TREATMENT OF SEPSIS-ASSOCIATED SEVERE ACUTE-RENAL-FAILURE WITH CONTINUOUS HEMODIAFILTRATION - CLINICAL-EXPERIENCE AND COMPARISON WITH CONVENTIONAL DIALYSIS

The syndrome of sepsis-associated severe acute renal failure is a freq uent component of sepsis-induced multiorgan failure. Continuous hemofi ltration techniques are often used in its dialytic manage ment but lit tle is known about their impact. The aim of this study is to define th e biochemical and clinical impact of continuous hemdiafiltration (CHD) in the management of this syndrome and to retrospectively compare it to that of conventional dialysis. A prospective, cohort study and retr ospective comparison with historical controls was conducted at an inte nsive care unit (ICU) of a tertiary institution. Eighty-seven consecut ive septic patients with acute renal failure were treated by continuou s hemodiafiltration and 40 consecutive similar patients by conventiona l dialysis. All new cases of severe acute renal failure with sepsis we re treated by means of continuous hemodiafiltration. Historical contro ls were treated by means of conventional dialysis. Illness and sepsis severity were assessed on admission and prior to initiation of teatmen t. Biochemical variables were assessed daily. Outcome was measured as discharge from the ICU, duration of oliguria and discharge from hospit al. Of the 87 patients treated by hemodiafiltration, 86 had multiorgan failure, 71 (81.6%) septic shock and 52 (59.8%) bacteremia/fungemia. Their APACHE II score on admission was 29.9 and their mean organ failu re score prior to treatment was 4.3. Hemodiafiltration resulted in a s ignificant fall in mean urea and creatinine levels within 24 h and in the correction of acidosis. The mean alveolar-arterial gradient fell f rom 276 to 211 mm Hg (p < 0.02) within 24 h of therapy. Complications were few and mostly related to vascular access. Hemodynamic stability was maintained throughout all of the 18,122 h of treatment. Thirty-one (35.6%) patients survived to hospital discharge. Comparison with conv entionally treated historical controls showed better control of uremia at 24 h. Among patients with an APACHE II score <30, survival was gre ater with hemodiafiltration (51.2 vs. 26.6%; p < 0.05). This was also true for patients with 4 or fewer failing organs (53.1 vs. 26.9%; p < 0.05). Continuous hemodiafiltration achieves rapid and reliable contro l of uremia and acidosis in spesis-associated severe acute renal failu re and is associated with improved gas exchange. Survival in these ext remely ill patients approached 35%. The use of hemodiafiltration is as sociated with better early control of uremia than with conventional he modialysis or peritoneal dialysis. In some patient subgroups, continuo us hemodiafiltration also appears to provide a survival advantage. The above findings suggest that continuous hemodiafiltration may be a for m of renal replacement therapy ideally suited to the management of sep sis-associated severe acute renal failure.