icu

肾置换技术的更新

Update on Renal Replacement Techniques: After Prevention, What Works?
Disclosures
Linda S. Efferen, MD
Introduction
It is generally well established that the main goal of therapy for acute renal failure (ARF) in the intensive care unit (ICU) is prevention. With that caveat in mind, avoidance of conditions or agents that could contribute to renal dysfunction is important. Ischemia is a contributing factor in the development of ARF in the ICU in the majority of cases,[1] with medullary ischemia overshadowing cortical ischemia in importance due to the high oxygen requirements and relative susceptibility of this area to significant hypoxic injury.[2] In general, in the ICU, severe ARF requiring renal replacement therapy (RRT) occurs in the setting of multisystem organ failure and rarely occurs as an isolated event. John Kellum, MD,[3] of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, reviewed the common conditions that may lead to medullary ischemia as well as what is known to work, and what does not, in the prevention of renal failure.

　　Acute Renal Failure: Prevention and Treatment
　　The Impact of Extracorporeal Removal Techniques on Outcome of Sepsis
　　Role of CRRT in Sepsis

Conclusion
In summary, the development of ARF in the ICU increases the risk for both significant morbidity and mortality. Prevention remains the primary goal and the guiding principle of management strategies. Once ARF has occurred, RRT is well established as a therapeutic strategy, although the optimal mode of treatment remains to be defined. The early application of CRRT in sepsis as a potential disease modifying strategy holds potential promise but remains experimental without adequate clinical data at the current time to support its routine use.
References
1. Thadhani R, Pascual M, Bonventre JV. Acute renal failure. N Engl J Med. 1996;334:1448-1460.
2. Brezis M, Rosen S. Hypoxia of the renal medulla -- its implication for disease. N Engl J Med. 1995;332:647-655.
3. Kellum J. Renal replacement therapy. Prevention and treatment of acute renal failure: what works and what doesn't. Program and abstracts of the 32nd Critical Care Congress; January 28-February 2, 2003; San Antonio, Texas.
4. Gilbert DN, Lee BL, Dworkin RJ, et al. A randomized comparison of the safety and efficacy of once-daily gentamicin or thrice-daily gentamicin in combination with ticarcillin-clavulanate. Am J Med. 1998;105:182-191.
5. Kellum JA, Decker JM. Use of dopamine in acute renal failure: A meta-analysis. Crit Care Med. 2001;29:1526-1531.
6. Australian and New Zealand Intensive Care Society Clinical Trials Group. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomized trial. Lancet. 2000;356:2139-2143.
7. Thompson BT, Cockrill BA. Renal-dose dopamine: a siren song? Lancet. 1994;344:7-8.
8. Tepel M, van der Giet M, Schwarzfeld C, et al. Prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine. N Engl J Med. 2000;343:180-184.
9. Schiffl H, Lang SM, Fischer R. Daily hemodialysis and the outcome of acute renal failure. N Engl J Med. 2002;346:305-310.
10. Cohen J. Renal replacement therapy. The role of hemoperfusion, plasmapheresis, and on-line selective removal of toxins in the treatment of sepsis. Program and abstracts of the 32nd Critical Care Congress; January 28-February 2, 2003; San Antonio, Texas.
11. Busund R, Koukline V, Utrobin U, Nedashkovsky E. Plasmapheresis in severe sepsis and septic shock: a prospective, randomized, controlled trial. Intensive Care Med. 2002;28:1434-1439.
12. Ulrich H, Jakob W, Frohlich D, et al. A new endotoxin adsorber: first clinical application. Ther Apher. 2001;5:326-334.
13. Corwin H. Renal replacement therapy. Continuous dialysis therapy: is there a role in sepsis and multiorgan failure? Program and abstracts of the 32nd Critical Care Congress; January 28-February 2, 2003; San Antonio, Texas.
14. John S, Griesbach D, Baumgartel M, et al. Effects of continuous haemofiltration vs intermittent haemodialysis on systemic haemodynamics and splanchnic regional perfusion in septic shock patients: a prospective, randomized clinical trial. Nephrol Dial Transplant. 2001;16:320-327.
15. Cole L, Bellomo R, Hart G, et al. A phase II randomized, controlled trial of continuous hemofiltration in sepsis. Crit Care Med. 2002;30:100-106.
16. Honore PM, Jamez J, Wauthier M, et al. Prospective evaluation of short-term, high-volume isovolemic hemofiltration on the hemodynamic course and outcome in patients with intractable circulatory failure resulting from septic shock. Crit Care Med. 2000;28:3581-3587.