Coupled Plasma Filtration Adsorption Application for Liver and Thyroid Toxins

Coupled plasma filtration and adsorption (CPFA) is a detoxification system that combines a plasma adsorption circuit and a continuous renal replacement therapy circuit. Its main application is for sepsis and septic shock with or without acute renal failure. Several recent studies have suggested that CPFA can reduce the mortality when the volume of plasma absorbed on the styrenic resin is at least >0.18 L/kg/day. At present, new applications for CPFA are under investigation, also in patients without significant kidney failure. We report here a successful case of CPFA use during acute liver failure, with a complete recovery of liver function in a patient after severe cholangitis and relapsing hemolytic anemia. The resin enabled the removal of bilirubin and protein-bound toxins, while the hemofilter removed the hydrophilic toxins such as ammonia and non-protein-bound toxins as free bilirubin. We also describe a second case of CPFA application during thyrotoxicosis to achieve free triiodothyronine (FT3) and free thyroxin (FT4) adsorptions. The CPFA efficacy seems to exceed that obtained by plasma exchange (PEX) as to FT3 and FT4 adsorptions. The resin allowed the adsorption of FT3 and FT4. The role of the hemofilter is to enhance the hemodynamic tolerance of the extracorporeal treatment and remove water-soluble toxins. The reduced duration of CPFA treatments, in case of normal renal function, is confirmed by the assessment of the resin cartridge saturation. Thus, multipurpose CPFA can play a role in the case of resistance to current medical therapy or as a bridge to liver transplantation or thyroidectomy

QTC INTERVAL, POTASSIUM AND ELECTROLYTES KINETICS DURING AND AFTER DIALYSIS WITH SUPRA HFR (PANDORA STUDY)

Background and Aims: The QTc interval is a marker of arrhythmic risk in dialysis patients and its lengthening has been associated with an increased risk of sudden death [1]. This phenomenon could be due to accumulation of uremic toxins and their rapid removal with dialysis causing imbalance of electrolytes currents [2]. The aim of the study is to describe the kinetics of potassium (K+) and other electrolytes during and after dialysis with the goal of validate a mathematical model for predicting the respective kinetics [3]. The secondary endpoint is to identify a correlation between the kinetics of intra (Ki) and extracellular K+ (Ke) during and after dialysis and QTc interval. Method: 6 anuric HD patients were enrolled in a interventional, exploratory, prospective study. Clinical and pharmacological factors favouring the onset of arrhythmias or influencing the total mass of K+ were excluded. Ki and Ke, Ca2+, Na, blood gas analysis, glucose and urea every 30 minutes were assessed during a 4 hour HFR Supra dialysis session, the subsequent 7 hours and at the start of the following session after 48 hours. A 12 lead ECG were performed with the same schedule and a bioimpedance vector analysis (BIVA) was obtained at the start and the end of the dialysis and 1- and 7-hours after dialysis. Dialysate electrolytes were: Na 140 mEq/L, K 3 mEq/L, Ca2+ 1.5 mEq/L, HCO3- 30 mmol/L. A selective ion probe was used to measure K+, the Ki value was obtained by an indirect formula expressed in a previous study [4]. The model of K+ kinetics includes the Na + / K + / ATPase-dependent pump, the passive diffusion of K+ from the intracellular to the extracellular compartment, the diffusion of K+ through the filter, the intradialytic volume variation, the K+ and solute rebound after dialysis, the role of plasma osmolality [3]. Results: The model showed a better correlation to the in vivo data during the HFR phase than the post dialytic one regarding Ke, sodium, HCO3- and Ca2+. The wide variability recorded by Ki is significantly in contrast with the stability predicted by the model and the entity of post dialysis Ca2+ drop was greater than that predicted by the model. Kinetics prediction of urea had a precise fitting with in vivo data in every phase. In Table 1 are resumed the in vivo results of the 5 patients regarding Ke, Ki, Ki/Ke, Ca2+ and QTc during and after HFR. In Figure 1 we see the data extrapolated from a patient (likewise the others), where the greatest waving of the QTc occurred in the first hour post HFR in parallel with fluctuations of Ki and Ki/Ke. Conclusion: The mathematical model for the prediction of the kinetics of solutes has shown a good correspondence with the in vivo data of K+, sodium, urea, Ca2+ and HCO3- during HFR, while it still needs to be refined in the post-dialysis phase. The major discrepancies for Ki could be due to difficult analytical processing. As to the greater drop of Ca2+ compared to the predicted, it can be due to the role played by other Ca2+ compartments in addition to the intra and extracellular ones. Although during the intradialytic period we faced a shortening of the QTc interval with a significant reduction in Ke, greater Ki/Ke and an increase in Ca2+, the post HFR period appeared to be the most critical period. This phase corresponded to the largest fluctuations in QTc values, Ki, Ki / Ke ratio, and to the rapid rebound of K+ and the drop of Ca2+

Sodium Prescription in the Prevention of Intradialytic Hypotension: New Insights into an Old Concept?

Background: Sodium prescription in patients with intradialytic hypotension remains a challenge for the attending nephrologist as it increases dialysate conductivity in hypotension-prone patients, thereby adding to dietary sodium. Methods: New sodium prescription strategies are now available, including the use of a mathematical model to compute the sodium mass to be removed during dialysis as a physiological controller. Results: This review describes the sodium load of patients with end-stage renal disease on chronic hemodialysis and discusses two strategies to remove excess sodium in patients prone to intradialytic hypotension, namely Profiled hemodialysis and the HFR Aequilibrium System. Conclusion: The Profiled hemodialysis and Aequilibrium System trials both proved effective in counteracting intradialytic hypotension

Acute Myeloma Kidney: free light chains removal associated with chemotherapy for patients and kidney survival

INTRODUCTION. Renal failure remains a principal cause of morbidity and mortality for patient with multiple myeloma. Among renal manifestation casts nephropathy (Myeloma Kidney) represents the most common. The aim of this study is to assess the efficacy and safety of the extracorporeal removal of free light chains by means of hemodialysis with double filter application in patients with Acute Myeloma Kidney associated with different schemas of chemotherapy. METHODS. Fourteen patients (M/F = 11/ 3) were considered in the study. Acute Myeloma Kidney affected all these patients. Ten patients underwent renal biopsy and 9 cases of myeloma cast nephropathy were diagnosed. The median age of the patients was 72 years (range ). Every patient underwent the chemotherapy together with the extracorporeal treatment for the removal of free light chains by using double filter. Hemodialytic treatments were scheduled three times a week and the hemodialysis dose was not related to the degree of the renal failure but to the removal of free light chains. The dialysis filter used were characterized by high adsorbitive properties: PMMA filter (polymethylmetacrylate; Filtryzer BK-F 2.1 m2 surface area) cut-off 20,000 daltons; PEPA filter (polyester polymer alloy FDX 210-GW, 2.1 m2 surface area) cut-off 35,000 daltons. Each dialysis session lasted 4 hours. Low molecular weight heparin was used as anticoagulation. During each session two dialyzers were used and the substitution of the filter was carried out at the second hour of the hemodialysis session. For each session the reduction rate of free light chains was calculated. Urine output, hemoglobin, platelets, white blood cell, renal function and electrolytes were assessed. RESULTS. Average number of dialytic session was 10. Median Reduction Rate for free light chains was 25 % (range 2.4% - 69%). There was no statistical significant difference in FLC reduction rate between PEPA double filter and PMMA double filter (median reduction rate 53% vs. 38%). Six patient involved in the study died because of the complications of multiple myeloma (infections, bone fractures, chronic kidney disease). They all required chronic hemodialysis. Eight patients survived: among these 6 restored their renal function and 2 required chronic hemodialysis treatment. DISCUSSION. Early removal of free light chains in patient with renal involvement associated with specific chemotherapy is a predictive factor of recovery of renal function and that the recovery of renal function is associated to a best outcome of the patient. The use of an extracorporeal treatment based on substitution of filter at the second hour of the dialytic session was assessed. The two types of filters (PMMA and PEPA) didn’t show statistical differences