Đánh giá hiệu quả lọc máu hấp phụ cytokin trong điều trị bệnh nhân covid-19

TÓM TẮT Đặt vấn đề: Lọc máu hấp phụ được xem là một phương pháp điều trị ở bệnh nhân Covid-19 nặng do có khả năng loại bỏ cytokine viêm. Nghiên cứu này mục đích để đánh giá hiệu quả lọc máu hấp phụ theo phương thức lọc máu ngắt quãng (IHD) ở bệnh nhân Covid-19. Phương pháp nghiên cứu: Nghiên cứu can thiệp, thực hiện trên các bệnh nhân được chẩn đoán viêm phổi do Covid-19 mức độ nặng ở trung tâm hồi sức tích cực bệnh viện dã chiến số 14, thành phố Hồ Chí Minh. Bệnh nhân được điều trị với thuốc kháng virus, kháng sinh, kháng đông và corticoid và liệu pháp oxy và 3 lần lọc máu hấp phụ sử dụng máy lọc máu ngắt quãng. Các chỉ số lâm sàng và xét nghiệm được thu thập và so sánh ở thời điểm trước và sau lọc máu. Kết quả: Có 6 bệnh nhân nam và 4 bệnh nhân nữ ở độ tuổi trung bình 54,60 ± 14,00 điều trị lọc máu hấp phụ, có 7 bệnh nhân cải thiện và cai dần với liệu pháp oxy. Giá trị SpO2 tăng từ 92,00 ± 2,31% đến 94,40 ± 1,71% với p = 0,02. IL - 6 trong máu bệnh nhân giảm từ 110,80 ± 126,84 pg/mL xuống 26,55 ± 26,80 pg/ mL với p = 0,06, CRP giảm từ 139,90 ± 57,41mg/L xuống 56,10 ± 53,10mg/L với p = 0,03. Kết luận: Lọc máu hấp phụ có thể giúp cải thiện SpO2 và hỗ trợ cai liệu pháp oxy ở hầu hết bệnh nhân trong nhóm nghiên cứu. Tuy nhiên, trong tương lai cần có nghiên cứu đa trung tâm, có đối chứng trên nhiều bệnh nhân để có thể đánh giá chắc chắn hiệu quả lọc máu hấp phụ ở bệnh nhân Covid-19. ABSTRACT EFFECTIVENESS OF HEMOPERFUSION IN COID-19 PATIENTS Backgrounds: Extracorporeal blood purification has been proposed as one of the therapeutic approaches in patients with coronavirus infection, because of its beneficial impact on elimination of inflammatory cytokines. This study aims to evaluate the effectiveness of hemoperfusion in coid-19 patients. Methods: This experimental research has been conducted on severe COVID-19 pneumonia patients who admitted in field hospital in Ho Chi Minh city, receiving antiviral, antibacterial drugs, anticoagulant drugs and steroid, and different modalities of respiratory treatments. No randomization and blindness were considered. All of the participants underwent three sessions of resin-directed hemoperfusion using intermittent hemodialysis machine. Results: Six men and four women with a mean age of 54.60 ± 14.00 years has been enrolled in the study, and seven of them have improved after the intervention. Peripheral capillary oxygen saturation (SpO2) changed after cytokine removal therapy. Mean SpO2 before the three session of hemoperfusion was 92.00 ± 2.31% and increased to 94.40 ± 1.71% after them (p = 0.02). Serum IL - 6 showed a reduction from 110.80 ± 126.84 pg/mL to 26.55 ± 26.80 pg/mL p = 0.06; and C-reactive protein decreased from 139.90 ± 57.41mg/L to 56.10 ± 53.10mg/L p = 0.03. Conclusions: Extracorporeal hemoadsorption using intermittent dialyisis machine could improve the general condition in most of recruited patients with severe coronavirus disease, however, large prospective multicenter trials in carefully selected patients are needed to definitely evaluate the efficacy of hemoperfusion in COVID-19 patients. Keywords: Intermittent dialyisis machine, hemoperfusion, COVID-19 pneumonia.

Prediction of hemodynamic tolerance of intermittent hemodialysis in critically ill patients: a cohort study

The evaluation and management of fluid balance are key challenges when caring for critically ill patients requiring renal replacement therapy. The aim of this study was to assess the ability of clinical judgment and other variables to predict the occurrence of hypotension during intermittent hemodialysis (IHD) in critically ill patients. This was a prospective, observational, single-center study involving critically ill patients undergoing IHD. The clinical judgment of hypervolemia was determined by the managing nephrologists and critical care physicians in charge of the patients on the basis of the clinical data used to calculate the ultrafiltration volume and rate for each dialysis treatment. Seventy-nine (31.9%) patients presented with hypotension during IHD. Patients were perceived as being hypervolemic in 109 (43.9%) of the cases by nephrologists and in 107 (43.1%) by intensivists. The agreement between nephrologists and intensivists was weak (kappa = 0.561). Receiver operating characteristic curve analysis yielded an AUC of 0.81 (95% CI 0.75 to 0.84; P < 0.0001), and a cutoff value of 70 mm for the vascular pedicle width (VPW) had the highest accuracy for the prediction of the absence of hypotension. The clinical judgment of hypervolemia did not predict hypotension during IHD. The high predictive ability of the VPW may assist clinicians with critical thinking.

Interest of beta 2-microglubulin determination in chronic hemodialysis patients

The amylase beta 2-microglobulin (β2m) is a common complication of long-term hemodialysis, mainly responsible for osteo-articular manifestations including carpal tunnel syndrome (CTS). With the aim to study the various parameters involved in the increase of and determine the interest of dosage, we conducted a cross-sectional study of 104 chronic hemodialysis patients for more than 6 months. The mean age of patients was 52.82 years with a male predominance (62.5%). 61, 3% of our patients are anuric. They all have intermittent hemodialysis at 12 hours per week using a low permeability membrane in 52% of patients. The average age of dialysis layout is 42, 18 years. The mean duration of hemodialysis was 74 months. The mean serum β2m is 35, 24 mg / l. regarding complications, there were four confirmed cases of carpal tunnel syndrome and 12 deaths. Our study objectify the parameters involved in the increase of β2m: The current age, age advanced dialysis layout, lack of urine output, low permeability membrane and extended duration hemodialysis. Increased serum levels of β2m in our hemodialysis demonstrate the poor treatment of middle molecules. Its reduction can be made by improving the quality of dialysis and will avoid all the complications.

Modelling COVID-19 transmission in a hemodialysis centre using simulation generated contacts matrices

The COVID-19 pandemic has been particularly threatening to patients with end-stage kidney disease (ESKD) on intermittent hemodialysis and their care providers. Hemodialysis patients who receive life-sustaining medical therapy in healthcare settings, face unique challenges as they need to be at a dialysis unit three or more times a week, where they are confined to specific settings and tended to by dialysis nurses and staff with physical interaction and in close proximity. Despite the importance and critical situation of the dialysis units, modelling studies of the SARS-CoV-2 spread in these settings are very limited. In this paper, we have used a combination of discrete event and agent-based simulation models, to study the operations of a typical large dialysis unit and generate contact matrices to examine outbreak scenarios. We present the details of the contact matrix generation process and demonstrate how the simulation calculates a micro-scale contact matrix comprising the number and duration of contacts at a micro-scale time step. We have used the contacts matrix in an agent-based model to predict disease transmission under different scenarios. The results show that micro-simulation can be used to estimate contact matrices, which can be used effectively for disease modelling in dialysis and similar settings.

Preserved Cerebral Oxygenation with Worsening Global Myocardial Strain during Pediatric Chronic Hemodialysis

Background Cerebral and myocardial hypoperfusion occur during hemodialysis in adults. Pediatric patients receiving chronic hemodialysis have fewer cardiovascular risk factors, yet cardiovascular morbidity remains prominent. Methods We conducted a prospective observational study of pediatric patients receiving chronic hemodialysis to investigate whether intermittent hemodialysis is associated with adverse end organ effects in the heart or with cerebral oxygenation (regional O2 saturation [rSO2]). We assessed intradialytic cardiovascular function and rSO2, using noninvasive echocardiography to determine myocardial strain and continuous noninvasive nearinfrared spectroscopy for rSO2. We measured changes in blood volume and central venous oxygen saturation (mCVO2) were pre-, mid-, and post-hemodialysis. Results The study included 15 patients (median age, 12 years; median hemodialysis vintage 13.2 [9, 24] months were included. Patients were asymptomatic. The rSO2 did not change during hemodialysis, whereas mCVO2 decreased significantly, from 73% to 64.8 %. Global longitudinal strain of the myocardium worsened significantly by mid-hemodialysis and persisted post-hemodialysis. The ejection fraction remained normal. Lower systolic blood pressure and faster blood volume change were associated with worsening myocardial strain; only blood volume change was significant in multivariate analysis (β coefficient, -0.3; 95% confidence interval [95% CI], −0.38 to −0.21; P=0.0001). Blood volume change was also associated with a significant decrease in mCVO2 (β coefficient 0.42; 95% CI, 0.07 to 0.76; P=0.001). Access, age, hemodialysis vintage, and ultrafiltration volume were not associated with worsening strain. Conclusion s Unchanged rSO2 suggested that cerebral oxygenation was maintained during hemodialysis. However, despite maintained ejection fraction, intradialytic myocardial strain worsened in pediatric hemodialysis and was associated with blood volume change. The effect of hemodialysis on individual organ perfusion in pediatric versus adult patients receiving hemodialysis might differ.