We had a Pros＆Cons themed who should have an initiative to decide the therapy, Intensivist or Nephrologist？ Nephrologists have advantages. They know method of treatment, principals of method and meaning of Kt/Vurea. On the other hand, Intensivists have other advantages. Primary causes of AKI are sepsis and operation. Major factor to affect patient death is not serum creatinine but SOFA or APACHEⅡ. So whole-body management is preferred to kidney itself. No superiority was decided between both opinions. Almost all audiences agreed to make up a team consist with intensivist, nephrologist, attending physician, clinical engineer, nurse, physiotherapist and pharmacist to have a best practice.

Many of cytokines are difficult to remove efficiently by hemofiltration because of their large sizes (molecular weight, 20 kDa). We performed an in vitro experimental hemofiltration using cytokine-adsorbing hemofilter (polymethyl methacrylate (PMMA) membrane, and polyethylenimine-coated polyacrylonitrile (AN69ST) membrane). Tumor necrosis factor (TNF)-α, interleukin (IL)-6, and IL-8 concentrations in the test solution were measured, and the clearances (CLs) of these cytokines were calculated. The CLs of TNF-α, IL-6, and IL-8 exceeded the theoretical limit of filtration (16.7mL / min in this experiment) when both the AN69ST hemofilter and PMMA hemofilter were used. In the AN69ST hemofiltration, the CLs of TNF-α, IL-6, and IL-8 were 38 ± 6, 23±7, and 78±3 (mL/min), respectively, in descending isoelectric point order of IL-8, TNF-α, and IL-6. In the PMMA hemofiltration, CL of IL-6 showed a maximum CL of 31±76 (mL/min). It was inferred that the adsorption mechanism involved in the AN69ST membrane was ionic bonding.

Using a non-cuff type catheter (catheter) enables recirculation in patients with an unusually thin vessel diameter caused by bleeding defects and changes in blood flow dynamics. During treatment, the catheter is usually connected in forward connection-, using the inflow lumen for blood inflow. However, if inflow failure occurs in the catheter, there is a possibility for reversal connection, where the outflow lumen is used for blood inflow. Recirculation is more likely to occur in reversal connection. In this study, we measured whether the difference in vessel diameter affects the recirculation rate, using three types of catheters. We used catheter’s tip shapes were end-hole types (inflow hole is on the same side or the other side), and streamlined catheters. In end-hole type catheters, recirculation did not occur during forward connection but occurred during reversal connection. Furthermore, recirculation rate increased as the simulated blood vessel diameter decreased. In the streamlined-type catheter, mild recirculation occurred during both forward and reversal connections. However, recirculation rate was nearly constant for all catheters, regardless of the simulated vessel diameter. Accordingly, there is a possibility that recirculation rate will become higher by catheter tip shape and connection method, in patients with thin vessel diameter.

When recognizing pathogenic microorganisms, leukocytes release extracellular DNA as part of their biological defense system. In-circuit blood clotting is a problem encountered when implementing acute blood purification therapy. Although anticoagulants are used to prevent this problem, the effect of anticoagulants on leukocyte extracellular DNA release in sepsis is unknown. In this study, blood was taken from rats under general anesthesia and anticoagulated with citric acid or unfractionated heparin (UFH). Then, the blood was stimulated with lipopolysaccharide and observed using a fluorescence microscope. Blood anticoagulated with UFH had more extracellular DNA components than blood anticoagulated with citric acid. Therefore, UFH may promote extracellular DNA release under septic conditions.

【Purpose】 The purpose of this study was to explore medical treatments that affect mortality rates and length of hospitalization in patients with sepsis, from the viewpoint of constructing an algorithm that would support treatment selections. 【Methods】 Weighted probabilistic latent semantic analysis (PLSA) was performed using the diagnosis procedure combination (DPC) data of 458 sepsis patients. Furthermore, features of clusters were analyzed, focusing on treatments related to blood purification, which is one of the direct treatment methods for sepsis patients. 【Results and conclusion】 By performing PLSA weighted 20 times according to variable “presence/absence of death” and variable “hospital days,” we extracted nine treatment clusters. We confirmed that it was possible to classify medical treatments into clusters, which characteristically show the relationship of medical treatments with mortality rates and length of hospitalization. Especially, all blood purification-related treatments belonged to one of the clusters with higher mortality rates. Given the cluster transition pattern of each patient, it was suggested that blood purification is one of the treatments that strongly affect the state change of sepsis patients. In addition, by performing the weighted PLSA on blood purification, clusters were separated according to the type of blood purification. This result shows that it is possible to determine which type of blood purification is more appropriate to select depending on the patients’ conditions.

Non-cuffed catheters (NCCs) are widely used to secure vascular access for emergency blood purification. We have actively used tunneled-cuffed catheters (TCCs), instead of NCCs, as indwelling catheters for emergency blood access (emergency BA), and have demonstrated the usefulness of TCCs for preventing decreased activities of daily living after rescue, shortening hospitalization and reducing catheter-related complications. This study aimed to determine the incidence of complications after the use of TCCs for emergency BA, including thrombus formation and venous stenosis in catheterized vessels. The study included 38 patients who underwent emergency blood purification and in whom TCCs were used for emergency BA during the treatment period. The examined TCC-catheterized vessels were the right internal jugular vein in 37 patients and the left in one. Intravascular lesions in catheterized vessels were noted in only two (5%) of the 38 patients. The low incidence of intravascular lesions after the use of TCCs for emergency BA suggests additional benefit of TCCs in preventing complications after rescue treatment with blood purification.

Acute liver failure, which has an extremely poor prognosis due to its progressive nature, is a reversible disease characterized by a high degree of liver dysfunction brought on by widespread hepatocellular necrosis and liver regeneration failure. Artificial liver adjuvant therapy, used in treating acute liver failure, can play an important bridging role until liver regeneration or transplantation can occur. In Japan, artificial liver adjuvant therapies are regularly conducted through plasma exchange (PE) in combination with hemodiafiltration. In our facility, artificial liver adjuvant therapy is conducted using plasma filtration with dialysis (PDF). PDF is a blood purification therapy in which a simple PE is performed using a selective membrane plasma separator while the dialysate flows on the outside of the hollow fibers. Every year, numerous patients suffering cardiac disease are treated in our institution, with unstable circulation being a common factor in many of these cases. Consequently, cPDF (continuous PDF), which lasts for 24 hours, is used in artificial liver adjuvant therapy. Herein, we report a case in which portal vein thrombus occlusion occurs during surgery leading to liver failure, hepatic blood flow was retained through thrombectomy therapy and cPDF was employed successfully in preventing further liver deterioration.

A 32-year-old pregnant woman with Graves’ disease was emergently admitted to our hospital. Her thyroid-stimulating hormone receptor antibody (TRAb) level remained extremely high at 394.0 IU/L despite the acute total thyroidectomy performed upon admission. In addition, the fetal heart beat became persistently tachycardiac after surgery. We initiated double filtration plasmapheresis therapy (DFPP) to remove TRAb from the mother’s circulation. DFPP decreased the serum TRAb level by 52％ to 60％, which finally reached 43.9 IU/L. A male infant was successfully born at 34 weeks 6 days of gestation via cesarean delivery. He had been growing well at the last follow-up. Our case suggests that acute removal of serum TRAb by DFPP therapy may be useful to control Graves’ disease activity in pregnant women, thereby preventing the development of life-threatening complications, such as non-immune fetal hydrops and airway constriction, at delivery.

【Case Report】A 31-year-old woman was referred to the emergency department of our hospital because of the ingestion of 4,000mg of carbamazepine as a suicide attempt. Upon physical examination, the patient was in a coma and was not responsive to any stimuli. Her serum carbamazepine level was 36.4μg/mL. After pre-dilution online HDF was performed for 3.5 hours at a blood flow rate of 250mL/min, a total dialysate flow rate of 700mL/min, and a substitution fluid flow rate of 250mL/min, the patient showed a marked improvement of nausea･consciousness disturbance and her carbamazepine level had decreased to 19.1μg/mL. The patient was discharged from the hospital because her serum carbamazepine level was normalized 2 days after pre-dilution online HDF was performed. Several modalities have been used to treat severe poisoning arising from carbamazepine overdose. Hemoperfusion has traditionally been considered the gold standard for the elimination of highly bound substances, such as carbamazepine. According to the Extracorporeal Treatments in Poisoning Workgroup recommendations, carbamazepine is dialyzable, and intermittent HD is the preferred modality suggested in cases with coma. Carbamazepine has a high plasma protein binding (70–80%); hence, HD is thought to have a limited effect on the removal of carbamazepine from the plasma. In the present case, we selected pre-dilution online HDF, which is more efficient than HD. We hypothesized that pre-dilution online HDF would be effective for the removal of protein-bound carbamazepine and removal of free serum carbamazepine.

Fluid balance abnormality was observed during plasmapheresis performed using a blood purification device (ACH-Σ; Asahi Kasei Medical Co. Ltd., Tokyo, Japan). Based on this case finding, it was thought that some problems may have occurred in the fluid control system. We verified the operation of the fluid system with obstruction in its circuit. When the circuit for fluid replacement was obstructed, an alarm indicated “abnormalities in filling of fluid replacement”. The alarm could not be reset unless the cause was removed. When the filtration circuit directly behind the plasma separator was obstructed, an alarm indicated “blood leak detection 1”. When the circuit directly before the filter pump was obstructed, an alarm indicated “abnormalities in plasma balance”. For the first and second alerts, it was possible to reset the alarm even if the cause of the alarm was not removed. For the third alert, however, the alarm could not be reset unless the cause of the alarm was removed. When the filtration circuit directly behind the filter pump was obstructed, the status of fluid replacement alone was observed. Thus, excessive body fluid due to excessive fluid replacement may trigger side effects (e.g., elevated blood pressure, cardiac failure, cyanosis, dyspnea, and pulmonary edema).

Many critically ill patients receive acute blood purification therapies such as continuous renal replacement therapy (CRRT). This is pivotal in intensive care units. CRRT increases stress for patients because of the corresponding long restriction of patients’ activities. Therefore, we are trying to provide nursing care that consists of both alleviation of suffering and restoration of normalcy for patients’ early recovery. Nurses should assess patients with diseases and offer treatment from several perspectives, including physical, mental, and social aspects, as well as equipment care instructions. It is important for nursing care and patients’ recovery for nurses to try to explore and assess the meaning and the thought of patients in their backgrounds by listening to and accepting their ideas and feelings.

Continuous hemodiafiltration using a Polymethylmethacrylate (PMMA) membrane has been shown to be effective in controlling hypercytokinemia associated with severe sepsis through its ability to adsorb cytokines. PMMA membranes have been widely used in dialysis therapy. We performed hemodiafiltration with a PMMA membrane (PMMA-HDF) on nine infected maintenance dialysis patients. PMMA-HDF was performed with a PMMA membrane (Filtryzer BG-1.3–1.6 PQ) over 4 hours at a blood flow rate of 150–200 mL/min, using Sublood-BSG as a substitution fluid (at a flow rate of 1.5–3.0 L/h), and at a dialysis fluid flow rate of 500 mL/min. Infections subsided in all patients. Except for one fatality unrelated to infection, all eight patients returned to regular maintenance dialysis therapy. The mean interleukin-6 levels before and after treatment were 949.4±807.8 and 226.0±277.2 pg/mL, respectively, and the corresponding white blood cell counts were 15,500±7,464 and 13,255±4,078 cells/μL, both of which tended to be decreased after treatment. The mean hospitalization period, excluding the mortalities and those who needed social hospital stays, was 12.6±4.8 days. Providing early treatment with PMMA-HDF to infected maintenance dialysis patients may be effective for ameliorating hypercytokinemia and preventing worsening of infection.

Continuous blood purification (CBP) is often selected for the management of acute kidney injury (AKI) . As experienced in the intensive care unit, it is seldom that kidneys alone are suddenly damaged but other organs are also often impaired depending on the disease condition；therefore, CBP therapy aimed at systemic correction is instituted until homeostasis is achieved in the patient. It is required for a continuous slow hemofilter (1) to demonstrate solute removal performance according to the disease state, and (2) to have high biocompatibility, so as to enable long-term CBP treatment. We are engaged in the sale of the UT-Filter, which utilizes a cellulose triacetate (CTA) membrane as the hollow-fiber membrane, and the Sure-Filter, which utilizes a polyethersulfone (PES) membrane as the hollow-fiber membrane. The UT-Filter has the following characteristics - it causes minimal platelet count reduction and has high biocompatibility, thereby enabling extended treatment continuity. Sure-Filter is characterized by high water permeability, thereby enabling realization of solute removal performance concordant with the disease state.