Is there a place for hyperimmune globulins in the treatment of refractory infections?
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Animals↗
Biomedical subjects
N Boyce
Publications and source records attributed to N Boyce.
Necessary evil?
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Clinical Trials as Topic↗
Effect of premedication guidelines and leukoreduction on the rate of febrile nonhaemolytic platelet transfusion reactions.
Platelet transfusion reactions were prospectively studied in haematology/oncology patients at five university teaching hospitals over three consecutive summers. The initial summer study provided baseline information on the use of premedications and the rate of platelet transfusion reactions (fever, chills, rigors and hives). Most (73%) platelet recipients were premedicated and 30% (95% CI 28-33%) of transfusions were complicated by reactions. The second study followed implementation of guidelines for premedicating platelet transfusions. Despite a marked reduction in premedication (50%), there was little change in the platelet transfusion reaction rate, 26% (95% CI 24-29%), or the type of reactions. The third study followed implementation of prestorage platelet leukoreduction while maintaining the premedication guidelines. The reaction rate decreased to 19% (95% CI 17-22%). For nonleukoreduced platelets, there was a statistically significant association between the platelet age and reaction rate (P = 0.04). For leukoreduced platelets, there was no statistically significant association between platelet age and reaction rate (P = 0.5). Plasma reduction of nonleukoreduced platelet products also reduced the reaction rate. These prospective studies document a high rate of platelet transfusion reactions in haematology/oncology patients and indicate premedication use can be reduced without increasing the reaction rate. Prestorage leukoreduction and/or plasma reduction of platelet products reduces but does not eliminate febrile nonhemolytic platelet transfusion reactions.
Blood Preservation↗
International forum: granulocyte transfusions.
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Granulocytes↗
In memoriam: tougher rules could be the legacy of gene therapy's first death.
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Advisory Committees↗
Who needs to know? Confusion reigns over the reporting of gene therapy deaths.
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Advisory Committees↗
A prospective comparative study of moderate versus high protein intake for critically ill patients with acute renal failure.
Critically ill patients with acute renal failure are traditionally treated with low-protein diets to help control uremia. This dietary approach may be deleterious to the patient's nutritional status and unnecessary, especially if continuous renal placement therapies (CRRT) are used. However, the optimal amount of protein supplementation during CRRT is unknown. In patients receiving CRRT, a high protein intake may result in a positive nitrogen balance in the absence of uncontrolled uremia. Accordingly, we studied nitrogen metabolism in two consecutive cohorts of acute renal failure patients receiving equal amounts of calories but variable amounts of nitrogen. One group received protein according to the preferences of the attending clinician, the other a high and fixed amount of protein (2.5 g/kg/day). Patients treated according to attending clinician preferences received significantly less dietary protein (1.2 g/kg/day vs. 2.5 g/kg/day; p < 0.0001) and had a negative mean nitrogen balance of -5.5 g/day. Patients receiving a high and fixed amount of protein had a less negative mean nitrogen balance (-1.92 g/day). Such patients were more likely to experience a positive nitrogen balance during any 24-h period (53.6% vs. 36.7%; p < 0.05). They also required more aggressive hemofiltration to maintain control of uremia (mean ultradiafiltrate volume: 2145 mL/h vs. 1658 mL/h; p < 0.0001) and had a significantly higher but still acceptable mean plasma urea level (26.6 mmol/L vs. 18 mmol/L; p < 0.0001). Survival was not significantly different in the two groups (37.5% vs. 31.3%). We conclude that a high-protein diet can be safely administered to critically ill patients with acute renal failure receiving continuous renal replacement therapy. Such a high protein intake improves nitrogen balance when compared to moderate protein intake. A low protein intake is unnecessary in patients treated with CRRT.
Acute Kidney Injury↗
Using outcome data to measure quality in health care.
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Humans↗
Treatment of sepsis-associated severe acute renal failure with continuous hemodiafiltration: clinical experience and comparison with conventional dialysis.
The syndrome of sepsis-associated severe acute renal failure is a frequent component of sepsis-induced multiorgan failure. Continuous hemofiltration techniques are often used in its dialytic management but little is known about their impact. The aim of this study is to define the biochemical and clinical impact of continuous hemodiafiltration (CHD) in the management of this syndrome and to retrospectively compare it to that of conventional dialysis. A prospective, cohort study and retrospective comparison with historical controls was conducted at an intensive care unit (ICU) of a tertiary institution. Eighty-seven consecutive septic patients with acute renal failure were treated by continuous hemodiafiltration and 40 consecutive similar patients by conventional dialysis. All new cases of severe acute renal failure with sepsis were treated by means of continuous hemodiafiltration. Historical controls were treated by means of conventional dialysis. Illness and sepsis severity were assessed on admission and prior to initiation of treatment. Biochemical variables were assessed daily. Outcome was measured as discharge from the ICU, duration of oliguria and discharge from hospital. Of the 87 patients treated by hemodiafiltration, 86 had multiorgan failure, 71 (81.6%) septic shock and 52 (59.8%) bacteremia/fungemia. Their APACHE II score on admission was 29.9 and their mean organ failure score prior to treatment was 4.3. Hemodiafiltration resulted in a significant fall in mean urea and creatinine levels within 24 h and in the correction of acidosis. The mean alveolar-arterial gradient fell from 276 to 211 mm Hg (p < 0.02) within 24 h of therapy. Complications were few and mostly related to vascular access.(ABSTRACT TRUNCATED AT 250 WORDS)
Acute Kidney Injury↗
Severe acute renal failure: a comparison of acute continuous hemodiafiltration and conventional dialytic therapy.
It is unknown whether continuous renal replacement techniques result in diminished morbidity and mortality when compared to conventional dialytic techniques. To investigate this issue a previously described, retrospectively studied group of critically ill patients with severe acute renal failure treated by conventional dialysis (CD) was compared to a prospectively studied group of similar patients treated by acute continuous hemodiafiltration (ACHD). A combined retrospective and prospective clinical and laboratory investigation was carried out for 234 consecutive critically ill patients with severe acute renal failure in the intensive care unit of a tertiary institution. Biochemical, clinical and outcome data in all patients treated by conventional dialytic techniques (intermittent hemodialysis and/or peritoneal dialysis) during a 5-year period were retrospectively analyzed, and a prospective analysis of the same biochemical, clinical and outcome data in all patients treated by acute continuous hemodiafiltration was done over a similar time span, with statistical comparison of findings. One hundred and fifty patients were treated by ACHD and 84 by CD. ACHD patients were more severely ill (mean APACHE II score: 28.2 vs. 25.8; p < 0.01) and older (mean age: 59.9 vs. 55.5 years; p < 0.01). There were no significant differences in the incidence of sepsis, bacteremia and need for mechanical ventilation. ACHD resulted in better control of uremia (mean steady-state plasma urea level: 20.1 vs. 31.7 mmol/l; p < 0.001) and hyperphosphatemia (mean serum phosphate: 1.26 vs. 1.95 mmol/l) after 24 h of initiation of therapy. It also allowed the administration of full nutritional support in a significantly greater percentage of patients (91.3 vs. 64.8%; p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
Acute Kidney Injury↗
Interleukin-6 and interleukin-8 extraction during continuous venovenous hemodiafiltration in septic acute renal failure.
OBJECTIVES: To determine whether continuous venovenous hemodialfiltration (CVVHD) is associated with the extraction of interleukin-6 (IL-6) and interleukin-8 (IL-8) from the circulation of critically ill patients with septic acute renal failure. To quantitate their clearance and assess any possible effect of CVVHD on these cytokines' serum concentrations. DESIGN: Prospective controlled study of IL-6 and IL-8 removal by CVVHD in patients with septic acute renal failure. SETTING: Intensive care unit of a tertiary institution. PATIENTS: Ten critically ill patients with sepsis, acute renal failure, and multiorgan failure. A control group of five patients experiencing an acute illness while undergoing chronic hemodialysis. INTERVENTIONS: Collection of blood samples before CVVHD. Simultaneous collection of prefilter blood and ultradiafiltrate after 4 and 24 h of treatment. IL-8 concentrations were measured in blood and ultradiafiltrate. Their clearances and daily extractions were calculated. MEASUREMENTS AND MAIN RESULTS: IL-6 and IL-8 were detected in the blood of all patients with septic acute renal failure prior to CVVHD. The median IL-6 blood level was 103 pg/mL (range: 19 to 900) and the median IL-8 blood level was 200 (range: 32 to 2925). Both cytokines were cleared by the hemofilter during CVVHD. The median hemofilter clearance of IL-6 were 1.99 L/day (range: 0 to 8.5) and the median clearance of IL-8 was 3.95 L/day (range: 0.31 to 42.8). These blood levels and clearances resulted in median daily extraction rates of 194 ng of IL-6 (range: 0 to 9031) and of 915 ng of IL-8 (range 47.5 to 3562). Control patients had negligible amounts of either IL-6 or IL-8 in their ultrafiltrate. The rate of extraction for IL-6 correlated with its blood levels (p < 0.0001). This was not true for IL-8. A correlation between IL-6 levels and the patients' white cell counts was found after 24 h of hemofiltration. CONCLUSIONS: CVVHD is associated with the extraction of IL-6 and IL-8 from the circulation of patients with septic multiorgan and renal failure. The biological significance of such extraction is undetermined, but such cytokine removal highlights the complexity of the effect of continuous hemofiltration on the soluble mediators of inflammation activated during human sepsis.
APACHE↗
Flow cytometric detection of anti-neutrophil cytoplasmic autoantibodies.
An intracytoplasmic immunofluorescence staining technique which allows the detection and quantification of anti-neutrophil cytoplasmic autoantibodies (ANCA) by flow cytometry is described. A polymorph neutrophil population from human peripheral blood was used in this study as indicator cells. These were fixed and permeabilized by paraformaldehyde, Tween 20 and saponin, to allow ANCA in the patients sera to reach their intracellular antigen targets. The numbers of indicator cells remained unaltered by the permeabilization protocol and no cell aggregation or loss of intracellular antigenicity was observed. An excellent agreement (91% (207/228)) between ANCA detection by immunofluorescence microscopy (IF) and flow cytometry was noted. Compared with IF assay, the flow cytometric method has a sensitivity of 93% (42/45) and a specificity of 90% (165/183). Although not able to discriminate between P-ANCA or C-ANCA, this flow cytometric method has the advantage of providing an objective, reproducible and quantitative measure of ANCA, which makes it an ideal technique for screening of patients sera for ANCA reactivities.
Antibodies, Antineutrophil Cytoplasmic↗
Combined acute respiratory and renal failure: management by continuous hemodiafiltration.
OBJECTIVES: To study the impact of continuous hemodiafiltration (CHD) on the morbidity and mortality of acute combined respiratory and renal failure in critically ill patients. DESIGN: Prospective clinical study. SETTING: Intensive Care Unit of a tertiary institution. PATIENTS: One-hundred fifteen critically ill patients with combined acute respiratory and renal failure. INTERVENTIONS: Treatment of all patients with either continuous arteriovenous hemodiafiltration (CAVHD) or continuous venovenous hemodiafiltration (CVVHD). MEASUREMENTS: Assessment of illness severity, measurement of plasma urea, serum creatinine, electrolytes and arterial blood gases prior to and during treatment. Duration of oliguria, ICU stay, hospital stay, and final outcome. RESULTS: One hundred fifteen critically ill patients with combined respiratory and renal failure (mean APACHE II score, 28.1; mean number of failing organs, 4.1) were studied. Thirty-five were treated with CAVHD and 80 with CVVHD for a mean treatment duration of 13.1 days per patient (range 2-47). Blood urea concentration fell from a mean of 29.4 mmol/l to a mean of 19.1 mmol/l (P < 0.001) and the serum creatinine concentration fell from a mean of 520 mumol/l to a mean of 374 mumol/l after 24 h of therapy (P < 0.001). The A-a gradient fell from a mean of 301 mmHg to a mean of 242 mmHg (P < 0.05). Despite the high degree of illness severity and the need for vasoactive drug infusion in 105 patients (91.3%), survival to hospital discharge was achieved in 33 patients (28.7%). For patients who required > 72 h of combined mechanical ventilation, survival was 22% (22 of 100 patients). Complications of continuous hemodiafiltration were few and all related to arterial vascular access. CONCLUSIONS: In critically ill patients with combined acute respiratory and renal failure, continuous hemodiafiltration controlled azotemia without hypotension and with early improvement in gas exchange. PATIENTS treated with this approach achieved promising survival rates. Our findings support the view that CHD is safe and effective and that it offers important advantages over intermittent hemodialysis. It may be the dialytic therapy of choice in critically ill patients with combined acute respiratory and renal failure.
Acute Kidney Injury↗
Use of a mean systemic filling pressure analogue during the closed-loop control of fluid replacement in continuous hemodiafiltration.
PURPOSE: To assess the use and validity of a mean systemic filling pressure analogue (Pmsa) in the closed-loop control of fluid replacement in continuous hemodiafiltration. METHODS: Cardiovascular variables were computer acquired from bedside monitor. Pmsa was calculated and compared with a target value. Gravitational fluid replacement to the extracorporeal hemodiafiltration circuit was regulated with a computer-controlled clamp. RESULTS: Ten patients (mean acute physiology and chronic health evaluation II score, 29.7; range, 21-33) received continuous venovenous hemodiafiltration for acute renal failure. Fluid replacement therapy was closed loop controlled to a target Pmsa for a total of 601 hours. During this period, 417 L of ultradiafiltrate were lost, and 409 L of replacement and nutritional fluids were administered. Despite such large fluid shifts, measured hemodynamic variables were kept within a narrow range (hour to hour variability: right atrial pressure, 1 +/- 0.1 mm Hg; mean arterial pressure 5.9 +/- 0.5 mm Hg; cardiac index, 0.44 +/- 0.05 L/m2/min). No complications of the technique occurred. CONCLUSIONS: The stability of cardiovascular variables achieved during Pmsa-based fluid replacement of critically ill patients with major fluid losses supports the validity of the use of the Pmsa as a measure of intravascular volume status. Such an analogue may be useful in nondialytic environments. The use of Pmsa as the basis for automated fluid replacement was safe.
Acute Kidney Injury↗