It has been proposed under the concept of “cytokine theory of disease” that many pathological conditions, especially acute pathological conditions such as severe sepsis, are developed by cytokine storm where blood interleukin-6 (IL-6) levels exceed 1,000 pg/mL. IL-6 has been chosen as a biomarker of cytokine storm because it is most easily measurable cytokine among many kinds of cytokines in clinical settings. As for the countermeasures against cytokine storm we apply continuous hemodiafiltration with cytokine-adsorbing hemofilter (CAH-CHDF). CAH-CHDF can effectively and continuously remove many kinds of cytokines from blood stream of a patient and thus CAH-CHDF can decrease the blood levels of cytokines. This decrease of the blood cytokine levels results in the improvement of various organ function and in the improvement of survival. Thus, we conclude that cytokine storm should be considered as a main feature of acute pathological conditions and that CAH-CHDF is a very effective countermeasures against cytokine storm.

It has been reported that the multimodal approach (MMA) can stabilize hemodynamics and fluid management during renal replacement therapy for critically ill patients. This method uses prolonged or iterative dialysis and multiple dialysis techniques such as high-sodium, low temperature, acetate-free, and high-calcium dialysates. It is reported that intermittent hemodialysis (IHD) with MMA can achieve hemodynamic stabilization and prognosis equivalent to continuous renal replacement therapy (CRRT), and IHD with MMA may achieve better results than CRRT in cases with stable hemodynamics and cases with lesser severity. The reasons why IHD with MMA improves the prognosis in some subgroups may be due to issues associated with CRRT trauma. In our intensive care unit, we consider using IHD with MMA for patients with CRRT trauma-related issues such as bleeding or malnutrition.

The approach to determining the dose of continuous kidney replacement therapy (CKRT) in Japan differs from approaches used abroad. Under the Japanese healthcare system, the prescribed daily volumes of dialysate and replacement fluid are fixed, and thus the CKRT dose varies from one individual to another depending on their body weight. We therefore retrospectively analyzed an observational cohort to assess how Japan’s unique approach affects mortality by age. We categorized 494 patients who underwent CKRT at Nara Medical University Hospital into four groups based on age (< 75 years or ≥ 75 years) and CKRT dose (above or below the median, 13.2 mL/kg/h) and then used multivariable Cox regression analysis to compare 90-day mortality between the groups. A higher CKRT dose was observed to be independently associated with lower 90-day mortality, regardless of age. A relatively higher CKRT dose might have contributed to improved survival in elderly patients, especially who tend to have lower body weight. The current Japanese approach of a fixed prescription of dialysate and replacement fluids might therefore mitigate age-related differences in mortality, highlighting the need to reconsider the CKRT dose prescription to ensure no variance with a patient’s body weight.

Objective: The AN69ST hemofilter, because of its negatively charged surface, adsorbs the anticoagulant, nafamostat mesilate (NM). However, temporal changes in NM adsorption capacity have not yet been reported. A decline in this capacity may increase the risk of bleeding. This study aimed to evaluate the temporal changes in NM adsorption capacity. Methods: Using the Prismaflex multipurpose blood purification system, NM was administered exclusively through the afferent blood circuit of an AN69ST hemofilter (membrane area; 1.5 m²). Activated coagulation time (ACT) was measured in the arterial and venous line blood circuits in 74 patients. The duration from the initiation of continues kidney replacement therapy (CKRT) to ACT measurement was stratified into six intervals, and the ACT values on the venous line blood side were compared across these time points. Results: The ACT on the venous line blood side was observed as follows (median [interquartile range]): at 12 hours, 162 s (IQR 145, 185); at 12-24 h, 201 s (IQR 178, 227); at 24-36 s, 229 s (IQR 190, 263); at 36-48 hours, 246 s (IQR 224, 274); at 48-60 h, 248 s (IQR 229, 302); and beyond 60 h, 249 s (IQR 228, 267). A statistically significant prolongation was observed compared to baseline (P<0.01). Conclusion: The NM adsorption capacity of the AN69ST hemofilter was suggested to decrease over time.

We examined factors affecting catheter Life Time during continuous renal replacement therapy (CRRT). A total of 617 cases in which either a conventional end-hole catheter (Gentle CathTM) or an elliptical end-hole catheter (Power Trialysis^®) was used between January 2018 and December 2023 were included. The factors affecting Life Time included previously reported predictors of circuit coagulation and catheter type. Multiple Linear Regression analysis revealed that platelet count (Plt), activated partial thromboplastin time (APTT), soluble fibrin (SF), and catheter type were significantly associated with catheter Life Time, with the Power Trialysis^® catheter showing an extended Life Time. Evaluation of the impact of these factors’ indicated that catheter type exerted the second-largest influence on Life Time, after Plt. These findings suggest that catheter type is an important determinant of Life Time during CRRT, with the Power Trialysis^® catheter demonstrating the potential to extend Life Time.

Based on experiences from large-scale disasters such as the Great Hanshin-Awaji Earthquake, the establishment of a system for providing rapid medical care to seriously ill patients in disasters, especially those with crush syndrome (CS), is recognized as an urgent issue. This study aimed to evaluate the current status of and identify challenges regarding the acceptance of patients with CS and the availability of blood purification therapy at disaster-based hospitals in Japan. A questionnaire survey was conducted in 770 disaster-based hospitals nationwide (as of April 2023), and valid responses were received from 170 facilities (response rate: 22.0%). The results indicated that while 148 of the 170 facilities (87.1%) reported the capacity to accept patients with CS, only 66 facilities (44.6%) had actual experience in accepting patients with CS. Blood purification equipment was available in 155 facilities (91.2%). Regarding blood purification therapy for pediatric patients (under 15 years old), 61 facilities (35.9%) reported the capability to provide treatment, but only 28 facilities (18.9%) provided such treatment during normal operations. Although the basic infrastructure for accepting patients with CS is in place, this study revealed operational challenges. Our study revealed the need to strengthen regional medical systems, including the establishment of efficient patient transport systems between facilities and enhanced interfacility cooperation.

Acute exacerbation of interstitial pneumonia (AE-IP) is associated with a high mortality rate. Recently, the effectiveness of endotoxin adsorption therapy (polymyxin B-immobilized fiber column direct hemoperfusion) for AE-IP has been reported. The patient was a man in his 60s with underlying IP who presented with dyspnea and was diagnosed with respiratory failure due to AE-IP, requiring mechanical ventilation. Arterial blood gas analysis after endotracheal intubation revealed hypercapnia and transthoracic echocardiography revealed right-sided heart failure. We administered combined hemodiafiltration (HDF) and PMX-DHP therapy and management using cardiovascular agents. After blood purification therapy, hypercapnia improved and right heart function recovered. We actively implemented prone positioning therapy and early respiratory rehabilitation, successfully weaned the patient from mechanical ventilation, and helped them survive during the acute phase.

A 66-year-old man underwent implantation of an implantable cardioverter defibrillator for syncope attacks due to sustained ventricular tachycardia. He was taking 300 mg/day cibenzoline succinate (CZ) to treat paroxysmal atrial fibrillation and hypertrophic cardiomyopathy. Two weeks previously he presented to our hospital complaining of appetite loss, increased general malaise, and difficulty with physical activity. He was admitted with hypoglycemia, marked prolongation of the QRS wave on ECG, severe renal dysfunction, and myasthenia gravis-like symptoms. His blood CZ level was 2,591 ng/mL and he was diagnosed with CZ poisoning. The patient presented with metabolic acidosis that could not be corrected with sodium bicarbonate injections and was complicated by acute kidney injury. Therefore, continuous hemodiafiltration (CHDF) was initiated. Various complications improved following early implementation of CHDF, resulting in a good course of treatment. The patient was discharged after confirming that his blood CZ level had reached normal level.

A 13-month-old boy presented with bradycardia and hypotension during centrifugal plasma exchange therapy for Kawasaki disease. A significant decrease in ionized calcium levels was observed, and its correction resulted in rapid hemodynamic stabilization. Compared to membrane plasma exchange, centrifugal plasma exchange has higher plasma removal efficiency and can be performed with lower blood flow, allowing treatment through peripheral vascular access without the need for central venous catheterization. However, citrate, an anticoagulant used in the procedure, accumulates when its metabolic clearance is exceeded. This accumulation can lead to reduced ionized calcium levels, elevated anion-gap metabolic acidosis, and potentially life-threatening circulatory instability. Citrate accumulation is a rare but serious complication requiring meticulous attention. In pediatric patients, the risk factors for citrate accumulation remain inadequately understood; however, clinical markers, such as an increased total calcium-to-ionized calcium ratio and a rising anion gap, may serve as useful indicators. To minimize the risk of complications, rigorous monitoring of vital signs, namely total and ionized calcium levels and anion gap fluctuations, is essential during centrifugal plasma exchange. Monitoring should be conducted in an intensive care setting to ensure timely detection and intervention, thereby preventing severe outcomes.

High-dose methotrexate (MTX) therapy is an effective treatment for leukemia and malignant lymphoma but can result in severe adverse effects, including MTX toxicity. Management of MTX toxicity typically involves the use of glucarpidase as an antidote, along with extracorporeal blood purification techniques such as plasma exchange, hemodialysis, and direct hemoperfusion (DHP). We present a case of MTX toxicity successfully treated with 24-hour DHP combined with continuous renal replacement therapy (CRRT). At the start of DHP, the MTX clearance rate was 84.5 mL/min, which decreased to 32.1 mL/min after 24 hours. For CRRT, the clearance rates were 35.7 mL/min at initiation and 30.7 mL/min at 12 hours. Importantly, DHP sustained significant clearance even after 24 hours, demonstrating its effectiveness as a therapeutic option for MTX toxicity. This case underscores the potential of prolonged DHP in managing MTX toxicity, particularly its capacity to maintain substantial MTX clearance over extended periods.