ART Kidney (Vividiffusion Apparatus) have been able to transfer solutes by diffusion from the animal blood to a dialyzing fluid. The blood is prevented from clotting using hirudin and is caused to flow outside the animal body through collodion tubes. The substances of small molecular weight are removed by diffusion whereas no substances of large molecular weight such as proteins pass through the collodion membrane. When Kolff WJ tried to construct the Kolff Kidney (Rotating Drum Kidney), fortunately excellent dialysis membranes (cellophane) and a reliable non-toxic anticoagulant (heparin) were available. In order to construct the Kolff Kidney of sufficient performance for clinical use, a small quantity of the blood in a thin layer confined with the cellophane tube membrane should be circulated over a large membrane surface in a closed system. Furthermore, the blood and also the dialyzing fluid should be caused to flow in a sufficiently mixed condition in the Kolff Kidney. The Kolff Kidney suitable for clinical use was developed in 1942 in cooperation with Mr H Th J Berk who was an engineer in Holland. The Kolff Kidney, Kolff-Brigham Kidney, Orange Juice Kidney and Tank Kidney are described in this special contribution paper.

Several guidelines for the management of sepsis and septic shock in children have recently been developed to promote best practices and improve patient outcomes. Surviving Sepsis Campaign Guidelines (SSCG) 2012, American College of Critical Care Medicine (ACCM) 2014 update, are now available, as well as J-SSCG 2016, which was developed in Japan. Based on these guidelines, we reviewed fluid resuscitation and blood purification therapies for sepsis and septic shock in children. There is no consensus regarding definitions for sepsis and septic shock in children； moreover, most statements were designated with weak or no recommendation, as well as low quality of evidence. Organ dysfunction criteria for children must be developed and validated to establish definitions for sepsis and septic shock in children, which should be used to guide future studies.

Blood purification through plasmapheresis therapy is often performed in critical care to treat Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and anti-glomerular basement membrane disease (anti-GBM disease). A simple plasma exchange using fresh frozen plasma as the replacement fluid is used particularly for diseases with bleeding, such as alveolar hemorrhage, as it supplements coagulation factors. However, the use of large amounts of fresh frozen plasma may cause complications, including allergies. Selective plasma exchange is a type of plasma exchange that uses a selective membrane separator to effectively remove pathogenic substances of smaller molecular weight than immunoglobulin G, while retaining the coagulation factors, such as factor XⅢ and fibrinogen, even when an albumin solution is used as the replacement fluid. Although the effectiveness of selective plasma exchange has been reported in immune-mediated disorders, there is little information regarding its use to treat SJS/TEN and anti-GBM disease. The present study presents an overview on the use of selective plasma exchange for the treatment of SJS/TEN and anti-GBM disease.

Here we assessed clinical effects of continuous hemodiafiltration (CHDF) using the AN69ST membrane for the treatment of sepsis/septic shock. This study included 56 patients diagnosed with sepsis/septic shock at the Department of Critical Care at the Emergency and Clinical Care Center, Tokyo Women’s Medical University Medical Center East between June 1, 2015 and November 30, 2017. Of them, 38 patients were treated with the AN69ST membrane (AN69ST group) and 18 were treated without the AN69ST membrane (non-AN69ST group). AN69ST membranes were used in all cases receiving CHFD, and endotoxin absorption therapy was not administered. In the AN69ST group, the mean blood pressure at baseline and after 72 hours was 66mmHg[interquartile range (IQR): 58–82mmHg] and 92mmHg (IQR: 82–108mmHg), respectively. In the non-AN69ST group, these values were 60mmHg (IQR: 55–72mmHg) and 87mmHg (IQR: 81–102mmHg), respectively. Despite the increase in blood pressure observed in both groups, the difference was not statistically significant. Similarly, there were no differences observed in pulse, PaO2/FIO2 ratio, blood lactic acid, catecholamine index, urine volume, or total infusion volume between the groups. Studies of additional cases are warranted to investigate survival in patients with sepsis/septic shock.

Vascular access hemodialysis catheters have been designed to overcome various challenges. For example, the catheters luminal diameter was increased to provide less resistance to the blood flow. The catheters were coated with an antithrombotic drug to avoid thrombus formation. The catheters occur trouble that suctioning towards a vessel wall during the treatment. So, we reported that rotating the catheter was effective to solve the trouble. This study aimed to investigate whether the structure of the aspiration holes on the catheter’s end can have an impact on the vessel wall suction. We analyzed 5 kinds of catheters with suction openings. We established an ex vivo evaluation system for visually confirming the adhesion of the catheter to the vessel wall by suction and for quantifying the extent of the adhesion. Using this model, we evaluated the catheters to come up with a solution for the problem. We found that the best catheter had wide openings and three-dimensional hole surface. On the other hand, the catheter with more wall adherence problems was the one with a simple suction pore structure. Our results suggest that the catheter’s tip structure does have a significant impact on the problem of the vessel wall suction, and that a careful tip design may improve the catheter’s performance.

The site and dose of nafamostat mesilate (NM) administration were examined in patients undergoing continuous hemodiafiltration (CHDF) using the AN69ST membrane hemofilter. Patients who were administered NM pre-hemofilter (group A) were compared with those who were administered NM post-hemofilter in addition to pre-hemofilter (group AV). In both groups, activated coagulation time on the blood return side was not elongated in comparison with the blood removal side. Coagulation in the circuit occurred 8 times in group A, and 9 times in group AV, but in the drip-chamber of the blood return side alone in 6 of 8 times in group A and 6 of 9 times in group AV. Group A showed distinct changes in circuit pressure due to circuit coagulation in the vein-side chamber when compared with Group AV. NM is adsorbed on the AN69ST membrane hemofilter and may exert an anticoagulant effect on the membrane. Increasing the post-hemofilter NM dose may also reduce circuit coagulation； however, the resulting increase in the total NM dose may increase the risk of bleeding and cost. Therefore, further investigation including cost-benefit analysis is necessary when CHDF using an AN69ST membrane hemofilter is adopted.

We report the cases of three patients with internal rewarming for whom hemodialysis (HD) was used to treat accidental hypothermia. All patients were elderly Japanese men, and the severity of their hypothermia was mild to severe. After external rewarming, HD was initiated to achieve a rewarming rate of 2℃/hr. In the mild hypothermia case, rewarming shock occurred within 2 hr of starting HD. In the most severe case, the starting dialysate temperature was set at 34℃, and the blood flow was 80 mL/min to avoid risks such as the induction of ventricular fibrillation caused by rapid temperature restoration. In this patient, the HD was stopped after a total of 3 hr, when the patient became more alert and his rectal temperature reached 30℃. The temperature of each patient’s blood circuit was measured using thermography (FLIR^® i3, FLIR Systems, Boston, MA) and controlled appropriately. Although HD is a useful method for treating severe hypothermia, it is necessary to control the rate of rewarming and body temperature carefully to prevent side effects due to rewarming.

Blood purification in critical care, which includes simple plasma exchange, bilirubin adsorption, and plasma filtration with dialysis therapy, is often performed to treat hyperbilirubinemia in postoperative liver failure and multiple organ failure. However, there is little information regarding selective plasma exchange. Here, we investigated the removal efficiency of bilirubin removal by selective plasma exchange, in a patient with thrombocytopenia, anasarca, fever, renal failure or reticulin fibrosis, and organomegaly (TAFRO) syndrome. Selective plasma exchange was performed using Evacure Plus EC-4A10 as a selective membrane plasma separator. During selective plasma exchange, an increase of the processed plasma volume from 1,000mL to 4,000mL, caused only a slight change on the sieving coefficients of total, conjugated, and unconjugated bilirubin. The mean sieving coefficients of total, conjugated, and unconjugated bilirubin were 0.81±0.02, 0.90±0.01, and 0.49±0.06, respectively. The percent reduction of total bilirubin and fibrinogen following a session of selective plasma exchange was 40％ and 3.7％, respectively. Selective plasma exchange can be performed to remove bilirubin while retaining coagulation factors, such as fibrinogen, even when an albumin solution is used as a replacement fluid.

【Background】At emergency units, it is often the case that the patient’s data such as consultation record, medical history, and baseline serum creatinine level and urine volume are unknown at the time of arrival, which can prolong the time necessary to diagnose acute kidney injury (AKI) or chronic kidney disease (CKD). We investigated the renal function and life prognosis of patients with septic shock who were transferred to our center and received CHDF.【Methods】The renal function and life prognosis of 40 patients who were transferred to our center between January 2014 and March 2016 and experienced septic shock at the initiation of CHDF were reviewed retrospectively.【Results】Patient demographics and other characteristics were as follows : age, 70±16 years old ; Acute Physiology and Chronic Health EvaluationⅡ(APACHEⅡ) score, 31 points ; 28-day survival rate, 85％ ; and standardized survival rate, 3.4. Of the patients with septic shock, 70％ had acute kidney injury (AKI) with a median “Kidney Disease : Improving Global Outcomes (KDIGO)” of 2, and 90％ had renal disorder, including chronic kidney disease (CKD). All patients with AKI who survived, excluding 4％ who switched to maintenance dialysis, were cured of AKI.【Conclusions】Of the patients, 70％ experienced AKI but had a good life prognosis.

Our group performs blood purification therapy more than 1,500 times per year in the ICU. We attempt to prevent circuit coagulation and reduce complications such as bleeding by adjusting the anticoagulant dosage, according to the disease or condition. In addition, we try to prevent blood removal failure via precise placement of the indwelling blood purification catheter. During blood purification therapy, when key drugs for treatment and drugs with narrow safety margins are administered, we frequently measure blood concentrations so as to not impair the therapeutic effect. When performing blood purification therapy, the doctor, nurse, and clinical engineer briefly share information with the patient and observe the patient until hemodynamic stabilization is achieved.