Kes Petar, Ljutić Dragan, Basić-Jukić Nikolina, Brunetta Bruna
Zavod za dijalizu, Klinicki bolnicki centar Zagreb, Kispatićeva 12 10000 Zagreb, Hrvatska.
Acta Med Croatica. 2003;57(1):71-5.
One of the most important achievements in the contemporary intensive care management is introduction of continuous renal replacement therapy (CRRT). The most common indications for CRRT are acute renal failure complicated with heart failure, volume overload, hypercatabolism, acute or chronic liver failure, and/or brain swelling. Less common indications include systemic inflammatory response (SIRS), sepsis, multiorgan failure (MOF), adult respiratory distress syndrome, crush syndrome, tumor lysis syndrome, lactacidosis, and chronic heart failure. Methods of CRRT could be used during or after open heart operations, heart, lung or/and liver transplantation in adults and children. Modern approach to treatment of acute renal failure introduces dialysis early in the course of disease in order to avoid complications on other organs. Sepsis, SIRS and septic shock are still major therapeutic problems in intensive care units with a mortality rate over 50%. Numerous uncontrolled and several controlled clinical studies have demonstrated that CRRT could remove inflammatory substances including cytokines, activated components of the complement, and derivatives of the arachidonic acid. Hemodynamic stability and gas exchange in the lungs were significantly improved. These is due not only to removal of inflammatory substances but also to other nonspecific hemodynamic effects (control of body temperature, fluid and metabolic balance). Besides the convection, cytokines could be removed from the plasma with adsorption on the membrane of dialyzer or hemofilter. Prophylactic use of CCRT in patients with normal renal function, without disturbances in fluid excretion and with normal hemodynamics is still controversial, while the possible benefit is not higher than the risks of invasive therapeutic method, and there is no evidence that prophylactic CCRT could prevent development of acute renal failure in these patients. However, current knowledge of MOF pathophysiology justifies the use of CRRT in patients with signs of heart failure, disturbances in metabolic and fluid homeostasis and sepsis, and in patients with the risk of developing acute respiratory failure or MOF, despite the mild impairment of renal function according to laboratory results.
当代重症监护管理中最重要的成就之一是连续肾脏替代疗法（CRRT）的引入。CRRT最常见的适应证是急性肾衰竭合并心力衰竭、容量超负荷、高分解代谢、急性或慢性肝功能衰竭和/或脑肿胀。较不常见的适应证包括全身炎症反应（SIRS）、脓毒症、多器官功能衰竭（MOF）、成人呼吸窘迫综合征、挤压综合征、肿瘤溶解综合征、乳酸性酸中毒和慢性心力衰竭。CRRT方法可用于成人和儿童的心脏直视手术期间或之后、心脏、肺或/和肝脏移植。现代治疗急性肾衰竭的方法是在疾病早期进行透析，以避免其他器官出现并发症。脓毒症、SIRS和感染性休克仍然是重症监护病房的主要治疗难题，死亡率超过50%。众多非对照和一些对照临床研究表明，CRRT可以清除炎症物质，包括细胞因子、补体的活化成分和花生四烯酸的衍生物。肺的血流动力学稳定性和气体交换得到显著改善。这不仅是由于炎症物质的清除，还归因于其他非特异性血流动力学效应（体温控制、液体和代谢平衡）。除对流外，细胞因子还可通过吸附在透析器或血液滤过器膜上从血浆中清除。在肾功能正常、液体排泄无紊乱且血流动力学正常的患者中预防性使用CCRT仍存在争议，因为可能的益处不高于侵入性治疗方法的风险，且没有证据表明预防性CCRT可以预防这些患者发生急性肾衰竭。然而，目前对MOF病理生理学的认识证明，在有心力衰竭迹象、代谢和液体稳态紊乱以及脓毒症的患者中，以及在有发生急性呼吸衰竭或MOF风险的患者中，尽管实验室结果显示肾功能轻度受损，使用CRRT是合理的。
