Since the introduction of a new concept of PRRs (pattern recognition receptors), PAMPS (pathogen-associated molecular patterns) and alarmin, much has changed concerning the pathophysiology of sepsis. Currently, endotoxins are considered only one of PAMPS and has lost considerable weight in the understanding of the pathophysiology of sepsis. On the other hand, hypercytokinemia is considered to play a pivotal role in the pathophysiology. Accordingly, some effective countermeasure against hypercytokinemia should be the mainstay in the therapeutic approach to severe sepsis/septic shock. One effective approach is PMMA (polymethyl methacrylate)-CHDF (continuous hemodiafiltration). The addition of PMMA-CHDF to the recommended treatments in the SSCG（Surviving Sepsis Campaign guidelines）has resulted in much better survival compared to previously reported survivals in patients with severe sepsis/septic shock who were treated according to the SSCG. When PMMA-CHDF is applied as a countermeasure against hypercytokinemia, the effect of cytokine-related genetic polymorphism should be taken into consideration since such polymorphism has considerable influence on the efficacy of anti-hypercytokinemic strategies such as PMMA-CHDF. From the new prespective on the pathophysiology, we should reconsider the role of PMX-DHP (direct hemoperfusion with polymyxin-B-immobilized endotoxin-adsorbing column) in the treatment of severe sepsis/septic shock. PMMA-CHDF is more reasonable, more economical, and more effective compared to PMX-DHP in the treatment of severe sepsis/septic shock.

Blood purification in critical care has made many advances in modulating humoral mediators. By adjusting dialysate and filtrate flow rates, membrane type, and surgical duration and manner, each presenter in this symposium (in the 20th annual meeting of the Japan Society for Blood Purification in Critical Care, 2009, Sapporo) reported a unique and interesting method of blood purification in critical care. High flow CHDF was reported to be effective for organ protection by regulating the renin-angiotensin-aldesterone system. High volume CHDF may suppress HMGB1, a key mediator of organ failure during late-stage septic shock. Increased clearance of medium molecular weight substances was achieved while maintaining clearance of lower molecular weight substances by super high-flux double hemofiltration, which uses a high cut-off membrane as the first filter. Early initiation of PMMA-CHDF during the disease course, and starting double PMMA-CHDF in refractory septic shock patients was proposed as a benchmark for treating sepsis. Highly efficient and intermittent but prolonged hemodiafiltration such as high flow-volume large PMMA-HDF may be preferred over other methods of blood purification under some pathological conditions. Sphingosine-1-phosphate was suggested as a possible predictive factor for PMX-DHP usage. (Intriguing measures of improvement on methods of blood purification in critical care were discussed.)

A clinical practice guideline is a document intended to guide decisions and establish criteria for diagnosis, management and treatment in specific areas of healthcare. Modern medical guidelines are based on an examination of current evidence within the paradigm of evidence-based medicine. For standardization, Japan Society for Blood Purification in Critical Care (JSBPCC) should develop appropriate guidelines in the near future. However, clear evidence is limited at present and it is difficult to generate evidence to clearly indicate which approach is better, using a large RCT, and is also time consuming and costly, especially in this area. The first step may be organized as “Clinical manuals for the technique of BPCC” to prepare for standardization.

In this article, issues related to drug dosage, particularly antimicrobial agents, and nutritional management during continuous renal replacement therapy (CRRT) presented in the panel discussion are reviewed Although water and toxic wastes are slowly excreted by CRRT, necessary substances are also incrementally removed. The removed gross per day is considered to reach a large amount when high volume hemofiltration or high flow hemodialysis is indicated. Accordingly, it is necessary to consider the additional replenishment of removed material. In particular, prudent decision making regarding the dosage of antimicrobial agents is necessary, since this is considered a fundamental treatment of infections and therefore influences the prognosis. In addition, CRRT can remove excess water to provide the appropriate amount of energy, but also eliminates a considerable amount of necessary macro-or micronutrients. summary of the presentations based on each speaker’s own experience for in managing these problems and several treatments plans are described in this issue.

This study discusses the prevention of blood coagulation in hemodialysis lines. First, Ono, J., et al. reported a study entitled “To clearly identify the high-risk portion of hemodialysis lines and the ideas of how to protect lines from coagulation of blood” Second, Kunou, S., et al. described the effect of a ten-minute preparation of hemodialysis lines using saline on coagulation in the hemodialysis lines and hemofilter. Third, Miki, T., et al. reported which factors, for example duration of dialysis, pressure in the lines, concentration of solutions, and ACT, affect coagulation in the hemodialysis lines? Fouth, Tsukamoto, I., et al. described important factors affecting anti-coagulation of continuous hemodialysis lines in order to continue long-term CHD. To perform good hemodialysis, it will be necessary to develop guidelines for anti-coagulation during hemodialysis.

A review, “The significance of blood purification for septic treatment” was carried out at the 20th annual meeting of the Japan Society of Blood Purification in Critical Care. Early goal-directed therapy using direct hemoperfusion with polymyxin B-immobilized fibers bring about an improvement of the circulation, respiratory condition, and the prognosis. It is suggested that its mechanism involves controlling the biological response and restoring the immune function. Plasma dia-filtration, a selective plasma filtration with dialysis method, modulates humoral mediators, and reduces mortality due to septic multiple organ failure. High flow-volume hemodiafiltration, a highly efficient intermittent blood purification method, removes pathologic substances such as cytokines from blood, resulting in the improvement of biological responses and survival rate of critically ill patients.

The polymyxin B-immobilized fiber (PMX) column was originally developed for the removal of endotoxins and used for the treatment of endotoxemia. Recent clinical studies have suggested the beneficial effects of PMX treatment in sepsis, ALI (acute lung injury)/ARDS（acute respiratory distress syndrome）and acute exacerbation of interstitial pneumonia or collagen vascular disease. In a animal model without endotoxemia, the arterial oxygen tension (PaO₂)/inspiratory oxygen fraction (FiO₂) (P/F) ratio has been increased by PMX. Effects of PMX treatment on inflammatory mediators or activated neutrophils have also been reported. Longer term treatment with PMX has been reported to be more effective not only for patients with septic ARDS but also for those with acute exacerbation of interstitial pneumonia.

Recently, continuous renal replacement therapy (CRRT) has not only developed markedly using new technology, but has also been become widely performed all over Japan. CRRT has been used to treat many patients with various diseases as well as those with kidney diseases. Although CRRT is very effective, there are several problems to be resolved. First, we currently have no guidelines regarding this therapy. Secondly, we need a sufficient number of skillful staff to operate machines. Thirdly, we need a system of performing CRRT safely for 24 hours. At present, we need to have our own devices in order to perform CRRT safely and successfully.

This study assessed the safety of the continuous blood purification device ACH-Σ (ASAHI KASEI KURARAY MEDICAL CO. LTD.) that has been newly developed and become commercially available. Concerning assembly and priming of the device, four points of the comparison with ACH-10 were evaluated on short-term use. The study also evaluated the error margins of the liquid system balance mechanism and air-free pressure chamber, which were new features of ACH-Σ， The result of the water system experiment was 0.02〜0.09% which was considered an excellent and higher than the manufacturer is claim of 0.5% as the error margins of the liquid system balance mechanism. It is thought that the error margin was reduced compared to that of ACH-10 as the result of changing one of the three liquids measured on another scale. The air-free pressure chamber was thought to be available for long-term because pressure in the circuit could be measured without differing from that of the dripchamber, and without coming into contact with air. There was no extension of the circuit longerity compared to that of the dripchamber in this examination. The number of items to be checked before use decreased from 43 to 24 compared with previous versions of the device and the self-diagnostic function before the beginning of treatment has been enhanced. It was suggested not to depend on staff’s proficiency and degree of specialization but rather to obtain a similar performance though assembly and priming of this device useing an automatic priming and guide function. ACH-Σ showed an improvement in safety compared with previous versions of the device.

In recent years, closed-infusion-systems have been used to prevent bacterial contamination or bloodstream infection due to injectors or infusion routes connected to infusion-lines. The Use of a double-lumen-catheter with a closed-infusion-system (QsyteTM) was attempted to further promote infection control. Tests were conducted to confirm that there was no pressure rise in either the arterial line or return blood line when connected with QsyteTM. There was no significant difference in arterial line intra-pressure or in return blood pressure compared to that for the puncture needle used in the usual blood purification therapy. Thrombus aspiration prior to the blood purification treatment excelled in simplicity and was easy to use. Neither thrombus formation nor connector leakage was found after long-term use. New closed-infusion-systems are being developed every year and it is important to understand the features and mechanics of these devices in order to avoid incidents. QsyteTM is cost effective, safe and easy to operate.

Despite improvements in medical care, the mortality of critically ill patients with acute kidney injury (AKI) who require renal replacement therapy (RRT) remains high. We describe a new approach, sustained hemodiafiltration (SHDF), to treat patients with AKI who were admitted to the intensive-care unit. In our study, 71 critically ill patients who required RRT for AKI were treated with either continuous hemodiafiltration (CHDF) or SHDF. The former was performed by administering a postfilter replacement fluid at an effluent rate of 35 mL・kg^-1・h^-1, and the latter was performed by administering a postfilter replacement fluid at a dialysate-flow rate of 300-500 mL/min. The SHDF was delivered on a daily basis. The baseline characteristics of the patients in the 2 treatment groups were similar. The primary study outcome─survival until discharge from the ICU or survival for 30 d, whichever was earlier─did not significantly differ between the 2 groups. The hospital survival rate after CHDF was 60.2% and that after S-HDF was 80.0% (p<0.05). The number of patients showing renal recovery at the time of discharge from the ICU and from the hospital and the duration of the ICU stay significantly differed between the 2 treatments (p<0.05). Our findings suggest that in comparison with conventional continuous RRT, including high-dose CHDF, more intensive renal support in the form of post-dilution SHDF decreases mortality and accelerates renal recovery in critically ill patients with AKI.

A 56-year-old woman who had received a bone marrow transplant for acute leukemia began dialysis in May 2007. She immediately developed a fever during maintenance hemodialysis. The cause of fever was considered conventional polysulfone membrane, and after changing the dialysis membrane to an EK membrane, fever disappeared. The present study investigated the biocompatibility of several dialysis membranes based on heart rate variability analysis. High frequency (HF) and low frequency (LF) conponents, HF/LF and CVRR were analyzed using a Memcalct^® system, and clinical characteristics including pulse rate and body temperature were also assayed. The dialysis membrane was sequentially changed from EK to KF, RC,VEP, PEPA and VEP. The clinical characteristics and sympathetic nervous activity of HF decreased during HD using the VEP membrane, and parasympathetic nervous activities (HF, CVRR) increased using the VEP membrane. Sympathetic activity and parasympathetic activity showed reciprocal results. In this case , fever suppression was better with the VEP membrane than with the EVAL membrane. This was related to improvement of the biocompatibility of the inner-surface of the PS membrane, which is coated with vitamin E.

The Revised Medical Care Law requires strict and proper maintenance of life support management devices. It is therefore necessary to carefully maintain continuous blood purification devices used in acute blood purification in critical care medicine. In our hospital, the maintenance of continuous blood purification device begins with inspecting the machine using the operation manual. Then we executed the program based on routine inspection recommended by the manufacturer manual. Ninety-eight inspections were performed between October 2008 and September 2009 before starting to use the machine and five specific problems were identified. A major problem with the machine occurred once. All staff was able to inspect the machine within 15 minutes before use was started and at present major problems can be prevented by inspection. We would like to propose a routine and thorough inspection before starting operation in continuous blood purification in critical care medicine.

(Background & Object) About 10〜40％ of ICU patients demonstrate acute kidney Injury (AKI), and their outcomes are poor compared with those of non-AKI patients. Furthermore, nutritional status is critical for the survival of ICU patients. However, there are a few studies that show a relation between AKI and nutritional status. To clarify this relationship, we report the present status at our center. (Study design, Participants & Methods) Single center, observational study between April 2007 and March 2008. Patients without pre-existing chronic kidney disease, treated in the ICU for over 24 hours were included. Study patients were divided into two groups, the AKI and non-AKI groups. RIFLE criteria were used for AKI definition. For these patients, we assessed the quantity and quality of nutrition, nutritional status and 30 days mortality. (Results) There were 224 patients with a mean age of 67.3 y.o. ; 62 patients had AKI (28%). Among these, 19 patients (9%) underwent renal replacement therapy. In the AKI group, initiation of enteral nutrition delayed, and of nutrition was insufficient compared with that in the non-AKI group. Furthermore, 30 days mortality was significantly higher in the AKI group and this was correlated with serum albumin. (Beta=−0.32, Relative risk=2.35, P=0.038). (Conclusion) The nutrition of AKI patients tended to be underestimated in our ICU. This may cause malnutrition and result in a worse outcome for AKI patients.

A number of critically ill patients in the intensive care unit (ICU) develop acute kidney injury, which often constitute a part of multiple organ failure (MOF). Organ support therapies for these patients such as continuous blood purification (CBP) should be guided by monitoring systemic conditions. Therefore, we conducted a study investigating the process of discontinuation of CBP for AKI patients in the ICU using parameters consisting of SOFA scores for respiration, coagulation, liver function and circulation, fold increases in serum creatinine level, urine volume, and serum CRP level. In our study, 74 patients were removed successfully from CBP and showed significant improvement in urine volume, serum creatinine, and respiration and circulation scores at discontinuation compared with those at the initiation of CBP. In contrast, 12 patients, who were removed from CBP, but died during the study, showed significant improvement only in urine volume and serum creatinine at discontinuation. Based on these findings, we concluded that urine volume over 1000mL/24h, dopamine administration less than or equal to 5microg/kg/hr, P/F over 200 without mechanical ventilation, and fold increases in serum creatinine less than 2 were possible determinants for the decision to discontinue CBP with a subsequently good outcome.

Severe sepsis is considered a highly critical condition involving hypercytokinemia with multiple organ failure. Continuous hemodiafiltration using polymethyl methacrylate (PMMA-CHDF) has been shown to be clinical effective in patients with severe sepsis and septic shock. However, although this method was effective for hypercytokinemia, increased transmenbrane pressure (TMP) was often observed while performing PMMA-CHDF. In this study, we examined the pressure in the circuit during PMMA-CHD (continuous hemodialysis). PMMA-CHD was performed in 4 patients with severe sepsis and septic shock. A stable pressure in circuit was observed in two of four patients, where as increased pressure on the blood side inlet was observed in the other cases. Motality after 28 days was 0％ in this serise. Observation of cases of severe sepsis in further studies might be required in order to investigate pressure in the circuit and its clinical effects during PMMA-CHD.

Extracorporeal blood purification in children is still associated with significant morbidity and mortality. The files of patients weighing less than 30 kg who were treated with extracorporeal blood purification at our institute between 1996 and 2009 were reviewed for background and treatment characteristics, morbidity and outcome. The study group included 16 patients (age range 2 months to 13 years) with a body weight range of 6.0〜30 kg. There was a mean of 3.4 extracorporeal blood purification sessions. Fifteen patients were dialyzed through a central venous catheter. Eighty-one percent of the catheters were located in the subclavian vein. Four patients had to discontinue extracorporeal blood purification due to kinking. Two patients had to discontinue extracorporeal blood purification because of decreased blood pressure. There was no need for central-line removal. Safe extracorporeal blood purification in children requires adequate blood flow with an adequate catheter.

During continuous renal replacement therapy (CRRT) for critically ill patients with hemorrhagic risks, nafamostat mesilate (NM) is widely used as the anticoagulant. NM is a novel anticoagulant with an extremely low rate of adverse hemorrhagic effects and excellent adjustability, considering its short half-life. Activated clotting time (ACT) is a commonly used marker to quantify the anticoagulation status of the patients receiving anticoagulants during CRRT ; however, there have been few previously reported data regarding optimal ACT value for patients receiving NM as anticoagulant. Here, we demonstrated the optimal ACT value after NM administration in patients undergoing CRRT. We performed a retrospective observational study of patients admitted to our hospital between July 2006 and June 2009, who underwent CRRT using NM as the anticoagulant. Fifty-one patient were identified. The results of our study demonstrated that every patient with outlet ACT<180 seconds developed coagulative complications. In contrast, only 37％ of the patients with outlet ACT≧180 seconds deveroped coagulation complications (p<0.006). Furthermore, 69％ (11/16) of the patients with adjusted outlet ACT ≧225 seconds experienced systemic ACT extension. The outlet ACT associated well with the dosage of NM, serum albumin and CRP, respectively, on multiple regression analysis. In conclusion, our study verified that the optimal value of outlet ACT in the patients undergoing CRRT using NM should be 180～225 seconds.

A study investigating continuous blood purification (CBP) therapy for severe acute pancreatitis was performed at our hospital to examine the importance of CBP therapy. This retrospective study examined the outcomes of 19 patients with severe acute pancreatitis who underwent CBP therapy between April 1, 2005 and September 30, 2009. The corrected Ca value was 8.43±1.14mg/dL at its initiation of CBP therapy and 9.35±1.00mg/dL at its withdrawal, showing a significant increase. The white blood cell count and C-reactive protein (CRP) level showed a decreasing tendency during CBP therapy. Before initiation and at withdrawal of CBP therapy, the white blood cell count was 15.25±6.22×1000/μL and 12.23±6.68×1000/μL while the CRP level was 21.31±11.75 mg/dL and 13.8±8.68 mg/dL, respectively. Thus, these values showed a significant reduction. With regard to the regulation of water balance (intake-output), before the initiation of CBP, many patients were In-Over. By elimination of excess water, the In-Out balance became close to zero, and an ideal body fluid balance was maintained. There are various opinions concerning the role of CBP in the treatment of severe acute pancreatitis; however, there is no doubt that blood fluid control is related to the prognosis of a serious illness. These finding suggest that in severe acute pancreatitis, CBP is useful for the control of body fluids, especially water, solutes, and electrolytes.

We investigated the renal prognosis of Septic Acute Kidney Injury (after AKI) using the RIFLE criteria. We classified 74 Septic AKI patients who had undergone acute blood purification between January 1, 2003 and March 31, 2009. We examined the relationship between RIFLE and APACHE Ⅱ, SOFA score, duration of blood purification, rates of change in BUN and Cr (⊿Cr). In addition, we examined correlation between RIFLE and base excess (BE), total bilirubin, serum potassium (K), and serum CRP. In our past study, these parameter were proven to be predictive factors for AKI. As a result, the SOFA score, duration of acute blood purification, and ⊿Cr correlated with the severity of AKI on RIFLE classification. As a predictive factor for renal prognosis, BE / K / CRP correlated with RIFLE. Therefore, it was suggested that the RIFLE criteria are useful for prediction of renal prognosis, and it is important to use the RIFLE criteria proactively to achieve adequate therapy for septic AKI.

【Introduction】We report a case of viper bite presenting with acute renal failure. Furthermore, we present a clinical study of cases previously treated at our institution.【Case patient】A 67-year-old woman did not receive viper antitoxic serum after being bitten. Due to acute renal failure complications, we performed continuous hemodiafiltration (CHDF). After weaning from CHDF 18 days later, the patient was discharged in remission 45 days after the initial bite.【Subjects and methods】The subjects were 64 patients who had been treated for viper bite at our institution between April 2001 and August 2009. We analyzed the clinical findings and treatment contents.【Results】The median duration of hospitalization was 8 days (range: 2〜44), and there was a tendency for the hospitalization period to increase with higher CPK values. Viper antitoxic serum was administered to 21 cases (33%), of which side effects were observed in 3 (14%). We observed 30 severe cases of Grade IV or above (47%), and there was a tendency for the severity to reach Grade V in cases where the serum was not administered.【Conclusion】It was thought that in cases where swelling is light at the time of initial examination but advances during the course of treatment, viper antitoxic serum should be administered during an early stage.

At our hospital, four types of ten continuous hemodiafiltration devices are used. Physicians or clinical engineers performe a pre-use test of all device. This report describes four types of clamp errors detected during the pre-use test. We use the checking program function built into the device during the pre-use test. We judge the device to be normal if an empty blood circuit placed into the clamp does not move up or down when the clamp is closed. During this study, four clamp errors were discovered in the JUN-600 model (JUNKEN MEDICAL) during 398 pre-use tests performed. The cause of the clamp errors was a gap in the closed clamp that was beyond the normal range. It is necessary to measure the gap in the clamp with a precision gauge and adjust when an error is found. We must not forget to perform a detailed test with a precision gauge regularly in addition to performing the standard pre-use test.

A 26-year-old woman was admitted to our hospital’s emergency room with complaints of general malaise and jaundice that had persisted for one week. Although she had been diagnosed with acute hepatitis and received adequate care, the assessment of her residual hepatic functional reserve showed a severe state including indirect hyperbilirubinemia and decreases in BUN that were not compatible with her serum creatinine level or ammonia level. She developed grade-2 hepatic encephalopathy on the eleventh day of her illness and was diagnosed with drug-induced subacute fulminant hepatitis based on PT 28.7％ and other laboratory data. She was transferred to our section and artificial liver adjuvant therapy (Artificial Liver Support: ALS) was provided. Dospite intensive care her state was progressively worsened. She was referred and transferred again to the transplant institute on the 16th day of her illness. Living related liver transplantation was carried out and she survived. When deciding on the treatment of acute hepatitis, we should always consider its potential for fulmination and, when needed, promptly provide adequate treatments including ALS or transplantation.

BACKGROUND : Necrotizing fasciitis is a rare infection of the deeper layers of skin and subcutaneous tissues with extremely high mortality. The mainstream treatments for necrotizing fasciitis are antibiotics and debridement. However, renal replacement therapy is sometimes required to manage sepsis-induced acute kidney injury. CASE PRESENTATION : We report a 62-year-old woman who developed necrotizing fasciitis complicated by acute kidney injury and was successfully treated with high-volume HDF (hemodiafiltration). The patient was admitted to our hospital with dyspnea and erythema, which rapidly deteriorated and progressed. Her blood pressure decreased and she was diagnosed as having septic shock due to group G streptococcal bacteremia. After admission, we performed high-volume HDF (Time: 4 hours, Dialyzer: ABH21F, QB (blood flow rate) 300mL/min, QD (dialysate flow rate) 500mL/min, QF (hemofiltration flow rate) 4L/hr, post-dilution). Hemodynamic status has improved after high-volume HDF, allowing a significant reduction of catecholamine dosage and higher systolic and diastolic blood pressure. CONCLUSION: High-volume HDF was indicated to be an effective treatment option for patients with septic shock due to group G streptococcal bacteremia and necrotizing fasciitis.

A 74-year-old man was admitted to the hospital due to faintness and chest pain about 2 days earlier. He had demonstrated a high fever for a few days, and his heart rate was 30〜60/min and blood pressure was 50mmHg with palpation. Electro cardiogram and echo cardiogram showed acute coronary syndrome. Emergent coronary angiography demonstrated that the culprit lesion was the middle of the left anterior descending artery. Primary PCI was successfully performed, however, hypotension, complete AV block and trans-venous cardiac pacing failure continued. We thought the primary pathophysiology in this case was not the recent myocardial infarction but sepsis, because of the high fever and inflammatory markers without an obvious infection focus, and he had already presented with septic myocardial depression. However, shock was resistant to basic therapies for sepsis. Blood purification therapy was performed for extreme hypercytokinemia, because the cytokines were considered to play pivotal roles in the pathophysiology of septic shock. PMMA-CHDF was carried out but shock was persistent. He was treated with direct hemoperfusion with polymixin B immobilized fiber column (PMX-DHP), which quickly ameliorated bradycardia and hypotension, resulting in smooth weaning from IABP and reduction of catecholamine. Gram-positive cocci were detected from blood culture the next day. The interplay of underlying septic cardiomyopathy mechanisms and effective and specific treatment remains enigmatic. We report a case in which PMX-DHP was effective for improving hemodyanamic stability on septic cardiac depression. Further study of thePMX-DHP in septic myocardial depression will be necessary.

We reported a severe case of toxic epidermal necrolysis (TEN) treated successfully by plasma exchange on the 12th day after onset. A 76-year-old woman developed TEN caused by antibiotics, and was transferred to our ICU on the 5th day. Since the skin lesion initially did not show deterioration general and local managements based on severe burn were started. However, the skin deteriorated thereafter. Therefore we performed plasma exchange for 2 days starting on the 8th ICU day. Thereafter, the re-epithelization started and the patient recovered. As the mechanism underlying the effectiveness of plasma exchange for TEN, removal of the offending drug, its metabolic products, inflammatory cytokines, and sFasL has been reported. In this case, plasma exchange at the phase of exacerbation, not at early phase, was effective for improvement of re-epithelization and the general condition.

We speculated that bilirubin would be adsorbed by a PMMA membrane during continuous hemodialysis (CHD). Therefore, we compared the effect of PMMA membrane to that of PAN membrane on the blood bilirubin concentration during CHD in an infant with hyper bilirubinemia. We found a decrease of plasma bilirubin concentration following CHD with a PMMA membrane, but not that with a PAN membrane. During CHD with a PMMA membrane, we also observed the appearance of bilirubin in the dialysate. Therefore, filtration may play some roles in the elimination of bilirubin during CHD.

We report here a case of liver failure caused by exertional heat stroke after running 10 km. A 35-year-old male with schizophrenia was hospitalized due to loss of consciousness and convulsion. His body temperature was 40.8 degrees C. Resuscitation with external cooling, and intravenous fluids was initially successful and he recovered from coma. However, hepatic failure developed the third day of hospitalization. He was transferred to our hospital and artificial liver support consisting of plasma exchange and high flow continuous hemodiafiltration was started on the same day. Liver function improved spontaneously thereafter. He recovered and was discharged from our hospital on day 17. If a patient with heat stroke has factors indicating a poor prognosis or shows on underlying disease, aggressive artificial liver support should be considered early after the development of hepatic failure.

The skeletal muscle relaxant, Baclofen, is emerging as a potentially effective treatment for intractable hiccups. However, there have been several reports describing the neurotoxicity of a low dose of Baclofen in patients with chronic renal failure, especially those with intractable hiccups. However, relationship between pharmacokinetic data and neurotoxicity of Baclofen in patients with chronic renal failure has not yet been well elucidated. We encountered a 74-year-old male on hemodialysis who rapidly developed side effects including coma, respiratory depression and tonic-clonic convulsion after taking a single 10 mg does of Baclofen for intractable hiccups. We performed hemodialysis to remove Baclofen under ventilator management. After the first hemodialysis for four hours, convulsion resolved and the plasma concentration of Baclofen decreased from 162 ng/mL to 78.9 ng/mL. The plasma concentration of the Baclofen did not show any further decrease without dialysis; that before the second hemodialysis was 83.7 ng/mL and after the second hemodialysis, the concentration was 31.8 ng/mL. Consciousness gradually recovered after the second dialysis. The present case indicates that Baclofen even at a therapeutic plasma level can cause serious neurological side effects in patients with renal failure. This suggests that patients with renal failure are susceptible to neurotoxic effects of Baclofen. Cautious dose reduction is recommended when treating intractable hiccups with Baclofen in patients with renal failure.

A female patient aged 93, weighing 44.7kg, and showing CL-Cr25mL/min, had symptoms of Cibenzoline Succinate (CIB) intoxication, such as bradycardia, hypoglycemia, anuria, and shock lever after taking 100 mg of CIB 3 times per day. Six days were required to reactivate the diuretic response. After measuring the level of CL-CIB on CHDF, we compared CHDF with other methods of blood purification described in the medical literature. The amount of CIB in the filtrate pooled for 13 hours was 7.95mg; area under the blood concentration-time curve was shown at 13430ng・h/mL, and CL-CIB was 9.87mL/min (≒filtrating speed / 2). On analysis using TDM software, it was shown that there was an extreme decrease in the patient’s CL-CIB as well as a 50% decrease in volume of distribution (Vd). From the perspective of pharmacokinetics, in patients of CIB with a large Vd (≒5.4～8.4L/kg), the data on extrarenal CL-CIB indicate that it is 7.7 times as effective as Hemodialysis (HD) CL-CIB, whereas according to the literature, when CL-CIB has HD (≒50〜100mL/min), and Direct Hemoperfusion is (≒100mL/min), we should examine the effectiveness of prolonged HD on a day-to-day basis (to a maximum of 48 hours in total) for patients with CIB intoxication, who are not expected to recover renal function.

A 34-year-old man was emergently admitted with burns (dermal burn BSA 28%). After surgery on day 8, the patient developed a high-grade fever. On day 10, the patient was diagnosed as having acute respiratory distress syndrome (PaO2/FiO2 ratio：31). We initiated treatment with percutaneous cardiopulmonary support (PCPS) and continuous hemodiafiltration using a polymethylmethacrylate membrane hemofilter (PMMA-CHDF), but the PaO2/FiO2 ratio was low. We started Polymyxin B direct hemoperfusion (PMX-DHP) for 6 hours on days 11 and 12, and evaluated the effect of PMX-DHP using the pulse contour cardiac output (PiCCO) system (Pulsion Medical Systems). PMX-DHP treatment effectively induced significant improvements in the extravascular lung water index (ELWI) and pulmonary vascular permiability index (PVPI). We were able to successfully monitor the effect of PMX-DHP using the PiCCO system. PMX-DHP may improve both pulmonary vascular permeability and improve oxygenation.

A 31-year old woman was hospitalized in the psychiatric hospital due to mental instability, gradually increasing disturbance of consciousness and convulsions. Because encephalitis was suspected, she was referred to neurology in our hospital, and admitted to our emergency and critical care center. Initially, we suspected infectious encephalitis, and started administration, an antiviral agent. However, since autoimmune encephalitis was also possible, steroid was added. On the third hospital day，seizures occurred and progressed to status epilepticus despite administration of an anticonvulsant. On the fifth day, we performed tracheal intubation and started ventilator management; continuous intravenous midazolam was also initiated. However, convulsions were uncontrolled. On the sixth day steroid pulse therapy was started. On the 11th day, there was no symptom improvement, so we tried plasma exchange (3L replacement per session performed three times on alternate days). On the 20th day, seizures began to decrease and on the 24th disease day, ovariectomy was performed. There after, convulsions disappeared and her general status improved. She was transferred from the intensive care unit on the 57th day. After rehabilitation, she became able to walk unassisted at discharge. Thereafter, antiN-methyl-D-aspartate (NMDA) receptor antibody was positive in serum and cerebrospinal fluid. The immediate effect plasma exchange of was poor, but it was considered effective for improving the severe convulsion state that required intensive care.

Since 1992, continuous Renal Replacement Therapy (CRRT) has been performed Kawasaki Medical School Hospital. Since it is important to obtain new information from clinical data smoothly, it is very useful to use a CRRT chart. In this article, we present the contents of our CRRT chart and discuss its usefulness.