title: Hemodiafiltration Decreases Serum Levels of Inflammatory Mediators in Severe Leptospirosis: A Prospective Study.
abstract: BACKGROUND
  Leptospirosis is a health problem worldwide. Its most severe form is a classic model of sepsis, provoking acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI), with associated mortality that remains unacceptably high. We previously demonstrated that early initiation of sustained low-efficiency dialysis (SLED) followed by daily SLED significantly decreases mortality. However, the mode of clearance can also affect dialysis patient outcomes. Therefore, the objective of this study was to compare the effects of SLED with traditional (diffusive) clearance, via hemodialysis, and SLED with convective clearance, via hemodiafiltration (SLEDf), in patients with severe leptospirosis.
  
  
  METHODS
  In this prospective study, conducted in the intensive care unit (ICU) from 2009 through 2012, we compared two groups-SLED (n = 19) and SLEDf (n = 20)-evaluating demographic, clinical, and biochemical parameters, as well as serum levels of interleukins, up to the third day after admission. All patients received dialysis early and daily thereafter.
  
  
  RESULTS
  During the study period, 138 patients were admitted to our ICU with a diagnosis of leptospirosis; 39 (36 males/3 females) met the criteria for ARDS and AKI. All patients were on mechanical ventilation and were comparable in terms of respiratory parameters. Mortality did not differ between the SLEDf and SLED groups. However, post-admission decreases in the serum levels of interleukin (IL)-17, IL-7, and monocyte chemoattractant protein-1 were significantly greater in the SLEDf group. Direct bilirubin and the arterial oxygen tension/fraction of inspired oxygen ratio were significantly higher in the SLED group. We identified the following risk factors (sensitivities/specificities) for mortality in severe leptospirosis: age ≥ 55 years (67%/91%); serum urea ≥ 204 mg/dl (100%/70%); creatinine ≥ 5.2 mg/dl (100%/58%); Acute Physiology and Chronic Health Evaluation II score ≥ 39.5 (67%/88%); Sequential Organ Failure Assessment score ≥ 20.5 (67%/85%); and inspiratory pressure ≥ 31 mmHg (84%/85%).
  
  
  CONCLUSIONS
  The mode of dialysis clearance might not affect outcomes in severe leptospirosis.
authors.affiliation: Intensive Care Unit, Emílio Ribas Institute of Infectology, Sao Paulo, Brazil.
authors.forename: Sérgio Aparecido
authors.initials: SA
authors.lastname: Cleto
authors.affiliation: Division of Nephrology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
authors.forename: Camila Eleutério
authors.initials: CE
authors.lastname: Rodrigues
authors.affiliation: Intensive Care Unit, Emílio Ribas Institute of Infectology, Sao Paulo, Brazil.
authors.forename: Ceila Maria
authors.initials: CM
authors.lastname: Malaque
authors.affiliation: Intensive Care Unit, Emílio Ribas Institute of Infectology, Sao Paulo, Brazil.
authors.forename: Jaques
authors.initials: J
authors.lastname: Sztajnbok
authors.affiliation: Division of Nephrology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
authors.forename: Antônio Carlos
authors.initials: AC
authors.lastname: Seguro
authors.affiliation: Division of Nephrology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
authors.forename: Lúcia
authors.initials: L
authors.lastname: Andrade
mesh_terms: D058186:Acute Kidney Injury / Q000097:blood / Q000150:complications / Q000628:therapy; D000328:Adult; D000368:Aged; D018932:Chemokine CCL2 / Q000097:blood; D005260:Female; D017583:Hemodiafiltration; D006801:Humans; D018836:Inflammation Mediators / Q000097:blood*; D007362:Intensive Care Units; D020381:Interleukin-17 / Q000097:blood; D015851:Interleukin-7 / Q000097:blood; D007922:Leptospirosis / Q000097:blood / Q000473:pathology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D012128:Respiratory Distress Syndrome / Q000097:blood / Q000150:complications / Q000628:therapy; D018805:Sepsis / Q000097:blood / Q000150:complications / Q000628:therapy; D012720:Severity of Illness Index; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: C111835:CCL2 protein, human; D018932:Chemokine CCL2; D018836:Inflammation Mediators; D020381:Interleukin-17; D015851:Interleukin-7