中田 孝明

The aim of our study was to examine renal replacement therapies (RRT) that have been used for acute renal failure (ARF) in our intensive care unit (ICU) patients and to compare their outcomes. Sixteen patients who underwent intermittent hemodialysis (IHD), 14 patients who underwent continuous hemofiltration (CHF) in combination with IHD (CHF + IHD), and 38 patients who underwent continuous hemodiafiltration (CHDF) were evaluated. Regarding the effects of blood purification on hemodynamics and renal function, the percentage increase in blood pressure and percent rapid increase in urinary output were the greatest in the CHDF group. The hourly urinary output after the start of initial blood purification increased only in the CHDF group. The survival rate was significantly higher in the CHDF group. These results suggest that CHDF should be the first-line therapy for patients with ARF and that we are moving in the right direction regarding the application of RRT to treat ARF in ICU patients.

敗血症ショックに対する新しい治療戦略を見出すことを目的に,敗血症ショック症例42例の検討を行った.42例の内訳は死亡例22例,救命例20例であった.敗血症ショックにおいては各種humoral mediator血中濃度を低下させることが救命に重要であることが示唆され,まず遺伝子解析を行い,高サイトカイン血症high risk症例であれば,重症化する前に積極的にポリメチルメタクリレート製膜(PMMA膜)hemofilterを用いた持続的血液濾過透析(PMMA-CHDF)を行い,同時にインターロイキン-6血中濃度迅速測定システムを用いたサイトカイン血中濃度モニタリングを行う.その結果,多臓器不全を呈したり,高サイトカイン血症であれば,腎不全の有無に関わらず,PMMA-CHDFを開始する.さらに,PMMA-CHDF単独ではサイトカイン血中濃度の低下が不十分な症例においてはサイトカイン吸着カラム等のさらに強力なmediator除去療法を併用することがサイトカイン血中濃度の低下につながると考えられた

Drug-induced toxic epidermal necrolysis (TEN) is a rare, but severe disease, resembling widespread second-degree burns. We report on two cases of TEN. Case 1: A 53-year-old woman presented with a skin rash in the clinical course of severe acute pancreatitis. She was diagnosed as having TEN, affecting 90% of her body surface area (BSA). She was transferred to our ICU, presenting with respiratory and renal dysfunction, and severe sepsis. She was treated in a similar manner as treatment for severe burns and underwent 6 plasma exchange series. However, the infection became uncontrollable and the skin lesion showed no improvement. She died of multiple organ failure (MOF) on the 61st ICU day. Case 2: A 34-year-old man was admitted to our ICU with a diagnosis of TEN, affecting 40% of his BSA. We performed 3 plasma exchange series. The skin lesion and general condition gradually improved, and he was transferred to a general ward on the 17th ICU day. Current evidence suggests that keratinocytes is died through apoptosis in TEN and that Fas-Fas ligand interactions are involved in TEN pathophysiology. We studied the serum soluble Fas ligand (sFasL), and evaluated the time course of sFasL concentrations in these 2 cases. Serum concentrations of sFasL in Case 1 were sustained at a high level, whereas those in Case 2 gradually decreased. The sFasL concentration may be related to the severity and clinical course of TEN.

Background/Aims: The basic principle of treatment of congestive heart failure is achieving adequate control of preload and afterload through enhancement of cardiac contractility. In severe cases, however, we have usually applied continuous hemodiafiltration (CHDF) as a type of mechanical support. In this study, we investigated hemo-dynamic changes caused by CHDF in patients with congestive heart failure. Methods: We treated seven patients with congestive heart failure complicated by multiple organ failure by CHDF over 72 h, during which we measured hemodynamic parameters to determine their changes. Results: Implementation of CHDF resulted in a significant decrease in pulmonary artery occluded pressure and significant increases in cardiac index and left ventricular stroke work index. In addition, 72-hour cumulative water balance was found to be -1,791 ± 2,119 ml, and systemic vascular resistance index decreased significantly. Conclusion: Hemodynamics of patients were improved with CHDF through strict control of preload and consequently tissue oxygen metabolism was improved. Copyright © 2002 S. Karger AG, Basel.