In the management of sepsis, supportive therapy to attenuate overwhelming systemic expression of mediators is important, as well as source control. Although several randomized controlled trials (RCTs) and propensity score matching analysis of endotoxin adsorption therapy (PMX-DHP) for sepsis have been conducted, its clinical benefits in terms of mortality or long term outcome are still controversial. However, prognostic improvement has been suggested when using PMX-DHP for the severely ill population. In addition to the main mechanism of endotoxin removal, which triggers the mediator cascade, the PMX column adsorbs endogenous cannabinoids, activated neutrophils, and HLA-DR-negative monocytes. Recently, PMX-DHP was reported to possibly protect against acute kidney injury by preventing renal tubular cell apoptosis. Furthermore, PMX-DHP may continue to improve hemodynamics and pulmonary oxygenation in patients with septic shock for more than 2 hours. We believe that with proper severe-patient selection and proper duration of perfusion, PMX-DHP can improve survival in patients with sepsis or septic shock.

An epidemiologic study on idiopathic pulmonary fibrosis (IPF) in Japan (Hokkaido study) have reported that the median survival time of patients with IPF after diagnosis was 35 months and the most common cause (40%) of death was acute exacerbation. The prognosis of IPF is extremely poor and no effective treatment for acute exacerbation has been established. Recent clinical studies have suggested the beneficial effects of direct hemoperfusion with polymyxin B-immobilized fiber column (PMX-DHP) on oxygenation and prognosis in IPF patients with acute exacerbation. PMX-DHP has been approved for the advanced medical treatment of acute exacerbation of IPF in Japan. Exploratory research on the safety and efficacy of PMX-DHP for the treatment of acute exacerbation of IPF is being conducted. From these results, PMX-DHP should be considered as a therapeutic option for acute exacerbation of IPF.

We carried out management on patients experiencing gastrointestinal (GI) perforation associated with septic shock using a protocol that included resuscitation by early goal-directed therapy (EGDT) and early source control. 137 patients were divided into an EGDT completed group and an EGDT not-completed group. The EGDT completed group are patients who achieved ScvO₂ of 70% within one hour after surgery of source control. In the results, a 60 day survival rate of 98% was observed in the EGDT completed group, but only 30% in the EGDT not-completed group (p-value＜0.001). The blood purification therapy was performed in all 37 cases in the EGDT not-completed group. In four cases in the EGDT not-completed group, ScvO₂ continuous monitoring and blood purification therapy was performed after surgery. Two cases showed improvement in ScvO₂ during blood purification therapy, and survived. However, two cases continued to have a low ScvO₂ and did not survive. ScvO₂ after surgery of source control may demonstrate a prognostic predictive value, and blood purification therapy may improve tissue oxygenation and contribute to good prognosis.

【Objective】We compared the clearance characteristics of creatinine, interleukin (IL)-8 and IL-6 during continuous hemofiltration (CHF) using three different materials for the hemofilter and different filtration flow rates in vitro. 【Methods】Phosphate buffer solutions containing creatinine, IL-8 and IL-6 were produced as test solutions. A CHF circuit was prepared using polysulfone (PS), polymethyl methacrylate (PMMA) and acrylonitrile-co-methallyl sulfonate surface-treated (AN69ST) hemofilters. The test solution flow rate was set to 150mL/min. The filtration flow rates were set to 600, 1,200 and 2,100mL/hr. Sampling of the test solution was performed inlet and outlet each hemofilter. Samples were collected 6 times over a period of 9 min after initiation of the CHF procedure. The concentration of creatinine and the concentrations of IL-8 and IL-6 were determined by an enzymatic method and ELISA, respectively. 【Results】There were no significant differences in creatinine clearance with the three hemofilter materials. Regardless of the hemofiltration material, the clearance of creatinine increased with an increase in filtration rate. However, clearances of IL-8 and IL-6 with PMMA and AN69ST hemofilters were significantly higher than that with the PS hemofilter, and the clearance of these cytokines were not associated with filtration flow rate. 【Conclusion】Clearance of large molecular weight substances such as cytokines in CHF using an adsorbing type of hemofilter is superior to that in CHF using a filtration type of hemofilter. The results suggest that selection of an adsorbing hemofilter is important for treatment of sepsis when performing CHF for removal of cytokines.

【Aim】To compare the ability of sepXiris100^® and sepXiris150^® AN69ST hemofilters to adsorb serum IL-6. 【Methods】Patients with serum IL-6 concentrations≧1,000pg/mL at the start of therapy underwent continuous hemodiafiltration （CHDF） with sepXiris100^® （1.0m²；n＝10） or sepXiris150^®（1.5m²；n=9） hemofilters. IL-6 clearance was measured 15min and 1, 24 and 48h after the start of therapy. 【Results】Mean IL-6 clearance at 15min, 1h, 24h, and 48h was 24.5±18.6, 8.8±7.8, 6.1±5.2 and 7.4±12.0mL/min, respectively, with sepXiris100^®and 25.4±8.2, 11.8±5.3, －0.1±7.2 and 6.0±6.6mL/min, respectively, with sepXiris150^®. 【Conclusion】There were no significant differences in cytokine adsorption by sepXiris100^® and sepXiris150^® hemofilters at any time point.

The beneficial effects and security of PowerTrialysis^® (PT) were investigated. The blood vacuum pressure during continuous blood purification (CBP) therapy and the frequency of vacuum alarm were investigated for different vascular access hemodialysis catheters. We examined the vacuum pressure and frequency of vacuum alarm in 61 patients who received CBP therapy in the intensive-care unit in this hospital between August 2015 and February 2017. Because the blood vacuum pressure was dependent on the length of the catheter, same length (24cm) was used for the comparison of various catheters. The results showed lower intentionally criteria of the blood vacuum pressure was demonstrated in the PT group. The PT group also showed a significantly lower frequency of vacuum alarm than other catheters. The PT device has a nose shape and is making a side hole Therefore, this catheter may prevent the so-called clinging phenomenon. The choice of catheter is important when performing CBP for avoiding unexpected trouble in the intensive-care unit.

We investigated the factors related to hemolysis, internal circuit pressure, and hemolysis in Continuous Renal Replacement Therapy (CRRT). We targeted 14 patients who underwent CRRT at AKI from April 2015 to December 2015 at the institution. The index of hemolysis was determined as plasma free hemoglobin value and measured 24h after the start of CRRT. On the basis of the blood removal pressure, arterial chamber pressure, venous chamber pressure, and transmembrane pressure difference the patients were categorized into the following two groups：the hemolysis group (＞30mg/dL; 5 cases) and the non-hemolytic group (＜30mg/dL; 9 cases). We also examined factors related to hemolysis. A significant difference was observed between the two groups (blood removal pressure, arterial chamber pressure, venous chamber pressure) (p＜0.05). Additionally, arterial chamber pressure [odds ratio: 1.222 （95% CI: 0.984-1.517), p=0.043)] was a factor related to hemolysis when a binomial logistic regression analysis was performed. Hemolysis was related to internal circuit pressure, and arterial chamber pressure was thought to be related to hemolysis. Additionally, monitoring of circuit pressure in CRRT was considered effective for preventing hemolysis.

【Aims】The effect of hemodialysis (HD) for hypermagnesemia was examined. 【Methods】We retrospectively analyzed nine patients who underwent emergency HD for hypermagnesemia at our hospital. 【Results】The median age was 76 (range: 59–87), including four males and five females. The symptoms were consciousness disturbance, blood pressure decrease, and bradycardia. The median serum Mg value was 6.0 (3.7–8.1) mg/dL, and the serum Cre value was 4.31 (0.62–9.93)mg/dL before HD. HD was performed for 2–4 hours at a blood flow rate of 80–120mL/min. After HD, the serum Mg value decreased 4.4 (2.9–5.6) mg/dL by 26.7 (17.9–41.2)%, with symptoms improving in all cases. Seven patients had elevated serum Mg values on the morning after HD compared to those values measured just at the end of HD, and the rate of elevation was 7.1 (2.0–18.2)%. These patients tended to show a lower eGFR before HD compared to the eGFR values of those who did not have elevated serum Mg values. 【Conclusion】HD for hypermagnesemia is thus considered to be an effective treatment modality for reducing the serum Mg values and achieving a rapid improvement in the symptoms, however, close attention must be paid to the occurrence of rebound phenomenon.

Blood-flow stagnation and water permeability are key areas for improving hemofilters. For reducing blood-flow stagnation at the inlets of hollow fibers within Excelflo hemofilters (AEF), a funnel-shaped design was introduced. On the other hand, to increase water permeability in Hemofeel hemofilters (SHG), the wall thickness of the hollow-fiber membranes was made thinner. In this study, both AEF and SHG hemofilters were tested for water permeability, lifetime, blood residue on the inner surface of the hollow fibers, and transmembrane pressure (TMP). Continuous hemofiltration with bovine blood was employed for this study, and a scanning electron microscope was used to observe the inlets. Through observations, the SHG filters were found to also have a funnel-shaped design, though this design is noticeably different from that of the AEF filters. The results of the study indicate that the water permeability of the AEF filters was lower than that of the SHG filters and that the lifetimes of both filters were approximately the same. Blood residue was observed throughout the hollow fibers from the blood intakes to the outlets of the AEF filters but were only observed near the inlets in the SHG filters. In addition, the TMP of the SHG filters was found to be lower than that of the AEF filters throughout the experiments.

A girl aged 1 year and 3 months accidentally swallowed her mother’s extended-release valproic acid (VPA) at 0:00 a.m. on the day of the visit. Subsequently, she went to sleep without any symptoms. After 8:00 p.m., her responses became poor. She was brought to our emergency department at 9:00 p.m. At presentation, there was impairment of consciousness (E1V1M5), hypoglycemia (5mg/dL), hypernatremia (150mEq/L), hyperammonemia (456μg/dL), hypocalcemia (7.0mg/dL), and acidemia (pH 7.18); the blood concentration of VPA was 771.9μg/mL. Thus, VPA poisoning was diagnosed. Respiratory management was initiated as the consciousness was impaired. As hyperammonemia persisted despite the administration of L-carnitine, continuous hemodiafiltration (CHDF) was initiated. The NH₃ levels improved immediately thereafter and the blood concentration of VPA also improved earlier than the Bayesian estimate. On the 75^th hospital day, however, she was transferred to another hospital for rehabilitation as she had residual neurological sequelae. Blood purification therapy in addition to supportive care is one of the effective ways for the treatment of hyperammonemia and impairment of consciousness associated with acute pediatric VPA poisoning. Furthermore, continuous renal replacement therapy (CRRT) is also thought to be effective in quickly reducing the blood levels of VPA to sub-toxic levels.

The new CHDF-FS^® circuit (Asahi Kasei Medical Co.) and its upgraded software program have been used for continuous hemodiafiltration (CHDF) with ACH-Σ^® (Asahi Kasei Medical Co.). The new circuits have a compact design, integrated infusion and anticoagulant lines, a needless port and altered position for anticoagulant administration. A hemofilter washing system and mechanism for adjusting the volume of sound according to the mode and pressure settings have been added to the upgraded software program. After using the CHDF-FS^® as well as the upgraded ACH-Σ^® software, we felt that adequate consideration had been given to improving the overall safety and usefulness of the device. However, a better way of avoiding the unanticipated rapid injection of drugs due to changing the position during anticoagulant administration needs to be developed.