Morabito S, Pistolesi V, Cibelli L, Pierucci A
Nefrologia e Dialisi, Dipartimento Nefro-Urologia, Policlinico Umberto I, Universita' degli Studi La Sapienza, Roma, Italy.
G Ital Nefrol. 2009 Jan-Feb;26(1):13-21.
In the last 10-15 years, user-friendly continuous renal replacement therapy (CRRT) machines have played a major role in increasing the popularity of these techniques in intensive care settings. At present it is not clear which modality of renal replacement therapy (RRT) is optimal for critically ill patients with acute kidney injury (AKI). The choice between different modalities should therefore not be based on unproven ''outcome'' advantages but on evaluation of the clinical picture and logistical circumstances. In hypercatabolic patients, CRRT and sustained low-efficiency dialysis (SLED) have been shown to provide similar metabolic control, but uncontrolled studies suggested a better hemodynamic stability during CRRT, intended as a higher mean arterial pressure and/or less frequent need to increase inotropic or vasoactive drugs. The incidence of hemorrhagic complications is higher with CRRT; however, in particular conditions, such as in patients at high risk of bleeding, CRRT can be performed without anticoagulation or with the use of alternative anticoagulation protocols. Among the different modalities, regional anticoagulation with citrate appears to be the most promising, and the continuous development of simplified protocols for citrate CRRT might facilitate the more extensive use of this technique in the near future. The presence of a mismatch between prescribed and delivered dialysis dose is frequently reported as an important drawback of CRRT. However, data from a recent study designed to evaluate the prognostic impact of the intensity of renal support in critically ill patients with AKI showed that the target Kt/V was obtained in only 67-69% of intermittent hemodialysis (IHD) sessions. Data from several studies comparing the costs of different RRT modalities showed that CRRT is more expensive than IHD or SLED. However, the costs related to SLED can fluctuate within a wide range and in particular settings the higher costs of CRRT could be partially justified by logistical advantages. Further improvements in CRRT device characteristics, anticoagulation protocols, and adaptation of dialysis/replacement fluids to clinical needs will possibly contribute to maintaining, in the coming years, the key role of CRRT in the treatment of hemodynamically unstable critically ill patients requiring RRT.
在过去10至15年中，用户友好型的连续性肾脏替代治疗（CRRT）机器在重症监护环境中提高这些技术的普及程度方面发挥了重要作用。目前尚不清楚哪种肾脏替代治疗（RRT）方式对急性肾损伤（AKI）的重症患者最为理想。因此，不同方式之间的选择不应基于未经证实的“预后”优势，而应基于对临床情况和后勤状况的评估。在高分解代谢患者中，CRRT和持续性低效透析（SLED）已被证明能提供相似的代谢控制，但非对照研究表明，CRRT期间的血流动力学稳定性更好，表现为平均动脉压更高和/或增加使用血管活性药物的频率更低。CRRT的出血并发症发生率更高；然而，在特定情况下，如出血风险高的患者，CRRT可以在不进行抗凝或使用替代抗凝方案的情况下进行。在不同方式中，枸橼酸盐局部抗凝似乎最有前景，简化的枸橼酸盐CRRT方案的不断发展可能会在不久的将来促进该技术更广泛的应用。经常有人报告，CRRT存在预设透析剂量与实际给予剂量不匹配的问题，这是一个重要缺点。然而，最近一项旨在评估肾脏支持强度对AKI重症患者预后影响的研究数据显示，在间歇性血液透析（IHD）治疗中，只有67%至69%的疗程达到了目标Kt/V。多项比较不同RRT方式成本的研究数据表明，CRRT比IHD或SLED更昂贵。然而，SLED的相关成本可能在很大范围内波动，在特定情况下，CRRT较高的成本可能因后勤优势而部分合理。CRRT设备特性、抗凝方案以及透析/置换液与临床需求的适配性的进一步改进，可能有助于在未来几年维持CRRT在治疗需要RRT的血流动力学不稳定重症患者中的关键作用。
