The American Society for Apheresis (ASFA) first issued its guidelines in 2007, which have been repeatedly revised thereafter until the latest edition in 2019. In the US, a centrifugal separation method is mainly used for apheresis, while the mainstream procedure in Japan is the membrane separation method. Due to these differences, directly adopting ASFA guidelines in Japanese practice would create various problems. We decided to prepare the Japanese Society for Apheresis (JSFA) clinical practice guidelines for therapeutic apheresis, and published “The JSFA clinical practice guidelines for therapeutic apheresis” in the summer of 2021. The guidelines cover 86 diseases in nine specialties : emergency medicine, hematology, collagen diseases/rheumatology, pulmonology, cardiovascular medicine, gastroenterology, neurology, nephrology, and dermatology. In addition, plasma diafiltration (PDF) using membrane technology was discussed as a new therapeutic tool.

In continuous renal replacement therapy, rapid detection of intracircuit clotting is a major challenge. In this study, we aimed to establish a model of accelerated clotting that can simulate intracircuit clotting in a short period. The arterial circuit was infused with citric acid as an anticoagulant, which was removed through dialysis to promote clotting in the venous chamber. By estimating the citric acid concentrations in both the arterial and venous circuits using a single-compartment model, we manipulated the citric acid concentration in bovine blood and carefully observed clot formation in the circuit. We achieved clot formation in the venous chamber with a venous citrate concentration of 5.1 mM after 129 min by maintaining an arterial citrate concentration in the range of 10.0-12.0 mM.

The recent development of data science has been fundamental. It is even called the “fourth paradigm of science” since the dawn of human history; the first three were experimental, theoretical, and computational science. The high operation speed by affordable computers and growing multivariable datasets stored in electronic health records are indispensable in the current boom of artificial intelligence (AI) in medicine. AI was first applied to image recognition tasks. A deep learning algorithm for detecting diabetic retinopathy in retinal fundus photos became famous with its high accuracy compared to board-certified ophthalmologists. DeepMind, which was one of the subsidiaries of Google, published another famous report of AI, consisting of a recurrent neural network; it can also predict acute kidney injury 48 hours before it happened. Because blood purification in critical care routinely records multivariable, time-series digital data in daily clinical practice, AI programs, which assist clinicians in this field, would be feasible. Additionally, there are some challenges in using AI in clinical medicine, including, but not limited to, skill atrophy of medical staff, patients’ privacy concerns, and poor interpretability of the results given by AIs. It would be of great value if medical professionals could adapt to this drastic paradigm shift in science and pave the way to the ideal coexistence of human beings and AIs.

In recent years, the focus of intensive care for critically ill patients is not merely to improve short-term survival but also to improve functional prognosis after discharge from the intensive care unit (ICU). Therefore, critical care practitioners primarily aim to restore patients’ physical and mental health to the pre-ICU status. The ICU is a stressful environment owing to restricted physical activity, social isolation, and exposure to noise and light in the ICU setting. Post intensive care syndrome (PICS) affects a patient’s long-term prognosis; therefore, prevention of PICS is important, and multi-professional collaboration is essential for optimal health care delivery. Continuous renal replacement therapy (CRRT) requires strict bed rest, which prevents early mobilization and rehabilitation. The alarm system (noise) and light from the CRRT machine interfere with patients’ quality of night-time sleep. The aforementioned adverse effects on patients’ sleep and mobilization are considered CRRT trauma. Maintenance of physical activity and good quality night-time sleep are important during the ICU stay. In this review article, we discuss the role of clinical engineering technology to minimize the adverse effects of CRRT.

Continuous renal replacement therapy (CRRT) for acute kidney injury and sepsis is used to replace renal function and eliminate cytokines. CRRT may cause changes in drug pharmacokinetics. Since antimicrobial agents are often administered when CRRT is performed, an administration based on pharmacokinetics/pharmacodynamics (PK/PD) theory is required from the viewpoint of efficacy, safety, and antimicrobial resistance. When planning the dose based on PK/PD theory, it is important to understand basic pharmacokinetic parameters, clearance, and volume of distribution. In this review, we outline the pharmacokinetic characteristics and changes of antimicrobial agents during CRRT and explain the concept of dosage adjustment and therapeutic drug monitoring based on the cases experienced at our hospital.

In providing healthcare after a major disaster, the principle is to save the lives of as many patients as possible, using limited resources. Patients who receive chronic hemodialysis treatment are particularly vulnerable during disasters, as this treatment requires extensive medical resources, water, and electricity. The Great East Japan Earthquake caused mass devastation, resulting in some patients having their treatment interrupted until the crisis was averted. Others were moved to safer areas for their dialysis treatment. Although it was difficult to explain to all the patients and their families that we could not provide the usual medical care, we believe that we were able to impart a significant degree of awareness of the crisis based on the normal relationship between dialysis patients and medical personnel. There were insufficient resources to elucidate the psychological symptoms and to provide psychological care to the medical personnel who needed to deliver regular medical care, and to the patients who had to continue dialysis treatment, despite the disaster. It is important to be prepared for emergencies and future disasters by having knowledge and measures in place for the disruption of dialysis treatment and psychological care.

Background: CRRT is widely performed for removing pathogenic substances and assisting organ functions in the emergency room and the intensive care unit. However, attention must be given to a possible rapid change in electrolyte concentration due to the removal of useful electrolytes by CRRT. It is known that adverse events such as central pontine myelinolysis and cerebral edema occur with rapid correction of Na concentration by CRRT in patients with severe Na concentration abnormalities including hyponatremia and hypernatremia. Gradual correction of blood Na concentration within 12 mEq/L/day (0.5 mEq/L/hr) is generally recommended. Methods : Since the commercially available dialysate/replacement solution has a Na concentration of 140 mEq/L, a rapid change in Na concentration may occur when used in severe cases of Na concentration abnormality. We inject 5% glucose for hyponatremia and 10% NaCl for hypernatremia into the dialysate/replacement solution to adjust the Na concentration of the solution according to the blood Na concentration. Electrolyte concentration of the dialysate/replacement solution after preparation was confirmed by measurement with a blood gas analyzer before use. Results: CRRT using the dialysate/replacement solution prepared for Na concentration has so far been performed in 10 patients (5 patients with hypernatremia and 5 patients with hyponatremia). Since the change in Na concentration after 24 hours was suppressed within 12 mEq/L, CRRT could be safely performed. Conclusion: Adjustment of the Na concentration in dialysate/replacement solution is considered to be useful for safe CRRT in patients with abnormal Na concentrations.

Rapidly progressing glomerulonephritis (RPGN) due to double-positive anti-neutrophil cytoplasmic antibodies and anti-glomerular basement membrane antibodies vasculitis is characterized by advanced renal damage, poor renal prognosis, and a high probability of relapse. The disease progression is rapid, and prompt therapeutic intervention, including plasma exchange therapy, is important. We report a case of selective plasma exchange (SePE) in addition to oral corticosteroid and cyclophosphamide pulse therapy (IVCY) for RPGN in a patient with crescentic glomerulonephritis. A 79-year-old woman was treated with oral corticosteroids, IVCY, and SePE. We suggest that early immunosuppressive therapy with SePE, which does not require coagulation factor replacement, may be useful in suppressing new antibody production and eliminating antibodies.

Direct hemoperfusion using a polymyxin B-immobilized polystyrene column (PMX-DHP) is a treatment that selectively adsorbs endotoxins; it is also expected to adsorb a variety of endogenous substances. To evaluate the efficacy and safety of PMX-DHP in oxygen-demanding COVID-19, we previously reported our experience (N=12). PMX-DHP was considered when P/F ratio was less than 300. On day 14 after the first treatment, disease severity decreased in 58.3 ％ of the patients. Subsequently, we have initiated a prospective, multicenter study.

Introduction : The venous air trap (V) chamber used in blood purification systems is a possible source of coagulation during blood purification. In this study, the fluid residence time of differently shaped V-chambers was evaluated in simulated experiments. Methods : The Prismaflex and ACH-Σ consoles were evaluated. The time from the injection of 1 mL of dye into the V-chamber to its disappearance was measured three times each, and the average values were compared. Additionally, the flow of fluids in the V-chamber was evaluated visually. Results: The fluid residence time in the V-chamber was significantly shorter in the Prismaflex group (p＜0.01). Moreover, visual evaluation showed that the fluid in the Prismaflex V-chamber flowed uniformly as a swirl. In contrast, in the ACH-Σ V-chamber, the fluid flowed unevenly pulsating only at the bottom, and stagnation was observed in the upper layer of the chamber liquid surface. Conclusion : It was suggested that structural differences in the V-chamber may affect the retention in the V-chamber.

Caring for the aging population of dialysis patients and preventing COVID-19 infection in these patients are urgent issues. The most pressing issues in older patients on peritoneal dialysis are the burden on caregivers and inadequate monitoring of patients. We are building a support system that will take advantage of the capabilities of information and communications technology (ICT). This system will be a remote monitoring cloud network system that will connect the University’s dialysis department with more than 5 home-visit nursing stations (home-visit ST). We have named this monitoring system “Cybervillage” (CV). Each week, 6 doctors will write the patient’s conditions on a Check Sheet, which they will share across the entire CV via the cloud network. Based on the Check sheet and in accordance with our own algorithm, the home-visit ST will provide treatment, examine patients (e.g., the condition of the port area, etc.) and give instructions to nurses. Visit reports also will be shared across the entire CV. These information in the cloud will be edited to create practical education materials. By creating and implementing the above CV, we plan to identify issues and present solutions for home medical care for older adults and to propose a model case of home medical care for older adults that can be further developed in the future.

In recent years, HEMOFEEL^® SNV, in which an NV polymer is localized on the inner surface of the hollow fiber of a Polysulfone (PS) membrane hemofilter, has been sold. NV polymers are believed to have improved antithrombotic properties by suppressing protein adhesion (fouling). In order to investigate the permeability and antithrombotic properties of HEMOFEEL^® SNV, we compared it with other companies’ PS membrane hemofilters. The subjects were 56 adult patients who underwent CHDF (continuous hemodiafiltration) using PS membrane hemofilters, and the number of membranes was 226. The patients were divided into the EXCELFLO^® AEF-13 group and the HEMOFEEL^® SNV-1.3 group, and the transmembrane pressure (TMP), ultrafiltration rate (UFR), and lifetime were compared. The results suggested that the HEMOFEEL^® SNV-1.3 group had significantly lower TMP and significantly higher UFR, which was advantageous for high flow rate filtration settings.

Direct hemoperfusion (DHP) with activated carbon adsorption membranes are used for patients presenting with methotrexate (MTX) intoxication due to its high dose administration and delayed excretion. There have been few reports on the efficacy and clearance of blood purification device when it is used for a prolonged time. We report a case of a 3-year-old with acute lymphoblastic leukemia who developed MTX intoxication after high dose administration and recovered without complications after treatment with prolonged DHP therapy for up to 24 hours. During the DHP therapy, the blood concentration of MTX and its clearance were closely monitored. DHP was performed at a blood flow rate (Qb) of 60 mL/min. After 16 hours, the removal efficiency and clearance were maintained at 0.85 and 48.9 mL/min, respectively, showing a good removal rate. There is a possibility that DHP can be performed longer than the designated time in pediatric patients, with less Qb than adults to reach a sufficient blood purification.

The first novel coronavirus infection was recognized in Wuhan, China, in December 2019. In Japan, the full-scale battle against the new coronavirus infection began in February of the following year with the treatment of passengers aboard the cruise ship Diamond Princess. Proper management of mechanical ventilation, blood purification therapy, and extracorporeal membrane oxygenation (ECMO) is essential in coronavirus treatment. Based on experiences with new strains of influenza, clinical engineers have extensive experience in this management. In addition to direct treatment of patients, intensive care units benefit from the extensive experience of clinical engineers, which has led to prevention of secondary infection, optimal selection of medical equipment, and enhanced safety measures. The important role of clinical engineers is to select medical equipment with infection control in mind, procure it, and explain its use to other medical staff. Additionally, clinical engineers collect information on treatment methods and medical equipment management methods, plan hospital measures, and respond directly to treatment. During the novel coronavirus outbreak, in which respiratory therapy has been of high importance, the experience and expertise of clinical engineers have been utilized in the selection of the ventilator model. Clinical engineers have made these important decisions based on the structural differences of ventilators and the study of airway humidification methods. Finally, the role of clinical engineers has also been important in introducing various technologies such as remote monitoring and IP radio. Such wireless communication tools have been essential to the medical field for managing communicable diseases.