Lang S, Küchle C, Fricke H, Schiffl H
Medizinische Klinik, Klinikum Innenstadt, Universität München, Germany.
New Horiz. 1995 Nov;3(4):680-7.
Since intermittent hemodialysis was first used systemically during the Korean war, the mortality of acute renal failure (ARF) in critically ill patients has remained high ( > or 50%). The lack of improvement may be a result of better resuscitation techniques and intensive care management that allow more severely ill patients to survive long enough to develop ARF. The concept that those patients with ARF die with, but not of, renal failure was challenged recently by the results of three prospective randomized trials. Each tested the hypothesis that the course of ARF and the fate of critically ill patients may be affected adversely by bioincompatibility reactions due to the dialysis membrane used (activation of complement and neutrophils). Schiffl and colleagues were the first to publish a full report on the results of their investigation comparing bioincompatible cuprophane (CUP) and biocompatible acrylonitrile AN 69 (Hospal, Lyon, France) membranes in 52 patients with ARF following cardiovascular surgery. The AN 69 group had a lower death rate (38% vs. 65%, p = 0.052), a lower proportion of patients dying from Gram-negative sepsis (40% vs. 71%, p = 0.0162), and an improved recovery of renal function. A similar trial comparing the use of CUP with biocompatible polymethyl-methacrylate (PMMA) was performed in 72 patients with medical categories of ARF. Again, the use of a biocompatible membrane resulted in an improved survival rate (57% vs. 37%, p = 0.11) and better recovery of renal function (62% vs. 37%, p = 0.04). Of the 20 patients in each group who initially had nonoliguric ARF, the survival rates were 80% with PMMA and 40% with CUP (p = 0.01). The preliminary results of another multicenter study including 121 patients dialyzed with either bioincompatible cellulosic membranes or PMMA or polysulfone membranes seem to confirm these findings. The management of critically ill patients is sophisticated and expensive. The use of biocompatible membranes adds little to the overall costs and appears to be justified.
自从在朝鲜战争期间首次全身性地使用间歇性血液透析以来，重症患者急性肾衰竭（ARF）的死亡率一直居高不下（＞50%）。死亡率缺乏改善可能是由于更好的复苏技术和重症监护管理，使得病情更严重的患者存活足够长的时间从而发展为ARF。最近，三项前瞻性随机试验的结果对ARF患者死于肾衰竭而非因肾衰竭死亡这一概念提出了挑战。每项试验都检验了这样一个假设，即ARF的病程和重症患者的命运可能会受到所用透析膜引起的生物不相容反应（补体和中性粒细胞的激活）的不利影响。施菲尔及其同事率先发表了关于他们调查结果的完整报告，该调查比较了生物不相容的铜仿膜（CUP）和生物相容的丙烯腈AN 69（法国里昂霍斯帕尔公司）膜在52例心血管手术后发生ARF的患者中的应用情况。AN 69组的死亡率较低（38%对65%，p = 0.052），死于革兰氏阴性菌败血症的患者比例较低（40%对71%，p = 0.0162），并且肾功能恢复情况有所改善。一项类似的试验在72例患有内科类ARF的患者中比较了CUP与生物相容的聚甲基丙烯酸甲酯（PMMA）的使用情况。同样，使用生物相容膜使存活率提高（57%对37%，p = 0.11），肾功能恢复情况更好（62%对37%，p = 0.04）。在每组最初患有非少尿型ARF的20例患者中，PMMA组的存活率为80%，CUP组为40%（p = 0.01）。另一项多中心研究的初步结果包括121例使用生物不相容的纤维素膜或PMMA或聚砜膜进行透析的患者，似乎证实了这些发现。重症患者的管理复杂且昂贵。使用生物相容膜对总体成本增加不多，似乎是合理的。
