Clinical Impact of Continuous Renal Replacement Therapy on Multiple Organ Failure

Abstract

Because continuous renal replacement therapy (CRRT) may enhance inflammatory mediator removal, this review assesses its impact on multiple organ failure (MOF). Regarding MOF with acute renal failure (ARF), the overall mortality of 2313 CRRT patients (43 studies) was 62.8% compared with 59.1% (p = 0.046) in 961 intermittent hemodialysis (IHD) patients (12 other studies). Of 13 CRRT studies with an IHD comparison group, 3 showed that the groups had a similar risk, but IHD mortality was higher; 1 noted that CRRT had lower mortality (risk not stated); and 4 showed similar mortality and greater CRRT risk. Aggregate mortality was IHD 69.5% and CRRT 63.9% (p = 0.02). Of the six studies with matched groups (age and APACHE II scores), IHD mortality was higher (70.9% vs. 60.1%, p = 0.01). CRRT pulmonary gas exchange, hemodynamic instability, azotemia control, fluid overload, and nutritional support were better. Regarding MOF without ARF, of 14 CRRT studies (14.5 patients per study), only 4 had comparison groups. Patient conditions were as follows: acute respiratory distress syndrome, six studies; sepsis, three studies; septic shock, two studies; pancreatitis, one study; critically ill patients, one study; and cardiac surgery with respiratory failure, one study. Of the three studies with a control group, the mortality was the same. There was minimal evidence that CRRT improved pulmonary gas exchange or hemodynamic instability. For MOF patients with ARF, there is compelling evidence that CRRT provides better survival than IHD and more improvement in pulmonary gas exchange, hemodynamic instability, azotemia control, fluid overload, and nutritional support. In patients with MOF and no renal failure, there is little evidence that CRRT enhances survival, oxygenation, or perfusion. Controlled trials demonstrating a CRRT benefit are necessary before CRRT can be recommended for MOF without ARF.

A Comparison of Continuous Renal Replacement Therapy to Intermittent Dialysis in the Management of Renal Insufficiency in the Acutely Ill Surgical Patient

“…23,25 Also, evidence suggests that CRRT may be the modality of choice for ARF with multiple organ dysfunction syndrome (MODS) and ID the choice for isolated ARF in stable patients. 25,26 Our study supports current literature showing hemodynamic stability and better renal function with CRRT versus ID. There was significant improvement in azotemia with CRRT as shown by lower BUN and Cr levels at the end of the study treatment period, as well as improvement in renal function measured by creatinine clearance.…”

A Comparison of Continuous Renal Replacement Therapy to Intermittent Dialysis in the Management of Renal Insufficiency in the Acutely Ill Surgical Patient

“…23,25 Also, evidence suggests that CRRT may be the modality of choice for ARF with multiple organ dysfunction syndrome (MODS) and ID the choice for isolated ARF in stable patients. 25,26 Our study supports current literature showing hemodynamic stability and better renal function with CRRT versus ID. There was significant improvement in azotemia with CRRT as shown by lower BUN and Cr levels at the end of the study treatment period, as well as improvement in renal function measured by creatinine clearance.…”

Continuous venovenous hemodiafiltration in patients with multiple organ dysfunction syndrome in an intensive care unit

“…[33] Apart from observed improvements in oxygenation and metabolic hemodynamic variables, the high rate of survival to ICU discharge of septic MODS patients with CVVH is noteworthy because lack of evidence for a survival benefi t is one of the criticisms of this procedure. [2,4,35,36] SMR calculated for the septic MODS group by comparing expected mortality per APACHE II values to observed mortality was similar to the SMR of 0.67 reported by Page for septic MODS patients, with 53% mortality. [25] This must be considered treatment effi cacy.…”

Hemofiltration and Peritoneal Dialysis in Infection-Associated Acute Renal Failure in Vietnam

“…3 This problem can be avoided by the use of continuous hemofiltra-A tion, particularly when a pump is used to ensure constant filtration. 4,5 Pumped venovenous hemofiltration, and variants such as hemodiafiltration, have therefore become standard renal-replacement therapy for acute renal failure. However, these procedures require highly trained staff, anticoagulant therapy, large volumes of fluids, and access to large veins and are associated with a risk of air embolism.…”

A Comparison of Continuous Renal Replacement Therapy to Intermittent Dialysis in the Management of Renal Insufficiency in the Acutely Ill Surgical Patient

“…23,25 Also, evidence suggests that CRRT may be the modality of choice for ARF with multiple organ dysfunction syndrome (MODS) and ID the choice for isolated ARF in stable patients. 25,26 Our study supports current literature showing hemodynamic stability and better renal function with CRRT versus ID. There was significant improvement in azotemia with CRRT as shown by lower BUN and Cr levels at the end of the study treatment period, as well as improvement in renal function measured by creatinine clearance.…”

Continuous venovenous hemodiafiltration in patients with multiple organ dysfunction syndrome in an intensive care unit

“…[33] Apart from observed improvements in oxygenation and metabolic hemodynamic variables, the high rate of survival to ICU discharge of septic MODS patients with CVVH is noteworthy because lack of evidence for a survival benefi t is one of the criticisms of this procedure. [2,4,35,36] SMR calculated for the septic MODS group by comparing expected mortality per APACHE II values to observed mortality was similar to the SMR of 0.67 reported by Page for septic MODS patients, with 53% mortality. [25] This must be considered treatment effi cacy.…”

Hemofiltration and Peritoneal Dialysis in Infection-Associated Acute Renal Failure in Vietnam

“…3 This problem can be avoided by the use of continuous hemofiltra-A tion, particularly when a pump is used to ensure constant filtration. 4,5 Pumped venovenous hemofiltration, and variants such as hemodiafiltration, have therefore become standard renal-replacement therapy for acute renal failure. However, these procedures require highly trained staff, anticoagulant therapy, large volumes of fluids, and access to large veins and are associated with a risk of air embolism.…”

A Comparison of Continuous Renal Replacement Therapy to Intermittent Dialysis in the Management of Renal Insufficiency in the Acutely Ill Surgical Patient

“…23,25 Also, evidence suggests that CRRT may be the modality of choice for ARF with multiple organ dysfunction syndrome (MODS) and ID the choice for isolated ARF in stable patients. 25,26 Our study supports current literature showing hemodynamic stability and better renal function with CRRT versus ID. There was significant improvement in azotemia with CRRT as shown by lower BUN and Cr levels at the end of the study treatment period, as well as improvement in renal function measured by creatinine clearance.…”

Continuous venovenous hemodiafiltration in patients with multiple organ dysfunction syndrome in an intensive care unit

“…[33] Apart from observed improvements in oxygenation and metabolic hemodynamic variables, the high rate of survival to ICU discharge of septic MODS patients with CVVH is noteworthy because lack of evidence for a survival benefi t is one of the criticisms of this procedure. [2,4,35,36] SMR calculated for the septic MODS group by comparing expected mortality per APACHE II values to observed mortality was similar to the SMR of 0.67 reported by Page for septic MODS patients, with 53% mortality. [25] This must be considered treatment effi cacy.…”

Hemofiltration and Peritoneal Dialysis in Infection-Associated Acute Renal Failure in Vietnam

“…3 This problem can be avoided by the use of continuous hemofiltra-A tion, particularly when a pump is used to ensure constant filtration. 4,5 Pumped venovenous hemofiltration, and variants such as hemodiafiltration, have therefore become standard renal-replacement therapy for acute renal failure. However, these procedures require highly trained staff, anticoagulant therapy, large volumes of fluids, and access to large veins and are associated with a risk of air embolism.…”