Vascular access hemodialysis catheters are mainly used for vascular access in patients with acute renal failure. Catheter dysfunction during dialysis may be caused by suction of the vessel wall, thrombotic occlusion. A thrombus can be removed from a within catheter using a syringe. However, this procedure won’t work if the arterial pore of the catheter causes suction of the vessel wall. Although attempts are made to solve this problem by repositioning the catheter and using a saline solution syringe, this procedure is not necessarily right. This study aimed to solve this problem by only repositioning the catheter. There are no published reports on using real-time monitoring to assess suction of the vessel wall by the catheter. Without such monitoring, medical staff cannot confirm that suction is the cause of catheter dysfunction in any particular case. We established an ex vivo evaluation system for quantifying and visually confirming that a catheter adheres to the vessel wall by suction. Using this model, we evaluated techniques to resolve the problem. One possibility is to withdraw the catheter slightly, while another rotates it. Withdrawing the catheter did not resolve the suction in all cases. Rotating the catheter had a higher success rate, depending on the rotation angle. However, even this method was not uniformly successful. We provide a method that enables easy observation of suction of the vessel wall by visual observation. Our results may prove helpful in solving this common problem.

Hemofilters are used in hemodialysis for critical blood purification. However, hemofilters usually operate at about half the blood flow as hemodialyzers, which may affect the blood-flow distribution within the blood side of the hemofilters and possibly result in an uneven distribution. If the blood-flow distribution is uneven, then it is possible that the filtration flow rate around the many hollow fibers may also be uneven. This research examines the blood-flow distribution of two hemofilters (Excelflo and Hemofeel) using a viscous dye solution instead of blood. Ten long hollow fibers were removed from five different locations within the filters. These individual fibers were then cut lengthwise and the insides of the fibers were examined for their color-concentration distribution. A difference in the color concentration between the two filters was discovered inside of the fibers, indicating that a difference in blood-flow distribution did exist. Furthermore, we also learned that the length and direction of the hollow fibers in the two filters produced a difference in the color-concentration patterns, also indicating a difference in the filtration flow distribution. This research suggests that it is possible to analyze flow distribution in hemofilters with dyes and that the arrangement of the hollow fibers also affects the distribution of the filtration flow.

Polymethylmethacrylate membrane continuous hemodiafiltration (PMMA-CHDF) therapy was used at our hospital, in conjunction with endotoxin absorption therapy, to treat septic shock due to intra-abdominal infection. The performance characteristics of a hemofilter CH-1.0N^® were compared with those of a hemofilter large-area CH-1.8W^® before and after the introduction of CH-1.8W^® at our hospital in October 2013. A single CH-1.8W^® had a significantly longer operational life span； it was associated with a significantly reduced catecholamine dose 12 hours after implementation and significantly increased urine volumes 24 hours after implementation. These results suggest that the large-area hemofilter CH-1.8W^® is more suitable for performing PMMA-CHDF in cases of severe sepsis due to an intra-abdominal infection.

Except for pediatric and neonatal cases, there are currently no specific criteria regarding the selection of hemofilters for continuous renal replacement therapy (CRRT). In the present study, we retrospectively assessed the influence of the membrane area on the lifetime of polysulfone (PS) and cellulose triacetate (CTA) hemofilters. We examined 36 patients who underwent 70 CRRT sessions at the Saitama Medical University International Medical Center. The sessions were divided into 2 groups based on the membrane area of the filter used：L group （membrane area＞1.0m²） or S group (membrane area＜1.0m²). The rate of achievement of hemofilter lifetime of 24 hours and the reasons for circuit exchange, with the use of PS and CTA hemofilters, were compared. With regard to the rate of achievement of hemofilter lifetime of 24 hours, no difference was observed between the L and S groups when PS hemofilters were used. In contrast, this rate was significantly higher in the L group than in the S group (p＜0.05) when CTA hemofilters were used. With regard to reasons for circuit exchange, abnormalities in filtration pressure were not observed in the L group when CTA hemofilters were used. In conclusion, membrane area could affect the lifetime of CTA hemofilter through the difference in filtration performance.

Recently, sepsis is commonly treated by acute blood purification. In this retrospective study, we examined 34 patients with septic shock and acute kidney injury who were treated with high-flow/high-volume continuous hemodiafiltration (CHDF) in order to evaluate the parameters relating to circulation and renal function. Mean arterial pressure and urine output increased two and six hours, respectively, after initiation of treatment. Vascular resistance also increased and body temperature decreased after treatment. Our findings suggest that high-flow/high-volume CHDF may improve circulatory and renal dysfunction in sepsis patients.

Continuous hemopurification therapy using a polymethylmethacrylate (PMMA) hemofilter has proved to be effective for the treatment of severe acute pancreatitis (SAP). Between January 2011 and December 2015, 20 patients with SAP were treated with continuous hemodialysis using a PMMA hemofilter (PMMA-CHD). Additional high flow-volume large size PMMA-hemodiafiltration (PMMA-HDF) was performed for six of these patients. Here we present the case of two of six patients. Among the 20 patients, all but one recovered from SAP. These results demonstrated that high flow-volume large size PMMA-HDF improves lung injury and severe complications of SAP through its ability to regulate cytokines.

【Background】 Although mobilization for patients during continuous renal replacement therapy (CRRT) has been reported it’s safety, we have at times experienced the access pressure alarm going off during physical therapy for them. 【Purpose】 The objective of this study was to observe the occurrence of access pressure alarms as well as a feasibility of physical therapy for patients undergoing CRRT. 【Methods】 Occurrence and types of alarms, stages that patients could be mobilized and catheter troubles were recorded during physical therapy for the patients admitted to ICU from April to December 2014. 【Result】 In this study, a total of 9 patients were undergoing CRRT in ICU. Four of these 9 patients were prescribed physical therapy. In 2 of these patients, access pressure alarms occurred during physical therapy, specifically in those with a femoral catheter. 【Conclusion】 Physical therapy during continuous renal replacement therapy might induce an occurrence of an alarm.

A 65-year-old man was admitted to our hospital with abdominal peritonitis due to sigmoid colon cancer perforation, and emergent abdominal surgery was performed. While the operation, the patient was developing septic shock, therefore a anesthesiologist administered substantial dose of dopamine and norepinephrine. An hour after the admission to our ICU, Direct Hemoperfusion with Polymyxin B-immobilizer (PMX-DHP) was started. Despite the volume replacement therapy, the administration of vasopressor, and PMX-DHP, unstable blood circulation persisted. Therefore, after 3 hour of PMX-DHP starting, we carried out continuous hemodiafiltration (CHDF) using an AN69ST followed by PMMA membrane hemofilter. After that, he kept blood pressure stable and we gradually decrease catecholamine. Three day later, CHDF was discontinued, and he was discharged from ICU 10 days later. We conclude that the blood purification therapy with a combination of PMX-DHP and CHDF with cytokine-absorbing hemofilter is considered to be effective to achieve early withdrawal from sever septic shock and not to lead multiple organ failure.

Maple syrup urine disease (MSUD) is an inborn error of branched chain amino acid metabolism. An increase in the blood leucine (Leu) level causes serious neurological symptoms. We report two patients with the acute exacerbation of MSUD for whom blood purification therapy was performed to remove amino acids. Case 1 was a 9-year-old boy. On arrival, the GCS was evaluated as 2T, and CT revealed marked brain edema. Continuous hemodialysis was performed for 17 hours at a intensity of renal-replacement therapy of 35mL/kg/h. The Leu level decreased from 20 to 11mg/dL, but there was no improvement in the consciousness level. Case 2 was a 6-year-old boy. On arrival, the GCS was evaluated as 11 (E4V3M4). CT did not reveal any abnormalities. Sustained low-efficiency dialysis was performed at a intensity of renal-replacement therapy of Qb 100mL/min, Qd 200mL/min for 8 hours on Day 1 and for 9 hours on Day 2. The Leu level decreased from 15.95 to 3.21mg/dL on Day 1, and from 5.15 to 2.37mg/dL on Day 2. The consciousness level was normalized on Day 3. In Case 2, for blood purification therapy, the intensity of renal-replacement therapy was increased in comparison with Case 1 in the early stage in which central nervous symptoms were mild, leading to a rapid decrease in the Leu level. This may have contributed to a favorable neurological prognosis.

Fulminant pneumococcal sepsis is a critical condition with a higher mortality rate than that in asplenic cases. The patient was a two-year-old girl with asplenia syndrome who had undergone a Glenn operation. She had fever, loss of consciousness and atrial-ventricular block, and she was admitted to the ICU with a diagnosis of pneumococcal meningitis and sepsis. Disseminated intravascular coagulation and acute kidney injury were obvious, and exchange transfusion and continuous hemodiafiltration were initiated. Pneumococcal antigen with filtrate was negative on the 4th and 5th days, and we therefore changed to continuous hemodialysis, which was discontinued on the 11th day. She was transferred to the general ward on the 18th day without any neurologic problems. We report that early exchange transfusion and continuous hemodiafiltration were effective for pneumococcal infection with a successful outcome.

Modified perioperative management consisted of three components: renal replacement therapy, drainage tube management, and abdominal organ management was started in 2013 for hemodialysis (HD) patients undergoing cardiac surgery. A total of 100 consecutive HD patients undergoing cardiac surgery between January 2008 and September 2014 were divided into two groups (Group M: modified management, 35 patients vs. Group P: previous management, 65 patients) and the outcomes were compared. There was no hospital death in Group M, whereas 8 patients (12.3%) died in Group P (p=0.048). In terms of postoperative complications, the rate of reexploration for bleeding was significantly lower in Group M compared to Group P. In Group M, the lengths of intubation period (p=0.034) and hospital stay (p=0.025) were significantly shortened.

Patients with chronic kidney disease (CKD) have various comorbidities such as hypertension, diabetes, and dyslipidemia, which are risk factors for cardiovascular disease. To reduce the risk of poor prognosis during perioperative management of cardiovascular surgery, a strict control of fluid and electrolyte are required in these patients. Despite the difference in the treatment options among our facilities, all facilities strictly have performed the preoperative fluid control and the prevention against hyperkalemia, which were attributed by the preoperative planning for the treatment strategy including blood purification therapy. Moreover, dilutional ultrafiltration (DUF), continuous hemodialysis (CHD), continuous hemodiafiltlation (CHDF), or hemodialysis (HD) was individually selected in each facility due to the differences in the equipment utilized in the facilities. CHDF was enforced when the hemodynamic condition was unstable. Depending on the condition of patient, sustained low-efficiency dialysis (SLED) was selected. Blood purification therapy has been thought to have a vital role in the perioperative management in patients with CKD. However, it remained to be clarified that the efficacy of the therapy is beneficial in the perioperative management in these patients. The application of blood purification therapy based on an objective index or the establishment of an integrated evaluation system for therapy outcomes will be needed.

Recent advances in reverse osmosis system (RO system) based on stricter administration standards for water quality increased the availability of ultra-pure dialysis fluid. Thereby, on-line HDF (OHDF) has become common among dialysis facilities in Japan. We successfully introduced the RO system for multipatient in the ICU from January 2012, and safely carried out acute blood purification therapy including continuous OHDF (OL-CHDF) using the RO system. We performed the continuous blood purification therapy in 16 cases for two years. The survival rate from ICU was 88%. We initially experienced issues to preserve the quality of ultra-pure dialysis fluid in the RO system when continuous running of OHDF was performed. In addition, we also assumed that the loss of drugs or useful substances from circulating blood by OL-CHDF required attention. To achieve safe and effective treatment of OL-CHDF in ICU, the appropriate protocols including maintenance of the RO system and staffing would be required.