讲座摘要
肾脏替代治疗最新进展   Up to date in extra-renal therapies: from renal replacement to blood purification
René ROBERT
   讲座课件    
Address correspondence to
  René ROBERT
  Service de Réanimation médicale
  University Hospital of Poitiers: INSERM U927 France
  E-mail: r.robert@chu-poitiers.fr
   
Abstract
  One important recent concern about extra-renal therapy in ICU patient is the dialyse dose.
  In patients under chronic extra-renal therapy, the nephrologists showed that increased dialysis dose assessed by Kt/V was associated with a better outcome.
  Similarly, several studies showed that early or repeated dialysis in the aim to lower urea levels may improve the prognostic of ICU patients with acute kidney injury (1,2).
  At the end of the nineties, C Ronco et all demonstrated that hemofiltration with ultrafiltration rate (UF)  dose of 35ml/Kg/h compared to 20ml/kg/h decreased significantly the 28days mortality in ICU patients with acute reanal failure (3).
  In the same way,  Saudan et al showed that  additional dialysis to hemofiltration (hemodiafiltration) increasing dialysis dose, improved the survival of ICU patients (4).
  However, three recent studies showed opposite results (5-7).
  Talwani et al reported similar mortality in patients treated with 20 or 35ml/kg/h hemodiafiltration (CVVHD) (5).
  The Acute Renal Failure Trial Network, in a study combining hemodialysis and hemofiltration and comparing two dialysis regimen intensive and conventional didn’t show any difference in mortality (6).
  Australia and New Zealand group comparing two doses of CVVHD (25 and 40 mL/kg/h) in 1,500 patients reported no effect on survival in ICU patients (7).
  Thus, it is difficult to recommend a specific dose for extra-renal therapy in ICU patients.
   
  Extra-renal therapies have also been proposed to improve prognosis in some ICU patients especially septic patients.
  Several possibilities are under investigation : high volume hemofiltration, hemofiltration with high cutoff membranes or techniques using cartridge able to adsorb various mediators.
  Polymyxin-B is known to bind to endotoxin, an outer membrane component of gram-negative bacteria that is thought to be an important pathogenic trigger for the production of inflammatory mediators.
  The PMX cartridge (Toraymyxin, Toray Industries, Tokyo, Japan) is an extracorporeal hemoperfusion device that uses polymyxin-B fixed to a-chloroacetamide-methyl polystyrene derived fibers that are packed in the cartridge.
   
  Some clinical studies have shown improved hemodynamic status (8,9) and improved survival (8,10) in patients with sepsis treated with PMX suggesting its potential interest in the treatment of severe sepsis.
  In a recent observational study (11), 36 patients with acute respiratory failure related to sepsis were treated twice with PMX cartridge with improvement of PaO2/FiO2 ratio.
  Some studies performed in patients with severe sepsis showed that mean endotoxin level could be decreased after 2h hemoperfusion (10,12).
  Considering both experimental and clinical studies, since 1994, PMX has been listed as a blood purification device in Japan and is reimbursed by Japanese national health insurance.
  In a recent review, the results of 28 studies (9 randomized) have been pooled, showing a favourable effect of PMX treatment on mean arterial pressure, catecholamine use, PaO2/FiO2 ratio and mortality (13).
  The prospective randomized Euphas study showed improvement of clinical status and mortality adjusted on SOFA score in patients with severe abdominal sepsis treated with hemoperfusion with PMX (14).
   
   
References
1.

Parker TF, 3rd, Husni L, Huang W, Lew N, Lowrie EG. Survival of hemodialysis patients in the united states is improved with a greater quantity of dialysis. Am J Kidney Dis 1994;23:670-680.
2.

Paganini EP, Tapolyai M, Goormastic M, Halstenberg W, Kozlowski L, Leblanc M, Lee JC, Moreno L, Sakai K. Establishing a dialysis therapy/patient outcome link in intensive care unit acute dialysis for patients with acute renal failure. Am J Kidney Dis 1996;28:S81-S89.
3.

Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 2000;356:26-30
4. Saudan P, Niederberger M, De Seigneux S, et al. Adding a dialysis dose to continuous hemofiltration increases survival in patients with acute renal failure. Kidney Int 2006;70:1312-7.
5. Tolwani, AJ.; Campbell, RC.; Stofan, BS.; Lai, KR.; Oster, RA.; Wille, KM. Standard versus highdose CVVHDF for ICU-related acute renal failure. J Am Soc Nephrol. in press
6. The VA/NIH Acute Renal Failure Trial Network Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury N Engl J Med. 2008; 359: 7–20.
7. The RENAL Replacement Therapy Study Investigators. Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients N Engl J Med 2009; 361:1627-38.
8. Tani T, Hanasawa K, Endo Y, Yoshioka T, Kodama M, Kaneko M, Uchiyama Y, Akizawa T, Takahasi K, Sugai K. Therapeutic aphereis for septic patients with organ dysfunction: hemoperfusion using a polymyxin B immobilized column. Artif Org 1998; 22: 1038-1044.
9. Vincent JL, Laterre PF, Cohen J et al. A pilot-controlled study of a polymyxin B-immobilized hemoperfusion cartridge in patients with severe sepsis secondary to intra-abdominal infection. Shock 2005; 23: 400-405
10. Nemoto H, Nakamoto H, Okada H, Sugahara S, Moriwaki K, Arai M, Kanno Y, Suzuki H. Newly developed immobilized Polymyxin B fibers improve the survival of patients with sepsis Blood Purif 2001; 19:361-369
11. Kushi H, Miki T, Okamaoto K, Nakahara J, Saito T, Tanjoh K. Early hemoperfusion with an immobilized polymyxin B fiber column eliminates humoral mediators and improves pulmonary oxygenation. Crit Care 2005; 9 R653-661
12.

Shoji H. Extracorporeal endotoxin removal for the treatment of sepsis: endotoxin adsorption cartridge (Toraymyxin) Ther Apheresis Dial 2003; 7: 10-114
Ronco C The place of early hemoperfusion with polymyxin B fiber column in the treatment of sepsis. Crit Care 2005; 9
13. Cruz DN, Perazella MA, Bellomo R, de Cal M, Polanco N, Corradi V et al. Effectiveness of polymyxin B-immobilized column in sepsis : a systematic review. Crit Care 2007; 11:R47
14. Cruz DN, Antonelli M, Fumagalli R et al. Early use of Polymyxin B hemoperfusion in abdominal septic shock. The EUPHAS randomized controlled trial. JAMA 2009;301:2445-2452
   
 
 
第二届中法危重病医学研讨会 暨 上海重症医学论坛 （2009年12月 中国 上海）
       
 
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