The important roles of blood purification for perioperative management of cardiac surgery include i) management of hemodialysis-dependent patients with end-stage renal failure using intraoperative ultrafiltration and simplified intermittent hemodialysis, ii) management of the patients with acute kidney injury after cardiac surgery using continuous or intermittent renal replacement therapy (RRT), iii) intraoperative management of in/out fluid balance using aggressive dilutional ultrafiltration during cardiopulmonary bypass for all patients, and iv) improvement of fluid overload and edema using RRT after surgery. Of these, postoperative RRT should be performed to support organ functions, guided by the goals to correct electrolyte disturbance and acidemia, to reduce hyperkalemia, to remove fluid overload, and to improve hemodynamic stability.

Acute respiratory distress syndrome (ARDS)/acute lung injury (ALI) is defined as an acute-onset, progressive, hypoxic condition with radiographic bilateral lung infiltration, which develops after several diseases or injuries, and was not derived from hydrostatic pulmonary edema. In 2012, in an effort to increase diagnostic specificity, a revised definition of ARDS was published, in which the term “ALI” was no more used. The Japanese Respiratory Society published a secondary version of ALI/ARDS guidelines in 2010, and currently a third version is being prepared. In this short review, I will introduce several topics in therapeutic strategy for ARDS.

It has been reported that removal of overproduced mediators using blood purification is an effective method to prevent and treat septic multiple organ failure. Although the mediators can be removed by any of filtration, dialysis, or adsorption when the blood purification is performed in appropriate settings, high-volume hemofiltration (HVHF) has not improved outcomes in large multicenter randomized control trials (RCTs). Because massive loss of essential substances such as antibiotics or nutrients is considered to be one of the reasons for this negative result, dialysis with high cut-off membrane will repeat the folly of HVHF. Blood purification using a cytokine adsorbing hemofilter (polymethylmethacrylate, AN69ST, and oXiris^®) has demonstrated a promising level of efficacy in some recent case series. Therefore, it will be necessary to prove its efficacy in RCTs in the future. In these RCTs, it will be important to enroll patients in critical condition as demonstrated by blood levels of cytokines or severity scores such as the Acute Physiology and Chronic Health Evaluation (APACHE) Ⅱ score to validate the efficacy of cytokine adsorbing hemofilters.

In recent years, the Japanese healthcare system has become highly advanced and complicated in some aspects. The Japanese Ministry of Health, Labour and Welfare aims to expand the choice of healthcare providers beyond physicians as a part of “team medical care”. There has been much discussion on this issue, and the training system entitled “Training System for Nurses pertaining to Specified Medical Acts” was finally adopted. In this training system, nurses are able to learn advanced and specialized knowledge and skills, that are termed specified medical acts. Nurses who are trained in this program, can perform 38 categorized techniques. Acute blood purification is one of these categories. We would like to evaluate whether this training system has any effect on operating acute blood purification treatment. In order to accomplish this purpose, we reviewed literature regarding the current roles of healthcare professionals in acute blood purification treatment. We conclude that the Training System for Nurses pertaining to Specified Medical Acts contributes to providing timely appropriate treatments, reduced workload for physicians, enhanced motivation of nurses, and standardized methods in acute blood purification treatment.

During acute blood purification, it is very important to precisely estimate severity and prognosis in order to select the appropriate treatment and manage medical resources efficiently. In this paper we summarize a report in the Journal of Japanese Society for Dialysis Therapy (42(10): 761-767, 2009） on the usefulness of severity scores for these estimations1）. Initial investigation showed that cases with a sequential organ failure assessment (SOFA) score≦9 points, multiple organ dysfunction score (MODS)≦5 points, and life-saving index≦6 points survived. In contrast, cases with a SOFA score≧15 points, MODS≧14 points, and life-saving index≧10 points all died. We then re-investigated 5 of 14 cases of septic shock who underwent acute blood purification in the 14 month periods from April 2013 to May 2014. This showed 1 of 5 cases survived in spite of a pre-dialysis SOFA score of≧15 points and life-saving index≧10 points. This case had developed of septic shock immediately after surgical treatment for obstructive pyelonephritis, and was treated successfully by early goal directed fluid therapy (EGDT) and acute blood purification conforming to PMX-DHP, resulting in a rapid improvement in renal failure and survival of the patient. This case represents an examples of a patient who survived despite a high severity score. In order to further increase the prognostic accuracy of the severity scores, it is necessary to integrate such cases in future evaluations of these scores.

The filter life and amount of total protein adsorption were examined for CH-1.8W (inside diameter of the hollow fiber: 240μm, membrane surface area: 1.8m², material: polymethylmethacrylate) and BK-2.1P (inside diameter of the hollow fiber: 200μm, membrane surface area: 2.1m², material：polymethylmethacrylate). Long-term in vitro continuous hemofiltration (CHF) experiments with porcine whole blood were performed using a blood flow rate of 100mL/min, and a replacement fluid flow rate and filtration fluid rate of 10mL/min. The filter life was evaluated by the times at which the transmembrane pressure (TMP) and pressure drop reached 200mmHg or their derivatives reached 15mmHg/hr. Both the TMP and pressure drop were stable for several hours from the start of the experiments, but increased rapidly after the certain period of time, which was almost the same for both CH-1.8W and BK-2.1P. The amount of total protein adsorption was significantly higher with BK-2.1P than with CH-1.8W.

We investigated indices possibly predicting circuit clotting. This study included 43 patients with severe sepsis treated at Kurume University Hospital Advanced Emergency Medical Service Center between January 2011 and June 2012. They were divided into the clotting group with the occurrence of circuit clotting within 24 hours and the non-clotting group free of circuit clotting for at least 36 hours. The blood test results obtained immediately before the first session of continuous renal replacement therapy (CRRT) were compared between these two groups. Significant differences were observed in lactic acid levels, platelet counts, and thrombin-antithrombin Ⅲ complex (TAT) levels. Multivariate analysis of these three variables identified each as an independent risk factor for circuit clotting (lactic acid [odds ratio: 2.333, 95% confidence interval (CI): 1.122-4.854, P=0.023], platelet count [odds ratio：0.802, 95% CI: 0.674-0.954, P=0.013], and TAT [odds ratio：0.860, 95% CI: 0.761-0.971, P=0.0151]). It may be possible to predict the occurrence of circuit clotting within 24 hours after the start of CRRT based on initial lactic acid levels, platelet counts, and TAT levels.

【Introduction】 The efficacy of cytokine elimination during continuous hemofiltration (CHF) largely depends on the characteristics of the membrane filter. AN69ST and polymethyl methacrylate (PMMA) membranes have strong adsorption capacities. We determined the elimination of cytokines by the AN69ST and PMMA membrane filters during CHF in the pig sepsis model. 【Methods】 Piglets weighing 17±3kg (n=7) were anesthetized and endotoxin 30μg/kg was administered. The Baxter sepXiris (AN69ST membrane) and the Toray Hemofeel 1.8W (PMMA membrane) were used as hemofilters. Samples were obtained at 1, 2, 4, and 6hr after beginning endotoxin administration.The inlet plasma, outlet plasma, and filtrate concentrations of TNF-α, IL-1β, IL-6, and IL-8 were measured and the clearance of each cytokine was calculated. 【Results】 Endotoxin administration increased the inlet plasma concentrations of all the measured cytokines. The AN69ST membrane filter showed higher plasma clearance of IL-8 (23.66±17.01mL/min) than PMMA membrane filter (−6.62±48.89mL/min) at 6 hr after beginning endotoxin administration (p＜0.05). However, the PMMA membrane filter showed higher adsorption clearance of IL-1β and IL-6 than the AN69ST membrane filter (p＜0.05). IL-6 did not appear in the filtrate of the PMMA membrane filter, and IL-8 was not eliminated in the filtrate of the AN69ST membrane filter. The filtrate concentration of TNF-α increased after its plasma concentration decreased with the PMMA membrane filter. 【Conclusions】 These results show the differences in adsorption of cytokines by the AN69ST and PMMA membrane filters.

【Introduction】Acute kidney injury (AKI) is an important complication, especially in critically ill patients. However, studies on AKI in Japanese neonates are few. We report on AKI in a single neonatal intensive care unit (NICU). 【Methods】From September 2007 to August 2010, we investigated neonates admitted to our NICU. AKI was defined using the proposed neonatal AKI classification. Patients were grouped by birth weight：extremely low birthweight (ELBW), very low birthweight (VLBW), low birthweight (LBW), and others. Incidence and outcomes were analyzed using the Cochran-Armitage trend test. Risk factors for AKI were analyzed using the decision tree analysis, and multivariate analysis. 【Results】 We included 1,059 patients (male, 563；female, 496; ELBW, 117; VLBW, 96; LBW, 453; others, 393). Serum Cr levels increased in 14.8%, and urine output decreased in 6.6%. AKI incidence was 14.8% (ELBW, 75.2%；VLBW, 18.9%；LBW, 6.6%；others, 5.3%); 1.2% required dialysis (ELBW, 3.4%; VLBW, 2.1%; LBW, 0.9%; others, 0.8%). Mortality was 4.2% (ELBW, 17.9%; VLBW, 10.4%; LBW, 1.3%; others, 2.0%). Mortality among AKI patients was significantly higher than that among non-AKI patients (18.5% vs. 1.8%), and that among oliguric patients was significantly higher than that among non-oliguric patients (34.3% vs. 5.7%). Inotropic agents, steroid, indomethacin, and gestational age were related to AKI onset. 【Conclusions】 AKI incidence in the NICU was high, especially in ELBW infants. Mortality among AKI patients was significantly higher than that among non-AKI patients. Premature birth, unstable circulatory status, and nephrotoxic drug use were related to AKI onset.

The aim of this study is the optimization of the endotoxin adsorbent apheresis with continuous hemodiafiltration combination method and to find out which factors are significant at the prognosis. The targets are 59 cases (male: 22, female: 37, average age: 70.3±12.0 years) had a diagnosis of septic shock or severe sepsis at our hospital intensive care units, and treated with endotoxin adsorptive removal therapy combined method of the continuous hemodiafiltration during the period from October 2012 to March 2015. The survival rate of the 28 days of whole target case was 65.3％. Data analysis using univariate analysis selects the six factors (P＜0.05); APACHE Ⅱ score (≧25), SOFA score (≧10), Catecholamine Index rate of change (%) (≧0), blood lactic acid value (≧4mmol/L), blood lactate value change rate (%) (＞0), and platelet counts (≦12×10⁴μL). Data analysis using multivariate analysis selected as an four independent prognostic factors (P＜0.05) in the order of significant difference establishment using the results of Stepwise method; Catecholamine Index rate of change (%) (≧0), APACHE Ⅱ score (≧25), blood lactate value change rate (%) (＞0), platelet counts (≦12×10⁴μL) using the Cox proportional Hazard model.

A 33-year-old male patient was diagnosed with single ventricle and pulmonary atresia during infancy. Beginning at the age of 20 years, he had onset and subsequent progression of renal insufficiency. Beginning at the age of 30 years, he required periodic (but temporary) blood purification to address acute exacerbation of chronic renal failure. At the age of 32 years, he was hospitalized for pneumonia. He developed hemoptysis during the course of his hospitalization, followed by the onset of anuria. Based on his general status, continuous hemodiafiltration was elected, and blood purification was performed for a period of 6 months. This report describes a rare case of chronic renal failure due to cyanotic nephropathy associated with cyanotic congenital heart disease an in which long-term blood purification was required.

【Background】Streptococcal toxic shock syndrome (STSS) is a severe infectious disease associated with Streptococcus pyogenes (GAS) and can cause severe septic shock and multiple organ failure emerging in just a few hours. Streptococcal pyrogenic exotoxins, which have superantigens, are known to induce the massive production of inflammatory cytokines.【Case】An 71 year-old man with fever and severe abdominal pain was suspected of having generalized peritonitis and underwent emergency surgery. Only purulent ascites were found around the duodenum. Cultures of ascites and blood were positive for S. pyogenes. Primary peritonitis due to S. pyogenes was diagnosed. Septic shock after surgery was improved immediately by Polymyxin B direct hemoperfusion (PMX-DHP) and continuous renal replacement therapy (CRRT) using AN69ST membrane hemofilter.【Conclusion】PMX-DHP and CRRT using AN69ST membrane hemofilter were considered to be an effective treatment for in patients with STSS. Further study is needed.

We recently experienced a patient with tumor lysis syndrome (TLS) secondary to Burkitt’s lymphoma who was successfully treated with a combination of chemotherapy and sustained high-efficiency daily diafiltration using a mediator adsorbing membrane (SHEDD-fA) without any deterioration in his clinical condition. [Case] A man in his 60s was admitted to the intensive care unit (ICU) due to the exacerbation of Burkitt’s lymphoma complicated with pneumonia and disseminated intravascular coagulation. He was diagnosed with spontaneous TLS presenting with extreme acidosis, hyperkalemia, hyperuricemia, anuria, and life-threatening electrolyte abnormalities and renal failure. SHEDD-fA was performed immediately, and his general condition gradually improved. On days 2 and 3 after the patient’s ICU admission, prednisolone (1mg/kg/day) was administered. After confirming that the patient’s condition had not significantly deteriorated, combination chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) was started on day 4. No TLS-induced adverse events occurred during the course of the chemotherapy. Although it is avoidable to give chemotherapy in patients with high-grade lymphomas occurring spontaneous TLS, we conclude that SHEDD-fA potentially enables chemotherapy more safe.

We report a case with acute kidney injury and severe hyponatremia who underwent continuous renal replacement therapy (CRRT). 47 years old woman visited our emergency room for disturbance of consciousness. On admission, she had anuric acute kidney injury and severe hyponatremia (serum sodium concentration of 96mEq/L). Anuria and hyperkalemia did not respond to fluid replacement therapy, and we started CRRT on Day 2. At the initiation of the CRRT, her serum Na was 100mEq/L；CRRT using standard replacement fluid can lead to rapid correction of sodium concentration, which may induce osmotic demyelination syndrome. To avoid rapid correction of hyponatremia while delivering adequate renal replacement therapy, we performed standard post-dilution CRRT methods (replacement fluid rate of 500mL per hour) combined with continuous infusion of 5% glucose solution for 200mL per hour to the Venous chamber. After the 24 hours, her urine flow recovered and we could withdraw CRRT. At the end of the CRRT, her serum Na was 108mEq/L. Her serum sodium concentration was gradually normalized and she could be discharged from the hospital after 22days without sequelae. This dilution method can control the sodium concentration ad libitum by changing the 5％ glucose infusion rate. This CRRT method is effective and convenient for anuric patients presenting severe hyponatremia.

A 69-year-old male was admitted to the hospital with a diagnosis of acute coronary syndrome. Coronary angiography demonstrated 100% stenosis of the left anterior descending artery segment 6, and percutaneous coronary intervention was thus performed. Subsequently, the patient developed a urinary tract infection, which exacerbated congestive heart failure, complicated by acute kidney injury (AKI), cardiogenic pulmonary edema, and sepsis. The patient was then placed on artificial ventilation due to difficulty breathing, and continuous hemodiafiltration (CHDF) was initiated to treat the AKI. However, frequent hemofilter clotting made it difficult to continue with CHDF. Therefore, Super Low Efficiency Dialysis with filtration (SPLED-f) was instituted. Using VPS-11HA (1.1m²) as a dialyzer, SPLED-f was administered for 7 hours daily, using a blood flow rate （Q_B） of 100mL/min, dialysate flow rate (Q_D) of 2,500mL/h, and ultrafiltration rate (Q_f) of 500mL/h. After completing the 18th session of SPLED-f, the patient could be weaned from the artificial ventilator and switched to intermittent hemodialysis. While minimizing hemodynamic changes with SPLED-f, we were able to effectively maintain fluid balance, correct electrolyte abnormalities, remove uremic toxins and improve metabolic acidosis, resulting in satisfactory progress for this patient. SPLED-f may be considered as a treatment option for patients in whom a reduction in anticoagulant dosage is desired due to hemorrhagic diathesis, those in whom continuous renal replacement therapy is not feasible due to facility limitations.

We retrospectively studied the factors influencing the occurrence of postoperative delirium (POD) in maintenance dialysis patients who had undergone cardiac surgery at the Saitama Medical University International Medical Center between April 2010 and July 2012. POD was diagnosed using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We divided the 71 patients into two groups, based on the presence (Group D, n=9) and absence (Group N, n=62) of POD. Group D patients were significantly older and had a higher postoperative APACHEⅡ scores (p＜0.05) than Group N patients. Moreover, their mechanical ventilation period, continuous renal replacement therapy (CRRT) duration, and postoperative ICU stay were also significantly longer (p＜0.05). Since the demographic factor of age was strongly associated with the presence of POD in maintenance dialysis patients, it was believed to have had an effect on the postoperative APACHEⅡ score, mechanical ventilation period, CRRT duration, and postoperative ICU stay.

【Objective】 In this study, we investigated the outcomes and issues associated with a nutritional therapy protocol for severe sepsis/septic shock patients treated with renal replacement therapy. 【Methods】 We retrospectively compared the patients who survived (32 cases) with those who died (16 cases). 【Results】 The mean starting times of enteral nutrition (EN) did not differ significantly between the two groups. The rates of energy and protein intake on day 10 were 111.9±11.7％ (EN: 93.7±18.6%) and 1.3±0.2g among the patients who survived and 112.4±19.9% (EN: 86.0±28.4%) and 1.3±0.4g among the patients who died. The cumulative fluid balance was significantly higher among the patients who died than among those who survived. The secondary infection rates tended to be higher among the patients who died. The white blood cell count and the C-reactive protein level on day 14 were significantly higher among the patients who died. The total protein and the albumin level on day 14 were significantly lower among the patients who died. 【Conclusion】 Implementation of the mainly EN protocol enabled the energy requirements of patients to be met, regardless of disease severity.

Artificial liver support is an essential bridging treatment of acute liver failure until the patient recovers or receives organ transplantation. In Japan, organ donors are few； therefore, the mainstay treatment of acute liver failure is intensive medical care under artificial liver support. Artificial liver support requires patients to remain alert and in good general condition for 2 weeks. Under such special condition, artificial liver support with excellent detoxification capacity was originally developed. Online hemodiafiltration (HDF) with a high-performance membrane and high-volume buffer is the most promising method. Under treatment with online HDF, more than 90% of patients regain alert consciousness. To standardize online HDF as a treatment of acute liver failure, a specific dialysate for liver failure should be developed and guidelines for fluid balance and vascular access should be established.