Acute kidney injury (AKI) has a poor prognosis and is associated with high mortality, especially in patients requiring dialysis (AKI-D). AKI-D reportedly has a poor in-hospital mortality rate of approximately 50%. Patients who survive have poor long-term prognoses and renal outcomes. Approximately 10% of patients with AKI-D continue to require dialysis therapy at the time of discharge from the hospital owing to persistent renal dysfunction; approximately 5% of patients require long-term maintenance dialysis. We analyzed 374 patients with AKI-D in our hospital over the past 10 years. We found that 4.8% of the patients required maintenance dialysis, similar to previous reports. Among the patients who survived, those on maintenance dialysis had a poorer prognosis than those who were weaned-off dialysis.

A dysregulated host response to infection causes sepsis-induced organ damage. Various mediators are associated with pathogenesis, and continuous hemofiltration is used to remove high molecular weight substances, such as cytokines and DAMPs, in sepsis-associated acute kidney injury. There have been various reports on the conditions of blood purification therapy (BPT) for sepsis, but no unified view has been reached. In this study, we present and discuss the BPT in our hospital from the viewpoints of (1) blood purification dose, (2) biocompatibility, and (3) hemofilter lifetime. From the viewpoint of “regulating” the general condition that may lead to organ damage or failure, a “body-friendly” blood purification system that considers biocompatibility and hemofilter lifetime should be established.

If an urban-type earthquake directly hits the area, the onset of acute kidney injury from crush syndrome occurs frequently, and the demand for acute blood purification therapy, such as hemodialysis and hemofiltration for hyperkalemia, increases for several days immediately after the disaster. However, if a disaster occurs, lifeline-dependent treatment cannot be performed; therefore, preparations are conducted daily so that peritoneal or non-machinery dialysis, which does not require critical authentic lifeline, can be selected until transportation to a higher level medical institution or other medical area.

This study elucidates the relationship between terminal medical care and end-stage renal disease care. When dialysis becomes necessary, terminal medical care is required in the field of kidney disease. This is because if dialysis is not initiated promptly when needed, a life-threatening situation can occur. The recently introduced conservative kidney management (CKM), which does not include renal replacement therapy, has been gaining acceptance as a treatment option for end-stage renal failure, particularly in North America and Western European countries. This article introduces CKM, with a focus on its history, definition, and comparison of its implementation across different countries, and provides a literature-based evaluation of CKM in Japan. Decision making through a multidisciplinary medical team is essential in Japan. Additionally, to facilitate its acceptance, it is imperative to establish an environment that includes guidelines and laws related to end-of-life medical care and to engage in discussions surrounding these issues.

【Objective】We compared the mass transfer properties of a small molecular weight substance using two types of adsorption membranes in vitro without the aid of principles such as diffusion or filtration. 【Methods】In vitro experiments were conducted using a test solution with creatinine (Cr) in a closed circuit with a polymethyl methacrylate (PMMA) (1.3 m² membrane area) and acrylonitrile-co-methallyl sulfonate surface-treated (AN69ST) (1.0 m² and 1.5 m² membrane areas) membranes as hemofilters. Regarding the experimental conditions, the test solution flow rate was set to 150 mL/min and the diffusion and filtration flow rates were not set. Samples were collected every 30 s before and after the use of the hemofilter. Cr concentrations were measured to compare the membrane materials. 【Results】Cr concentration before the use of hemofilter decreased for all three membranes: 7.6％ for the PMMA membrane and 29.9％ to 43.4％ for AN69ST membranes. 【Conclusion】In AN69ST membranes, Cr concentration decreased in a closed circuit devoid of principles such as diffusion or filtration, suggesting adsorption properties for small molecular weight substances with no electric charge.

Cytokine-adsorbing hemofilter (CAH) -continuous renal replacement therapy (CRRT) is performed in both patients with sepsis and those with acute kidney injury (AKI). We previously reported significantly higher survival rates when CRRT was performed consistently with surface-treated AN69 (AN69ST), a type of CAH. Thus, AN69ST has the potential to improve the prognosis of patients with sepsis or AKI during CRRT. In this study, we retrospectively examined how survival rates changed over 7 years when it was possible to change the membrane material during CRRT. The results showed that using AN69ST, as the filtration membrane for CRRT, higher survival rates with and without sepsis were observed as compared with polymethyl methacrylate (PMMA). Multivariate analysis showed that the mortality rate was 0.682 times using AN69ST as compared to PMMA, implying that survival increased with AN69ST. Further, in the presence of sepsis, the mortality rate was 1.641 times higher, suggesting that the presence of sepsis increased mortality. These results suggest that CRRT with AN69ST followed by change to a non-CAH membrane is just as likely to result in higher survival as the constant application of AN69ST, suggesting that AN69ST may be a better initial blood filter in the first few days of CRRT.

In this report, we describe a case of possible accidental overdose of carbamazepine (CBZ) treated successfully with hemodiafiltration (HDF). An unconscious 70-year-old female was brought to our hospital and intubated with a bronchial tube. She was managed under a respirator because of epilepsy, bradycardia and circulatory failure. She was diagnosed with CBZ toxicity on day 1, and continuous HDF (CHDF) was performed for three days, followed by HDF. Once HDF was initiated, CBZ serum concentrations returned to normal range, which coincided with regained consciousness. She was extubated and weaned from the respirator on day 14, and she was discharged on day 25．Direct plasma absorption (DHP) has been reported as a standard treatment for CBZ toxicity. However, recent reports indicated that hemodialysis may be as effective as DHP for CBZ toxicity. In fact, HDF was shown to be beneficial for our case. Since the efficacy of CHDF is inferior to HDF, HDF should be the preferred treatment. However, for a patient with circulatory insufficiency like our case, HDF would be difficult to initiate. Thus, we have shown that for a patient with unstable hemodynamics, it may be optimal to introduce CHDF at first and subsequently shift to HDF.

Milrinone, excreted primarily through the kidneys, should be carefully administered in patients with renal dysfunction because of the risk of adverse effects caused by prolonged half-life and increased blood concentration due to delayed metabolism and excretion. Milrinone, with its high plasma protein binding rate, cannot be efficiently eliminated even by blood purification therapy, and the most appropriate method of milrinone administration during such therapy remains unknown. In the present study, we report a case of sepsis induced cardiomyopathy caused by peritonitis, for which life-saving treatment was successfully performed without adverse effects by carefully continuing the administration of a low dose of milrinone during blood purification therapy and discontinuing its administration early after the improvement of hemodynamics. If administering milrinone during blood purification therapy, it should be carefully continued at a low dose for a limited period of time under monitored conditions to promptly identify adverse effects, such as fatal arrhythmia and hypotension.

A 70-year-old female patient diagnosed with interstitial pneumonia was kept under observation due to the absence of respiratory symptoms. Five days before admission, she experienced worsening respiratory distress and was admitted to our emergency center with acute exacerbation of interstitial pneumonia. She presented with type Ⅱ respiratory failure and was treated with steroid pulse therapy and polymyxin B-immobilized fiber column under ventilator management for diffuse alveolar damage. After 8 hours of polymyxin B-immobilized fiber column administration, her oxygenation improved to a P/F ratio of 199. She was placed on high-flow nasal oxygen therapy on day 6 and transferred to the Department of Respiratory Medicine on day 8.

Liver transplantation is the only evidence-established treatment for acute liver failure with hepatic encephalopathy and is the first-choice treatment in Europe and the United States. In Japan, owing to a chronic shortage of deceased donors, most patients are first treated medically with a view to living donor liver transplantation. The main component of medical treatment is artificial liver support (ALS), which efficiently awakens patients from hepatic encephalopathy, and blood purification therapy is administered to maintain liver function. Plasma exchange and continuous hemodiafiltration have been traditionally used for ALS. However, hemodiafiltration using a highly permeable hemofilter to increase blood filtration rate may result in a higher rate of encephalitic arousal. This article reviews the conditions, efficacy, and adverse events of high-volume hemodiafiltration, especially online hemodiafiltration.

Acute blood purification therapy is essential for the effective management of severe patients, but errors that can sometimes develop during such therapy may cause serious medical accidents. Especially in an intensive-care unit (ICU) where high-level and complex treatments are provided, it is essential to correctly perform blood purification therapy and promote safety management with the collaborative and complementary involvement of medical workers from various fields. In our hospital, we prepare for and conduct blood purification therapy by confirming the “7Rs of acute blood purification therapy” as well as using our manual and a checklist. In addition, these procedures are standardized so that safe and correct therapy can be performed independently regardless of the individual skill levels of the medical professionals. In our hospital, effective team medicine with various medical workers can be provided for intensive care because full-time clinical engineers in the ICU focus continually on improving their knowledge and techniques (technical skills) and encouraging smooth communication among the various staff members (non-technical skills). High-quality and safe blood purification therapy can be further secured when team medicine techniques are improved through the continuous education of medical workers in other fields.

When performing continuous renal replacement therapy (CRRT), it is necessary to monitor the conditions of blood flow, blood coagulation conditions, and circuit conditions. Currently, only a circuit pressure can be measured for these conditions. We thought gyroscope sensor could measure these conditions, and if so, this method would enable safer treatment. In the aqueous filtration experiment, we found that the gyroscope sensor captured the vibration of the pillow as changes of an angular velocity, and the change coincided with the rotation of the blood pump. Furthermore, the peak area of the angular velocity decreased with increasing the circuit pressure by a roller clamp attached with the return circuit. This is because the increase in circuit resistance by the roller clamp decreased the actual flow rate and decreased the peak area of the angular velocity. From these results, it is suggested that a gyroscope can measure changes in the pressure in the circuit.

[Introduction] We have reported that different structures of the V-chamber affect retention conditions. This study evaluated whether the angle of blood flow into the V-chamber and the presence of a mesh inside the chamber affect blood retention. [Methods] Four V chamber types (horizontal and vertical inflow, with and without mesh) were used in a simulated experiment to evaluate blood retention. The time from the injection of 1 mL of simulated blood into the V-chamber to color disappearance was measured 10 times each. The dye flow in the V-chamber was evaluated visually. [Results] The dye disappearance times were 33 s, 27 s, 120 s, and 120 s for the horizontal inflow with mesh, horizontal inflow without mesh, vertical inflow with mesh, and vertical inflow without mesh groups, respectively. The fluid flow Visual evaluation showed that the fluid flowed uniformly as a swirling flow in the horizontal inflow chamber; in the vertical inflow chamber, the fluid flowed pulsatile and non-uniformly only at the bottom and stagnation was observed at the liquid surface. [Conclusion] Differences in the blood inflow into the V chamber methods contributed to stagnation.

In continuous renal replacement therapy, the venous chamber (VC) is a site of frequent coagulation due to a longer blood retention time and air contact. In our hospital, the VC fluid level is controlled at a high level to separate the layer between the blood and replenishment fluid; however, this requires adjustment of the fluid levels every few hours and is unstable. In this study, using an in vitro system, we evaluated the liquid layer separation conditions with six types of VC to investigate the VC structure that would enable stable liquid layer separation. In addition, the blood retention of the different VC structures was evaluated. As a result, the conditions for the formation of liquid-layer separation were that the blood inlet should be placed below the replenishment fluid inlet and that the fluid level should be controlled above the replenishment fluid inlet. Among the VC that satisfied both conditions, Prismaflex Sepxiris set, which has a replenishment fluid inlet that is connected to lower than of the VC, consider to be the safest and most stable of the current VC because of its low possibility of filter wetting and large volume until the liquid layer separation is resolved by the inflow of air bubbles.

There is a tendency to take long periods of hospitalization to treat with acute blood purification therapy in intensive care unit. We examined patients treated with acute blood purification therapy in intensive care unit and patients picked out hospitalization until 28 days without fatal cases, about characteristics and treatment progress. The number of patients is 38 cases, average age is 64.4±16.4 years old, average day of hospitalization is 16.6±7.0 days and average day of treatment in intensive care unit is 8.3±5.4 days. At the time of discharge 24 patients had got off dialysis. 20 patients underwent treatment changing location in intensive care unit to hemodialysis center. We adopt a policy that undergoing blood purification in hemodialysis center as soon as practicable without untransferable patient. It can speed up the patient’s discharge from the intensive care unit by eliminating the need for acute blood purification therapy in the intensive care unit. This may have led to prevention of post-intensive care syndrome (PICS) and discharge before ADL decline.