engleski

Continuous renal replacement therapy (CRRT) or intermittent hemodialysis (IHD) - What is the procedure of choice in critically ill patients?

In order to answer the question what is the procedure of choice in critically ill patients, one must eliminate certain forms of intermittent hemodialysis which by themselves carry frequent problems during extracorporeal circulation. Since the machines with controlled ultrafiltration and bicarbonate dialysate imply smaller incidence of complications, only these devices can be considered comparable with continuous hemofiltration. It has been well established that cytokines affect the severity of the septic process. The possible removal of proinflamatory mediators may permit a blocade of systemic inflammation, a modulation of the altered immune response in these patients, and it may lead to a partial or total restoration of the lost homeostasis. A statistically significant reduction in heart rate, increase in systemic vascular resistance an systolic blood pressure were documented in the group of patients who underwent CRRT. On the other side according meta analysis in published and unpublished trials in any language CRRT in comparison to IHD does not improve survival or renal recovery in unselected critically ill patients with ARF. On the other hand, continuous procedure of hemofiltration has less effect on the stability of circulation. Comparison of value of intermittent hemodialysis with continuous procedures of hemofiltration should therefore be considered in the light of the mentioned fact. In our prospective randomized study with 104 patients, we also did not observed any difference in 28 days survival, in total survival, as well as in circulatory instability between two treatment modalities. Even in subgroup of 8o patients with sepsis and septic shock there were no difference in survival. Sepsis was the underlying disorder in 52 and septic shock in 28 patients out of 104 patients analyzed in this study. The statistical evaluation of the obtained data revealed no significant difference in patient outcome between the two observed methods of renal replacement therapy. The number of hypotensive attacks defined by blood pressure fall over 10 mmHg in our group of patients on continuous procedures was not significantly smaller. When choosing the method of extracorporeal circulation, despite the fact that prospective randomized studies did not prove better survival using one of them, intensivists are advised to use the method with less side effects, and of greater benefit in a given case. Our prospective randomized study did not show a statistically significant difference between the two methods of renal replacement therapy. Survival rates were not affected and neither was the occurrence of hemodynamic instability. We therefore believe that the management of the underlying condition outweighs the choice of the procedure of renal replacement. Currently, the use of these methods in the world varies.

Continuous renal replacement therapy; intermittent hemodialysis; critically ill patients

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