Search Results (157)

During pregnancy and in the postpartum period, several diseases may arise or become exacerbated. Acute pancreatitis incidence during pregnancy is similar to the general population but increases in the first two years after delivery. This case report describes the evolution of necrotizing acute pancreatitis in a 30-year-old woman five months postpartum, with an atypical debut of acute pancreatitis, where the high levels of triglycerides caused by hormonal changes in the late postpartum period overlapped with an underlying hyperlipemia. Despite aggressive, multidisciplinary care, including surgical necrosectomy, continuous renal replacement therapy (CRRT), protective ventilation, and venovenous extracorporeal membrane oxygenation (VV-ECMO), the prognosis was influenced by the hormonal changes both secondary to hypothalamic–pituitary–adrenal dysregulation and the postpartum hormonal changes, leading to an altered inflammatory response, evolution to MODS, ultimately resulting in death. The case highlights the complex interplay between postpartum immune and hormonal changes and the systemic inflammatory response of pancreatitis, emphasizing the critical need for postpartum-specific guidelines in managing acute pancreatitis, particularly regarding early risk stratification in order to prevent this pathology and its complications. Full article

Background: Severe sepsis and septic shock remain major contributors to ICU mortality. Polymyxin B hemoperfusion (PMX-HP) has been widely adopted as adjunctive therapy in Asian ICUs for endotoxemia, but its real-world effectiveness and prognostic factors remain uncertain, especially in high Gram-negative settings. Methods: This retrospective cohort study included 64 adult patients with severe sepsis or septic shock who received at least one session of PMX-HP in a 25-bed tertiary medical ICU in Taiwan between July 2013 and December 2019. Demographic, clinical, microbiological, and treatment data were extracted. The primary outcome was 28-day mortality. Prognostic factors were analyzed using logistic regression. Results: The mean age was 66.1 ± 12.3 years; 67.2% were male. Pneumonia (29.7%) and intra-abdominal infection (18.8%) were the most common sources of sepsis, with E. coli and K. pneumoniae as leading pathogens. Median APACHE II score at ICU admission was 26 (IQR 21–32), and 79.7% received two PMX-HP sessions. The 28-day mortality rate was 46.9%, with ICU and hospital mortality both 53.1%. Non-survivors were older, had higher APACHE II scores, and more frequent use of continuous renal replacement therapy (CRRT). Positive changes in vasoactive-inotropic score (VIS) after PMX-HP were also more common among non-survivors. Multivariate analysis identified advanced age, higher APACHE II score, and CRRT requirement as independent predictors of mortality. Conclusions: In this real-world Asian ICU cohort, PMX-HP was used mainly for severe cases with a high disease burden and Gram-negative predominance. Despite its frequent use, overall mortality remained high. Prognosis was primarily determined by underlying disease severity, organ dysfunction (especially renal failure), and persistent hemodynamic instability. In this high-severity cohort, mortality appeared to be primarily driven by baseline organ dysfunction and persistent hemodynamic instability; PMX-HP session number or sequencing showed no association with survival. Given the absence of a contemporaneous non-PMX-HP control group, mortality observations in this cohort cannot be causally attributed to PMX-HP and should be interpreted with caution as hypothesis-generating rather than definitive evidence of efficacy. Further multicenter studies are needed to clarify the optimal role of PMX-HP in modern sepsis management. Full article

Background and Objectives: Severe sepsis complicated by refractory shock is associated with high mortality. Adding continuous hemofiltration to venovenous extracorporeal membrane oxygenation (ECMO) may accelerate clearance of inflammatory mediators and improve haemodynamic stability, but evidence remains limited. We analysed 44 consecutive septic-shock patients treated with combined ECMO-hemofiltration (ECMO group) and compared them with 92 septic-shock patients managed without ECMO or renal replacement therapy (non-ECMO group). Methods: This retrospective single-centre study reviewed adults admitted between January 2018 and March 2025. Demographic, haemodynamic, laboratory and outcome data were extracted from electronic records. Primary outcome was 28-day mortality; secondary outcomes included intensive-care-unit (ICU) length-of-stay, vasopressor-free days, and change in Sequential Organ Failure Assessment (SOFA) score at 72 h. Results: Baseline age (49.2 ± 15.3 vs. 52.6 ± 16.1 years; p = 0.28) and APACHE II (27.8 ± 5.7 vs. 26.9 ± 6.0; p = 0.41) were comparable. At 24 h, mean arterial pressure rose from 52.3 ± 7.4 mmHg to 67.8 ± 9.1 mmHg in the ECMO group (mean change [∆] + 15.5 mmHg, p < 0.001). Controls exhibited a modest 4.9 mmHg rise that did not reach statistical significance (p = 0.07). Inflammatory markers decreased more sharply with ECMO (IL-6 ∆ −778 pg mL⁻¹ vs. −248 pg mL⁻¹, p < 0.001). SOFA fell by 3.6 ± 2.2 points with ECMO versus 1.6 ± 2.4 in controls (p = 0.01). Twenty-eight-day mortality did not differ (40.9% vs. 48.9%, p = 0.43), but ICU stay was longer with ECMO (median 12.5 vs. 9.3 days, p = 0.002). ΔIL-6 correlated with ΔSOFA (ρ = 0.46, p = 0.004). Conclusions: ECMO-assisted hemofiltration improved early haemodynamics and organ-failure scores and accelerated cytokine clearance, although crude mortality remained unchanged. Larger prospective trials are warranted to clarify survival benefit and optimal patient selection. Full article

Background/Objectives: Continuous renal replacement therapy (CRRT) is an important treatment method that is becoming a commonly-used procedure in neonatal intensive care units (NICUs), especially in critically-ill neonates. Methods: We conducted a retrospective study aimed to evaluate factors influencing the outcomes of CRRT in neonates and preterm infants. The study analyzed data from 41 newborns treated with CRRT at our NICU over a ten-year period. Demographic, clinical, and laboratory parameters were assessed, including gestational age, birth weight, PRISM III score, and laboratory markers like urea, creatinine, and potassium levels, as well as characteristics of CRRT. Results: Our research found that the duration of CRRT, the presence of anuria, and higher potassium levels after initiation of CRRT were significant predictors of a poor outcome. Despite the lack of significant correlation between demographic characteristics, PRISM III score and the outcome, our findings highlight the importance of timely CRRT initiation and efficient management to improve survival. Conclusions: Our study identified several significant prognostic indicators in neonates undergoing renal replacement therapy. While these findings provide valuable insights, further research is needed to establish clear theoretical guidelines and improve clinical decision-making. Full article

Background: An elevated urea–creatinine ratio (UCR) is used as a surrogate for catabolism and elevated protein metabolism in critically ill patients. This study investigated the effect of continuous renal replacement therapy (CRRT) on UCR. Methods: In this retrospective single-centre study, ICU patients from 2011 to 2022 with an ICU stay >2 days before CRRT and a CRRT duration of ≥4 days were included. Patients were grouped by UCR at CRRT initiation into high (UCR ≥ 75 mg/dL:mg/dL) and low groups and compared to matched controls not requiring CRRT. Propensity score matching considered age, sex, bodyweight, SAPS3, SOFA score, and UCR values on baseline and pre-baseline days. Results: In the high UCR group, UCR significantly decreased after CRRT initiation, reaching a significant difference from controls on day 2 (85.0 [IQR: 69.5–96.4] vs. 94.4 [IQR: 83.0–115.2]; p = 0.036) and falling below the threshold of 75 by day 3. In the low group, UCR increased post-CRRT initiation, but was less pronounced than in controls, with significant differences on day 1 (44.0 [IQR: 34.2–59.8] vs. 40.6 [IQR: 32.1–52.5]; p = 0.024). Conclusions: CRRT significantly affects UCR in critically ill patients, showing a marked decrease when compared to matched controls. Full article

Background/Objectives: Red blood cell distribution width (RDW) and mean platelet volume (MPV) are well-established prognostic biomarkers across various medical conditions. However, their role in predicting mortality among critically ill pediatric patients remains unclear. This study investigates the association between RDW, MPV, and 28-day mortality in pediatric intensive care unit (PICU) patients. Methods: This retrospective cohort study analyzed data from children aged 1 month to 18 years who were admitted to the PICUs at Chiang Mai University Hospital for ≥24 h between January 2018 and December 2022. The primary outcome was 28-day PICU mortality. A log-binomial regression analysis was conducted to assess the association of RDW and MPV with 28-day PICU mortality, adjusting for age, sex, mechanical ventilation, vasoactive drug use, continuous renal replacement therapy, and multiorgan failure. Results: A total of 580 PICU patients were included, 55.3% male, with a median age of 5.9 (IQR: 4.7–10.4) months. The 28-day PICU mortality rate was 9.8% (57/580). Respiratory failure and acute respiratory distress syndrome were the most common admission diagnoses (72.1%). Elevated RDW (≥15%) and MPV (≥10 fL) were independently associated with increased 28-day PICU mortality (adjusted RR: 2.73, 95% CI: 1.45–5.13 and 2.38, and 95% CI: 1.43–3.93, respectively). Both markers demonstrated high negative predictive values (RDW: 96.0% and MPV: 94.6%). Conclusions: Elevated RDW (≥15%) and MPV (≥10 fL) were independently associated with increased 28-day PICU mortality. These findings highlight their potential utility as accessible and cost-effective biomarkers for early risk stratification in critically ill pediatric patients. Full article

Objectives: The impact of initial emergency room (ER) factors on survival and renal function in critically ill patients undergoing continuous renal replacement therapy (CRRT) remains unclear. This study aimed to evaluate whether these initial factors influence survival and renal recovery in such patients. Methods: This single-center, retrospective study included 190 critically ill patients admitted to the intensive care unit (ICU) via the ER for CRRT between 1 March 2018, and 31 May 2021. Clinical parameters, including urine output, estimated glomerular filtration rate (eGFR), and serum neutrophil gelatinase-associated lipocalin (NGAL), were assessed. The primary outcomes were 30-day and 90-day mortality, while secondary outcomes included 30-day and 90-day RRT-free durations. Results: Patients with low urine output (LUO, defined as the average of <0.5 mL/kg/h over 6 h) were significantly associated with higher 30-day and 90-day mortality rates. Multivariable Cox regression analysis revealed that the LUO group had an increased risk of 30-day and 90-day mortality (hazard ratios: 1.935 and 2.141, respectively) compared to the high urine output (HUO, defined as the average of ≥0.5 mL/kg/h over 6 h) group. No significant association was observed between mortality and initial eGFR or plasma NGAL levels. However, the HUO group and patients with initial eGFR ≥ 30 mL/min/1.73 m² had longer RRT-free durations at 30 and 90 days. Plasma NGAL levels did not significantly correlate with RRT-free durations. Conclusions: Initial 6-h urine output in the ER is a significant predictor of 30-day and 90-day mortality in critically ill patients undergoing CRRT. Full article

Background: Hemolysis during sepsis may be driven by patient-specific factors, including the intensity of the inflammatory response and the etiology of infection, as well as treatment-related factors, such as the use of extracorporeal life-support devices. Methods: We evaluated the incidence of hemolysis—reflected by decreased plasma levels of haptoglobin and hemopexin—in a cohort of septic patients with acute respiratory failure (n = 50) admitted to the intensive care unit (ICU). Results: Hemolysis was observed in 60% of patients. Its incidence was significantly higher among those with septic shock (86%) and those receiving extracorporeal membrane oxygenation (ECMO) therapy (81%). While continuous renal replacement therapy (CRRT) alone did not increase the incidence of hemolysis, its combination with ECMO was associated with hemolysis in 100% of those treated. Logistic regression analysis identified low haptoglobin levels (odds ratio [OR] 27.1), advanced age (OR 1.2), and stage 3 acute kidney injury (OR 22.2) as significant predictors of mortality. Conclusions: These findings highlight the clinical relevance of monitoring hemolysis in septic patients. Given the routine availability of haptoglobin and hemopexin assays in most hospital laboratories, these biomarkers offer practical and accessible tools for the detection and monitoring of hemolysis in critically ill patients. Full article

Purpose: To assess the impact of beta-lactam therapeutic drug monitoring (TDM) timing and therapy adjustment on clinical cure and 30-day mortality. Methods: This was a prospective study of critically ill patients admitted to the University of Florida Health Shands Hospital intensive care unit (ICU) between 2021 and 2022, ≥18 years old, and requiring beta-lactam therapy for a suspected or confirmed infection. Beta-lactam concentrations were measured per standard of care, pharmacokinetic/dynamic (PK/PD) target attainment was calculated, and therapy was adjusted if needed. Multiple regression and time-to-event (TTE) analyses were performed. Results: A total of 297 infection episodes from 268 patients were included. The mean (SD) age was 56 years (17), weight was 82 kg (32), and 14% received renal replacement therapy. The most common infection source was the lung, and the most common beta-lactam was cefepime. The most common infusion duration was 30 min. The median (IQR) time to first TDM was 2.7 days (1.7–4.7). Fifty-seven percent of patients required therapy adjustment. Increases in beta-lactam dose, frequency, or infusion duration were associated with lower 30-day mortality compared to continuing the same regimen (aOR 0.30, p = 0.015). Delay in performing TDM was associated with lower probability of clinical cure (aOR 0.92, p = 0.0023). Patients who had the regimen increased had shorter hospital stay compared to those who had it decreased. Timing of beta-lactam TDM in ICU patients was a significant predictor of clinical cure, while adjusting beta-lactam therapy to achieve higher exposure was a significant predictor of 30-day mortality. Full article

Renal cell carcinoma (RCC) is the most common type of kidney cancer, accounting for a significant proportion of all cancer cases in Korea. This case report presents a unique instance of spontaneous dramatic tumor regression in a 42-year-old Korean male diagnosed with clear cell RCC. The patient initially presented with right lower back pain, weight loss, and a loss of appetite. Following systemic immunotherapy with nivolumab and ipilimumab, and right radical nephrectomy, the patient was diagnosed with metastatic clear cell RCC, with new metastatic lesions detected in the liver, and on the chest wall on follow-up imaging. Second-line systemic treatment with pazopanib was initiated. Shortly thereafter, the patient developed severe systemic inflammatory syndrome, resulting in a mental stupor and acute kidney failure. Intensive care, including continuous renal replacement therapy and high-dose immunosuppressants, was administered. The patient’s condition improved significantly with the intensive care regimen, leading to unintended tumor regression. These potentially fatal side effects occurred without infection, as confirmed by negative blood and urine cultures, and were attributed to the recent introduction of pazopanib. Follow-up imaging showed a significant reduction in hepatic metastatic lesions and the disappearance of chest wall nodules. This is the first reported case of RCC tumor regression following the side effects of pazopanib, underscoring the need for further studies into the immune mechanisms involved in RCC treatment and highlighting potential therapeutic strategies that leverage innate immune responses. Full article

Background: Current severity scoring systems in intensive care units (ICUs) are complex and time-consuming, limiting their utility for rapid clinical decision-making. This study aimed to develop and validate simplified prediction models using readily available biomarkers for assessing in-hospital mortality risk. Methods: We analyzed 19,720 adult ICU patients in this retrospective study. Three prediction models were developed: a basic model using lactate-to-albumin ratio (LAR) and neutrophil percent-to-albumin ratio (NPAR) and two enhanced models incorporating mechanical ventilation and continuous renal replacement therapy. Model performance was evaluated against Sequential Organ Failure Assessment (SOFA) score and Acute Physiology and Chronic Health Evaluation (APACHE) II score using machine learning approaches and validated through comprehensive subgroup analyses. Results: Among individual biomarkers, SOFA score showed the highest discriminatory power (area under these curves [AUC] 0.931), followed by LAR (AUC 0.830), CAR (AUC 0.749), and NPAR (AUC 0.748). Our enhanced Model 3 demonstrated exceptional predictive performance (AUC 0.929), statistically comparable to SOFA (p = 0.052), and showed a trend toward superiority over APACHE II (AUC 0.900, p = 0.079). Model 2 performed comparably to APACHE II (AUC 0.913, p = 0.430), while Model 1, using only LAR and NPAR, achieved robust performance (AUC 0.898) despite its simplicity. Subgroup analyses across different ICU types demonstrated consistent performance of all three models, supporting their broad clinical applicability. Conclusions: This study introduces novel, simplified prediction models that rival traditional scoring systems in accuracy while offering significantly faster implementation. These findings represent a crucial step toward more efficient and practical risk assessment in critical care, potentially enabling earlier clinical interventions and improved patient outcomes. Full article

Background: Sepsis is a major global health issue and the leading cause of death in critically ill patients, with rising incidence and associated healthcare costs. Early administration of antibiotic therapy is crucial, but increasing antibiotic resistance poses a threat. Beta-lactam antibiotics, commonly used as a first-line therapy option against sepsis, often demonstrate unpredictable concentrations due to pharmacokinetic and pharmacodynamic changes in critically ill patients. Acute kidney injury (AKI) affects a significant portion of septic patients, and continuous renal replacement therapy can further complicate treatment by reducing antibiotic levels and, consequently, increasing antibiotic resistance risk. Objectives: To develop pharmacokinetic/pharmacodynamic models for beta-lactam antibiotics in septic shock patients undergoing continuous renal replacement therapy (CRRT), with the goal of optimizing antibiotic dosing and then improving treatment outcomes. Methods: Septic shock Caucasian adult patients treated with beta-lactams and who have undergone major surgery in AKI failure that requires CRRT will be eligible with previous informed written consent. CRRT will be performed exclusively using Continuous Venovenous Hemodiafiltration (CVVHDF) modality. Antimicrobial determination analyses will be carried out with LC-MS/MS. Further calculation of pharmacokinetic parameters and determination of PK/PD breakpoints will be made using Monte Carlo simulation. Conclusions: The expected results from this study will lead to a better understanding of the pharmacokinetics of beta-lactam antibiotics in critically ill patients with AKI and septic shock undergoing CVVHDF, allowing for improved therapeutic strategies. Full article

End-stage renal disease (ESRD) is a serious and lethal disease that carries with it a high morbidity and mortality rate if left untreated. Treating ESRD is conducted via renal replacement therapy and/or kidney transplantation, with the latter being the preferred option given the better outcomes and quality of life for the patients. However, as ESRD rises in prevalence, kidney transplantation rates remain largely unchanged. In every kidney transplantation, ischemia–reperfusion injury (IRI) is inevitable and the effect this has on the kidney depends based on donor type. IRI works through a variety of molecular mechanisms, primarily mitochondrial oxidative stress and programmed cell death mechanisms. Given the urgency to ensure the best outcomes for these limited kidney transplants, there has been a continued effort to find various potential therapeutic mechanisms to counteract IRI preoperatively, intraoperatively, and postoperatively. These include hypothermic machine perfusion, ischemic conditioning, nanoparticle removal of free radicals, peptide-based therapies, microRNA, and more. There is an ongoing effort to find the best way to mitigate IRI in kidney transplantation and this is being achieved through a better understanding of the molecular mechanisms of IRI. Full article

Acute kidney injury (AKI) remains a significant challenge in critical care medicine, affecting up to 50% of intensive care unit patients with substantial mortality rates. While traditional approaches to AKI assessment rely on static measurements like serum creatinine and urine output, the furosemide stress test (FST) has emerged as a dynamic functional tool for evaluating renal tubular function and predicting AKI progression. This comprehensive review examines the historical development, physiological basis, technical aspects, and clinical applications of FST in various patient populations. Originally developed and validated in 2013, FST has demonstrated superior predictive capabilities for AKI progression and the need for renal replacement therapy compared to conventional biomarkers. The test’s mechanism relies on assessing the kidney’s response to a standardized furosemide challenge, providing insights into both the structural integrity and functional reserve of the renal tubular system. Standardized protocols have been established for different clinical scenarios, though implementation challenges remain, including timing considerations, patient selection, and resource requirements. FST has shown utility in critical care, post-cardiac surgery, sepsis-associated AKI, and heart failure settings. Recent developments include integration with artificial intelligence, personalized medicine approaches, and combination with novel biomarkers. While limitations exist, including contraindications and technical challenges, ongoing research continues to refine protocols and expand applications. This review highlights FST’s role as a valuable prognostic tool in modern AKI management and discusses future directions, including automated monitoring systems, protocol standardization efforts, and potential applications in different patient populations. Full article

Objectives: We aimed to develop a population pharmacokinetic (PopPK) model and evaluate dosing regimens for different renal clearances and continuous renal replacement therapy (CRRT) settings. Methods: Data were collected from four studies in intensive care unit (ICU) adult patients receiving 400–600 mg of ceftaroline every 8–12 h in a one-hour infusion. The PopPK model was developed according to non-linear mixed effects modeling implemented in Monolix 2024R1. To investigate dosing recommendations, Monte Carlo simulations and probability of target attainment (PTA) analysis were performed in Simulx 2024R1. Results: We collected 296 plasma concentrations from 29 non-CRRT patients and 24 pre-filter (systemic), 23 post-filter, and 23 effluent concentrations from four CRRT patients using WebPlotDigitizer (Version 4.7). A five-compartment model, with the first-order elimination from the central compartment and additional elimination with the effluent during CRRT, best described the ceftaroline concentrations. Creatinine clearance (Cl_Cr) was identified as a covariate on the clearance of elimination (Cl) and CRRT modality on the central and peripheral compartments’ volumes and intercompartmental clearance. The results of dosage simulations for different CRRT modalities and Cl_Cr, S. pneumoniae (MIC = 0.25 mg/L) and methicillin-resistant S. aureus (MRSA) (MIC = 1 mg/L) infections, and assumed 100%ƒT_>MIC target, revealed that registered ceftaroline dosages are sufficient to achieve assumed PTA, except MRSA infection in patients with augmented renal clearance (ARC). Conclusions: Our successfully developed model allows flexible PK simulations of ceftaroline, including real-time changes in settings and even temporary or permanent cessation of CRRT. However, the results of our study warrant clinical validation and should be used with caution primarily due to the limited CRRT patient number included in the analysis. Full article