Background and AimsBoth insulin and plasma exchange (PE) are used in hypertriglyceridemic acute pancreatitis (HTG-AP). Our aim was to compare the efficacy of both treatments.MethodsA randomized, parallel group study performed in a tertiary hospital in 22 HTG-AP patients with non-severe prognosis and triglycerides between 15 and 40 mmol/L. Patients were randomized to daily PE or insulin infusion until triglycerides were <10 mmol/L. Primary outcome was % reduction in triglycerides within 24 h. Secondary outcomes were days needed to lower triglycerides <10 mmol/L, highest CRP and percentage of patients with a severe course of pancreatitis.ResultsThere was a trend toward a greater decrease in triglycerides within the first 24 h in the PE group (67 ± 17% vs. 53 ± 17%, p = 0.07), but the absolute difference was modest [mean difference of 6 mmol/L (14% of initial value)]. Triglycerides fell below 10 mmol/L in a median (IQR) of 1 (1–2) and 2 (1–2) days, respectively (p = 0.25). Secondary outcomes related to disease severity were also comparable: highest CRP 229 vs. 211 mg/L (p = 0.69) and severe course of pancreatitis in 2/11 cases in both groups (p = 1.0). Regarding treatment complications, there was one mild hypoglycemia and one allergic reaction during PE. Survival was 100% in both groups.ConclusionThere was no significant difference, but only a trend toward a greater decrease in triglycerides with PE, and the clinical course was also comparable. These results do not support universal use of PE in patients with HTG-AP.Clinical Trial Registration[ClinicalTrials.gov], identifier [NCT02622854].

Association of higher serum levels of uremic toxins and inflammatory markers with poorer physical performance is understudied. We measured the six-minute walk test (6MWT), 10 repetition sit-to-stand test (STS-10), handgrip strength (HGS), and Human Activity Profile (HAP) questionnaire score in 90 prevalent hemodialysis patents, with low comorbidity to reduce the potential confounding of concomitant disease. Midweek pre-dialysis serum levels of asymmetric dimethyl-arginine (ADMA), β2-microglobulin (B2M), high-sensitivity C-reactive protein (hs-CRP), indoxyl sulfate (IS), insulin-like growth factor 1 (IGF-1), interleukin 6 (IL-6), myostatin, and urea were analyzed as predictor parameters of physical performance measures in adjusted models. Serum levels of most measured toxins were not significantly related to performance, except for ADMA, which was significantly related to poorer performance in the STS-10 test (B = 0.11 ± 0.03 s, p < 0.01). Higher hs-CRP was associated with poorer results in the 6MWT (B = −2.6 ± 0.97 m, p < 0.01) and a lower HAP score (B = −0.36 ± 0.14, p = 0.01). There were no other significant associations found. We conclude that inflammation may be a more important pathway to physical impediment than uremic toxemia. This suggests that there is a large physical rehabilitation potential in non-inflamed uremic patients.

The remission rate after rituximab treatment in our cohort of patients with idiopathic membranous nephropathy was lower than in other studies. The reason for this is possibly the application of a single dose of rituximab in the majority of patients, which might have been insufficient in patients with higher proteinuria.
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<b><i>Introduction:</i></b> The role of extracorporeal myoglobin removal in the treatment of rhabdomyolysis-associated severe acute kidney injury (AKI) is not yet fully established. High cut-off (HCO) and medium cut-off (MCO) dialysis membrane and cytokine adsorber (CytoSorb®) have been used to this purpose in clinical practice. The data on comparative effectiveness of those methods are scarce. <b><i>Methods:</i></b> In this single-center retrospective study, we included patients with AKI and concomitant rhabdomyolysis (myoglobin &#x3e;20,000 μg/L), who underwent at least one extracorporeal myoglobin removal procedure. The main outcome parameter was myoglobin reduction ratio, whereas albumin was assessed as a safety parameter. <b><i>Results:</i></b> We analyzed data for 15 patients, who underwent 28 procedures (13 HCO, 9 MCO, and 6 adsorber). Pre-treatment serum myoglobin levels were similar between the groups and myoglobin reduction was significant in HCO (<i>p</i> = 0.03) and MCO groups (<i>p</i> &#x3c; 0.01) and borderline significant in adsorber group (<i>p</i> = 0.06). Reduction ratios were comparable between the groups (median 0.64 (inter-quartile range IQR 0.13–0.72), 0.54 (IQR 0.51–0.61) and 0.50 (IQR 0.37–0.62), respectively, <i>p</i> = 0.83). Both pre- and post-procedure serum albumin levels were significantly lower in the MCO group. However, with routine albumin substitution in the HCO group only, serum albumin remained stable during the procedures in all subgroups. <b><i>Conclusions:</i></b> Novel MCO membrane might represent the optimal mode of treatment of severe rhabdomyolysis-associated AKI, as it allows for efficient removal of myoglobin, avoids albumin supplementation and is associated with lower costs. For patients requiring cytokine removal, the adsorption capsule can simultaneously reduce cytokine and myoglobin levels.

Intraosseous hibernoma is a rare finding that has only recently come to light in the literature. We report a case of intraosseous hibernoma in the sacrum identified as an incidental finding in a 40 year-old female with chronic lower back pain. The tumor was characterized with all routine imaging modalities. In the review of the literature we correlate the imaging findings with previously reported cases. With increasing number of radiologic investigations it is expected to discover more intraosseous hibernomas and the radiologists should consider intraosseous hibernoma as differential diagnosis of the sclerotic bone lesion.

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Background. Systemic inflammatory response syndrome (SIRS) is a complex pathophysiologic response to several hostile stimuli. The excessive release of cytokines during SIRS often leads to a cytokine storm causing refractory hypotension and ultimately multiple organ failure with high mortality. Cytokine removal with hemoadsorption has emerged as a possible adjuvant therapy, but data on IL-6 reduction and clinical outcomes are scarce. We aimed to evaluate the effect of CytoSorb hemoadsorption on laboratory parameters and clinical outcomes in shocked patients with SIRS. Methods. We designed a retrospective analysis of all patients with SIRS treated with CytoSorb in intensive care units. Interleukin 6 (IL-6), hemodynamic parameters (mean arterial pressure – MAP and vasoactive inotropic score - VIS), pH and lactate levels at the beginning, after 6h, 12h, 24h and 48h of CytoSorb treatment were analyzed in the whole cohort and in a subgroup of patients with septic shock. Predicted and observed mortality rates were compared using Chi-squared test. Statistical significance was defined as p <0.05 and <0.012 in multiple comparisons where a Bonferroni correction was applied.Results. After screening 147 patients, we included 118 patients with various etiologies of SIRS (septic shock 69%, SIRS after cardiac arrest 16%, SIRS after acute pancreatitis 6%, other 9%). In all but one patient CytoSorb was coupled with renal replacement therapy. During the observed period of 48 hours, a statistically significant decrease in IL-6 levels, increase in pH, increase in MAP and decrease in VIS was observed already from 6h onward. Reduction of lactate levels became statistically significant at 48 hours. In a subgroup of patients with septic shock, the results were similar, and PCT levels did decreased after 24 hours. Observed ICU and in-hospital mortalities in the whole group were lower than predicted by SOFA (61% vs 79%, p=0.005) and APACHE II (64% vs 78%, p=0.031). There were no serious complications attributed to CytoSorb treatment.Conclusions. Hemoadsorption with CytoSorb used in patients with SIRS of different etiologies was associated with a rapid decrease in IL-6 and hemodynamic improvement, with improved observed vs. predicted survival. These results need to be confirmed in a randomized study.

Excessive release of cytokines during systemic inflammatory response syndrome (SIRS) often leads to refractory hypotension and multiple organ failure with high mortality. Cytokine removal with hemoadsorption has emerged as a possible adjuvant therapy, but data on interleukin-6 (IL-6) reduction and outcomes in clinical practice are scarce. We aimed to evaluate the effect of CytoSorb hemoadsorption on laboratory and clinical outcomes in shocked patients with SIRS. We designed a retrospective analysis of all patients with SIRS treated with CytoSorb in intensive care units (ICU). IL-6, laboratory and hemodynamic parameters were analyzed at approximate time intervals during CytoSorb treatment in the whole cohort and in a subgroup with septic shock. Observed and predicted mortality rates were compared. We included 118 patients with various etiologies of SIRS (septic shock 69%, post-resuscitation shock 16%, SIRS with acute pancreatitis 6%, other 9%); in all but one patient, CytoSorb was coupled with renal replacement therapy. A statistically significant decrease in IL-6 and vasopressor index with an increase in pH and mean arterial pressure was observed from 6 h onward. The reduction of lactate became significant at 48 h. Results were similar in a subgroup of patients with septic shock. Observed ICU and in-hospital mortalities were lower than predicted by Sequential Organ Failure Assessment (SOFA) (61% vs. 79%, p = 0.005) and Acute Physiology and Chronic Health Evaluation (APACHE) II (64% vs. 78%, p = 0.031) scores. To conclude, hemoadsorption in shocked patients with SIRS was associated with a rapid decrease in IL-6 and hemodynamic improvement, with improved observed vs. predicted survival. These results need to be confirmed in a randomized study.