The objective was to evaluate the effects of prolonged (24–72 h) high-adsorption membrane hemofiltration on the hemostatic system.Materials and methods. A retrospective study included 91 patients with COVID-19 who received prolonged high-adsorption membrane hemofiltration (Prismaflex system) as part of complex therapy. The group was divided into two subgroups, taking into account the outcome of the disease. We analyzed the level of D-dimer, fibrinogen, platelet count, percentage of large platelets, thromboelastogram indicators, reflecting external and internal coagulation pathways (Intem, Extem) before and after the procedure. The levels of serine proteases (tPA, PAI) were additionally analyzed in 35 cases.Results. An increase in the D-dimer level, accompanied by a decrease in the fibrinogen concentration, was detected after sorption, which was especially noticeable in patients with unfavorable outcome (by 2.8 times). The thromboelastogram parameters after the procedure did not go beyond the normal range, the level of tPA and PAI became lower in both subgroups but there was no connection with the outcome.Conclusion. Prolonged high-adsorption membrane hemofiltration in COVID-19 patients does not have a negative influence on hemostasis system. A decrease in fibrinogen level after the procedure is associated with its mechanical removal from the circulation because of fibrin adhesion on the filter’s membrane and on sets’ walls; an increase in the D-dimer level should not be associated with the detection of degradation of fibrin networks.

The use of high-adsorption membrane hemofiltration in COVID-19 positive patients to reduce the severity of a cytokine storm is clearly beneficial but at the same time, there are no certain procedures for its practical use.The objective: to study the change in the levels of IL-6 and IL-18 in response to prolonged (24-72 hours) high-adsorption membrane hemofiltration.Subjects and methods. We retrospectively analyzed the data on IL-6 and IL-18 levels and their changes in 69 patients who were COVID-19 positive and had different degrees of lung damage, they had received high-adsorption membrane hemofiltration during their stay at the intensive care unit. The extent of lung lesions was the following: 4 people had CT-2, 44 people had CT-3, and 21 patients had CT-4. 18 patients had an unfavorable outcome of the disease. High-adsorption membrane hemofiltration (Prismaflex) was used in the group of patients who had clinical signs of the rapid progression of the disease and also such laboratory findings as elevated values of C-reactive protein (above 100 mg/L), ferritin (more than 600 μg/L), and progression of lymphopenia. This intervention lasted for 24 hours at CT-2/3, and 48 hours at CT-4. The effluent dose was 30.0 ± 6.4 ml/kg/h. The levels of IL-6, IL-18, and procalcitonin were tested before and after the completion of the intervention, and the difference between their concentration before and after high-adsorption membrane hemofiltration was calculated. The potential association between received data (IL-6, IL-18, delta of IL-6, delta of IL-18) and degree of lung damage and outcomes was analyzed.Results. It was detected that the more the lungs were affected, the lower levels of IL-6 and IL-18 were and vice versa and this correlation was not associated with the use of tocilizumab (used in 44 people). The maximum decrease in the level of cytokines was observed in the group of patients with CT-2. There was a significant association between the delta of IL-6 (F = 6.69; p ≤ 0.05) and the outcome which was especially pronounced in people with a favorable outcome.Conclusion. As the inflammation progresses in the lungs, the levels of IL-6 and IL-18 decrease which may be a manifestation of the depletion of the cytokine storm. The use of prolonged high-adsorption membrane hemofiltration (24-48 h) allows reducing the level of cytokines. The delta value reflects a decrease in IL-6 concentration, it significantly correlates with the outcome which indicates the importance of using this method in a continuous mode.

Changes in classification criteria and active introduction of biomarkers of acute kidney injury (KDIGO, 2012) are changing approaches to diagnosis and treatment of postoperative renal dysfunction including cardiac surgery patients operated with cardiopulmonary bypass (CPB). The objective: to compare the detection rate of AKI after surgery with CPB with the use of biomarkers and kidney disease improving global outcomes criteria, as well as to evaluate the cause and localization of structural changes of the nephron.Subjects and Methods. A monocenter observational study among elective cardiac surgery patients (n = 97) was conducted. Inclusion criteria: age over 18 years, duration of surgery (coronary bypass surgery, prosthetic heart valves) from 90 to 180 minutes, no signs of end stage kidney disease. AKI was diagnosed based on changes in serum creatinine and biomarkers (NGAL, IgG, albumin in urine). The studied parameters were recorded 15 minutes after the start and end of anesthesia, as well as 24 and 48 hours after surgery. Retrospectively, the group was divided into three subgroups: 1) patients without AKI after surgery; 2) patients in whom signs of AKI were detected after 24 hours but regressed by the 48th hour; 3) patients in whom AKI persisted during all 48 hours of follow-up.Results. 24 hours after surgery, AKI based on KDIGO criteria was recorded in 56.3% of patients. Using biomarkers, signs of tubular damage (NGAL) at the end of anesthesia were detected in 95.9% of patients; after 24 hours, they were registered in 73.2% of cases. In a subgroup where AKI persisted for more than 24 hours, glomeruli were damaged in addition to tubules which was manifested not only by selective but also by non-selective proteinuria. The duration of CPB, hemodilution (Hb < 90 g/l), the release of free hemoglobin in the blood (> 1.5 mg/l) at low (< 1 g/l) values of haptoglobin were significantly associated with AKI development.Conclusion. The KDIGO criteria do not allow detecting a subclinical form of renal dysfunction which may occur in about 40% of patients after surgery with CPB. AKI can be caused by damage to both the tubular part of the nephron and glomeruli in cases of prolonged CPB with the development of hemolysis, the release of free hemoglobin in the blood, and persisting anemia at the end of the surgery. The NGAL assessment makes it possible to detect subclinical kidney injury in the absence of elevated serum creatinine levels.

Estimations of the frequency of acute kidney injury in SARS-CoV-2 (COVID-19) coronavirus disease are very diverse. The literature data is highly inconsistent and shows AKI ranging from 0.5 to 80%.The objective: to analyze the incidence of renal dysfunction in COVID-19 patients and assess the significance of systemic inflammation for its development.Subjects and methods: The analysis was performed basing on data of 3,806 patients with COVID-19 treated at the Pavlov State Medical University, 395 of them were admitted to the intensive care units (ICU). The criterion for establishing renal dysfunction (RD) is the increase in blood creatinine level above the upper limit of reference values (0.115 mmol/l). Patients with end-stage chronic kidney disease who needed to continue routine long-term dialysis were not included in the study. We analyzed the incidence of renal dysfunction, changes in blood levels of creatinine, urea, and electrolytes during 8 days. In addition, glomerular filtration rate, diuresis volume, levels of hematocrit, hemoglobin, LDH, CRP, ferritin, and procalcitonin were evaluated.Results. The frequency of RD among all patients was 19.0%, among patients in the ICU – 41.0%. In 79% and 81%, respectively, it was detected on the first day of hospitalization. The increase in the number of patients with RD and the aggravation of the existing dysfunction occurred after 6 days. At the initial stage of the disease, the manifestations of RD in most cases were not expressed even in those with an unfavorable course of the disease but the level of creatinine showed a weak but significant (p < 0.5) correlation with changes in CRP (r = 0.110), ferritin (r = 0.137), and procalcitonin (PCT, r = 0.418). The difference in the level of creatinine in patients with PСT level above and below 0.5 ng/ml was observed on the first day only; the value of this parameter returned to normal faster in the subgroup of patients whose procalcitonin level did not exceed 0.5 ng/ml.Conclusion. In case of the signs indicative of RD, it is advisable to distinguish between primary and secondary injury. In the first case, it is primarily due to systemic inflammation, in the second case it is caused by additional impact of other aggressive factors. This will make it possible to clarify the renal and non-renal indications for renal replacement therapy (RRT) in patients with COVID-19, and to evaluate the results adequately since the effectiveness of RRT at different stages of the disease cannot be the same.

THE AIM. Assessment of factors associated with cardiopulmonary bypass (CPB) in acute renal dysfunction in patients in the early postoperative period after cardiac surgery. PATIENTS AND METHODS. Monocentric observational study in patients (n = 97) who underwent elective open-heart cardiac surgery (coronary artery bypass grafting -50.44 %, aortic valve prosthetics – 31.04 %, mitral valve prosthetics – 12.61 %) using cardiopulmonary bypass. Inclusion criteria: the study included patients not younger than 18 years old, undergoing cardiac surgery with CPB lasting up to 95 minutes (coronary bypass surgery, valve replacement), without signs of end-stage renal disease. Using nonparametric correlation analysis, we evaluated the effect on the development of acute kidney injury (AKI) of the following extracorporeal circulation factors: duration of CPB, aortic cross-clamp, mean arterial pressure (MAP), cardiac index (CI), perfusion flow rate (PFR), transport, consumption, and oxygen extraction variables. The diagnosis of AKI was made on the basis of the KDIGO classification, the studied parameters were recorded initially (before the operation), 15 minutes after the start of general anesthesia, 30 minutes after the start of cardiopulmonary bypass and 15 minutes after the end of general anesthesia. RESULTS. The frequency of AKI in 24 hours after surgery was 56.3 % (58 cases): including stage 1 in 37 (35.9 %), stage 2 in 17 (16.5 %) , stage 3 – in 4 (3.9 %) patients. In the 48th hour of the postoperative period, signs of AKI regressed and were presented in only 26 people (25.2 %), including the stage 1 in 18 (17.5 %), the stage 2 – in 5 (4.8 %), stage 3 – in 3 (2.9 %). Among the risk factors for AKI in cardiac surgery with CPB, the main effect of the anemia was revealed, especially a decrease in hemoglobin levels of less than 90 g / l and hematocrit of less than 25 %. CONCLUSION. Hemodilution below the "threshold" values of hemoglobin and hematocrit during the CPB provoke acute kidney injury in patients undergoing open-heart surgery.