Dr. Filippo AucellaDirettore Scientifico Seminario ANTE 2010

Direttore S. C. di Nefrologia e Dialisi, IRCCS “Casa Sollievo della Sofferenza”San Giovanni Rotondo

La Nefrologia nel

Paziente Critico

Criteria for consideration of BP

• Progressive deterioration despite intensive support therapy;

• Depression of midbrain function: hypoventivation, hypothermia, hypotension;

• Complications of coma;

• Impairment of normal drug excretory function: hepatic, cardiac, renal failure;

• Agents with delayed effects (mushrooms or paraquat) ;

• Hepatic failure (?)

• ESRD and Al intoxication ;

• Regional HP for anticancer drug toxicity.

Choosing between HD or HP

Toxin characteristics

• Low molecular weight HD

• High molecular weight HP

• Water solubility HD

• Lipid solubility HP

• Low protein binding HD

• High protein binding HP

Patients characteristics

• Renal failure HD

• Acid-base problems HD

• Electrolytes problems HD

• Hypotension HP

• Haemodynamic instability HP

• Low platelet count HD

In vitro removal of therapeutic drugs with a novel adsorbent system

Reiter K et al, Blood Purif 2002

BetaSorb™ is designed as an

adjunctive treatment to traditional

high-flux HD. Target are MMW

toxins not cleared well by HD. The

marker is β2μ. Studies show that

reduced levels of β2μ lead to a

reduction in morbidities like

amyloidosis, hospital stays, and

lowers mortality rates compared to

patients on high-flux HD.

Effective removal of:

• Digoxin

• Theophylline

• Phenobarbital

• Phenytoin

• Carbamazepine

• Valproic acid

• Glycopeptide antibiotics

The next step from HF dialysis: application of sorbent

technologyWichester JF et al, Blood Purif 2002

Sorbent augmenteddialysis systems

Wichester JF et al, Contrib Nephrol 2002

Adsorbents. From basicstructure to clinical application

technologyRonco C et al, Contrib Nephrol 2002

Qb

Quf

HFR

Renal Dysfunction is Common in Patients with Acute Decompensated Heart Failure (n = 105,388)

0

10

20

30

40

50

<15 15-29 30-59 60-89 >90

Estimated GFR, ml/min

Pati

en

ts (

%)

Heywood JT, et al. Heart Failure Reviews 2004

80% of patients have at least

moderate renal dysfunction

Hillege HL. et al. Circulation 2000

Days

100

90

80

70

60

50

40

30

0 250 360 500 750 1000

> 76 ml/min

59-76 ml/min

44-58 ml/min

< 44 ml/minPro

port

ional surv

ival (%

)

eGFR

Clinical Effects of Ultrafiltration in CHF

Before UF Soon after UF

“Mini-invasive” Ultrafiltration

Costanzo MR for the UNLOAD invest. JACC 2007

Giorni di ospedalizzazioneG

IOR

NI D

I

RIC

OV

ER

O

GIO

RN

I D

I

RIC

OV

ER

O

MESIINIZIO D.P. MESIINIZIO D.P.

Ricoveri per motivi cardiologici

Ricoveri per complicanze della D.P.

P<0,05 P<0,05

Frazione di eiezioneF

RA

ZIO

NE

DI

EIE

ZIO

NE

(%

)

INIZIO D.P. 4 MESI 8 MESI 12 MESI

0

10

20

30

40

50

60

FE

%

Inizio DP 4 mesi 8 mesi 12 mesi

Funzionalità renaleC

RE

AT

ININ

A (

mg

/dl)

INIZIO D.P. 3 MESI 6 MESI 12 MESI9 MESI

INIZIO D.P. 3 MESI 6 MESI 12 MESI9 MESI

UR

EA

(m

g/d

l)