of their psoriatic lesions. Five patients had little or no apparent benefit during the course of hemofiltration treatments. They subsequently had dramatic clearing, however, when previously ineffective topical therapy was resumed. No patient had worsening of his condition during the hemofiltration series, and there were no perceived adverse effects.

Adult↗

PubMed1986

Heterogeneity of the cardiovascular response to hemofiltration.

Twenty-one stable maintenance hemodialysis patients were studied in a crossover format with hemofiltration to determine whether the lower incidence of symptomatic hypotension noted with hemofiltration could be correlated with changes in baroreflex function as tested using the cold pressor test and amyl nitrite inhalation study. Baroreflex function remained abnormal and unchanged in all patients in the face of a reduced incidence of symptomatic hypotension. Subdivision of the patients into frequent (greater than 1 episode/treatment) and infrequent (less than 1 episode/treatment) reactors during the hemodialysis control period resulted in the infrequent reactors, showing a significant increase in episodes of symptomatic hypotension/hemofiltration treatment where a significant reduction was noted with the frequent reactors. No clear correlation could be made between the incidence of symptomatic hypotension and the pre- to post-treatment change in body temperature. The presence of pretreatment hypertension, another previously identified correlate of symptomatic hypotension with hemodialysis, also could not be corroborated. Further, changes from baseline predialysis values in mean arterial pressure noted with hemofiltration could not be correlated with a changed incidence of symptomatic hypotension. We conclude that previously identified correlates of symptomatic hypotension noted in the hemodialysis setting may be dissociated during treatment with hemofiltration and that there is a heterogeneous patient response to this treatment. These data suggest that there are additional, as yet undetermined, pathophysiologic events that underly the symptomatic hypotension of artificial kidney treatment.

Adult↗

PubMed2004

Severe hypotension during hemofiltration in an uremic patient with metabolic alkalosis.

We describe a case of medication induced metabolic alkalosis in a maintenance dialysis patient who developed severe hypotension while undergoing a lactate hemofiltration procedure. A 73-year-old man with ESRD due to renovascular disease was used to ingesting up to 30 grams per day of a non-prescription medication (Effervescent granulare 250 grams, CRASTAN, Pisa Italy) consisting of sodium bicarbonate, citric acid, glucose and lemon flavor. For technical problem lactate hemofiltration was performed and thirty minutes after dialysis was started a severe symptomatic hypotension occurred (blood pressure 65/35 mmHg). Lactate hemofiltration was suspended and one-hour later standard bicarbonate dialysis was performed without any clinical problem. The different mechanisms in acidosis buffering occurring in lactate and bicarbonate hemofiltration were discussed.

Aged↗

PubMed1985

Continuous arteriovenous hemofiltration as an adjunctive therapy for septic shock.

The effects of continuous arteriovenous hemofiltration were studied in septic patients with acute renal failure and gross fluid overload. Hemofiltration was performed for a mean of 7 days per patient (range 1 to 14 days). The mean filtration volume was 3.64 L/day. The mean total ultrafiltration volume per patient was 25.5 L. The patients were hemodynamically stable during hemofiltration, as indicated by measurements of arterial blood pressure, CVP, pulmonary artery pressure, pulmonary artery wedge pressure, and cardiac output. Multiple simultaneous measurements in both serum and ultrafiltrate showed a very close correlation for sodium, potassium, phosphorus, urea and creatinine levels. There was no detectable protein in the ultrafiltrate. The calcium concentration in the ultrafiltrate was relatively low. Finally, antibiotic levels in the ultrafiltrate were almost equal to serum levels. There were no significant complications; in this series of patients hemofiltration was a safe and effective treatment of fluid overload.

Acute Kidney Injury↗

PubMed1978

Clinical and technical aspects of hemofiltration.

The removal of uremic substances in hemofiltration, in contrast to hemodialysis, is achieved by means of a convective transport across membranes of high porosity. Since 1974, more than 30 patients with chronic renal insufficiency have been treated with regular hemofiltration three times weekly for four to five hours each. After completing a pilot study, a controlled study to compare hemodialysis and hemofiltration was initiated during January, 1978. A normalization of blood pressure in patients with severe hypertension, and remarkable stability of the circulatory system, even after dehydration in patients who had hypotension in spite of fluid overload, could be demonstrated. Hemofiltration is preferred, especially in older patients with cardiovascular or cerebrovascular problems, because of its lower frequency of hypotensive episodes compared to dialysis. An important aim--the miniaturization of the artificial kidney--has not yet been achieved, however, because of the necessity for an extensive monitoring system for the exact proportioning of the sterile substitution fluid. First results in the application of a fluid regeneration system consising of a charcoal cartridge and a bioelectric cell, for degradation of urea, are presented.

Blood Pressure↗

PubMed1978

Preparative isolation of middle molecular weight fractions from the hemofiltrate of patients with chronic uremia.

Fractions in the molecular weight range of the so-called middle molecules (500--3000 daltons) were isolated on a preparative scale from hemofiltrate of patients. Hemofiltration was performed with an RP-6 dialyzer using a predilution technique. The hemofiltrate was concentrated and desalinated by reverse osmosis with membranes with a normal cut-off of 500 daltons. The retentate was freeze-dried, redissolved in volatile buffer and fractionated on Sephadex G-15 macrocolumns. The middle molecule molecular weight range in the elution profiles (detected at 206 and 280 nm simultaneously) was marked with peptides. Isolated fractions in the middle molecule molecular weight range showed strong inhibitory activity upon 3H-thymidine incorporation into rat bone-marrow cells in vitro. The described combination of hemofiltration, reverse osmosis and gel chromatography is suggested as a useful approach to the isolation of these ninhydrin-positive substances which, according to their proved heterogeneity, are to be subfractionated by further procedures.

Chromatography, Gel↗

PubMed1987

Massive plasma arginine vasopressin (AVP) removal during hemofiltration stimulates AVP secretion in humans.

Arginine vasopressin (AVP) was measured in the plasma and its ultrafiltrate in 11 patients with end-stage renal failure treated by hemofiltration. Nineteen liters of ultrafiltrate were produced in 170 min and continuously replaced by an isoosmotic substitution fluid to maintain constant body weight. Plasma and ultrafiltrate AVP concentrations were not significantly different and did not change with time. The AVP clearance rate due to hemofiltration was 114 +/- 2.6 (+/- SE) ml/min, which represented more than two thirds of the predicted MCR in these patients. Corrected plasma osmolality, body weight, mean blood pressure, hematocrit, and PRA did not change during the hemofiltration session. These results indicate that there is a compensatory increase in AVP production which maintains plasma AVP unchanged in response to the increased MCR resulting from hemofiltration. The responsible stimulus could be a direct effect of the decrease in plasma AVP on the AVP-secreting neurones. Alternatively, ultrafiltration itself, via the hemodynamic changes it produces or the loss of an unrecognized inhibitory substance, may be the stimulus to AVP secretion.

Adult↗

PubMed1977

Lipid metabolism in uremia: effect of regular hemofiltration and hemodialysis treatment.

Plasma triglycerides and cholesterol were measured in controls, non-dialyzed patients with chronic renal insufficiency and uremic patients receiving either regular hemodialysis or hemofiltration treatment. Normal and elevated cholesterol levels remained generally unaffected by chronic hemodialysis and hemofiltration as well. Whereas long-term hemodialysis even up to 59 months (home-dialysis) was unable to improve hypertriglyceridemia, patients undergoing regular hemofiltration showed a prolonged decrease in plasma triglycerides. In one case, excessive hypertriglyceridemia still existing after five years of chronic hemodialysis could be normalized by hemofiltration.

Adult↗

PubMed1977

Alterations of clotting factors and platelets during hemofiltration.

The influence of hemofiltration on the number of platelets and on coagulation factors was investigated in patients with chronic renal insufficiency. These investigations were done on 12 patients during 22 treatments with hemofiltration. Blood samples were taken before hemofiltration, 10, 30 and 120 minutes after the beginning of the treatment and at the end of hemofiltration. In comparison to the original values we found a loss of platelets, a small decrease in the concentration of fibrinogen and a small increase in the fibrin monomer complex, plasminogen, antithrombin III, alpha1-antitrypsin and in alpha2-macroglobulin. The thrombin time, the partial thromboplastin time and Quick's test showed that the blood of these patients contained sufficient hepatin. Use of fibrin plates (Astrup) showed no signs of fibrinolytic activity. Compared to the results, which were obtained some years ago during hemodialysis, we found a smaller extent of alterations of blood coagulation factors and number of platelets.

Antithrombins↗

PubMed1977

Parathyroid hormone-, 25-OH-vitamin D-, and digoxin levels in patients treated by chronic hemofiltration.

Immunoreactive parathyroid hormone (iPTH) was measured in the serum and filtrate before, during and after hemofiltration. iPTH regularly declines during hemofiltration; one patient, investigated for a longer period, showed a normalization of iPTH serum level with this treatment. The iPTH values found in the hemofiltrate were remarkably high, a finding that could be explained by non-specific effects, by the occurrence of hormone fragments or by an increased secretion rate. At any rate, the results suggest a filtration of parathyroid hormone and/or hormone fragments. On the other hand, it was impossible to detect any 25-OH-vitamin D in the hemofiltrate. Finally, digoxin could be found in the filtrate, but only in very low concentrations.

Digoxin↗

PubMed1977

Elimination of hormones through hemofiltration.

The concentrations of testosterone, cortisone, gastrin, GIP, somatomedin B, insulin, HGH, and TSH have been determined in the plasma and the ultrafiltrate of five uremic patients undergoing intermittent hemofiltration treatment. There was a considerable loss of gastrin, GIP, somatomedin B, and insulin by hemofiltration treatment; the plasma concentrations, however, did not decrease. Cortisone, HGH, and TSH were not detectable in the ultrafiltrate. Our results therefore indicate that hemofiltration does not cause a hormone deficiency syndrome. On the contrary, the loss of degradation products of hormones with disturbing biological activity may be a favourable effect of the hemofiltration treatment.

Cortisone↗