The significance of endotoxemia during cardiopulmonary bypass remains incompletely understood. This review summarizes decades of research and highlights that clinically relevant endotoxemia affects only a subset of patients, making indiscriminate endotoxin-targeted therapies unlikely to provide meaningful benefit. Future research should therefore focus on identifying high-risk phenotypes, refining endotoxin assessment, and developing personalized therapeutics. Key priorities include standardization of endotoxin measurement, source tracking, gut barrier dysfunction, bypass-related factors, immunological profiling, EndoCAb-guided risk stratification, novel pharmacological approaches, and extracorporeal endotoxin removal. Regarding patient selection for therapeutic intervention, two high-risk subgroups warrant consideration. First, patients with EAA values >0.40 may be considered biologically exposed, while those with EAA values >0.60 represent a subgroup with endotoxin activity approaching levels seen in severe systemic inflammation or sepsis. Importantly, endotoxin activity must always be interpreted in relation to the host's neutralizing capacity. Second, reduced EndoCAb levels independently predict adverse outcomes after cardiac surgery, including prolonged mechanical ventilation, postoperative complications, and extended hospitalization. These patients may be particularly vulnerable to even moderate endotoxin exposure due to impaired endogenous neutralization. Precision medicine strategies targeting these identifiable subgroups represent the most promising path forward.
Introduction: Continuous renal replacement therapy (CRRT) is effective for severe acute kidney injury (AKI); however, predicting successful CRRT discontinuation and long-term outcomes remains challenging. Although urinary neutrophil gelatinase-associated lipocalin (NGAL) levels and kidney volume measured by computed tomography (CT) have been associated with renal prognosis, it remains unclear whether their combination improves predictive accuracy. This study evaluated whether combining urinary NGAL levels with kidney volume measured by CT improves prediction accuracy. Methods: In this retrospective cohort study, urinary NGAL levels and height-adjusted total kidney volume (HtTKV) were assessed for their ability to predict successful CRRT discontinuation and major adverse kidney events at 90 days (MAKE90). Results: Among the 74 patients included, CRRT discontinuation was successful in 55 (74.3%), and MAKE90 occurred in 31 (41.9%). Urinary NGAL (area under the curve [AUC], 0.86; 95% confidence interval [CI], 0.76–0.95) was a significant predictor of CRRT discontinuation, whereas HtTKV was not. For long-term outcomes, urinary NGAL (AUC, 0.73 [95% CI, 0.61–0.85]) and HtTKV (AUC, 0.67 [95% CI, 0.54–0.80]) were significantly associated with MAKE90. Adding HtTKV to urinary NGAL significantly improved the prediction of MAKE90, as demonstrated by reclassification analyses (net reclassification improvement and integrated discrimination improvement). Conclusions: Adding HtTKV significantly improved the prediction of long-term MAKE90 based on NGAL levels, but not that of short-term CRRT discontinuation. These findings in this proof-of-concept study suggest that structural kidney assessment by CT volumetry may complement urinary NGAL for long-term risk stratification in patients with severe AKI requiring CRRT.
Persistent uremic symptoms remain common among patients receiving maintenance hemodialysis, even when contemporary dialysis prescriptions are optimized. These symptoms are only partially captured by conventional adequacy metrics and represent a major determinant of health-related quality of life. A growing body of evidence suggests that incomplete removal of protein-bound uremic toxins and larger middle molecules contributes to persistent symptom burden. Hemoadsorption, when integrated into the extracorporeal circuit, provides an additional clearance mechanism that may enhance solute removal beyond diffusion and convection alone. The ICHARUS study is a prospective, multicenter, observational, real-world registry enrolling adult patients receiving hemodialysis with persistent uremic symptoms despite optimized conventional therapy. Hemoadsorption combined with hemodialysis will be prescribed according to routine clinical practice. Study visits are scheduled at baseline and at one, three, and six months. The primary endpoint is the change in patient-reported symptom burden, assessed using the Dialysis Symptom Index, from baseline to three months. Secondary endpoints include changes in symptom-specific patient-reported outcomes, health-related quality of life, selected biochemical markers, and safety. By focusing on patient-reported outcomes in a pragmatic setting, the ICHARUS study aims to generate structured real-world evidence on the feasibility, safety, and potential clinical relevance of hemoadsorption combined with hemodialysis, supporting patient phenotyping and informing future hypothesis-driven interventional studies. ClinicalTrial.gov ID: NCT07522008.
Extracorporeal membrane oxygenation (ECMO) is a well-established life support technology. However, among patients receiving ECMO, acute kidney injury (AKI) is common, and a substantial proportion receive concomitant support with renal replacement therapy (RRT). There are several techniques for combining RRT with ECMO in patients, including the use of in-line hemofilters in the ECMO circuit, integrated RRT machine circuits into the ECMO circuit and the use of parallel circuits where ECMO and CRRT are provided by discrete vascular access. Enclosed is a summary of work group findings from the joint Acute Disease Quality Initiative (ADQI) and Extracorporeal Life Support (ELSO) consensus meeting focused on “ECMO, AKI, Fluid Management and CRRT,” which identified priorities, knowledge gaps and research opportunities, along with generating key consensus-based statements to guide best practices for performing CRRT during ECMO.
Introduction: We describe an institutional nursing protocol used for patients with neuromyelitis optica spectrum disorder (NMOSD) undergoing TR-350 tryptophan immunoadsorption (IA) therapy. We retrospectively analyzed the clinical and nursing records of 67 patients with NMOSD who underwent TR-350 IA between January 2019 and August 2025. Methods: We evaluated 334 treatment sessions and recorded demographic characteristics, observed clinical and serological changes, adverse events, and device alarms. Nursing management before, during, and after the procedure was reviewed. Results: After the IA treatment course, reductions in the median Expanded Disability Status Scale score and the geometric mean anti-aquaporin-4 immunoglobulin G (AQP4-IgG) titer, together with improvement in visual acuity, were observed. Laboratory testing revealed hypofibrinogenemia (<1.0 g/L) in 13 of 67 patients (19.4%). Nurses identified hypotension in two sessions (2/334, 0.6%) and catheter-site bleeding in one session (1/334, 0.3%); in all, 29 device-alarm events were recorded. With nursing intervention and timely troubleshooting, 333 of 334 sessions were completed; one session (0.3%) was terminated prematurely because of extracorporeal circuit clotting. Conclusion: TR-350 IA demonstrated feasibility and safety in this cohort of patients with steroid-refractory NMOSD. Adherence to nursing protocols refined locally from institutional standard operating procedures and clinical experience, together with proactive management of complications, supported a high treatment completion rate and patient safety.
