Naslov
Acute renal failure in intensive care unit

Autori
Gašparović, Vladimir ; Gornik, Ivan

Vrsta, podvrsta i kategorija rada
Sažeci sa skupova, sažetak, znanstveni

Izvornik
Abstracts of the 4th Central European Congress of Intensive Care Medicine – CECIM 2008 : 140th Anniversary of Novel Laureate Dr. Karl Landsteiner ; u: Wiener klinische Wochenschrift 120 (2008) (S3) / - , 2008, S10-S11

Skup
4th Central European Congress of Intensive Care Medicine : 140th Anniversary of Novel Laureate Dr. Karl Landsteiner (4 ; 2008) (S3) S2-S60

Mjesto i datum
Baden, Austrija, 24.10.2008. - 25.10.2008

Vrsta sudjelovanja
Poster

Vrsta recenzije
Međunarodna recenzija

Ključne riječi
acute renal failure; intensive care unit

Sažetak
Acute renal failure (ARF) is a clinical syndrome characterized with electrolyte and water disturbances, azothemia, metabolic acidosis and symptoms of basic illness. Very common reason for ARF in ICU patients is septic event from different ethyology. Acute renal failure in ICU is as a rule only a part of the problem in patients with multiple organ failure. All supportive procedures are in the function of maintenance of impaired organ function, and they mostly aid in overcoming acute disorders in critically ill. The most important condition for a favorable outcome is control of the underlying disease, mainly sepsis. Multiple organ failure (MOF) is a clinical syndrome even more common, than isolated ARF observed in ICU patients and burdened with a high mortality rate. It is well known that a higher number of failing organs results in an increased death rate. As pointed out in the introduction, evaluation of the role of a supportive procedure is hindered by the fact that the principal indicator of the outcome is the underlying disease itself. Since sepsis is the also most frequent cause of multiple organ failure in surgical as well as medical intensive care, only control over sepsis allows evaluation of the procedure of extracorporeal circulation. Which supportive therapy in the patients with ARF should be chosen is the question. In current literature there is no prospective randomized study, which documented better patient survival on continuous in relation to intermittent procedures. The majority of intensivists advocate this technique of renal function replacement due to generally accepted opinion that it has less effect on circulation of already hemodynamically unstable patients. In oral communications it is not infrequent to hear that this procedure is “probably better”. It is indisputable that intermittent haemodialysis can affect hyperkalemia and volume excess faster, and it solves more rapidly the acute threat of electrolyte and water disturbances. Weekly dose of hemodialysis in chronic renal failure is defined, mainly by the quotient Kt / V > 1.2. The required dose of extracorporeal elimination in acute renal failure is not defined well enough, however it does not essentially differ from the said quotient. It has been well established that cytokines affect the severity of the septic process. According to some recent publications CRRT might play a significant role in the elimination of pro-inflammatory cytokines, in addition to clearing nitrogen products as well as other medium and large sized molecules. The possible removal of pro-inflammatory mediators may permit a blockade 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. 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. 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. 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. However, there is a randomized prospective study which showed better survival with high volume hemofiltration 35 ml/kg/h compared to low volume ultra filtration in which 25 l of volume are replaced in 24 hours. 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 fewer 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. Almost all intensive care units in England utilize continuous methods. In USA intermittent procedures are used more commonly than continuous ones, which is similar to the situation presently found in Croatia. We believe that both methods are complementary ; IHD for faster elimination of electrolytes and waste products elimination, CRRT for regulation of higher calories requirements and for hemodinamically unstable patients. The expectations that one method is superior to the other in the term of better survival have not been corroborated by the current data available in the literature. The choice of the method should be individualized because both methods have advantages and disadvantages. ARF, which is an integral part of MOF, is a problem frequently encountered in critically ill patient treated in the ICU, but outcome of these patients depends closely on the control of basic event. Evaluation of each of the supportive procedures is therefore hindered by the fact that the underlying disease has the crucial effect on survival and the type of supportive procedure less so. It is our opinion that these patients will more likely be treated by continuous methods by appropriately trained ICU personnel.

Izvorni jezik
Engleski

Znanstvena područja
Temeljne medicinske znanosti

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